Technology and policies for health in SSA - Hounsell, Prentice 2014

The use of appropriate technology and policies for the monitoring and promotion of health services in Sub-‐Saharan Africa Global Classroom – Policy Paper, Fall 2014, Sciences Po.

B. Hounsell & M. Prentice 7 December 2014

B. Hounsell & M. Prentice

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Table of Contents 1.0 TECHNOLOGY AS A TOOL FOR DEVELOPMENT ........................................... 3

1.1 Can policy keep pace with delivering innovations in health? ........................................ 5 2.0 CASE STUDIES ................................................................................................... 6

2.1 Case Study 1: MOTECH for prenatal and neonatal care in Ghana .............................. 6 2.2 Case Study 2: M-Health in South Africa for HIV/AIDS Services ................................. 10 2.3 Case Study 3: Delivering cost effective eye care to rural communities in Kenya using ‘PEEK’ ............................................................................................................................... 15

3.0 POLICY REVIEW AND SUMMARY ................................................................... 18 3.1 Success ...................................................................................................................... 19 3.2 Failures ....................................................................................................................... 20 3.3 Lessons Learned ........................................................................................................ 21 3.4 Developed country policy considerations ................................................................... 22

4.0 POLICY RECOMMENDATION .......................................................................... 23 4.1 Overview ..................................................................................................................... 23 4.2 Checklist ..................................................................................................................... 23

4.2.1 Is the application on the mobile device fit for purpose? ....................................... 23 4.2.2 Can the health service be effectively delivered with the technology available? .. 24 4.2.3 Are the necessary partnerships in place? ............................................................ 25 4.2.4 Is the m-health solution equitable? ...................................................................... 26 4.2.5 Is the project sustainable? ................................................................................... 26 4.2.6 Have trials provided conclusive evidence of patient benefits? ............................ 28

4.3 Policy considerations .................................................................................................. 28 4.3.1 Elevation of m-Health at government level: ......................................................... 28 4.3.2 Policy harmonization: ........................................................................................... 29 4.3.3 Review of regulation regarding mobile devices in health settings: ...................... 29 4.3.4 Ensuring patient privacy: ..................................................................................... 30

5.0 CONCLUSION ................................................................................................ 30 APPENDIX A ............................................................................................................ 31 REFERENCES ......................................................................................................... 32


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1.0 TECHNOLOGY AS A TOOL FOR DEVELOPMENT

Information and communication technology (ICT), from mobile phones to the Internet

and portable computing has had a profound effect on the lives of millions of Africans

over the past decade in a way that is unique to the continent. Farmers in Ghana are able

to send text messages to inquire about market prices for crops without relying on market

boards1. In Malawi, HIV/AIDS patients can receive daily text messages to ensure they

follow medicine schedules1. M-PESA, a mobile-based money transfer and micro-

financing service launched during 2007 in Kenya, offers financial access to those without

bank accounts. The service is used by over two-thirds of the nation’s adult population,

and has now expanded to other countries including Tanzania, Afghanistan and India2.

This trend towards using ICT for development is reflected in the fact that three-quarters

of all investment led projects from the World Bank Group had an ICT component in

2011, with more than $4 billion invested in ICT between 2003 and 20103.

Furthermore, the growth of mobile telephony in Africa in the last decade has transformed

it into a market larger than either the European Union or the United states. It is now the

2nd most connected region in the world, next to Asia, with over 800 million subscribers

and on track to hit one billion by the end of 20154.

The timeline below underlines the rapid growth of mobile services in developing

countries for the three important domains of development: financial services, health and

agriculture. The number of mobile services launched has grown quickly since 2007, with

a strong provision of health products and services in regions where they have

traditionally been lacking.


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Many of these mobile applications are successful because they were designed

specifically for local needs and with a good understanding of the environments in which

they are used. However, despite these and may other successes, the sheer number of

social, political, economic and technological differences between African countries pose

significant challenges for development practitioners and policy makers looking to use

information technology as a tool for development.

These challenges are especially strong in the provision of health services, as

government, health practitioners, civil groups and technology platforms must all

converge if a project is to be truly successful. This paper will therefore focus on the

challenges of delivering health services through mobile technology, as it is the keystone

on which all areas of sustainable development must depend.


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1.1 Can policy keep pace with delivering innovations in health?

Technology-focused solutions have proven successful in improving access to health for

those living in rural areas in developing countries5 . Success however, is critically

dependent on how development practitioners and policy makers address three key

questions:

• Which technical solution is most suitable for a given problem?

