Open Health Initiative

In November 2012, the Heads of State of the East African Community (EAC) Partner States approved the implementation of the Open Health Initiative (OHI) to leverage the collective market size of experience and knowledge of the five countries to reach their goals for women’s and children’s health. The objectives of the OHI are to promote innovative interventions, enhance access to data and information for better results, and provide stronger oversight of results and resources for women’s and children’s health within the EAC through three thematic areas: Accountability for Results and Resources, Results-Based Financing, and Innovation for Improved Health Outcomes.

Innovation is defined broadly in the OHI as the use of technologies or approaches that can help accelerate the achievement of a result, make more efficient use of limited staff time and resources, or support interventions made possible with new tools and technologies. mHealth is therefore a key component. Currently in the region, technological innovations are seldom widespread, often small scale, and not coordinated or integrated within the broader health system. The lack of scale and evidence for projects often leads to inefficiencies and duplications of successful- and unsuccessful- pilots. By addressing innovation as a regional theme, the OHI can leverage successes and accelerate scale-up, with a focus on technological innovations such as mHealth.

A Regional Approach

mHealth has enormous potential to make an impact on reproductive, maternal, newborn, and child health (RMNCH), but will require strong coordinating and knowledge sharing mechanisms to reach its full potential. While the five Partner States are at dramatically different stages of development within the technology space, East Africa has one of the largest concentrations of mHealth pilots and programs in the developing world, which both stresses the incredible opportunity the region has to be a leader in this area, as well as the importance of sharing information across the region to avoid repetitive programs that do not make it beyond the pilot stage.

During the development of the OHI, the EAC hosted a regional ICT conference with representatives from e-health to share experience, evidence, and strategic plans. Following this collaboration of experts within Ministries of Health, the OHI developed a formalized mechanism to encourage knowledge sharing. The OHI will be supporting Technical Exchanges of ministry officials to learn through hands-on experience how a neighboring country is successfully addressing aspects of women’s and children’s health and creating a strong foundation for mHealth activities. These exchanges will be one ministry to another when there is an identified need, thereby reducing the duplication of efforts. With leadership coming from the highest levels of government and a huge amount of success coming from experts in the field, this approach will help encourage a decrease in pilots and an increase in adaptation and scale-up of successful innovations across borders.

With implementation beginning this year, the OHI will empower government experts to share best practices- not to stifle innovation but to encourage efficiency- and empower ministry officials to utilize data and evidence to identify where the greatest need for mHealth programs exist thereby maximizing the ability to reach and aid as many people as possible.

Since 2010 major progress in the fight against malaria has been made. Malaria mortality rates have fallen by more than 25% [2] globally and by 33% in the WHO African Region. Despite this progress, in 2010 there were still about 219 million malaria cases and an estimated 660 000 malaria deaths.

This year’s key message is “Invest in the Future: Defeat Malaria.” With the fact that malaria is preventable and curable and that increased malaria prevention and control measures dramatically reduce the malaria burden, there is a lot of potential to completely eradicate malaria.

mHealth offers various solutions from prevention and promotion to diagnoses and monitoring when considering the patient pathway, as well as educating health workers, enabling disease surveillance and mapping, collecting health data and improving reporting and supply chains when looking at health systems strengthening. One study in Bangladesh found that mobile phones, along with local knowledge, helped to ensure effective diagnosis and treatment of malaria in remote areas.

Unfortunately, not many mHealth initiatives are happening, but those that are happening are worth highlighting. One in particular is Vodafone & Novartis’ SMS for Life in Tanzania, which is one of the most recognised mHealth services where mobile and electronic mapping technology is used to track the stock levels of anti-malarial drugs at health facilities to manage supplies. For a better understanding of SMS for Life’s impact have a look at the video here.

Another interesting initiative was developed in Botswana by PING (Positive Innovation for the Next Generation) within their Disease Surveillance & Mapping Project mobile phone application that allows:

• health facilities to submit regular reports back to the Ministry of Health (MOH), and
• health workers to report real-time disease outbreak data, tag the data with GPS coordinates, and blast out SMS disease outbreak alerts to all other healthcare workers in the district.

