0 Recommendations

Scaling mHealth in LMIC

By Amal Bholah Moderator Emeritus | 27 May, 2015

The unprecedented spread of mobile technologies as well as advancements in their innovative application to address health priorities has evolved into a new field of eHealth, known as mHealth. According to the International Telecommunication Union (ITU) there are now close to 5 billion mobile phones subscriptions in the world, with over 85% of the world’s population now covered by a commercial wireless signal [1]. The term mHealth was coined by Robert Istepanian as use of “emerging mobile communications and network technologies for healthcare [2]. A definition used at the 2010 mHealth Summit of the Foundation for the National Institutes of Health (FNIH) was “the delivery of healthcare services via mobile communication devices” [3]. The mobile phone can be a vector for enhancing the continuity of care. Six in ten clinicians and payers (NHS, insurers and private payers) believe that the widespread adoption of mHealth is inevitable in the near future [4]. As healthcare becomes increasingly overstretched due to aging population and the rising number of chronic diseases, mHealth alleviates the burden on the healthcare system. Service and care providers, researchers and national governments are excited at the opportunities mobile health has to offer in terms of improving access to health care, engagement and delivery, and health outcomes [5]. In a key note lecture, Professor Alain Labrique who is director of John Hopkins University Global mHealth Initiative mentioned five C’s that make mobile phone an innovative health tool: Collect data, Count events, Connect individuals, Compress time and Create Opportunities to improve health [6]. The increasingly common use of generic, configurable tools makes it more important than ever to define and discuss mHealth initiatives not only in terms of technology, but also with reference to the plans and activities that are needed for efficient and effective implementation.

An application can represent a patient journey (e.g. pedometer on smartphone and wearables) that collect data and displays them into a comprehensible manner for the patient to interpret. It can represent a workflow e.g. a patient interacting with a healthcare provider, prescription given and text messages update patient’s knowledge regarding disease and also reminds patient of the next appointment. Mobile medical apps and hardware present a golden opportunity to make modern medicine more accessible. According to Ira Brodsky, it is our best chance to retool healthcare. He believes that entrepreneurs should be free to innovate and that physicians and patients should enjoy the widest choice of apps and also condemns the dinosaur attitudes of government agencies which according to him are often the last to understand new technologies [7]. Many patients want to employ digital and mobile technologies in their medical care.

The concept of scaling is increasingly the dominant framing for how success is understood in the field of social innovation (Dees 2004, 2010; Westley, 2010; de Bruin & Stangl, 2013). Scale is a kind of Holy Grail and according to Bradach (2010), “there may be no idea with greater currency in the social sector than ‘scaling what works’ ” [8].

“Solutions to many of the world’s most difficult social problems don’t need to be invented, they only need to be found, funded and scaled.” - Judith Rodin

Scalable mHealth initiatives need to consider cost of scale, keep end users at center of design process, align key partners and decide priorities as well as invest in evaluation. Without national strategy and leadership, mHealth projects that were technologically sound fail. Too often, mHealth initiatives promoters have no knowledge regarding the healthcare landscape. Building code is a small part of developing a health app if one wants to be successful. The complexity of mHealth lies in its transdisciplinary nature incorporating medicine, engineering, psychology, public health, social science and computer science [9]. As more people start to focus on mHealth, more studies will emerge that demonstrate the impact on clinical outcomes and hence ensure scalability of projects. According to Michael E. Porter, the ultimate outcome should be adding value in healthcare. Value is defined as the health outcomes achieved per dollar spent. The proper unit for measuring value should encompass all services or activities that jointly determine success in meeting a set of patient needs. However value is a word that has long aroused skepticism among physicians, who suspect it of being code for “cost reduction” [10]. Enrico Kochi, Senior Advisor to the Executive Director of Innovation at UNICEF mentions four critical success factors to scale any mHealth Initiative
• Consider costs at scale
• Design for and with end users
• Align with key partners
• Invest in evaluation

The MAMA (Mobile Alliance for Maternal Action Analogue) partnership delivers health messages to new and expectant mothers in Bangladesh, India and South Africa via their mobile phones. MAMA started in 2011 with a three-year, $10 million investment. MAMA also creates tools and resources for mHealth programs serving mothers in a variety of languages. The goal is that these messages can increase knowledge and change behaviors to improve maternal and child health. The scale achieved is incredible with about 1.1 million subscribers in Bangladesh and 552 829 users in South Africa. Since the launch, over 20 000 unique users have interacted with MAMA SA which translates into over 67 000 unique page views, hundreds of mobi-site comments, more than 110 000 SMS’s and 8500 USSD messages being sent this far. MAMA SA data indicates high acceptability and satisfaction with the project [11]. The major challenges were managing cross-sector partners and their expectations, requirements and agendas. Engagement, collaboration with, and buy-in from stakeholders from the start, especially governments was essential to MAMA’s success. Substantial up-front investment allowed MAMA to be strategic and flexible, and build a brand and partnerships that enabled its success. [12]