• What is the best way to implement the solution?

• How is the performance of the solution to be monitored and measured?

Sufficient access to technical resources and expertise is therefore vital to understanding

the capabilities of key technologies, as are government policies that foster innovation

and widespread user adoption. Furthermore, co-operation and partnership with the

private sector is often essential to achieving long-term success and project

sustainability, as underscored in Target 8.F of the Millennium Development Goals

(MDGs) “In cooperation with the private sector, make available benefits of new

technologies, especially information and communications”6.

Setting goals and measuring outcomes are essential. Bill Gates has recently reinforced

the message “What gets measured gets done”, citing examples such as health

improvements in Ethiopia and teacher evaluation in the United States7. Data helps to

identify gaps and provide the basis for goal setting, Randomized Control Trials (RCTs)

can ascertain effective strategies8, and monitoring and evaluation compare results with

objectives to present opportunities for improvement. Technologies that facilitate reliable

and robust data gathering must therefore be at the heart of any project if it is to be

successful.


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This complicated mix of actors, technology requirements and commercial considerations

creates significant risk, which must be mitigated by identifying potential ‘show-stoppers’

and other key challenges in the project-planning phase. Clear policies and

implementation guidelines must therefore form the foundation on which technology-

focused projects are to be successfully implemented.

This paper will therefore seek to develop an overarching policy template that can be

tailored to deliver effective, technology-focused solutions in the area of health to differing

country environments within Sub-Saharan Africa. Three case studies will be analysed,

each in a different country, to determine common causes of success or failure. In

particular, the impact of policies affecting each project will be evaluated, and successful

elements used to generate an overarching policy template that can be tailored to deliver

effective, technology- focused solutions in the area of health to differing country

environments within Sub-Saharan Africa.

2.0 CASE STUDIES

2.1 Case Study 1: MOTECH for prenatal and neonatal care in Ghana

Mobile Technology for Community Health (MOTECH) is an initiative that strives to

improve prenatal and neonatal health care in rural Ghana through the use of a mobile

phone based health information system. It is a partnership between Ghana Health

Service, Grameen Foundation and Columbia University’s Mailman School of Public

Health, funded by the Bill & Melinda Gates Foundation. The program is implemented

under the Community-based Health Planning and Services (CHPS) Initiative policy,

created in 1999 when the Ghana government reformed the health care system through

decentralization and aimed to improve access to basic health care9.


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The MOTECH pilot program was implemented in 2010 in the Upper East Region, the

poorest of 10 regions in Ghana, yet the one with highest CHPS coverage at over 80

percent9. It has now been expanded to the Central Region, Greater Accra and Volta.

There are 136 facilities, over 68,000 MOTECH registrants and more than 13,000 active

mobile midwife enrolees. Over 1,000 Community Health Workers have been trained10.

There are two primary users of the system – pregnant women and nurses. Through the

“Mobile Midwife” application pregnant women register to receive SMS or voice

messages in their language with information on what actions to take at each stage of

pregnancy and after the baby is born, as recommended by Ghana Health Service. This

includes a wide range of guidance from education on nutrition, foetal development and

the use of bed nets, to alerts reminding of post-natal visits and immunization schedules9.

The application is now being expanded to provide advice on a greater variety of health

concerns such as abnormal blood pressure trends and high-risk alerts for low-birth-

weight babies or women outside of the age range between 19 and 3411. The figure

below illustrates the distribution between women who have a personal phone, or share

with their household or community.

Proportion of MOTECH Ghana patients who posses a personal mobile phone, versus sharing10


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A nurses’ application allows Community Health Workers to track patient care. Nurses

can enter information about their patients during medical visits on low-cost GSM mobile

phones using a Java 2 Platform Micro Edition (J2ME). The data is transmitted using

general packet radio service (GPRS) to a central patient electronic medical records

system stored on the MOTECH server11 which analyses the data and sends alerts to

nurses and patients with reminders of missed appointments, upcoming activities, and

personalized educational information. The software program is available via

OpenSource license and thus presents an opportunity for program expansion into other

regions and other areas of health. The centralized system collects information about a

patient from all health facilities so data is centrally recorded and practitioners can see a

complete health history. A weekly report is sent to nurses on Monday morning with a

summary of their patients activities, including upcoming delivery dates, missed

appointments, immunization schedules, and other information. Due to the time-critical

nature of postnatal care, information about deliveries and postnatal care schedules are

sent in current time11.

