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Introduction

The World Health Organization (WHO) has proposed the use of low-cost information and communication technology (ICT) to improve the quality of service delivery and to build up health workers’ capacity especially at the primary health care (PHC) level.¹ This application of ICT in health care has been termed e-health.² Mobile e-health, or m-health, involves using wireless technologies such as Bluetooth, GSM/GPRS/3G, WiFi, WiMAX, on to transmit e-health data and facilitate services. Usually, these are accessed by the health worker through devices such as mobile phones, Smartphones, personal digital assistants (PDAs), laptops or tablet PCs. Health data stored on devices such as USB memory sticks and memory storage cards (SDs) can also be regarded as m-health tools.

The International Telecommunication Union (ITU) has been piloting m-health for health system and workers development in developing countries since 2002, especially at the PHC level.³ Most e-health development has been aimed at employing mobile/wireless ICT for PHC service development in developing countries. However, this is often not grounded within local practices in these countries. Attempts to develop new applications without taking account of local sensibilities have been known to fail.⁴ How can m-health be made sustainable for health workers and for PHC delivery in developing countries? To answer this question, case studies on the use of m-health applications by community-based health workers (CBHWs) from four developing countries in three continents are presented in this chapter.

Opportunities in m-health for addressing global
health problems

Health systems in developing countries face the double burden of chronic and infectious diseases. Scarce financial resources, coupled with the brain drain, have led to the loss of mostly high- and medium-level health workers. The Millennium Development Goals (MDGs) set out by the United Nations in 2000 provide targets for tackling the disease burdens in developing countries.⁵ The health-related MDGs are to:

• reduce child mortality from childhood diseases
  
  
• improve maternal health
  
  
• combat HIV/AIDS, tuberculosis and malaria.

These diseases have affected the fabric of society. Timely achievements of the health-related goals of MDGs in developing countries according to WHO can be attained by adopting the principles of the Alma Ata Declaration on Primary Health Care.⁶ This implies that the PHC service model could be the best approach to the management of the health-related MDGs in developing countries. However, the shortage of human resources is a major impediment to achieving the MDGs. Recently, there have been calls to focus strategies on the development of ‘substitute health workers’ for providing health services in developing countries.^7,8 CBHWs are long-standing providers of primary health care in many developing countries, and can be considered as ‘substitute health workers’ in this context.

These factors all provide a rationale for introducing m-health for CBHWs and making policy changes to produce health system reforms in developing countries.

Primary health care

PHC is operationalized through the district health system (DHS). The DHS is a hierarchical organizational structure for PHC service delivery, and is made up of four or five integrated levels of health service delivery configuration. PHC forms the first level of contact of individuals, the family and community with the national health system. Essential health services are provided through the PHC system using community outreach programmes and facilities. CBHWs are regarded as the lowest cadre within the PHC system.

CBHWs are a variety of health workers who are selected, trained and work within communities. They normally have a shorter education than professional workers. In developing countries, they are usually located in rural and semi-urban settings, but may also operate in urban areas. CBHWs are either paid staff or volunteers, and are trained within the local community in which they are expected to operate. They also perform specialist functions such as providing reproductive health and family planning, nutrition education, and community rehabilitation for convalescing and disabled patients. As well as delivering essential health services, CBHWs are also agents for health promotion in the community in which they live and work. They also act as advocates for socioeconomic development and community empowerment.

Five case studies that illustrate aspects of implementing m-health innovations with CBHWs in developing countries are presented below.

Case study summary

The development and implementation of the m-health applications in the above case studies involved mostly international and not-for-profit academic and research organiz ations working with local collaborators. These are listed in Table 5.1.

Different low-cost technologies were employed in the m-health work described in the case studies (Table 5.2). The source of funding for these m-health programmes was mostly international not-for-profit organizations (Table 5.3).

The effects of the m-health projects can be considered under four headings: technology interfaces, social, finance, and government.

Technology interfaces

The m-health projects described above were generally employed to extend essential PHC services to mostly rural communities previously without services. Different types of CBHWs were involved. For example, in the Ca:sh project, they performed specialist functions in maternal and childcare.

The importance of engaging users in the development process was a common factor in most of the cases. The participatory design approach^15,16 adopted in the Ca:sh¹⁷ and EHAS¹⁸ projects should be more widely employed, even though it did not result in sustainability for the Ca:sh project. Participatory action research¹⁹ was employed in the design and implementation process of the TeleDoc and EHAS projects. Here, community members, the users of the m-health services, were engaged in the development work. An iterative design approach was employed in all the projects, but most notably in the Ca:sh¹⁷ and EHAS²⁰ projects.

User interface design was also important. The users were involved in the mobile devices interface design process, especially in the Ca:sh project. Of particular importance is engaging users in the adaptation process of fitting paper-based content to device screens. User engagement in interface design has a role to play in successful mobile device usability and eventual adoption.¹⁵ However, this cannot be carried out in isolation. In a failed innovation, CBHWs abandoned their devices, despite an intensive long-term action, research-oriented design process, because other contextual factors were not appropriated into the planning process.²¹

The prior exposure of the CBHWs to mobile devices in the Cell-Life project and their exposure to desktop computers in the Ca:sh project were reported as being important to rapid adoption. Another factor was the training provided to the CBHWs. Training for users has been identified as important to the successful adoption of e-health in developing countries.²² In the Cell-Life project, there was an increased health care workload on the CBHWs.²³ However, the health care competence of the CBHWs was observed to be enhanced by m-health in both the Cell-Life and UHIN projects.^14,23

Social

Personal security concerns may be a barrier to the adoption of m-health. In the Cell-Life project, some CBHWs were observed to leave their mobile devices at home because of fear of armed robbery while working in the community.²³ There were also social effects of m-health on the work of the CBHWs. Some CBHWs complained about intrusion into their private lives in the Cell-Life project.²³ This perceived intrusion was identified as a limiting factor in the adoption of m-health.