HIV prevalence in Uganda has leveled off, however trends indicate that incidence is on the rise and disproportionately affects certain vulnerable groups, such as women. There is growing support for using mHealth programs to reach vulnerable populations. As part of a national strategy, the Ugandan Ministry of Health launched HIV/AIDS SMS campaign. However, the campaign failed to address the sociocultural vulnerabilities. In early 2009, an SMS quiz about HIV/AIDS, in multiple choice and true/false formats was disseminated to 10, 000 mobile phone numbers of highly active subscribers. Despite extensive campaign reach, quiz participation rates via SMS were relatively low: one-fifth of recipients participated (3-8% valid responses received per question) and only 0.3% answered all questions. Women who tend to be more affected by stigma associated with being HIV positive in Uganda may not have benefited from SMS campaigns due to their lower mobile phone ownership. A true/false quiz question that might have reduced fear of discovering one’s HIV status was answered by only 3.6% of the recipients, one of the lowest response rates. The quiz question did little to reduce stigma-related fears associated with a positive test result. Also, the quiz messages required ability to read and understand English and to access and respond to SMS messages. While participants were given economic incentives to participate, the majority of the population do not own mobile phones. Also partnering with only one telecommunication provider made subscribers of other providers automatically ineligible [13]. To counter sociocultural and informational vulnerabilities, future SMS interventions should include the community in designing campaign messages to ensure the wording is clear. If necessary, automated voice messages in local languages and other formats (e.g. multimedia messages) could be used to reach people with low literacy. Improving access and familiarity with technology through mHealth programs and training classes. It is important to consider program sustainability beyond initial outreach and single-time testing.

“Involve the user” is a mantra in IT development, yet numerous projects fail (some sources report 70% failure [14]) because of inability to capture user insights. It is attributable to failure on the part of developers to understand the workflow of health professionals and to meaningfully involve users in the design, development and implementation. People are now taking responsibility of their own health, receiving information about health matters and participating in decision making related to personal health issues from prevention to care and follow up [15]. eHealth as well as mHealth strategy is the driving force, the first essential ingredient that can place countries in charge of their own eHealth destiny and inform them of the policy necessary to achieve it [16]. Health challenges present arguably the most significant barrier to sustainable global development. Technology has the potential to solve many problems faced by the developed and developing countries which range from basic education to primary health care. The unique characteristics (e.g. easy accessibility, personalized solution and location based services) of mobile devices compared to other platforms have made them attractive to the health sector. In low income countries, mHealth is the ultimate platform to serve the unserved. [17] Mobile communications are part of our everyday lives and for this reason alone, they have the potential to transform our wellness and healthcare.

1. Organization, W.H., mHealth: New horizons for health through mobile technologies. 2011: World Health Organization.
2. Istepanian, R., S. Laxminarayan, and C.S. Pattichis, M-health. 2006: Springer.
3. Torgan, C., The mHealth summit: local & global converge. Washington DC, 2009.
4. PWC mHealth in the UK: Paths for growth. 2015.
5. Heerden, A.v., M. Tomlinson, and L. Swartz, Point of care in your pocket: a research agenda for the field of m-health. Bulletin of the World Health Organization, 2012. 90(5): p. 393-394.
6. Alain, L. Global mHealth: An overview of Mobile Innovations and Evidence. 2013 March 2015]; Available from: https://youtu.be/UIeEJZwgDbI.
7. Thompson, B.M. and I. Brodsky, Should the FDA regulate mobile medical apps? Bmj-British Medical Journal, 2013. 347: p. 3.
8. Davies, A. and J. Simon. How to grow social innovation: a review and critique of scaling and diffusion for understanding the growth of social innovation. in 5th International Social Innovation Research Conference, September. 2013.
9. Kumar, S., et al., Mobile Health Technology Evaluation The mHealth Evidence Workshop. American Journal of Preventive Medicine, 2013. 45(2): p. 228-236.
10. Porter, M.E., What is value in health care? New England Journal of Medicine, 2010. 363(26): p. 2477-2481.
11. Coleman, J., Monitoring MAMA: Gauging the Impact of MAMA South Africa. Journal of Mobile Technology in Medicine, 2013. 2(4s): p. 9-9.
12. Wilson K, G.B., Arenth B, Salisbury N, The Journey to Scale: Moving Together Past Digital Health Pilots. 2014, PATH.
13. Chib, A., H. Wilkin, and B. Hoefman, Vulnerabilities in mHealth implementation: a Ugandan HIV/AIDS SMS campaign. Global health promotion, 2013. 20(1 suppl): p. 26-32.
14. Kaplan, B. and K.D. Harris-Salamone, Health IT Success and Failure: Recommendations from Literature and an AMIA Workshop. Journal of the American Medical Informatics Association, 2009. 16(3): p. 291-299.
15. Gatzoulis, L. and I. Iakovidis, Wearable and Portable eHealth Systems. IEEE Engineering in Medicine & Biology Magazine, 2007. 26(5): p. 51-56.
16. Organization, W.H., National eHealth strategy toolkit. 2012.
17. Akter, S. and P. Ray, mHealth-an ultimate platform to serve the unserved. Yearb Med Inform, 2010. 2010: p. 94-100.


This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.