Patients can register for the program by speaking with a Community Health Worker

directly or over the phone. They are given an ID number for tracking and asked to

provide demographic information, which is used to generate a plan specific to their

needs and birth schedule if pregnant. For privacy, patients who do not have a private

cell phone can access information by calling a toll-free number and entering their

MOTECH ID. “Flashing” is used frequently in Ghana; this is when someone calls a

number and hangs up, then the receiver calls back immediately and is charged for the

call. People use this system to receive messages from MOTECH, which has been quite

successful as it is a familiar method where they trust they will not get charged for the


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call. Network coverage is incomplete in the region and there are frequent connection

problems. To address this, the call system assumes calls dropped after less than 5

seconds were not received and calls back three times. If still not successful, calls back

the next day. With regards to the nurses’ application, documents are only 1KB in size so

multiple can be stored on the mobile phone until network coverage resumes. Any

network can be used, and the server continues to send messages until they successfully

send. For data protection and security and to ensure adequate bandwidth, patient and

operational data are stored on a server located outside the country9. Nurses are

required to record hard-copy data on a paper register for the first three months, along

with the electronic entry. If after three months there is a high degree of accuracy

between the hard copy and electronic reports, the nurse can switch to solely entering

data electronically11.

Before MOTECH the information management system did not provide timely data to

nurses; this hindered their ability to respond promptly to patient needs. One especially

high risk with this was their inability to ensure post-natal care within 48 hours of birth, a

key provision for mother and child health care. In addition, nurses spent a large portion

of their time logging service encounters and completing insurance forms9. Timesaving

efficiencies have been achieved due to the creation of condensed, “simplified register”

forms and the easy transfer of information to mobile devices. With less administrative

burden, this leaves practitioners more time to focus on patient care. MOTECH has

allowed for more thorough and accurate data collection, which is incredibly important for

improving the effectiveness of the program to ensure patients are properly tracked and

followed up with when necessary. Monthly reports are created by the system, which

provide information on the number of patients cared for and those overdue11. The ability


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to obtain support of policymakers to expand a program is largely influenced by the

presentation of sound and convincing statistics.

Despite overall improvements in the health services, there have been challenges and

lessons learned with program implementation. “Unanticipated findings attest to the

importance of trial, experimentation, and operations research in m-Health systems

development” (page 1)9. Therefore the data collected thus far has been very informative

and useful. There is a need for the execution of a Randomized Control Trial (RCT) to

assess whether the use of mobile technology can in fact improve prenatal and neonatal

health care quality and quantity in an impoverished rural area.

Originally nurses used their own phones, but this proved to be unsuccessful as several

had to share the phone with family members and some older nurses were unfamiliar

with basic commands. The issuance of the same mobile phones and handsets to all

practitioners allowed for easier training, however there was a lot involved with the

deployment of phones.

2.2 Case Study 2: M-Health in South Africa for HIV/AIDS Services

M-Health presents a significant opportunity in South Africa, as the majority of people

have access to a mobile phone. However the level of access is higher in urban versus

rural areas, and a larger proportion of people in rural areas share a phone between

members of a household.


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Urban versus rural mobile phone subscriber base in South Africa12

The two biggest applications for m-Health technology in South Africa are Maternal,

Newborn and Child Health (MNCH) and HIV/AIDS services. Since the first topic was

discussed in the Ghana case study, the latter is analysed with regards to South Africa.

With 42 services directed towards HIV/AIDS, this is the most addressed m-Health

market in the country12. This is appropriate, as a large number of people live with the

disease and it is the biggest cause of death in South Africa. According to UNAIDS,

approximately 18 per cent of the adult population (5.7 million people) aged 15 to 49 have

HIV/AIDS, and around 240,000 people die each year from the disease13. “In Vulindlela, a

semi-rural area in KwaZulu-Natal’s Midlands, two thirds of the women are HIV positive

by the age of 30”14.

M-Health services perform many functions including training health care workers,

supporting patients through education, monitoring and treatment, tracking drugs and

supplies and managing supply chains. Two of the most prominent applications are

Young Africa Live and JustTested. Young Africa Live combines education and pop

culture to generate interest towards HIV/AIDS issues. A variety of online resources can

be accessed such as blogs, instant messaging, surveys and videos. Topics discussed


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go beyond HIV/AIDS to spark conversation through discussions about relationships, sex,

movies and music. The platform is free, private and secure so youth feel they can give

their honest opinion without risk of the information being compromised15. The fact that

HIV/AIDS has been treated differently to other infectious and sexually transmitted

diseases has created a stigma and avoidance of diagnosis and treatment. “Ironically,

anti-retroviral therapy (ART) has become increasingly available; nevertheless despite

the prevalence of extensive public HIV clinics, less than 5% of South Africa’s population

has been tested. Furthermore, for those who are HIV positive, only 10% are currently

receiving ART”14. Programs such as Young Africa Live that encourage open dialogue,

dispel myths, and provide clear information on the disease are essential to increasing

levels of diagnosis and treatment.