A positive social effect observed in the Cell-Life project was that the CBHWs’ status within their working and professional community was enhanced by the m-health work.²³ Another social effect, albeit a negative one, was observed in the UHIN project as an outcome of the CBHWs’ team-working. As a consequence of the shortage of mobile devices, the CBHWs had to share them.¹⁴ Sharing a mobile device is common in many developing countries.²⁴ This should not, however, be the case with CBHWs, because of their health care role. Each health worker deserves to have a personal device in order to manage and secure their patients’ data, access email and use the device at any time for educational purposes.

Finance

Sustaining m-health projects in developing countries should be important to health policy makers. Most of the cases described above started as pilots, and most have since been expanded beyond their sites of origin. Thus, valuable lessons can be gained from their experiences.

The funding sources for these m-health projects are summarized in Table 5.3. Most were funded from outside the countries of implementation, with the exception of Cell-Life and Jiva TeleDoc. Most of the financiers were non-governmental organizations. It is known that developing countries are replete with abandoned health projects caused by the short-term focus of international implementers.^4,25 This observation is also supported by empirical work on the sustainability of PHC innovations in developing countries.²⁶ Sustainable PHC innovations were dependent on the degree of integration of local and contextual organizational factors in their planning. Financial sustainability of PHC innovations was observed to be important to local stakeholders.²⁷

The financial basis of some of these cases is therefore worth considering. For instance, both the Jiva TeleDoc and Cell-Life innovations were run as social enterprises. Social enterprises are organizations that develop new solutions to social problems.²⁸ They can be run as a business or as a not-for-profit operation. However, the common goal is to ensure financial sustainability while solving societal issues. They are also known to provide an alternative to inefficient public services.²⁸ The m-health projects were social enterprises that filled the gap created by underperforming public health services. In future, perhaps, health policy makers should adopt this approach to meet the health-related MDGs of developing countries.

However, taking the social enterprise approach is not without its own problems.²⁹ Both the TeleDoc and Cell-Life applications were developed with seed funding from their sponsors, but achieving financial sustainability was difficult. The Cell-Life m-health work started as a donor-funded research project in response to government policy on HIV/AIDs care.³⁰ However, it has since mutated to an ‘academic research-based’ social enterprise.

Other m-health applications have also struggled to achieve financial sustainability. In the case of the now defunct Ca:sh innovation, long-term sustainability could not be attained owing to withdrawal of funding by its main sponsor, the Indian government.⁹ Indeed, the long-term viability of private funding for m-health innovations in developing countries has been questioned. In an analysis of the financial constraints encountered in scaling up the TeleDoc application, Singh³¹ argued for complementary government funding.

Government

Despite some impressive results in the UHIN project, including scaling up from two to five health districts,¹⁴ institutionalization into the national health system has not yet been achieved. The UHIN project started as a commitment made by government leaders on MDGs at the G8 meeting in 2002. It was funded initially by the Canadian government. Substantial buy-in has been achieved with governments at the district level. However, this has not occurred at the national government level. This may jeopardize its future financial security.³²

Despite these financial concerns, the UHIN project managed to attain international visibility. It has been transferred to neighbouring Mozambique and planning is under way in Rwanda. Information from the Mozambique project indicates that early involvement of the government has contributed immensely to its diffusion.³²

From the above, it can therefore be surmised that direct or indirect government support affects the financial sustainability of m-health applications in developing countries. Governments at local/district, national and even international levels have a significant role to play.

International governmental and non-governmental financial support is also important. Funding from the Spanish government enabled the implementation of the EHAS project. Non-governmental international financiers may, however, have a different outlook. Engineering professionals, telecommunication companies and international development organizations all contributed to the EHAS project.

Conclusion

Frequent misalignment between international development strategies and local realities in developing countries has been observed as a major cause of failure of initiatives and of wasted resources.⁴ There has often been a lack of coherence between micro-level practices and strategic or macro-level policies.³³ The outcomes of the m-health case studies are the results of micro-level practices within the health systems of developing countries. National and international policy initiatives, especially within the sphere of global health, are typical of macro-level practices. National and international grants, and social philanthropy, are important for sustainable m-health. So is institutional support from both national and international organizations. Institutional and financial support from national and district governments is required for long-term, successful m-health.

Further reading

Al-Hakim L, ed. Web Mobile-Based Applications for Healthcare Management. Hershey: IRM Press, 2007.

Istepanian R, Laxminarayan S, Pattichis CS, eds. M-Health: Emerging Mobile Health Systems. Berlin: Springer, 2005.

Bangert DC, Doktor R, Valdez M, eds. Human And Organizational Dynamics in E-Health. Oxford: Radcliffe Publishing, 2005.

Latifi R, ed. Current Principles and Practices of Telemedicine and e-Health. IOS Press, 2008.

Spil T, Schuring RW. E-Health Systems Diffusion and Use: The Innovation, the User and the UseIt Model. Hershey: Idea Group Publishing, 2005.

Xiao Y, Chen H. Mobile Telemedicine: A Computing and Networking Perspective. Boca Raton: Auerbach Publications, 2008.

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