The mobile health community is growing up. After years of piloting ideas and trying to bring them to scale, mHealth leaders are setting their sights on a more ambitious target: integrated health systems.
For years, mHealth was seen more as a niche solution than a way to link and transform health systems in developing countries.
Change has come quickly. Just in the past year, the dialogue, technology and tools in mHealth have changed significantly.
Last year, many in the mHealth community bemoaned “pilotitis” and their inability to scale and move beyond continual generation of new projects. This year, there are examples of projects that have successfully scaled up, especially those using mobile technology to improve maternal and child health interventions.
Those examples, technologies and programs were highlighted at the annual mHealth Summit held last week in Washington, D.C. While many of the formal panels focused on specific projects, the discussions in the hallways were more focused on integration, partnerships and how mHealth strategies can improve health systems.
“Mhealth is now becoming part and parcel of global strategies on health,” said Patricia Mechael, executive director of the mHealth Alliance. “Now, what we’re seeing is real support for the enabling environment and helping to facilitate the development of supportive policies, regulation that will enable investors and implementers and donors in many ways to have an additive impact on global health through the use of mobile technology tools.”
Beyond ensuring that existing systems work efficiently, mHealth may help create systems and linkages where they haven’t existed in the past. Often, in poor and developing countries there are individual pieces of health systems that function well but they don’t interact, noted Marc Mitchell, president of D-Tree International and a lecturer on international health at the Harvard School of Public Health.
“For the first time we have the opportunity to use technology to make that health system work by linking the different pieces into a unified system” built on communications, real-time data, decision support for health workers and linking consumers to providers, he said, adding that to get there, we must think differently, think bigger and re-imagine a health system that supports a continuum of care, ensures minimum standards of quality, and promotes accountability of managers and health workers.
So what might an integrated mHealth system look like? It could include mobile reminders for vaccines, mobile platforms that allow community health workers to track their work, be held accountable and learn how to do their jobs better, technology at health centers to register and track patient treatment and a national database that allows all of the information to be measured and is used to determine needs.
The search for integrated approaches
Governments around the world are increasingly interested in including some aspects of mHealth in their healthcare policies and strategies, but the challenge they face is how to choose which solutions or technologies to use, and how to integrate them into existing systems.
They want to be better informed about what works and what doesn’t, and they want to be sure they are making smart decisions, said Garret Mehl, a scientist at the World Health Organization.
Governments are asking: Does it improve the delivery of health services? Does it reduce costs and improve the quality of care?
The mHealth Alliance has seen an uptick in requests for assistance, explained Mechael, adding that governments feel as though everyone approaching them about mHealth programs is a salesman.
“There is a real need for a neutral broker, convener, facilitator at the country level to take mhealth from an idea, a concept and a series of pilot projects into policies, strategies and systems,” she said.
As a result, the alliance is increasingly looking to play a role in helping to support strong local leaders in designing and developing health infrastructure and policy.
“We have a tool that can help reach the Millennium Development Goals,” noted Mechael. “If I have the opportunity to help facilitated an enabling environment in a handful of countries that can start to see some really good scale ups and impacts of systems and platforms implemented that would be huge.”
Multilateral organizations like UNICEF and WHO, NGOs and donor agencies are also now taking on the role of building government capacity to successfully integrate mHealth into their health systems strategies.
WHO is working to develop a “filter” to identify quality mhealth strategies and programs, to grow the evidence base and use that data to inform recommendations to governments, said Mehl, who identified several key emerging mHealth strategies:
Providing information to clients.
Sending out reminders.
Helping frontline workers make better decisions.
Ensuring health workers are accountable to their clients.
All of them can be carried out in different ways. Reminders for appointments or vaccines can be sent by text message or through voice calls, registration can happen by simple mobile phone or by tablet, and information can be stored on any number of platforms.
As part of its work on mHealth, WHO provides research and technical support to the Innovation Working Group catalytic mHealth grantees. Its role as a research partner enables the U.N. agency to understand what makes for successful strategies, and how governments may adapt them.
“These are mature enough solutions and have the beginning of an evidence base to be able to feel confident that they are promising solutions … that I think will form the basis of a package that I think governments will be looking for,” said Mehl.
In Uganda, UNICEF supports a sustained campaign to increase awareness and understanding of the mhealth issues, identify champions within government and provide them with the knowledge they need to promote mHealth’s integration into policies and plans. It did so in part by bringing together representatives from the public, private and nonprofit sectors to discuss needs and challenges, which convinced some mHealth skeptics.
“They saw it’s not just about creating a useful tool but they understood how it fit into the larger ecosystem,” said Sean Blaschke, a health systems strengthening specialist for UNICEF.
Show me the money
Many countries still lack clear and consistent mHealth policies. Investments often focus on projects and not on building the necessary systems, linkages and attitudes. Foreign aid agencies, while increasingly interested in new technologies, often don’t allocate money to support lasting change.
In shorter one-to-three-year funding cycles, money may run out before a program can be fully integrated. Even with fairly lengthy five-year funding cycles, it can be difficult to successfully change a system, said Blaschke, while acknowledging the constraints donor agencies face.
In Uganda, he said, UNICEF’s health systems program took two years to be initiated, another year and a half to start to scale, and about another two years for it to become institutionalized.
“Very little is costing money, but it costs time, it costs energy,” Blaschke said, adding that the time was necessary to build support within government.
The mHealth community also needs to do a better job of making the case for funding linkages between mobile and other health projects, he said.
“One of the most critical components is convincing donors that extra time needs to be taken packaging tools and documenting tools, building these registries, these hubs, these points of intersection,” noted Blaschke.
D-tree, for instance, was able to show that providing pregnant women in Tanzania health information via mobile phones contributed to more pregnant women moving into the districts where the program was active to take advantage of the service.
The future of mhealth partnership
Because technology changes so quickly, mHealth advocates are encouraging the adoption of standards that allows governments to keep pace.
The key to developing standards and improving health systems, then, is to create frameworks and recommendations that are technology-agnostic and flexible to account for progress.
“There is a big danger of picking winners at this stage,” Blaschke said.
In places where private health care dominates, governments may at least encourage the adoption of best practices through an accreditation process. But governments won’t be able to do it alone, according to Mehl. Partnerships are needed to create fully integrated health systems that incorporate mHealth strategies effectively.
In Uganda, for example, the government decided that it needed to develop a roadmap it could use to determine which innovations or mhealth solutions aligned with its interests, and to monitor the quality of care. South Africa did a similar assessment and both focused on creating shared health records that could be linked to a variety of mhealth applications.
Partnerships among donors can help them leverage existing funds and avoid duplicating work. But the private sector has a role to play, too, and may increasingly get involved as regulatory uncertainties are reduced.
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