The Ministry of Health in Uganda developed a monitoring platform that allows clinics to send in their weekly disease and malaria data via a multi-SMS report.  This involves replacing the MOH form with a “SMS-able” paper version  and creating web dashboard that provide overview of disease burden, including specific malaria treatment and diagnosis data and drug levels to help report stock outs. In addition, four students at Makerere University in Kampala have developed software called “Matatibu”, which will be able to diagnose malaria patients without a single prick on their skin, as well as showing them where the available treatment centre is located.

In 2010, 90% of all malaria deaths occurred in the WHO African Region, MOSTLY among CHILDREN UNDER FIVE years of age. A child dies every minute from malaria with an estimated 80% of malaria deaths occurring in just 14 countries. Together, the Democratic Republic of the Congo and Nigeria account for over 40% of the estimated total of malaria deaths globally [3]. As seen above, mHealth offers solutions to enhance eradication of malaria, but there can be challenges that make these solutions hard to implement. Various papers offer suggestions on how to overcome these, one of them being m-Enabled Inclusive Business Models: Applications for Health by SHOPS.

What are the challenges that your organisation is coming across? How are you overcoming it? And what are your thoughts for a small number of malaria-focused mHealth initiatives?

If you are interested in various mHealth initiatives, please have a look at the mHealth Tracker here. If you are aware of any other mHealth initiative that we are not listing on our mHealth tracker we would be very keen to learn more about it. You can either email us on mHealth@gsma.com or complete an online form here.

While mobile technology has attracted widespread recognition of the enormous opportunity for its application to development challenges, few mobile-enabled solutions are commercially viable.  New business models in mHealth are needed that take into account the constraints of a country’s health system and a community’s purchasing power.

SHOPS co-funded a study conducted by the Monitor Group which mapped 430 inclusive businesses* from nine African countries.  The purpose of the study was to identify successful business models that enable enterprises to engage profitably at scale with base of the pyramid (BOP) populations.  In the study, twelve m-enabled businesses were identified, but none were profitable other than M-PESA, which offers financial transactions through mobile phones.  A new primer released last week entitled m-Enabled Inclusive Business Models: Application for Health, examines enterprises leveraging mobile technology with considerable potential to contribute to poverty alleviation.

The aim of the primer is to highlight key practices that will assist m-enabled enterprises in potentially reaching commercial viability in the near term.  The selection of initiatives examined in the primer differs from other mhealth inventories in that its screen focused on financial sustainability, primarily consumer-facing models delivering health or agriculture information or services targeting the poor.  The ten business model lessons for mhealth are drawn from market-based solutions in other sectors that are on their way to commercialization and scale.

Following is a sampling of three of the ten lessons highlighted in the primer:

• Use trusted intermediaries:  Volatile cash flows make the BOP risk averse consumers, particularly for intangible goods. While ever-increasing mobile penetration has established a powerful channel to reach this market, successful service uptake requires engagement of trusted agents.  This translates into higher customer acquisition costs as experienced by the Pesinet program in Mali.

• Bundle services:  Intangibles such as insurance, information and preventive health care can enhance sales by combining with other offerings, focusing on portions of the bundle with near-term benefits.  Kilimo Salama bundles a crop insurance premium with agriculture inputs such as seeds and fertilizer.  Registration in the service is done via SMS and pay-outs are made through M-PESA.

• Diversify the customer base: mHealth programs driven by social mission and donor targets to serve the poor should consider their target market across broader income segments to secure a stable customer base.  Esoko provides market updates and trading information for agriculture value chain players.  A tiered pricing structure allows large corporate subscriptions to subsidize services to individual smallholder farmers.

By applying these and other levers to improve self-sufficiency of mhealth enterprises, sustainable business models are emerging.  But time, experimentation, and patience are needed.  As noted in Monitor’s earlier study on market-based solutions in India, it can take as long as 10 to 15 years for social enterprises to reach scale.  This suggests that the proliferation of pilots in the mhealth field today is an important contributor to the evolution and maturation of m-enabled solutions over time.

*Inclusive business, or market-based solutions, include those initiatives that offer socially beneficial goods or services to poor consumers or provide improved incomes to small producers, agents or distributors, at scale, in a way that is commercially viable.

Photo: By Jessica Scranton. Photo Courtesy of SHOPS.