Examples of the Young Africa Live platform1617

JustTested is a platform supported by Cell-Life’s web-based software Communicate and

directed towards people who have recently undergone HIV testing. It aims to provide

counselling and support, regardless of whether the person tested positive or negative.

Over 1.5 million users receives 39 messages over the course of three months, providing


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advice based on their HIV status. The program was created in accordance with the

Health Belief Model, which asserts that people will take action against something they

believe is a threat to their wellbeing provided they are confident in the effectiveness of

the treatment. A pilot study was conducted, and found that the number of subscribers

increased by a factor of 10 when counsellors recruited patients. This illustrates the

importance of health practitioner buy-in and is aligned with the Health Belief Model –

people are likely to trust the advice of their medical counsellor and thus will take their

advised actions if they understand HIV presents a serious threat to their health. The

platform makes it easy for users to register or opt-out, an incredibly important feature

when people are now inundated with mobile technology features and applications.

Overall feedback indicated subscribers found the application informative, positive and

easy to use. In fact, many suggested SMSs should be sent for at least six months

instead of three15.

Some lessons learned from the JustTested pilot program were the messages should use

simple language and be clearly identified as coming from the JustTested program.

Several people accidentally unsubscribed, so suggested a function that makes it easy to

re-subscribe if this occurs. The extremely sensitive nature of information emphasizes the

importance of ensuring the platform is secure to protect user’s information. In addition,

the secure and private nature of the platform must be clearly communicated to users to

they are confident their information is protected15.

The recent expansion of the m-Health landscape in South Africa and fragmentation

between the 101 (83 live) total services indicates the need for consolidation and a

coherent strategy. This can be facilitated through improved communication between


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health practitioners, patients, policymakers and the public, as well as government

regulation of the m-Health industry.

Reliable and widespread network coverage is essential to program success. 90% of

South Africa is covered, although 3G technology only exists in urban areas. Equitable

mobile phone accessibility is another crucial aspect, especially because poorer people

are more likely to have HIV/AIDS due to lack of education or access to protection.

Studies have shown there isn’t much difference in penetration between high and low-

income groups, indicating that mobile phones are seen as a necessity rather than a

luxury and all groups generally have access to a phone12. Although as illustrated in

Figure 1, inequity exists with regards to whether individuals have their own mobile phone

or share one with their household or community. This represents a barrier to program

success with low-income groups, as people are less likely to access platforms related to

health information if worried that someone else will see the information. Therefore it is

important not only that individuals have access to mobile technology, but that they

possess their own phone.

A large number of m-Health platform providers in South Africa are financed through

donor investment and do not generate revenue. This does not represent successful

business models and individuals will lose confidence in the industry if services are

discontinued and unreliable. Therefore investment needs to be concentrated towards

businesses that have a sustainable long-term financing structure.


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2.3 Case Study 3: Delivering cost effective eye care to rural communities in Kenya

using ‘PEEK’

According to recent estimates by the WHO, 285 million people in the world suffer from

visual impairment 18 . Although 80% of all causes of visual impairment are either

preventable or curable, the vast majority (90%) of cases go untreated as sufferers live in

the developing world where lack of money and remote locations prevent access to

health care.

In many countries throughout sub-Saharan Africa more people have access to mobile

phones than clean running water. Delivering eye care through mobile technology

therefore offers an effective way reach millions of Africans living in rural areas where

traditional optometric eye care is simply not available.

With this in mind a team of ophthalmologists from the Centre for Eye Health at the

London School of Hygiene & Tropical Medicine partnered with engineers and software

developers to create a unique application called PEEK. PEEK is a portable, Smartphone

based system designed to provide comprehensive eye examinations. PEEK uses the

smartphone’s camera to scan the lens of the eye for cataracts and uses the flash to

illuminate the retina to check for disease. It also includes a basic vision test inspired by

shrinking letter wall charts, which appear on the phones screen. All data recorded on the

smartphone can be immediately transmitted to specialists for analysis, providing rural

patients access to global health expertise. Peek also enables geo-localization to

determine patient locations, which are then recorded on Google Maps. This enables

local officials and healthcare workers to manage health campaigns, which can target

patients for treatment or follow up examinations.


