Cellphones could bring about the next revolution in healthcare. If, that is, the industry can create a scalable, sustainable model that truly meets citizens' needs and functions within an interoperable system.
It's a big 'if', and is a problem the field's best and brightest are working hard to crack.
At the GSMA/m-health Alliance Mobile Health Summit, held in Cape Town last week, international speakers from governments, operators, m-health initiatives, and the healthcare industry gathered to discuss how to turn m-health's prospects into a workable reality.
Peter Benjamin, GM of Cell-life, says the summit was both impressive and disillusioning.
“On the up side was the fact that it was the first major m-health summit held in the developing world, and there was a strong focus on strengthening m-health solutions in developing countries.”
He notes that government also showed keen interest, with ministers and officials from the departments of health (DOH) and communications (DOC) joining discussions and attending workshops.
“The conversation has moved on from the previous major summit, held in November [in Washington] last year, with concrete examples of m-health systems being used at scale and published reports showing medical benefits of m-health solutions,” says Benjamin.
“On the negative side, seeing as this represented the state-of-the-art in developing countries, it was sad to see we haven't made a clear case yet for m-health yet,” he adds. ”There still isn't mass use of this technology that demonstrates how it can overwhelmingly help solve problems in healthcare.”
You had members of the DOH asking 'How do we integrate this into our workflow?' It's not a trivial question.
David Haddad, director, Health Unbound
Benjamin points out that cellphones are being used to strengthen traditional health systems, through services like data collection. “But what was shockingly present in its absence was the fact that we're not yet putting cellphone technology into the hands of the majority of people.”
He explains that around 15% of the population are on medical aid, another 9% use their own money from time to time, while the remaining 75% to 85% depend on the public health system. “The same amount is spent on that 15% than on the other 75% to 85%.
“Getting support for the health system and applications that help people with smartphones manage their health are great, but those things bypass the majority of the population in SA.”
According to Benjamin, that's the real potential of m-health - to provide easier access to healthcare for the 80% of underserved people. “There are a handful of pilots being implemented, but the elephant in the room at the summit was the gap between the 15% and the 80%, and the fact that all these clever people haven't yet found a way to do something about it.”
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Where more progress is being made, says Benjamin, is in the area of creating an open architecture for m-health solutions, so various systems can all link up through a national system and communicate seamlessly.
One local group working on this problem is Jembi Health Systems, a non-profit spinoff of the South African Medical Research Council (MRC) that focuses on strengthening health information systems in low-resource settings.
Dr Chris Seebregts, executive director of Jembi and senior manager of Biomedical Informatics at the MRC, says there's an opportunity for greater coordination of the m-health initiative.
Jembi is working with the ministries of health in several African countries on various projects, including the development of national enterprise architecture blueprints, health information exchange and platform technologies.
“The overall aim of these projects is to maximise the use and benefit of existing and new information systems including improving interoperability and integration of data into the national health data system,” says Seebregts.
According to David Haddad, director of online collaboration forum Health Unbound, m-health initiatives need to be structured around existing problems, as opposed to thrusting random solutions at the market.
“At the summit, you had members of the DOH asking 'How do we integrate this into our workflow?' It's not a trivial question; when you've got hundreds of different systems at different levels, you can't just dump a phone into the mix; the problems lie much deeper.”
He adds that a lot of people working on m-health approach it with a typical technology mindset - 'If we build it they will come'. “But if you start from the problem and begin to scratch at the surface, you see it becomes enormously complex.”
Of the more or less 600 people at the summit, I'd be surprised if more than 50 were medical doctors.
Peter Benjamin, GM, Cell-life
Seebregts agrees, saying the m-health movement is being driven primarily by technology, with a slower level of alignment of health systems and medical practice to absorb this technology.
According to Benjamin, this was reflected in the representation of conference goers. “Of the more or less 600 people at the summit, I'd be surprised if more than 50 were medical doctors.
“Until the field is led by the health sector, it's little more than a sales show,” he adds. “We need to progress to a stage where, at the beginning of the conference, the medics will come up and say, 'These are the problems... techies, how can you help?' versus people just showing a few clever things you can do with USSD.”
Seebregts stresses that collaboration between these two players - technologists and healthcare providers - along with a numerous other stakeholders including governments, donors, developers researchers, and mobile operators, is critically important in the development of holistic solutions.
“There's no real glue in this m-health ecosystem, to foster connections, harmonise funding and solve problems together,” adds Haddad. “We're talking about really diverse communities here - developers, doctors, healthcare providers, donors - and they're not talking to each other, they're talking at each other.”
Private health expenditure equates to 21 times the total combined revenue of all the South African network operators.
Gavin Krugel, GSMA
Part of the creation of Health Unbound was driven by the need for a comprehensive database and easy mechanism to make connections between the various m-health stakeholders.