Similar to other countries, even South Africa is fighting the Pilotitis problem. Most of the services are small and focusing only on certain districts. Not many services are commercial and most are still trying to build a better understanding of a sustainable commercial business model. As of January 2013, 41 services were funded by donors and 7 by the government [2]. None of the services that are listed are funded by an advertising model and rare are the examples where organisations developed successful customers’ or business’ revenue generation business models.

The GSMA mHealth team is conducting research to obtain in-depth understanding of the commercial and technical landscape of the mobile industry in South Africa. An important part of this research is the update and verification of existing entries in the mHealth Tracker to provide a better overview of the current state of mHealth services in South Africa.

With this in mind, we would like to kindly ask you to have a look and let us know if any updates are required if your product or service is already listed. If you are not yet included in the mHealth Tracker, please let us know so we can add you to the Tracker and ensure you are included as part of our Country Feasibility Report.

Please send updates and additions to mHealth@gsma.com. Thank you for your help!

It is time for us to get past the proof of concept stage for mHealth. The concept has been proven. We now have evidence that mobile phones in the hands of a health worker can lead to more accurate diagnosis and treatment of acute problems such as pneumonia and dehydration. Diagnostic tests linked to a phone can improve identification of malaria. Reminders and alerts can help patients remember take their drugs at home. We can reduce the number of stock outs of drugs in a health facility. Community health workers (CHW) can do more with mobile phone support and supervisors can know what they are doing. We have seen a great quantity and quality of health knowledge through broadcast messages and social media to adolescents, mothers, and patients with chronic disease. People can monitor their diet, blood pressure, heart rhythm, breathing, and exercise while sitting at home. Better client knowledge, better provider competence and better systems management lead to better efficiency, higher quality and better health outcomes.

The question now is: where is mHealth going? What will be the shape of mHealth 2.0? Of course, “it’s difficult to make predictions, especially about the future.” (A quote often but incorrectly attributed to Yogi Berra and Nils Bohr. More info). But I think that the future of mHealth can be predicted since most of the components are either already developed or in late stage development. So here is what I see for mHealth 2.0.

The phone will be the center of diagnostics at home and at all levels of health facilities. Some of you will know about the Qualcomm Tricorder X prize. Ten million dollars for a phone-based device that can diagnose anemia, infections, stroke, lung disease, and a variety of other conditions. But the trick is that most of these diagnostic tests exist today, just not through a mobile device. Each is a standalone device, available for use in the doctor’s office. What is being asked in the competition is to modify the technology so it can use the processing and sensing capability of the phone to accurately make these diagnoses. But this is only the beginning. Within 10 years we will have a mobile phone that can accurately diagnose almost all conditions, using the camera, microphone, and touch screen for inputs with perhaps one or two other wirelessly-linked (think Bluetooth but one that actually works) inputs for things like cardiograms, encephalograms or analysis of blood. This is a modern-day conception of the original tricorder of Star Trek. No limits, it told you what was wrong and how to fix it. Soon to be in the hands of every health worker worldwide.

But now let’s consider how would we train Dr. McCoy [1] to use this tricorder. Since the tricorder knows which sensing device to use and which test to run, the training would not need to include this. All those years of learning anatomy, physiology, and pharmacology would be unnecessary. What Dr. McCoy needs to know is how to use the machine correctly and how to do procedures that cannot be done by a phone. I wouldn’t expect a phone to remove your appendix, although of course a robot could.

In low income countries, a community health worker would have a tricorder that could diagnose pneumonia, dehydration, malaria and meningitis and tell the CHW what drug to use and when to refer the patient. But the CHW needs to know how to examine a child or how to collect blood for a test. So the training would focus on these skills related to the use of the machine. It might also focus on how to counsel someone with questions about health or about how to take their medicine or nutrition. And knowing the CHW will have a phone in his/her hand also means that we can send periodic updates about new treatments or new diagnostics. Or perhaps the CHW needs to refresh her knowledge of the skills she learned in school. We can send short training videos to the CHW that are based on the original training material and we can have additional information available to the CHW if she wants to know more.

Now imagine a world in which every health worker has a mobile device that does diagnostics like a tricorder. But because it is a phone, the record of what is done at each visit can be documented and analyzed. This is the basis of an electronic patient record so that we can track a patient across multiple visits, keeping track of weight gain or loss, progress during pregnancy, immunizations, or control of a chronic disease. This record is kept on the phone but also synchronized with a cloud-based database enabling records to be transferred from one facility to another when a patient is referred or goes to multiple sites for different types of treatment.