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Example of an eye examination using Peek. Copyright Peekvison.org

PEEK has been designed as an easy to use, affordable and portable system for testing

eyes outside of clinics and hospitals. Traditional equipment needed for eye examinations

is typically, cumbersome and expensive. Using PEEK, only basic training is required,

meaning that local health workers can provide the service without the need for expertise

in optometry.

The system was initially deployed in rural Kenya where heath practitioners were

attempting to deliver eye care, but were facing significant difficulties in transporting the

equipment needed to remote locations. Kenya has very good mobile coverage; with over

95% of the population able to get a signal. This made an ideal testing ground for the

team involved with PEEK. To date, two studies in the country are on going.


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Identifying visual impairment in children at an early age is essential in preventing a root

cause of under achievement at school19. With this in mind teachers in thirty schools are

using PEEK to identify children with visual impairment as part of a pilot study. The study

aims to identify and then manage eye problems early in life, so as to limited possible

exclusion as they grown older. The study is particularly relevant as sight issues with

children are often missed during routine eye check-ups20.

Throughout Nakuru County in Kenya a study of eye disease is being conducted that

follows up on around 5,000 people who received an eye examination 5 years earlier.

The team is using fragile and expensive hospital based equipment that must be

transported to over 100 destinations in order to examine the study participants. The

same patients undergoing the study are also receiving a separate eye examination by

community health care workers using PEEK. The results will then be compared to

measure PEEKS accuracy and effectiveness. Initial results are extremely positive.

One downside to PEEK however is its dependence on Smartphones rather than more

basic mobile handsets. This makes its use by local healthcare workers in rural

communities challenging as fewer have access to smartphone devices. In order to

ensure widespread adaption, PEEK and its partners on the ground must find ways of

donating, or sharing smartphones with healthcare workers where necessary.

The WHO has developed the global eye health action plan. Among other things the plan,

which runs from 2014 to 2019, aims to reduce avoidable visual impairment in addition to

recognising it as a global public health problem. PEEK has the potential to make a

significant contribution if its initial promise holds true.


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PEEK is an excellent example of private business engaging with local country partners

to provide much needed services that are not adequately provisioned by the state. The

company is currently raising additional finance on the crowdfunding website Indiegogo to

fully commercialise its operations. At the time of writing this paper it had achieved 67%

of its funding goal.

3.0 POLICY REVIEW AND SUMMARY

The now countless m-Health programs on the market are helping patients to

increasingly taking more responsibility for their own health. The success of the case

studies described and similar programs led the Bill & Melinda Gates Foundation to write,

“using mobile phones to access and relay health information in developing countries… is

one of those “simply brilliant” innovations that seems to make perfect sense”21. Platforms

provide instant medical information between doctors and patients, remind of medical

appointments, reduce hospital wait times, and protect against counterfeit drugs. This

industry is one of the few areas where research and development efforts and market

employment are more advanced in less developed countries and emerging economies

than developed. Greater demand for change and fewer regulatory and process barriers

are two of the reasons the industry has taken off in low-income settings. Despite initial

excitement, the success of m-Health hinges on the adequacy and strength of a country’s

health care system, as well as rule of law and institutions. Although this may slow down

the speed of adoption, it is essential for proper implementation and long-term industry

sustainability.


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3.1 Success

All case studies evaluated executed the program within the existing health care system.

In Ghana, MOTECH has been integrated with the policy structure of CHPS and relays

recommendations from Ghana Health Service. The centralized system collects

information from all facilities, so a person’s health record is complete and practitioners

have easy access to give accurate and current advice.

The three programs are all easy to use, affordable and portable. With MOTECH, the

registration process is easy and patients can contact a practitioner if they need

assistance. Advice and reminders are provided in the individual’s chosen language in a

way that is easy to understand. The flashing method for people to call back and receive

information has been very successful, as citizens already used and trusted this routine.

Efficiencies and time savings have been achieved for nurses with the simplified data

collection forms and electronic entry.

To address the problems with network coverage and connection, the MOTECH system

in Ghana assumes calls dropped after less than 5 seconds were not received and calls

back three times. If still not successful, calls back the next day. With regards to the

nurses’ application, documents are only 1KB in size so multiple can be stored on the

mobile phone until network coverage resumes. Any network can be used, and the server

continues to send messages until they successfully send. For data protection and

security and to ensure adequate bandwidth, patient and operational data are stored on a

server located outside the country9.


