mHealth (285)

Many pregnant women live in informal settlements in Embakasi, Kenya. They have to rely on private healthcare, and so find the money to pay the hospital bills. It’s due to the limited availability of public hospitals in their area. Mobile phones and pre-payment plans can help.

An article in the African Healthcare IT News says the average maternal billing for medical check-ups and delivery and postnatal care received at a private health facility in Kenya is estimated at 10,000 to 15,000 Kenyan shillings, roughly US $100 to $150 or €95 to €142. It’s a considerable financial burden for women and their families in this community.

While most people in the settlements are wage earners, they often rely on  unpredictable means of income. The added stress of pregnancy and the fears of not easily affording medical treatment are realities for many women living here.

These maternal challenges caught the attention of relief organisation Malteser International. It led to the mHealth system M-Afya, M for Mobile and Afya meaning health in Kiswahili.

The app doesn’t provide financial support, but helps in saving the money that is needed. Women who register at private clinics are provided with a birth plan and encouraged to create accounts. They can then use M-Pesa to deposit money in their accounts. People pay as much as they can afford each time, so having no requirement of fixed amounts is very helpful. The system uses SMS to send updates and other information too.

M-Afya also provides access to a database that helps promote maternal and child health. Twice a week, women who have registered, receive messages on their mobile phones with information about their pregnancy. They’re reminded of doctors’ appointments, given advice about their pregnancy and sent health data about their unborn children. After they've given birth, M-Afya sends messages of support to mothers and family members.

The initiative has two main benefits. It reduces levels of stress associated with medical bills. Secondly, it promotes maternal and child health, helping to address core issues of the Sustainable Development Goals.

"We need new energy to change the world,” said Maud Olofsson, former Swedish Deputy Prime Minister. She was opening the fifth STIAS-Wallenberg Roundtable in Stellenbosch, South Africa. She was talking about the energy of innovation and the people driving it. She emphasised how mHealth experts should help politicians to understand these rapidly changing technologies and work with them how to secure the benefits and opportunities for health systems strengthening. 

The roundtables are an initiative of the Marianne and Marcus Wallenberg Foundation. They have been run every year since 2013. Delegates are from South Africa, Sweden and the broader international community, invited to engage in dialogue and debate to explore solutions to global challenges.

The February 2017 Roundtable focused on image-based mobile health. Over 60 participants attended from 16 countries. The event provided an opportunity for cross-sectoral and cross-disciplinary discussions and networking, says an article in africahealthnews.

A tangible output of the roundtable is a roadmap to be published in a special issue of Global Health Action devoted to mHealth. eHNA will share it once it's available.

The roadmap emerged from discussions on five key questions about the implementation, expansion and up-scaling of image-based mHealth in resource-constrained settings:

  1. How should the most important barriers to the implementation of image-based mHealth in the clinical setting be overcome?
  2. How can frontline healthcare workers adopt image-based mHealth in their practice?
  3. Which key strategies are needed to overcome organisational challenges to implementing image-based mHealth?
  4. Which are key strategies to overcome technical challenges in implementing image-based mHealth within the health sector?
  5. For each stakeholder groups represented, what are the most important priorities to build and sustain mHealth leadership?

Emphasis on finding solutions and crafting a tangible roadmap provides a constructive model for this type of sector engagement. African eHealth experts included African Centre for eHealth Excellence’s (Acfee) Dr Sean Broomhead (South Africa), Prof Peter Nyasulu (South Africa and Malawi), Dr Ousmane Ly (Mali) and Dr Eddie Mukooyo (Uganda). They will take lessons from the roundtable experience into the Acfee stakeholder events planned for Southern Africa and East Africa towards the end of 2017.

Helping end users make better decisions and provide better care was critical a focus. Discussions included how best to deal with barriers such as regulatory aspects, costs, Internet accessibility, airtime, power shortages, lack of training, use of personal phones and safety issues around phones, data accuracy and security - a long list - so that users are able to embrace mobile health.

Delegates included nurses and doctors sharing practical experiences using mHealth in clinical settings, overcoming implementation challenges, and leading change. Their stories fuel optimism for what is possible. We look forward to reading the roadmap and to sharing it with eHNA readers.

Image courtesy of STIAS

HIV/AIDS remains one of the leading causes of death worldwide. Avert has estimated that   more than 7 million people in South Africa live with HIV. About 70% of the total global prevalence lives in sub-Saharan Africa, with South Africa carrying the highest burden of the epidemic in the world in 2015. HIV/AIDS is a major health concern in South Africa, with 380,000 HIV incidences and 180,000 HIV/AIDS fatalities in 2015 as reported by Avert. KwaZulu-Natal tops the chart of the country’s nine provinces with nearly 20% of HIV/AIDS patients. 

