Africa: Using Mobile Technology to Improve Health
Last year the Rockefeller Foundation, the United Nations Foundation and the Vodafone Foundation - three of the leading foundations involved in global health, technology and humanitarian assistance - banded together to create the Mobile Health Alliance.
Karl Brown, associate director of applied technology at the Rockefeller Foundation, leads its electronic health and mobile health work. He recently spoke with AllAfrica about the Mobile Health Alliance, Rockefeller's contribution, and the foundation's other health initiatives in Africa.
What are your thoughts about the mHealth Summit that was held in Washington in October? Achievements?
For me one of the key things that came out of it was [that] the growth of this space was even bigger than any of us have thought. There were 2,600 people there, hundreds of posters and hundreds of booths and technologies. The excitement was one of the things that took me a little bit by surprise.
One of the things I'm worried about is that it might be in a hype cycle.
So the question is: how many of the companies entering this space are going to survive in the next five years? And that often happens in new technology domains. Lots of people rush in and start developing technologies, but at some point there's a process by which the victors emerge and the rest fall to the side. So far that hasn't happened. It just keeps growing and growing.
I think everything about mobile always ends up surprising everybody. The growth of mobile money has surprised people; just the growth of mobile phones has surprised people. So I think the future of mobile health is still very, very unclear. But in the past when I've heard people talk about mobile health, it was talked about in isolation from other things in the health system. It was this cool little pilot or this cool technology that people were doing something interesting with.
But now people are starting to see mobile health as part of a wider ecosystem of eHealth. People are starting to talk about how does it integrate to the back end, how does it connect with databases, how do you make sure that mobile health is really, really helping to track outcomes? So I think the level of the conversation has gotten more serious and more complex because people are starting to wrestle with how the mobile integrates with the rest of the health system rather than being a fancy add-on to it.
The Rockefeller Foundation recently gave a U.S. $1 million grant to the Mobile Health, or mHealth, Alliance. What will that fund?
The grant is for core support for the mHealth Alliance. The core goals of the alliance are first in terms of thought leadership. They [are publishing] some important pieces, for example, on the linkage between mobile money and mobile health. They also did a paper on policy gaps and mobile health. They've also done a number of [gatherings] in the mobile health space.
The mHealth Summit was a big success, but they also organized the whole mobile health track along with GSMA at the GSMA world conference in 2010 and also 2009. (The GSMA represents the interests of the worldwide mobile communications industry.)
Our funding is going to all these areas. But one area that I'm going to be most focused on is the Maternal and Newborn Health Initiative. It is part of the UN Secretary-General's innovation working group, which is trying to identify new innovations in the world that can help maternal and child health. So along with the mHealth Alliance and the Partnership for Maternal and Child Health at the WHO (World Health Organization), the Norwegian government and a number of other partners are going to be looking at the full spectrum of maternal and newborn care, and then stimulating mobile development and application.
There is a proliferation of mobile health applications and a lot of reinvention of the wheel. The challenges of maternal and newborn care in low-income countries, while diverse, have a lot of commonalities that can be leveraged. If you look at the potential to bring greater resources concentrated on developing some kind of common, reusable pieces of technology that can then be scaled much more broadly, there are some great opportunities for scaling up maternal and newborn mobile health applications, and through that other sorts of applications throughout the world.
An example of scale-up is the Voxiva text for baby campaign. They have about 100,000 women signed up in the U.S. so far and they're signing people up in Mexico. They send free text messages to mothers during their pregnancy and during the first year of the child's life, giving them information about healthy behaviors and so on.
They're scaling this up and are going to franchise it in a number of countries. Once you have the technology written in a certain way then you can scale it up into new geographies with not a very high cost.
How do you meet the challenges of scaling up?
One of the issues in scaling up is inter-operability, which is the ability to communicate with one another. Imagine a district in Kenya that has a mobile health application that's collecting three things by community health workers, and then there's another district that has a different mobile application that's collecting another three things. If you think of trying to scale those up, at some point you're going to run into the issue where the community health workers will have to use two different systems or fill in two different forms or use two different phones.
A lot of these systems weren't really designed with the full spectrum of needs in mind. They were designed for a specific program, for a specific place with a specific information need. Sometimes that's the right thing to do but if you want to scale anything nationally you need to think about the problem differently from the start.
One example of a national-level scale up that we're in the midst of right now is in Rwanda. There are two things that are going on there.
One is they're planning on doing a nationwide rollout of primary care clinical records, which is electronic medical records at the point of care. In order to figure out how to do that they've done a requirements gathering process. They're looking at requirements from a number of different clinical sites - not just looking at the easy ones and not just looking at the most rural ones, and not just talking to doctors, but talking to nurses and other clinical staff, and also understanding what sort of information the district health officers and the ministry will need out of it.
As a result of that they now have a set of requirements for primary care that can be used to design the technology system. In this case the technology they've selected is OpenMRS. So we've provided a grant through Partners in Health to revise OpenMRS in line with these requirements for primary care. I think that is going to be an important lesson in scaling up - how do you scale up around a common medical records platform. The process is ongoing now; it will probably be another year or two before it's fully rolled out.
Are you doing other work in Rwanda?
Another project we're doing is around enterprise architecture and this is taking a step back and saying that even if you have the electronic medical record in all the clinics that's not the only information system in Rwanda and there are lots of other ones.
Could you define "enterprise architecture"?
Enterprise architecture is a view of an enterprise that shows the relations between all of the parts of the whole. When we talk about health we usually are defining the enterprise as the country, the health system. So it's all of the people and organizations who are responsible for the delivery of preventative and curative services in health - all of the public clinics, private clinics, private hospitals and so on.