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The reason for Young Africa Live’s success is “knowing your audience”. With the large

number of young people in South Africa and the large proportion of youth newly

diagnosed with HIV/AIDS, Cell-Life developed an application that targets this group and

adheres to their interests. In addition, a pilot study was conducted that allowed

researchers to see the impact of their program, and the results were very positive.

The PEEK program’s test that compared results with known figures was a positive

initiative to show data accuracy. The engagement of private businesses with local

country partners improves communication and the creation of mutually beneficial

solutions. Lastly, the PEEK initiative has been working on an innovative way to finance

its activities other than through loans or grants – crowdfunding.

3.2 Failures

Initially MOTECH used phones nurses already owned; this was not successful. The

various systems had different degrees of compatibility, training was more difficult with

multiple devices, and some older nurses lacked basic knowledge on using a mobile

phone.

The landscape for m-Health in South Africa is saturated and there is insufficient

coherence among the multitude of m-Health providers. This has led to confusion, market

crowding, duplicated efforts and inefficiency. There is a need for m-Health providers to

consolidate efforts to improve the quality of coverage and provide patients with clear

information about their options.


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Network coverage and reliability is patchy in developing countries, particularly in rural

areas. This creates issues of inequality where people living in rural areas do not receive

the same level of access as those in urban areas.

Technology needs to be fit for purpose and widely available; the PEEK program has to

be run on smartphones and although many people have a mobile phone, most do not

have smartphones.

3.3 Lessons Learned

Technology should be easy to use, affordable, convenient to transport, and require

minimal training. Network coverage and connection is important to ensure equitable

dissemination of technology and improved health care services in rural and urban areas,

and across income levels. Assurance around data privacy and protection reassures

patients that their personal information is protected and incentivizes technology

adoption.

Public-private partnerships and other forms of collaboration between health and mobile

sectors are important to improve chains of communication and ensure a coordinated

effort with regards to policymaking, research and development and program

implementation. Laws and regulations around the industry form the framework for

industry standards.

Revenue generating businesses models and innovative financing mechanisms should

be encouraged to promote the creation of sustainable businesses that will remain in the


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industry without official assistance. These companies will often be more efficient,

structured, and successful.

Pilot programs, RCTs and other testing is important to determine not only the extent of

program implementation, but whether health objectives are being accomplished. Overall,

providers should be incentivized to foster confidence in the system through data

accuracy and integrity, and assurance that information is secure and protected.

3.4 Developed country policy considerations

As developing countries gradually adopt the characteristics of wealthy nations, they will

also adopt social security and other systems the m-Health industry needs to adapt to

this changing regulatory environment. “To succeed [in developed countries] innovators

must manoeuvre through culturally conservative, highly regulated and fragmented yet

often monopolistic systems that often provide contradictory incentives” (page 2)22.

There is uncertainty around m-Health regulation and standards in the United States

regarding which technologies should be treated as medical devices versus general

health and wellness such as pedometers and caloric intake23. This is influenced by the

diversity of interests between practitioners, patients and financial providers. Global

standards should be created that encourage innovation while addressing regional

differences. Laws applying to health devices are different to those for regulating the

mobile network. With regards to financial coverage, insurance needs to cover m-Health

consultations, diagnosis and treatment. Currently many people in developing countries

accumulate debt to pay for health services and become more impoverished.


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4.0 POLICY RECOMMENDATION

4.1 Overview

Many African states are unable to deliver basic universal healthcare. Such states must

focus on policies that enable health service delivery at low cost and high efficiency,

whilst taking into account poor infrastructure – such as roads and access to electricity –

and minimal levels of local governance. The challenge is therefore to create sustainable,

large-scale health programmes that can be delivered without being a drain on scarce

healthcare resources. The provision of m-health services through mobile phone

technology provides such a solution.

Services delivery must focus on preventative health cover, particularly for high incidence

cases such as prenatal care, eye disease and child mortality from preventable diseases

such as diarrhoea and malaria.

4.2 Checklist

In order to ensure the successful deployment of an m-health service, this policy paper

recommends reviewing the following six checkpoints:

4.2.1 Is the application on the mobile device fit for purpose?

A critical component of any m-health service is the application (or app) that runs on the

mobile phone. The app acts as the window through which health services are delivered.

Consideration must be given to how information will be conveyed to both the healthcare

worker and the patient to avoid possible misuse, or misdiagnosis.