“The thing really lacking in this space is solid leadership; who is going to come and transform systems and consider not only what data is collected, but how it is collected?”
However, for government to truly move forward, argues Haddad, it's not enough to just collect data, there has to be a transformational shift to create a really vibrant m-health ecosystem.
“It's going to be a slow process. It's going to involve a lot of figuring out what we normally do and how to digitise it and become more efficient. We need a complete paradigm shift.”
Taking the lead
A notable difference from previous conferences, says Cell-life's Benjamin, was the level of government engagement.
One of the summit highlights was the Leadership Forum, where about 30 specially invited people from various sectors met to get the country on track. “This was very useful, because you had the deputy ministers, operators, the big healthcare players, all in one room,” says Benjamin.
Speaking at the summit, deputy communications minister Obed Bapela said the mobile health plan should be rooted in the country's Negotiated Service Delivery Agreement, government's response to addressing HIV, Aids, TB, child and maternal deaths, non-communicable diseases and violence and injuries.
He noted that SA's high mobile penetration rate would be a catalyst for m-health deployments, with the four main benefits being increased life expectancy, decreasing maternal and child mortality rates, combating HIV/Aids and controlling tuberculosis, and strengthening the entire health ecosystem.
However, Bapela added there are a number of hurdles the country has to overcome before m-health services are integrated into the mass market.
The DOH is in the process of finalising the draft e-health strategy and revising SA's telemedicine strategy, with m-health to be outlined within these strategies.
At present, there are two health projects approved by the DOH. One involves the tracking of tuberculosis patients in eThekwini (Durban), whereby teams go out into the community and track cases with the help of geo-location technology. The initiative is backed by US research group URC and local company GeoMed.
The other is a data collection initiative run by Cell-life as part of the government's HIV testing campaign, planned to reach 15 million people. The DOH will distribute the 12 000 handsets donated by major cellphone operators to 4 300 public health facilities in aid of the campaign.
A case of 'pilotitis'
One of the industry's major problems is too many pilots and no real take-off. This so-called 'pilotitis' is seeing a flood of small programmes, few of which ever seem to make it to full-scale implementation. A major report by the World Health Organisation (WHO), released at the summit, highlighted the situation.
According to the study, 83% of governments report at least one area where mobile phones could support national health activities. However, the majority of these m-health activities are limited in size and scope.
The report, 'M-health: New horizons for health through mobile technologies', supported by the m-health Alliance, the United Nations Foundation and the Vodafone Foundation, analysed data from 112 countries according to 14 m-health activity types.
While the report shows an upsurge in m-health activity globally, these projects are still in pilot phase. Two-thirds of countries surveyed reported between one and three m-health activities, yet only 12% of reported efforts to evaluate these activities.
Dr Fisseha Mekuria, principal research scientist at the CSIR's Modelling and Digital Sciences unit, says the lack of a sustainable business model for m-health initiatives increases the reliance on NGOs to provide these services.
“There is a lot of business opportunity in utilising the advances in m-health such as mobile device technologies, wireless computing and networking, sensor technology, and e-health.”
He adds, however, that the lack of local R&D and initiatives to address the issue is stifling innovation. “The likelihood is high that we will not only be buyers of the technology infrastructure, but also the services that could be developed on available infrastructure.”
Gavin Krugel, head of health at the GSMA, said in a pre-conference Webinar: “There isn't an answer yet to what a functioning mobile health business looks like and there isn't an answer to the exact business models and exact revenues that the mobile industry is looking to extract out of the opportunity of m-health.
“What we've seen as a mobile industry is an opportunity in the pains the healthcare sector is facing right now. Within the mobile industry, we have degrees of efficiency and degrees of scale, and we definitely have an appetite to move into adjacent markets and partner with the healthcare industry to provide solutions to the cost, access and quality challenges they're having.”
Krugel uses local statistics to demonstrate the opportunities in the field. “In SA, 26% of total healthcare expenditure is funded out of pocket by consumers paying for healthcare in cash. There's an opportunity to start looking at how to reduce the burden on the end consumer in terms of the costs of overall healthcare access by delivering new technology.”
The scope is huge, adds Krugel. “Private health expenditure equates to 21 times the total combined revenue of all the South African network operators. So even if the mobile health solutions introduced into the market can take a sliver of the business opportunity within the private healthcare industry, that should be quite a substantial opportunity for the mobile industry.”
He says by partnering with the private sector and government, and catalysing these larger coalitions, the industry can move beyond the pilot stage and create sustainable and scalable m-health programmes.
According to Seebregts, the m-health initiative is still slightly immature in the sense that it is still technology-driven.
“However, there is massive energy and interest in this area that, if channelled correctly, could stimulate a paradigm shift in the way healthcare is delivered in low-resource settings.”
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