Imagine an example of a pregnant woman on treatment for TB.. She gets followed for TB in one clinic, while her pregnancy is followed in another. She needs a common record so that the staff in each clinic know about what is happening in the other. No problem. Or she visits her mother to have the baby in her home district. Also no problem. This is the value of an electronic patient record. But the record can also be used for other things. By look at patterns of diagnosis we can use it for surveillance. Perhaps there is an outbreak of diarrhea in one region, or an increase in cases of malaria. We can look at diagnosis by provider and find that one provider diagnoses every patient with hypertension. Perhaps the health worker could use some instruction (remotely of course) on hypertension. Or perhaps there is actually an epidemic of hypertension in one area (however unlikely this seems).

In any case, by having the records of each clinical interaction we can know what the health worker is doing, what are the patterns of disease, what are the utilization patterns of drugs. And by using the data we can help supervise the health worker, improve drug logistics and plan resources. Real-time comprehensive data in an easy-to-use format creates an information link across the entire health system improving efficiency and quality of care.

Finally, imagine too that patients have access to this information – their own patient record. Messages tailored to them about pregnancy, about disease, about care, about their next scheduled appointment. All of this is currently being done, but only in a few places and only one piece at a time. Soon, however, patients will receive information they want in a format that they like. Can I get pregnant from kissing someone? Can I get AIDS from kissing someone? Where is the nearest health facility that can diagnose the cause of my weight loss? Individualized access to information is one of the hallmarks of the internet. Individualized access to health information will be one of the hallmarks of mHealth 2.0.

For those with a smart phone, (which will soon be the only kind of phone – do you really want a stupid phone?) apps will help you with your diet, with your kid’s health needs, with your ability to keep track of drugs you take (or those that your parent or child takes), and with your next appointment. If you need to pay for a clinic visit or a drug or transportation, you will use mobile banking like M-PESA in Kenya and Tanzania. Need to schedule an appointment? Text this number. Want to check if a drug is counterfeit? Text this number. Want to complain about a health worker? Text this number (toll free).

mHealth 1.0 was about technology. mHealth 2.0 is about linkages. Linking clients or patients to knowledge. Linking diagnostics to treatment. Linking health workers to each other. Linking data to action. In making these linkages, mHealth 2.0 will create a new kind of health system — one that works. Or at least one that has the potential to work. Will mHealth 2.0 cure the many problems of health systems today? Obviously not. Only people can make things work. But we now have a tool that uses existing infrastructure to do things that we could never do before. And with that tool we will see health workers who are more competent, patients who are more knowledgeable and systems that are more efficient. That is a good start.

It is nearly impossible to discuss mHealth without the topic of “scale” coming up. Although achieving scale is not required or even appropriate for some use cases, governments in the developing world are increasingly frustrated with pilotitis and are requiring mHealth innovators to start planning for national scale interventions. However, there is another problem: scale is often discussed only in very superficial terms. The metrics of achieving “scale” are often associated with either percentage of population covered, or geographic reach. Yet these metrics miss key indicators – including those measuring sustainability – required to accurately guide if an initiative is truly “scaled up”.

In Uganda, the Ministry of Health – with support from UNICEF, WHO and DFID – are “scaling-up” a RapidSMS based, mobile disease surveillance and medicine tracking tool – mTrac – that extends the reach of DHIS2 to the Health Facility level. A year after launching, we currently have over 15,000 staff trained and registered, and 1,500 government health facilities using the system. This covers approximately 70% of the country, and we expect to reach 100% coverage by May 2013. By most standards, this alone should equate to “scale”. But does it?

For many mHealth initiatives, government ownership is crucial to long-term success. Yet working with government is not always quick and easy; donors, development partners and private sector companies sometimes take short-cuts, bringing government along only in a cursory fashion or not at all. mHealth projects are piloted (some at significant scale), achieve all of the projects objectives and are deemed a huge success, project funding comes to a close, and the project implementers prepare to hand over the initiative to the government only to find that they are unable to or unwilling to either scale-up or sustain the initiative. The mHealth project joins the graveyard of other “successful” mHealth projects. What went wrong, and what other key factors are required not only to reach scale but to sustain it?