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If an m-health application requires the user to interact directly with the mobile phone,

then simple icons that convey clear messages are preferable to written text. This will

ensure that even those will poor or no literacy can interact efficiently with the service.

Icons are also language independent, enabling the application to be deployed across

regions without modification. For example, an application that remotely monitors the

health of a patient after a course of medication might use the following icons to access

their current health status:

Where mobile phones do not support richer icons, text-based equivalents should be

used wherever possible. Using the same health-monitoring example, patient health

status might be conveyed as follows:

:-) :-| :-(

This leads us to another important aspect of technology deployment for m-health.

4.2.2 Can the health service be effectively delivered with the technology available?

Two specific considerations should be made when determining the suitability of an m-

health service to a target population:

1. Does the region have reliable mobile network coverage?

Coverage is essential if patient data must be sent to health professionals for

analysis, or stored as part of a database of patient records. At the very least the

healthcare worker must be able to find a suitable location where coverage is


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available after the consultation. Where necessary the confidentiality of patient data

must also be accounted for, either using a secure network, or providing simple

encryption on the mobile device before the data is transmitted.

2. What type of mobile device is needed to deliver the service?

Apps such as PEEK require the use of smartphones that have large, colour screens

and powerful computer processors. When delivering m-health services care must

therefore be taken to ensure that the majority of the target population owns, or has

access to, a mobile device capable of running the application. For example, m-health

apps that require smartphones may be used by the health worker and given to

patients for diagnosis only under their direct supervision. Such apps would therefore

not be suitable for remote patient interaction, as many patients will not own the

device needed to deliver the service.

4.2.3 Are the necessary partnerships in place?

Linkages between local actors and both public and private institutions are critical to

achieving long-term objectives regarding m-health. Different linkages may be required at

various phases in the projects deployment and deployment cycle.

Early communication with relevant stakeholders and expert advisors is essential during

the projects design phase, and will help to ensure the m-health solution meets

development objectives. Dialogue must include relevant health practitioners and medical

experts to establish how best to deliver services. Where necessary policymakers and

public bodies should be included to ensure that the health service can be deployed

efficiently and complies with local laws and regulations. Local healthcare workers must

also be consulted to ensure that they feel comfortable delivering the solution and are


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technically competent to do so. Above all, the patient groups that the service will be

targeting must be consulted to ensure that what is being delivered is of genuine value to

the community and is widely perceived as a positive intervention.

Other partnerships must be forged as required. For example, some m-health services

may need to partner with pharmaceutical suppliers so that apps can be used to directly

order medications, which can be then delivered to local communities by healthcare

workers.

Furthermore, public-private partnerships can be used to increase investment in

technology needed to deliver health services. This includes base-stations in rural areas

to ensure signal coverage and local charging kiosks where users can re-charge their

mobile phones without having to travel long distances into larger towns.

4.2.4 Is the m-health solution equitable?

As much as possible m-health should provide equitable services that reach rural areas

and low-income groups – particularly as it is these groups that are often marginalised by

government-led initiatives. As discussed, equitable access to suitable mobile phone

technology must also be ensured if m-health services are to deliver widespread benefits

to target populations.

4.2.5 Is the project sustainable?

All projects must consider long-term sustainability and how this will be achieved.

Sustainability in this regard includes ensuring patients continue to use the service (it


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remains relevant to their needs), and that sufficient finance is available to continue

operations.

Ensuring continued relevance of the m-heath app might require software updates to

keep pace with changes in patient needs, as well as keeping track of newer mobile

phone technology as it becomes available to users.

Financial stability can be achieved with support from government budgets, NGOs and

private enterprise. Health impacts often take several years to show significant benefits,

so finance should be secured for at least five years where possible. Furthermore, it may

be reasonable to charge a nominal amount for the services provided. An example may

be remote access to health advice, where users pay in the region of $0.05 to receive

medical advice from a health expert. Whilst these sums are small, when multiplied

across populations they can make a significant contribution to the operational viability of

health programs. There is evidence to suggest that communities value health services

more, when they are paid for, even if the amount is relatively small24.

In-app payments would be the main mechanism to pay for health services. Mobile

payment services are now commonplace in a number of African states including, Kenya,

Nigeria, South Africa, Tanzania and Ghana. For example, Kenya is a world leader in

mobile payment and the country’s M-PESA system is used by over 50% of the

population25. Systems such as these provide an excellent way to monetise health and

can even be provided alongside the growing number of health insurance policies now

provided directly over mobile phones.


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4.2.6 Have trials provided conclusive evidence of patient benefits?