In 2015, eThekweni District in KwaZulu-Natal’ started using mHealth to help improve services for people living with HIV. Access to HIV/AIDS treatments services remains a challenge, with only 48% of adults receiving Antiretroval Treatment (ART) in the country. South Africa, like many other African countries, face many health challenges, patient and community barriers against the smooth delivery of HIV/AIDs treatment and services.

Health system barriers include a growing shortage of staff due to high turnover, highly congested and poorly coordinated healthcare facilities and a knowledge gap between healthcare providers and their patients. Patient barriers are long distances, transport costs and longer waiting times before receiving primary healthcare or treatment. Lastly, HIV/AIDS related stigma and discrimination remains prevalent in communities.

Health-e News has a report saying the project includes an app so healthcare providers can track individual performances of caregivers in every ward, while indicating where health services are inefficient. The app enables healthcare providers to login with their own personal username to report on their activities and interventions. Managers can use the app to monitor activities in each ward. The project focuses on HIV patients and has received a twelve-month grant of £96,944 roughly R1 547 086 in 2015.

Integrating apps like these in healthcare can increase efficiency in the delivery of HIV treatment and services and can build trust between healthcare providers and their patients. It should help improve co-ordination, address staff shortages, allow healthcare providers to monitor and track their patients’ status, and enable managers to improve the functioning of facilities. It could help other districts too.

Emergency Rooms (ER) are busy. mHealth that eases workload and makes ER doctors’ working lives better are worth it. In Med Page Today, Dr Iltifat Husain has identified four that help.

GoodRx for Doctors, described by Dr Husain as “fantastic … for helping your patients be compliant with their prescriptions,” it included a bookmark to find medications prescribed frequently but may be unaffordable for patients. An equivalent for Africa’s health systems would be well received by communities.

OrthoFlow was developed by UK orthopaedic surgeons and doctors working in Accident and Emergency. Dr Husain says it’s “A great fracture management app that essentially puts an orthopedic surgeon in your pocket.” It helps with fracture management and understanding essential features of fractures, such as how much displacement needs changed management.

STD Tx Guide, developed by the US Center for Disease Control and Prevention (CDC) provides alternative antibiotic regimes for patients allergic to penicillin (PCN). The app was updated recently to include new guidelines.

Gout Diagnosis avoids tapping red or painful joints. Dr Joshua Steinberg took a validated study on gout diagnosis and created an app. He’s a bit of an appthusisast. They’re all available from iTunes.

Africa’s mHealth plans could include investment programmes in ER services. These would have to be in parallel with investment in mHealth for citizens and communities.

The demand for evidence to steer more mHealth investment may not be fulfilled in the immediate future. A team from University of Washington and Columbia University has reviewed 39 mHealth economic evaluations and found several limitations. The report in PLOS One says there’s often inadequate evidence drawn from incomplete methodologies to support cost effectiveness claims.

While most studies address several of mHealth’s economic components, many also omit factors that could affect economic impact. The full range is in the Consolidated Health Economic Evaluations Reporting Standards (CHEERS) guidelines. They were developed by the International Society for Pharmacoeconomics and Outcomes Researcher (ISPOR).

  1. A simple summary is that:
  2. Evaluations included under 80% of the CHEERS guidelines
  3. Under a third of the studies were considered high quality using CHEERS guidelines as a measure.

The study’s firm evaluators should refrain from using the term cost-effectiveness in findings in the absence of rigorous economic evaluations. The same can be said for the term value for money (VFM), an equivalent economic concept that’s crept into management speak.

The value of economic evaluations is limited without a business case for comparison. An important goal’s comparing estimated actual performance with planned and required performance over time. The difference, and the reasons for it, provides valuable knowledge and learning for future mHealth decisions.

Transferability of finding’s another important theme. The study says using an appropriate methodology and data collection strategy increases transferability of findings across locations. There are many other factors needed too, such as:

  1. Standards and functionalities of mHealth services, including networks and smartphone requirements, interoperability (IOp), cyber-security
  2. Healthcare resources available before mHealth
  3. Users and beneficiaries cultures
  4. Communities’ health and disease profiles, demographics and socio-economic profiles
  5. Healthcare models, especially for healthcare continuity
  6. For African communities, the number of secondary mobile phones as shared users.

