mHealth (280)

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.

Africa’s eHealth initiatives accord an important role for mHealth services. There’s a very wide range of mHealth projects, but still plenty to do. African countries scored between 50% and 60% in the mHealth section of the WHO Global eHealth Survey 2015the data source for the  WHO and Global Observatory for eHealth (GOe) publication Report of the third global survey on eHealth Global diffusion of eHealth: Making universal health coverage achievable. Its key findings for Chapter 2 on mHealth are:

  1. 87% of responding countries say they’ve at least one mHealth programme
  2. 80% of the low income countries say they’ve at least one mHealth programme
  3. 91% of high-income countries have at least one mHealth programme
  4. More mHealth programmes operational for at least two years with finance for at least two more
  5. Only 14% of countries have an evaluation of a government-sponsored mHealth programme.

These numbers say nothing about the utilisation or coverage of the programmes. The evaluations say nothing about their costs, benefits, net benefits or timescales needed to achieve net benefits.

Africa’s average performance is below the average for low income countries. While this seems to indicate that more can be achieved, extra spending needs pursuing with considerable care. eHNA post about the American Medical Association (AMA) Executive Vice President and CEO’s view seems relevant - that it’s vital to separate digital snake oil from the useful, and potentially magnificent, digital tools, and quell the undesirable digital dystopia that doesn’t improve health, healthcare or make it more efficient. He includes Ineffective mHealth apps of questionable quality.

While his vocabulary’s exotic, he emphasises an important theme of good mHealth investment. It’s challenging to produce rigorous mHealth business cases when the evidence is from 14% of countries. It’s not much more than the 12% found in 2010. African countries comprise about 18% of these, with three evaluations. eHNA has posted on several research findings that show that much of mHealth benefits are questionable or short term. It’s essential that mHealth business cases are explicit and about the net benefits expected, then followed by evaluations to add to mHealth knowledge.

mHealth’s a multifarious term. It includes fitness wearables. Chapter 2 has 14 other types:

  1. Health call centres                                             
  2. Appointment reminders
  3. Telehealth                                                                
  4. Community mobilisation
  5. Awareness raising                                              
  6. Emergency access
  7. Emergency management                               
  8. EPRs
  9. Patient monitoring                                             
  10. mLearning
  11. Health surveys                                                      
  12. Surveillance
  13. Treatment adherence                                      
  14. Decision support systems.

Four future mHealth themes are seen as:

  1. Evaluate implementation and outcomes
  2. Develop regional and global networks to share mHealth knowledge
  3. Determine the best areas for mHealth to help adoption and local innovation
  4. Researchers, health authorities and global entities promote mHealth indicators.

Africa can lead on these. It needs the information.

About 56% of men in Diepsloot, Johannesburg have sexual or physically abused a woman. A survey by Sonke Gender Justice and the University of the Witswatersrand School of Public Health revealed the extent of violence for the Sonke Change Trial. In response, journalists at Bhekisiss Centre for Health Journalism, part of the Mail & Guardian group, worked with local organisations to develop an app to support a helpline.

An article in Bhekisiss says how they launched the free Vimba Helpline in Diepsloot on 25 November, International Day for the Elimination of Violence against Women. It works on all mobile phones. Users don’t need airtime or data to use it. With 90% of Diepsloot households having access to a mobile phone and no reliance on unaffordable Internet access, it has wide coverage. It uses Unstructured Supplementary Service Data (USSD), used for mobile phones to communicate with service providers, so it doesn’t need data or a download.

There‘s a video too. It’s in the article. Mia Malan, Bhekisiss Editor describes Vimba and how it works. It collects data too, including date and times of contacts, location and the help needed. It’ll be used to identify trends, hotspots, service deficits and develop better responses to violence against women and children.

Vimba, Zulu for prevent, stop or halt, can benefit all-Africa. This could be the goal after it’s available across South Africa.

Healthcare and chronic disease rates aren’t distributed evenly across Africa’s communities or countries burden. A report by a team from Aetna Foundation in the Journal of Public Health Policy, Population health-based approaches to utilizing digital technology: a strategy for equity may offer a way to use eHealth to even them up. More specifically, it proposes that mHealth can help.

mHealth has a big role in engaging individuals and their communities in health and healthcare. It extends across accessing the Internet to find information about health conditions, monitoring health and fitness. Africa already has a wide range of mHealth services with plans for more. It’s 59% score on the WHO 2015 eHealth survey shows a respectable strategic foundation.

Aetna Foundation takes a long-term, systematic view in making its grants. Its focus is promoting wellness, health and access to high quality healthcare. It evaluates bids for projects using “strong evidence-based criteria.” They include sustainability, scalability, potential for positive societal impact, leveraging available evidence such as population health data or healthcare data, and digital health technologies built on strong foundations of behavioural research or other applicable theories.