Robust data collection for evidence-based decision-making is crucial to determining the

benefits offered by m-health services. Mobile phones enable individual patient

responses to be logged so that general trends in patient behaviour can be examined and

the efficacy of mobile-driven treatments assessed.

Furthermore, randomised control trials should be used to demonstrate whether or not a

platform is in fact improving the quality of health coverage in comparison to a control

group that does not receive the m-health service. This process adds valuable credibility

to project and can help widen the service’s distribution and secure additional political

and financial support.

Appendix A provides a scorecard that can be used to determine the suitability of an m-

health service for deployment into a target population.

4.3 Policy considerations

Whilst government policies vary with regards to the provision of healthcare

communications and technology adoption, this policy paper suggests four key actions

that will benefit the creation and deployment of m-health services across Sub-Saharan

Africa.

4.3.1 Elevation of m-Health at government level:

Governments should create a national coordinator for m-Health and establish an m-

health strategy that brings together key actors from civil society, the medical profession,

academia and industry. Extensive examples of m-health policies (also referred to as


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eHealth) can be found on the World Health Organizations Directory of eHealth

Policies26. African countries with strategies already in place include Nigeria, South

Africa, Zambia and Zimbabwe.

4.3.2 Policy harmonization:

Policy makers must harmonize health care and communication policies to ensure both

can operate effectively together. Typically health policy is patient driven, whilst

communication policy is commercially motivated27. These different motivations need not

be mutually exclusive and mobile operators and health providers, including hospitals and

health clinics, should be encouraged to partner for the mutual benefit of all. Where

necessary, government and multilateral organizations may provide mobile operators with

appropriate financial incentives to help offset costs associated with infrastructure needed

to better deliver healthcare services over mobile. An example of this might be support

the deployment of base-station transmitters in rural areas to increase healthcare

outreach.

4.3.3 Review of regulation regarding mobile devices in health settings:

Many countries still regulate against the use of mobile devices in hospital settings, or

require expensive and often complicated certification procedures for equipment deemed

to have a medical use. Whilst certification is entirely appropriate for certain devices such

as MRI scanners, smartphones and other mobile devices are already regulated under

CE and FCC standards and have been shown to pose a negligible health risk. As such,

policy should ensure their use for health applications does not fall into a regulatory grey

zone. One way to ensure this is to clearly define areas in health where mobile services

can play a valuable role and are free from medical regulation.


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4.3.4 Ensuring patient privacy:

The storage and use of patient data must be subject to data protection at standards

recognised internationally. Where absent or lacking data protection policy should be

enacted as a matter of urgency so as to ensure public confidence in services that record

patient data. Above all situations where patient data is made publicly available or sold to

third parties should be avoided, as they will undermine hard-earned trust between health

professionals and patients wary of new technologies.

Best practices for the collection and monitoring of mobile data should be followed to

ensure that data can be meaningfully analysed over the long-term. Doing so will help

focus research and policy making on the impacts of delivering m-health services over a

number of years. Once again the WHO provides valuable guidance on how this can be

achieved28.

5.0 CONCLUSION

In many respects Sub-Saharan Africa is leading the way in delivering innovative mobile

phone based health services (m-health) to rural communities at low cost and with high

levels or patient outreach.

Despite these many successes, there is no one size fits all approach to providing m-

health, so governments must continue to implement policies that foster partnerships

between cross-sector stakeholders and ensure bureaucracy does not stifle innovation.

This in turn will stimulate wider adoption of m-health services as their benefits become

ever more apparent.


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APPENDIX A

m-Health deployment scorecard.

Key questions Score

Excellent Average Poor

Is the application on the mobile device fit for purpose?

Can the health service be effectively delivered with the technology available?

Are the necessary partnerships in place?

Is the m-health solution equitable?

Is the project sustainable?

Have trials provided conclusive evidence of patient benefits?

Scoring: Excellent: 5 points Average: 3 points Poor: 1 point

Possible results: Maximum score: 30

Minimum score: 6

Total:

Result analysis:

Score: 22 – 30 Excellent chance of succeeding: The m-health deployment is well conceived with a plan of action and partnerships that are clearly identified.

Score: 14 – 21 Reasonable chance of succeeding: Certain elements of the deployment are well conceived, but other are lacking. Revisit core deliverables to see how improvements can be made.

Score: 6 – 13

Low chance of success: Key aspects of the service and delivery mechanism should be reviewed and the user base clearly identified. Partnerships should be revisited to ensure all stakeholders are included in the analysis.


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