Economic costs have a different definition to financial costs. Consequently, economic evaluations of mHealth don’t provide an accurate view of its affordability, in terms of both cash flow and income and expenditure. These are often the last hurdle in investment decisions, so critical. There’s a need for evidence about this aspect too, especially in Low and Middle Income Countries (LMIC), so Africa.

While Africa’s mHealth initiatives scored highly in the 2015 WHO eHealth survey, a constant challenge for all countries is fitting them into the wider eHealth setting. A whitepaper by Athena Health, Going Mobile: Integrating Mobile to Enhance Patient Care and Practice Efficiency identifies how mHealth is used and how its strategic setting can be developed. mHealth Intelligence says healthcare leaders need a “thoughtful approach to integrate mobile health technology.”

The whitepaper says it includes: 

  1. Clinical decision support (CDS) by evaluating and selecting the best mHealth
  2. Workflow efficiencies, using mobile-enabled devices, services, and software to optimise data retrieval, documentation and healthcare transactions
  3. Communication and co-ordination by connecting and sharing information between providers to improve healthcare co-ordination
  4. Patient engagement to support population health, improve compliance, and engaging patients in their care
  5. Security and privacy and ensuring its effective for mHealth.

These present two challenges for healthcare organisations:

  1. Evaluating and selecting mHealth solutions that maximise support for clinical outcomes, co-ordinated healthcare, workflow efficiency, patient engagement, and population health
  2. Protecting the security and privacy of information shared using mHealth.

mHealth features that need assessing in these decisions include:

  1. Secure, and compliant with laws and regulations
  2. Focused on efficiency and measurable results
  3. Integrated with patient communication and EHRs
  4. Supporting CDS and better health outcomes
  5. Easy to use by clinicians and patients
  6. A strong platform for patient engagement
  7. Flexible, to accommodate mHealth innovations and changes.

These provide Africa’s health systems with an initial strategic structure to integrate and direct their current mHealth services and plans. A bigger challenge is evaluating a widening range of mHealth innovations and opportunities as a set of integrated business cases.

HIV’s still a global epidemic affecting most Low and Middle Income Countries (LMIC).  Some 4% of people in Africa are HIV+. At 12% of all deaths, HIV/AIDS is the biggest cause.

Lesotho’s no exception, in fact it’s much worse. According to the UNAIDS Gap Report, 310,000 people in Lesotho are living with HIV, about 23% of the population. Only 42% of adults receive Anti-Retroviral Treatment (ART).  Most of Lesotho’s population live in rural areas, making healthcare access challenging.  

One of the benefits of mHealth is meeting challenges of poor healthcare delivery, especially for HIV treatment. To address this challenge, The Guardian has reported that Lesotho’s Ministry of Health (MOH) has introduced an mHealth programme developed by Vodacom. It’s a combination of a smartphone app for healthcare providers and M-Pesa, a mobile money service for the patients. M-Pesa is a money transfer service for people to receive or send money using a mobile phone. It’s widely available throughout Sub-Saharan Africa. Since women and young children are most affected by the HIV epidemic, the programme focuses mainly on them.

The programme allows healthcare providers to undertake on-site HIV testing through a mobile clinic in remote areas where travelling’s difficult so that community members can receive care. Healthcare providers can register HIV+ patients in the central database that’s used to provide patients with funds through M-Peas for transport costs. Health care providers can also use the database to plan, record and access treatment.

If the mHealth programme’s delivered as planned, it should achieve three benefits set out by Ken Congdom of Health IT Outcomes:

  • Improved data accuracy
  • Improved data access
  • Improved patient care

HIV is an immense healthcare crisis for the people of Lesotho. This programme aims to ensure that thousands of mothers and young children in some of the poorest communities in the world receive the care and support they need.  

Tracking and stocking essential medication are challenges for many African countries. People living in rural areas often don’t have access to primary health care facilities, and even if they do, facilities frequently run out of essential medicines. To address this problem, Kaduna State Ministry of Health, the third most populous region in Nigeria, Vodacom and Novartis have implemented SMS for Life 2.0, an mHealth programme.

SMS for Life 2.0 isn't a new concept. It builds on the SMS for Life programme launched by Novartis in 2009, which used cell phones to manage stock-outs of malaria medicines in more than 10,000 healthcare facilities across sub-Saharan countries says an article in eHealthNews.

Pharmi web has the Novartis press release. It says SMS for Life 2.0 uses smartphones and tablet computers to improve access to medicines and increase disease surveillance, helping to provide better care for patients. It also builds on its success and introduced eLearning for local health workers.

