Can mobile phones transform healthcare in low and middle income countries?

Many are hopeful

“M-health will be the future of healthcare in Africa, no doubt about it,” Ethiopia’s health minister, Kesetebirhan Admasu, told a recent conference on m-health hosted by University College London and sponsored by BMJ among others.

Even though his country has relatively low mobile ownership (only 8% of the population), Ethiopia was identified in 2010 as a “learning lab for national m-health strategies” by Vital Wave Consulting, a California based firm that advises the United Nations, World Bank, and others on using technology to advance development.3 Since then the country has invested in recruiting and training a mass of frontline health workers to visit rural communities and use mobile technology to connect people with basic services. They have also started to gather basic data (births, deaths, and causes of death, for example), which has been impossible until now for many governments in low and middle income countries.

With only one doctor for every 35 500 people and 84% of the 84 million population living in rural areas, Ethiopia has also seen a medical phone line called “Hello Doctor” grow from pilot project to nationwide service. It gives many people access to simple medical advice for the first time, as well as the possibility of calling a doctor to their home for a fraction of the cost of travelling to their nearest clinic (perhaps $2 versus $15).4

Alain Labrique, associate professor and director of Johns Hopkins University’s global m-health initiative, thinks that mobile phone technology has the potential to improve the access of rural communities to formal healthcare services. He and Smisha Agarwal argued in a recent paper that it could, as a result, improve the fate of the 7.6 million children under 5 years old who die each year worldwide.5

Scaling up effective interventions

“M-health can be a way of taking efficacious interventions to effective coverage,” he told the conference. “We run into potholes in the struggle between knowing what to do and doing it at scale—m-health is the way to fill those potholes.”

Excitement about the potential of mobile phones to transform every area of healthcare has spawned thousands of pilot projects in low and middle income countries, from supporting pregnant women, to reminding patients to take their drugs, to recording children’s arm circumferences as a way of monitoring malnutrition.

Some governments and donors have announced partnerships with mobile phone companies to improve access to healthcare.6 7 So far, though, it is mainly the “low hanging fruit,” says Labrique, that are being expanded to reach significant numbers of people, including interventions that accelerate blood testing, encourage behavioural change for better adherence to drug regimens, and support maternal health.

But we lack conclusive knowledge about the effects of m-health.8 Few pilot programmes, however exciting, have been expanded into national programmes because of costs. Donors and governments need strong evidence to justify investment in national programmes, and mobile phone companies, although collaborating in many projects, have yet to be convinced that a market exists for them.

Garrett Mehl, a scientist in the department of reproductive health and research at the World Health Organization, thinks that this is all about to change. He told the London m-health conference that an “astronomical numbers of papers” will soon be published.

Endless potential

The possibilities seem endless. Mobile money systems could, for the first time, make it possible for people to pay on the spot for healthcare through simple, cheap insurance services. In Kenya such a programme now allows previously uninsured people to pay for care.9

When facing public health emergencies, such as last year’s outbreak of Ebola virus disease in west Africa, mobile technology may in future allow governments to track outbreaks and respond much faster.10

And mobile phones may save time and money for health ministries. In India, a project began in February that aims to convert paper health registers, introduced in the colonial era, to digital systems that can receive data gathered on mobile devices. The aim is to save the one day a week that government employees spend collecting data on paper.

Hype and challenges

But how much of this is hype? Even if evidence indicates the value of scaling up m-health interventions, many obstacles are still to be overcome.

The populations that could benefit the most from m-health are often illiterate, do not know how to text or use an app, or speak languages that are not available on mobile phones. They tend to change SIM cards, and therefore phone numbers, often and may share a phone with their family and have limited means to pay for calls or to charge their phone. Sharing phones and changing numbers may threaten confidentiality.

For these reasons, frontline health workers rather than patients may be the key to unlocking the potential of m-health in the poorest countries. For example, Bangladesh has just invested in 45 000 tablets for its frontline health workers to use, Labrique said.

African countries will be able to invest in national m-health programmes only if phone companies can offer cheaper devices, services, and systems. Paul Merry, of the global association of mobile operators (Groupe Speciale Mobile Association), told the conference that he expects m-health to become a viable market in low and middle income countries in the next five years.

For m-health to work in Africa, Admasu said, frontline health workers will need to deliver multiple interventions, which must be tailored to each country’s needs. “So far I have not seen any projects to integrate different health interventions,” he said.

Many countries do not have legislation or regulation in place to govern the use of mobile health technology and identify fraud or misuse. Global standards need to be agreed so that data can be shared and compared without compromising privacy.

If these challenges can be overcome, many low and middle income countries could progress in only a few years from having weak or non-existent health systems to being fully digitised. They may never need to build the traditional health infrastructure that the developed world uses.