This business case approach can help Africa’s health systems take good mHealth decisions. With a large mHealth evidence deficit, business cases enable rigorous assessments assumptions and estimates. They also support a switch away from seeking to achieve potential benefits to identifying more modest and realistic probable benefits. They also provide an analytical foundation for subsequent M&E, so adding to the current limited evidence pool.

Acfee’s preparing guidelines for Africa’s health systems on using a proven methodology for preparing business cases. It also deals with the business case process as part of good eHealth governance. Both a methodology and a process are needed for business cases to fulfil their role in decision taking.

Encouraging mHealth’s supply side’s important too. Aetna Foundation mentors mHealth innovators. Its approach to mHealth training that brings together leaders, behavioural sciences and clinical researchers offers lessons for Africa’s health system. Ministries of health, technology and economic development can collaborate to develop countries’ mHealth industries by setting clear mHealth priorities and working with local mHealth suppliers to develop and provide solutions and services.

These themes combine into mHealth strategies that extend beyond healthcare and into the technology world of universities and business entities. This extended value chain offers a structure to expanding mHealth from the valuable progress achieved in Africa so far.

South Africa’s mHealth service, MomConnect has used SMSs to provide pregnant women information with health advice for nearly a year and a half. The team has analysed its compliments and complaints and scrutinised the databases containing information on its operation. The result’s an improved service, showing the benefits of M&E.

In an article in of the Journal of Public Health Policy, The MomConnect mHealth initiative in South Africa: Early impact on the supply side of MCH services, the MomConnect review team from the School of Public Health, University of Witwatersrand, South Africa National Department of Health (NDoH) and South Africa MEASURE Evaluation Strategic Information for South Africa (SIFSA), says more than 580,000 pregnant women registered on MomConnect, less than half pregnant women booking their pregnancies in South Africa’s public health sector. About 4,170, 0.7%, provided compliments. There were 690 complaints, 0.1%, of which 74% were resolved, leading to better quality such as fewer drug stock-outs and improved behaviour of some health workers.

Once registered, women receive free SMSs linked to the stage of their pregnancy. They receive messages postnatally, linked to the age of their infant, up to one year. Pregnant women can also interact in three ways with a DoH health desk:

  1. A rating system the day after registration comprising ?ve basic questions about quality
  2. Women can ask for additional information on any topic about their pregnancy
  3. They can log a complaint or compliment about the service they’ve received.

These activities should be seen in the context of MomConnect’s aims to:

  1. Connect pregnant women to health services
  2. Enable these women to interact with the health system
  3. Improve service delivery
  4. Encourage pregnant women to attend antenatal clinics as early as possible, preferably before 20 weeks of pregnancy.

The review deals mainly with aims one to three. The findings lay down benchmarks for a subsequent review. Improvements should be expected in the ratio of compliments to complaints by exceeding the 6:1 rate, a general levelling of complaints across the nine provinces and fewer drug stock outs.

Equivalent benchmarks could be set on the socio-economic and health impact on mothers, babies, infant, families and communities of goal four. These are much more challenging to set and to measure, but provide important information.

eHNA reported on the MomConnect presentation at eHealth ALIVE in September. The audience was very responsive.

Malaria’s Africa’s fourth biggest killer. It takes between 25% to 40% of outpatient visits, and 20% to 50% of hospital admissions, depending on the African country. Making diagnosis easier and quicker’s a step forward in combating the disease and easing healthcare demand. A report in Disrupt Africa says Brain Giitta, a Makerere University graduate, has developed Matibabu, a non-invasive device  with a smartphones to diagnose malaria.

His company thinkIT is developing the technique where light sensors can read blood oxygen content through people’s skin. Plasmodium, the parasite, in affected people changes red blood cells’ shape and chemical properties and contain hemozoin, a crystal-like substance. Matibabu looks for these differences compared to uninfected blood. Users insert a finger into the device, plugs it into a smartphone, select “start diagnosis” on the phone, and wait for the diagnosis. About a minute later, it’s available.

The device helps malaria disease management by providing simple, cost-effective and early diagnoses. Benefits include:

  1. Reduces the number of people who suffer malaria’s severe effects
  2. Reduces medication
  3. Shorter treatment times
  4. No need for trained health workers
  5. Prevents appearance of symptoms
  6. Reduces malaria’s large socio-economic burden.

thinkIT financed Matibabu development with grants and partnerships that include the Resilient Africa Network and Merck, and prizes from competitions. It’s now seeking finance for further development to reach markets before the first quarter of 2018. Potential customers are domestic and foreign. They include individuals, hospitals, health ministries and NGOs. Uganda’s the primary market, then Sub-Saharan Africa. It can soon be part of Africa’s eHealth plans.