SMS for Life 2.0 allows healthcare workers to track stock levels for  HIV, TB and leprosy treatments, and antimalarial vaccinations. It also allows them to send notifications to district medical officers when stock levels are low, ensuring adequate and timely supplies of all essential medicines.

SMS for Life 2.0 will also:

  1. Monitor disease surveillance parameters of maternal and infants deaths, malaria, yellow fever and cholera
  2. Improve stock visibility which will improve supply chain management, by allowing authorities to improve demand forecasts for the treatments
  3. Facilitate health workers’ training in local facilities using eLearning modules
  4. Improve healthcare by better access to essential medicines so reducing disease prevalence in communities

Zambia’s Ministry of Health has recently signed a Memorandum of Understanding (MOU) with Novartis to roll out SMS for Life 2.0 to some 2,000 health facilities. It’ll start in 2017.

Tucking into a tasty Mediterranean diet’s seen as adopting traditional healthy habits of people living in countries bordering the Mediterranean Sea, especially France, Greece, Italy and Spain. While their cuisines vary, and sometimes within countries’ regions, so has a range of definitions, its common components are mainly vegetables, fruits, nuts, beans, cereal grains, starchy foods like bread and pasta, olive oil, fish and modest amounts of meat. The diet’s similar to the UK government's healthy eating advice set out by the NHS in the Eatwell Guide.

It’s not feasible for all Africans to comply with this advice. Many of the required ingredients aren’t readily available across all-Africa. Where they can, it’s worth the attempt. Strokes and Ischaemic heart disease are the causes of about 8% of deaths across Africa. The diet’s associated with good health and a healthier heart. In 2013, a study found that people eating a Mediterranean diet had a 30% lower risk of heart disease and stroke. With such good results, researchers have sought the best way to convert people’s dietary preferences and exercise more. A report in the Journal of Medical Internet Research (JMIR) on the Short-Term Effectiveness of a Mobile Phone App for Increasing Physical Activity and Adherence to the Mediterranean Diet in Primary Care: A Randomized Controlled Trial (EVIDENT II Study) tested the value of mHealth in Spain.

The randomised controlled clinical trials included 833 participants. It had a follow-up of twelve months with a three month short-term follow-up. Two groups were counselling and mHealth combined with counselling. A GT3X accelerometer from ActiGraph recorded continuous, physical activity, and sleeping and wake information.

Measurements looked for:

  1. More Physical Activity (PA) evaluated by the seven-day Physical Activity Recall (PAR)
  2. More leisure time spent on Moderate-to-Vigorous PA (MVPA)
  3. Mediterranean Diet Adherence Screener (MEDAS) scores.

Both groups achieved more PA, with the mHealth and counselling group increasing a bit more for MVPA. The differences weren’t significant. The accelerometer analysis showed the mHealth and counselling group that used GT3X most had a net increase in MVPA, and a net decrease in sedentary times. Both groups had similar MEDAS scores too.

There’s still no conclusive evidence for mHealth in improving lifestyles. This’s an important finding for Africa’s mHealth programmes. Rigorous assessment and business cases are vital before committing resources.

As mHealth expands across Africa, which are the best health routes to take? A report of a research project in the Health Affairs says some mHealth isn’t as good as patients think it is.

Seen as full of potential to high-need, high-cost populations in managing their health, mHealth doesn’t always live up to it. There’s a set of challenges that must be addressed as the number of available mHealth apps keeps increasing. The research team evaluated mHealth for diabetes, hypertension, obesity, arthritis, depression and bipolar disorder. The team’s evaluated 137 mHealth services highly rated by consumers, recommended by experts and for people with significant needs and high costs. It found:

  1. Few meet patients’ needs
  2. No clear strategy on how providers should evaluate and recommend mHealth to patients
  3. Most apps can’t go beyond a basic level of patient engagement in helping consumers manage specific chronic illnesses
  4. Few offered functionalities such as guidance based on information entered by patients or rewarding behaviour changes
  5. Consequently, stakeholders, including medical professional bodies, insurers and policy makers have avoided formally recommending mHealth
  6. Many patients are left to find recommendations from other sources.

Other findings are:

  1. Patients’ ratings were poor indications of mHealth’s clinical utility or usability
  2. Most mHealth didn’t respond appropriately when patients entered potentially

Some mHealth has considerable risks. As Africa’s health systems pursue their mHealth strategies, this study shows it’s vital that mHealth services are rigorously evaluated before they’re rolled out and scaled up. There’s merit in setting up a central registry of tested, approved and certified mHealth services for healthcare professionals to refer too. It should help to mitigate risks.