In these final months leading to the 2015 Millennium Development Goals deadlines, we find ourselves redoubling efforts to bend downward the trajectories of change, striving to reach the U.N. targets set in September 2000. Over the past decade, these shared goals have galvanized the global community, across national boundaries and political agendas, to strive for certain universal targets – from dramatically reducing global poverty and improving equitable access to education to achieving substantial reductions in infant, child and maternal mortality. As of October 2011, these ambitions were further challenged by a global population that now exceeds 7 billion, further straining efforts to reduce inequities.
These MDG challenges start at the very beginning of life (providing a clean and safe birth, attended by competent care providers) through childhood (ensuring timely vaccination against major causes of death) into adolescence (providing education that prepares young men and women for a productive future). Into adulthood, these encompass access to employment, appropriate financial remuneration, competent and affordable health care, access to adequate nutrition and protection from disease.
With a denominator of 7 billion, it is not difficult to rationalize both why inequities in health, education or gender equity persist and why national or global institutions fail to deliver on promises. Populations – rural and urban, socially or economically disenfranchised – have been characterized as the “Bottom Billion” or the “ultra poor,” where incomes stagnate at less than $1.25 per day. One basic component linking these challenges is that of measurement: making every life count, irrespective of where a child is born or when a pregnant woman dies. This has remained a lofty, unattainable goal – until now.
The International Telecommunication Union estimated that by the end of 2010, more than 90 percent of the world’s population lived within reach of a mobile phone network, with more than 143 countries having access to high-speed Internet services. In 2011, this U.N. agency estimated that 5.9 billion mobile phone subscriptions globally reflected a 79 percent penetration in the developing world alone. Of the one-third of the global population using the Internet, 62 percent are residents of the developing world. In the last fiscal quarter of 2011 alone, 180 million new mobile subscribers were registered, reflecting the rate of the near-exponential growth in this sector. This is, however, not to be mistaken for corporate, industry-led hype. We have observed in our own Johns Hopkins University collaborative rural field research sites across the globe the steady infiltration of mobile technologies in even the most remote settings. In less than a decade, every one of our 850 female fieldworkers in rural Bangladesh has gone from being completely disconnected, to owning and using a personal mobile phone to connect with family, friends and co-workers.
This rapid, market-driven technologic revolution has spawned a sea change in global development. Initially, organizations like the Grameen Bank capitalized on mobile technology as an innovative small enterprise solution for landless women to provide connectivity to their villages. These business models are rapidly becoming obsolete as mobile penetration increases and access to phones becomes ubiquitous.
In the past decade, entirely new fields of research and implementation science have emerged, prefaced by an “m,” representing the novel “mobile” facet of their approach – mHealth, mBanking, mAgriculture and mLearning. Mobile technologies are also rejuvenating the domain of telemedicine and electronic health (eHealth), which were previously largely “tethered” systems, focused on facility-based record-keeping, supply chain monitoring and, sometimes, decision support. Mobile technologies serve to untether these systems from their facilities. They widen the reach and versatility of the eHealth infrastructure to support front-line health workers where and when they need access to patient information, while also allowing them to contribute to the clinical record from the field.
This is to many of us the most exciting endgame for mobile health, or mHealth: a pragmatic and now tested series of solutions to help us bridge that last mile – to accelerate progress toward the MDGs by 2015 and beyond.
Over the past five years, hundreds of pilot projects across the globe have tested mHealth strategies to increase the capacity of community health workers and improve the quality of care received by the populations they serve. From this field of a “thousand flowers” of innovation, a healthy bouquet of solid enterprise solutions have emerged and are being used in countries at regional and even national levels. These systems enable tasks that were previously thought to be logistically impossible – enumeration of populations; registration of pregnancies, births and deaths; scheduling of antenatal, postpartum and immunization visits with accountability for missed or delayed contacts; and provision of at least a rudimentary health record. Importantly, these systems also provide a means to improve system efficiencies, from worker management to ensuring vital public health supply chains (including identifying counterfeit medications), as well as real-time monitoring and reporting of vital events and system performance. The most vital function of mobile phones, often lost in the whirlwind of innovation, is voice communication that allows workers to access peer and supervisor guidance when and where they need it.
Front-line health workers, who are often the first and only point of care for most of the Bottom Billion and the world’s rural poor, have been disconnected from broader health systems. Their isolation and often rudimentary training limited the capacity of this cadre to provide little more than basic care with disjointed, if any, continuity of care for the clients being served. Mobile systems now exist to address gaps, which, until recently, seemed intractable. Strategies exist that provide continued skills development and training to front-line health workers, and that integrate them as full-fledged members of their health systems. MHealth systems have empowered families with the information they need to maintain their health and knowledge about services they should expect from the government or health providers. Exciting strategies that bridge the worlds of mHealth and mFinance offer novel approaches to demand-side financing and performance-based incentive schemes.
In 2012, we find ourselves armed with functional mHealth systems, with a growing evidence base for what works under various conditions. Mobile technologies continue to grow in sophistication and shrink in cost, providing fuel to several visions. We can imagine, in the not-too-distant future, a mobile phone being part of the core set of tools provided to every new community health worker – or a “health phone” – connected to essential downstream services and health information, being given to pregnant women as part of their antenatal services, as banally as an iron-folic acid supplement. These simple yet radical changes are achievable within the next five years and could be as revolutionary to global health as access to vaccines.
Through these visions, we build on the legacies established by public health giants John B. Grant, whose work established the models for training China’s “barefoot doctors” in the 1960s and 1970s, and Carl Taylor, founder of the academic discipline of international health and proponent of the vision that empowered communities and that front-line health workers can shape their own futures. Without mHealth, these leaders changed the delivery of care to disconnected populations across the globe – imagine what is possible to accomplish under a new paradigm of universal connectedness.
Our next barrier to mainstream these solutions, beyond demonstrations of success, remains one of advocacy: to galvanize agreement across donors, ministries of health and global health professionals that the right “bouquet” of approaches can be scaled up and integrated into health systems. In the next decade, if mobile-enhanced systems have not been integrated into the next generation of mainstream approaches to delivering health, financial, education and legal services across socio-economic boundaries, it will not be because we weren’t able to do so, it will be because we will have chosen not to.
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