Taking mHealth Applications to Scale

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.

Each year, approximately 1.4 million mothers with HIV become pregnant and deliver babies. With access to testing and treatment, the risk of a mother transmitting HIV to her baby is minimal. And yet in 2011, 330,000 children were newly infected with HIV. Ninety percent of these children live in sub-Saharan Africa, and nearly all of them aquired HIV from their mothers. If effective treatments are available to prevent transmission, what else do we need to do to solve this problem?

One of the greatest barriers to preventing the transmission of HIV from mother to child in sub-Saharan Africa is low usage of health care services by pregnant women. There are many contributory factors. Women living in rural areas often travel great distances to reach a health facility, endure long waits, and then ultimately get only a few minutes of service from over-burdened nurses. Responsibilities at home and the stigma associated with HIV also make it difficult for many women to access treatment. As a result, many women do not receive antenatal care, and those who do often do not return for subsequent visits. Cell phone technology has provided an answer to this challenge of retaining women and their infants in the health care system.

mothers2mothers (m2m) employs and trains mothers living with HIV as “Mentor Mothers” to work in health care facilities. These women provide education and psychosocial support to HIV-positive pregnant women and new mothers, both to prevent mother-to-child transmission of HIV and to promote healthy motherhood. Through a monitoring system called active client follow-up (ACFU), Mentor Mothers can identify a woman at risk of falling out of treatment, remind her of missed appointments, and encourage her to access and use the critical medical interventions available to her. Cell phones are central to this follow up, enabling Mentor Mothers to prompt clients with text messages and phone calls.

m2m’s ACFU initiative began in 2010. It has scaled up to more than 80 percent of m2m’s program sites in seven African countries. In these facilities, Mentor Mothers are equipped with a cell phone and are given a stipend ($15-$20 per site per month) to make phone calls to clients. In recent years, cell phones have penetrated into African communities at an extraordinary rate. We estimate that in some countries nearly all of our clients have cell phones (more than 90 percent in Swaziland and Lesotho). In other countries with more rural populations, the proportion is much lower (30 percent in Malawi). mothers2mothers monitors ACFU outcomes: More than 8,000 new ACFU clients enrolled between July and December 2012, 73 percent of clients were reached, and, of these, 78 percent returned to care.

While cell phones have been effective in keeping women in care, they are not a solution on their own. Barriers we face in achieving scale include variable cell phone coverage in urban and rural areas; issues of disclosure and confidentiality, as some clients share phones with partners; and low literacy levels, making text messages impractical. There is a need to combine m2m’s mHealth approach with other means of reaching clients (including home visits), something we might best achieve by partnering with community health workers and community based organizations.

For other organizations that seek to implement mHealth solutions, it is essential to know your clients and how they want to be contacted. Stigma associated with HIV is an enormous barrier to overcome. Text messages or phone calls that might be intercepted by a friend or family member could condemn a program to failure. Faced with issues of confidentiality, it is essential that clients consent to participate in services offered to them.

An important lesson we have learned is that the people we serve live complicated lives. Phone numbers and addresses can change. At each medical visit, we reconfirm the phone number and residential address, and when clients haven’t responded to text messages, we ask if they are being received. Women want care. A personal text message or phone call goes a long way toward encouraging a woman to walk great distances, endure long waits, and seek health care in a world with many competing priorities.

NGOs are frequently able to implement programs that are beyond the capacity of governments. For ACFU and mHealth programs to endure, we must find ways for Ministries of Health to integrate these services into health systems (including resources to support technology, integrate systems, and ensure data use for decision making). Ultimately, we believe that the investment in mHealth and the contribution ACFU makes to improving uptake of and adherence to essential health services will pay dividends in averting adverse health outcomes and saving lives.

Read more stories by Frank Beadle de Palomo.