Building the mHealth Ecosystem

mHealth has the potential to transform healthcare, particularly for the hardest-to-reach women and children around the world. The debate about exactly how, when, and in what form is alive and well. Successful pilots are in abundance, but most of the sector has been slow to reach scale. In short, the sector has a case of mHealth Pilotitis. In the first debate of a series on mobile health, the Skoll World Forum on Social Entrepreneurship partnered with Johnson & Johnson and Stanford Social Innovation Review to surface important lessons and learning from some of the world’s leading organizations who have taken mHealth services to scale. This debate will also set the stage for a larger discussion on mobile for development at this year’s Skoll World Forum in Oxford, UK.

Too often, children and their mothers die because they can’t access simple care. The promise of mHealth is that it can help lessen the “distances”—whether infrastructural, political, physical, or financial—that add up to the preventable deaths of over 7 million women and children each year. Unfortunately, most countries have graveyards filled with failed mHealth initiatives that were technologically sound but missing key components to scale: costing for scale, designed for their end users, alignment with important partners and priorities, and adequate evidence.

There are examples of scale and impact. UNICEF, in partnership with the Government of Rwanda, has put in place a system where community health workers use simple mobile phones to register and track every pregnancy, report on danger signs, and ensure that the woman in labor, an ambulance, and a doctor end up at the hospital in time to deal with any complications. Across Zambia and Malawi, the results of an infant’s HIV test come back to the clinic via SMS, and the same system then triggers reminders to community health workers who ensure that the mother comes back to the clinic to get that result and that the child gets the appropriate medication. In Nigeria, the same system—RapidSMS—is used to register every birth, and across Uganda, RapidSMS is used to prevent and respond to stock-outs of lifesaving medicines.

The success of an mHealth initiative is ultimately measured in two ways: how many more deaths and incidence of disease it prevents over traditional models, and whether its benefits outweigh its costs. Hence, success means that the initiative has scaled to even the most underserved areas (where the majority of deaths occur), and is funded and supported over the long-term.

The three major barriers facing mHealth initiatives often stem from:

• The donor community, which still invests in activities but allocates insufficient resources and time to generating robust evidence in the space. They are largely disinterested in investing in scale, and often invest in technology rather than an approach to build large-scale mHealth initiatives.
• The lack of established national eHealth and mHealth strategies. Without a national strategy and leadership in the government, promising pilots have very little chance of scaling.
• A technology and public health culture clash. Public health experts often see the application of technology as a silver bullet for—or a distraction from—their health programs. Their inexperience in using mobile as a tool in their work and their hesitation to engage with technologists on a deep level can hinder the development of strong mHealth initiatives.

Developing, scalable mHealth initiatives need to:

1. Consider costs at scale. Buying devices and creating the infrastructure to maintain or replace them becomes a barrier to scale. For example, say an initiative is dependent on frontline health workers using smartphones, yet the average frontline worker doesn’t own a smart phone. In Ethiopia, where there are 40,000 frontline health workers, this would mean $1.2 million of investment for a $30 device.
2. Design for and with end users. Donor requirements are often confused about the needs of the end user. If the project creates a tool that makes the job of the end user easier and it is easy to use, it will be adopted and scale naturally; if you burden the end user with additional work that is hard to do, it will work poorly at scale.
3. Align with key partners and priorities. Working directly with governments in conceiving and implementing an mHealth initiative is key to scaling. If an initiative does not fit with national and global health priorities, the partners you need to scale won’t engage. If the Ministry doesn’t have the desire or capacity to scale, then even the most successful pilot will not scale.
4. Invest in evaluation. Impact assessment and evaluation is a field of work that often gets little play early on, but it is usually a prerequisite to attract further support and investment. Unless an approach can show real value that justifies allocation of already scarce resources and can be repeatedly replicated, it does not stand a good chance of being transformational at scale.

For UNICEF, the path to scale has had fewer barriers for a small technology focused group—we work directly with governments and have longer-term funding. The mHealth community needs an ecosystem in which smaller groups that are able to develop scalable mHealth initiatives can effectively partner with funders, larger organizations, and governments to develop long-lasting and scaled mHealth initiatives.

Read more stories by Erica Kochi.