Enterprises can be defined at different scales but we're using the virtual enterprise of a country as our enterprise model.
So the enterprise architecture approach says: how do all of these different pieces fit together? How does the electronic medical record communicate with the information system that the community health worker is gathering? How does that integrate with the health management information system? How do you manage the financing and billing and so forth?
This is actually a project that came out of Bellagio [in Italy], called HEAF, the Health Enterprise Architecture Framework. It's being supported by Rockefeller and IDRC (International Development Research Centre), and soon Pepfar, in Rwanda and several other countries.
The idea is to generate a reusable and somewhat generic framework for enterprise architecture that can be repurposed and used in a number of these countries. That project is now very active, and they've recently completed at Medinfo a very interesting prototype, proof of concept of how the enterprise architecture would work in Rwanda.
They showed a demonstration of five systems, which are all built by different teams using different technologies, sponsored by different donors in some cases, and even within Rwanda under the leadership of different departments.
All of these information systems were able to share information about a single patient through open standards. It was a very important demonstration because it illustrated the goal of this interoperability is in providing continuous care for a patient. In this case the patient is a pregnant woman who is HIV-positive and [it was possible to gather] all of these facts about her and put her on treatments as a result of the information captured in these systems.
How do you measure the impact and quality of these sorts of programs?
In the case of the open-source medical records system, the OpenMRS, there have been a number of evaluation studies done and published both in Kenya and Rwanda and Uganda that demonstrate both positive clinical outcomes and management outcomes. We don't yet have the evidence if you scale this up nationally because that hasn't happened yet, at least in Africa.
IDRC, which is one of the funding partners on this, is very interested in the research and evaluation angle. So they are going to be digging deep into this and probably dispatching a group to study this enterprise architecture rollout to establish the case for what sort of add-on benefits can you measurably show from having an enterprise architecture and showing inter-operability. We know that inter-operability has had huge impacts in other domains for health in which it's been put.
How would you characterize the future or the potential of mobile health for improving lives in Africa?
I think it's huge. We haven't yet really scratched the surface of the potential for the technology. I think in the next five years as the 3G and high broadband coverage continues to extend within Africa and the price of smartphones continues to decrease we could get to basically everyone holding in their hand a 50 dollar telemedicine portal where they could speak with one of the best doctors in the world.
That kind of potential is still untapped. I think if you look at the mobile money stuff that is happening, like in Kenya you have about 50 percent of people in Kenya using the service. We haven't found a mobile health thing like that yet. But when it does, if you think about the impact of mobile money on financial services and on provision of money transfers and banking and then even more sophisticated financial services, the possibilities for mobile health are really infinite.
Do you think these advances in mobile health might be able to help combat brain drain in Africa, by somehow bringing knowledge back to the continent?
What I've thought about is how the mobile can help with task shifting.
So if you have a health worker who does not have a deep amount of training but they have this expert in their pocket, either a computer or a connection point with someone else who knows more about health than they do, then that can have a potentially transformative impact on provision of services.
With the health worker shortage in Africa, there aren't really any great plans for how that is going to be addressed in the next five to 10 years. There are certainly a lot of people who are scaling up health training, but the gap in terms of what the WHO (World Health Organization) recommends, it seems it is going to remain. This is why a lot of people are looking at technology to extend the reach of the health workers that they have.
There was a pilot I saw, and we are supporting an expansion of this pilot in Bangladesh, where you have a community health worker who's in a slum in Dhaka and she goes and visits with pregnant women, takes a picture, and walks them through a set of questions on her mobile phone - and this is a 50-dollar phone so it's a bit more sophisticated than an SMS type of phone, but it's not like an android smartphone sort of thing.
So you have this community health worker going through a guided clinical interview with this patient and the information is being sent back to a server where it can be seen by a doctor, and then the doctor can enter comments and send them back to the health worker.
I remember asking the health worker about what she liked about the system. She really liked it because she knew there was a doctor who was behind her, who had her back, and it was very powerful because it's not likely that doctors will reach that slum at least in the near future.
For this community health worker, she feels like she can go and she can reach these patients and there's a doctor behind the scene checking on high risk pregnancies and giving her suggestions on what to do.
Can you tell us more about Rockefeller's health initiatives?
In Rwanda one of the important things we've done is create an eHealth unit at the Ministry of Health that is partially paid by Rockefeller and partially paid by the ministry. There is a director, there is a project manager, a health information [worker] and a health assistant. Their job really is to help bring threads together, not to be programmers. Their job is to manage all of the different eHealth projects that are happening in Rwanda.
There are other things we're also doing besides on the technology side.
One is around capacity. We've always felt from the beginning, while it's important to move things forward on information technology, if you don't have people on the ground who have a capacity to design and plan and manage and purchase and extend these systems then overall their sustainability is going to be limited. To date we have supported the creation of health informatics training programs For now our main countries in Africa where we're working are Rwanda and Ghana and a little in Kenya.
In Ghana they're doing a needs assessment inside the ministry in terms what it needs in terms of health information workers so that we can go back and support the schools to create programs to create that supply that is needed by the ministry. That's on the capacity building front.
Is there something else that you would like to tell us?
I would just say that the one thing that I'm really excited about in mobile health - and I think we're trying to sort out how we can play a role in making this happen - is around innovation and the idea of whether we could help create a platform upon which people could add new innovations, for example.
Especially in the context of Africa, if you can set it up right some of the best mobile health innovations might come from Africa, not be brought to Africa. If you look at Kenya, the number of mobile innovations that they've been generating has been quite impressive.
There's great possibility for Kenya and other African countries to continue to create innovations that can spread around the world.