Enabling Regulatory Environments

For most mHealth initiatives, even those driven by the private sector and which we can assume will start with a sound business model and projected revenue streams required to sustain the project, at some point government must be engaged. This is especially true with the growing number of mHealth applications in developing countries which provide consumer oriented services, including those that register pregnant mothers, and send them general information, tips, reminders for clinic visits, and notifications to pick up test results. Unless these mHealth applications adhere to government laws and policies, such as those that address privacy and security of electronic health records, a well-intentioned project could quickly find itself on the wrong side of the law. What complicates this further is that these laws and policies do not yet exist in many developing countries (although this is quickly changing). mHealth innovators in countries with gaps need to at minimum be aware, and ideally play a role, in advocating for appropriate laws and policies that create an enabling environment – understanding that too much regulation can cause as many problems as too little regulation.

Country Ownership

In the past, most Ministries of Health in developing countries did not have a single entry point, or coordinating unit, for mHealth. If a funder interested in malaria diagnostics wanted to support an electronic system to track consumption of anti-malarial drugs, they would go to their countries department charged with malaria control or medicines. At the same time, another funder would be approaching the epidemiological surveillance department with a similar tool for tracking notifiable diseases, while a third funder would be working with the communications team to send reminders for patient adherence to anti-retroviral medicines.

This is also changing, but many countries still see mHealth not as a cross-cutting enabler that impacts all programmes but as “IT issue”. However, some countries – including both Rwanda and Uganda – are setting up actual Health Information Departments and creating eHealth Coordinator positions that do not just create a token coordination roll but have real power with senior level decision making and budgets.

 “Islands of Data”

Even where there is coordination and government leadership, too often there is a project –rather than systems – focused approach that creates vertical information silos, or “islands of data”.  As these vertical systems overlap, confusion is created amongst end-users and new barriers to interoperability – and sustainability – are created.

Now, many Ministries of Health are taking a different approach: they are looking at the Health Information System as a whole, with interconnection and interoperability a tacit requirement of a properly functioning system. This includes recognizing that there are certain databases or registries, such as those for facilities, providers and clients, which should be centrally managed and shared across applications. Without a common baseline of shared information, a health system, particularly one dependent on IT systems, cannot function.

Private sector partners, donors and mHealth application developers should all take heed. Some government bodies are beginning to consider “accrediting” mHealth applications, and failure to comply with emerging standards around system architecture and accompanying Application Programming Interfaces (APIs) could lead to projects with the potential to scale being shut down.

Sustainable Financing and Human Resources

As part of this approach to developing an enterprise level health architecture, many governments are now also taking a new look at the infrastructure, human resource and financing requirements needed to meet these new needs. It is critical for government to fully understand the total cost of ownership of any initiative before they decide to invest resources, and make an investment case on using these resources to support and maintain them.

If government has not dedicated sufficient human resources to manage the systems, including hardware support to deal with broken devices (including phones) and technical resources (either in house or outsourced) to maintain and upgrade the software applications, and financial resources to pay for them, then these mHealth initiatives – particularly those approaching or operating at scale – are sitting on shaky ground. If donor funding disappears, equipment begins to degrade and breakdown over time, or a myriad of other unplanned issues arise, quick wins could rapidly turn into painful lessons learned.

Conclusion

In Uganda, through initiatives like mTrac, we are grappling with these challenges. The Ministry of Health, along with partners like UNICEF, are now regularly meeting with other Health Development Partners to address duplication of efforts and coordinate support and funding. We have greatly reduced “competition” between partners and provided a forum for dialogue, which has been a key factor in the successes we have achieved so far. However, it is also clear that there are also no easy answers and each win is often hard fought.

Designing a successful mHealth application is only the first part – technology should not be the driver, but serve the people and the systems it is meant to support. It is only when you look beyond the numbers and address the structures required to sustain them that true scale – and sustainability – can be achieved.

Photo: Courtesy of author.

Arjen Swank, Text to Change’s Programme Manager and Business Developer, spoke as part of the session ‘Health: Innovating for Global Health’ about the challenges, tools and lessons learnt.

In fact, Text to Change’s main lessons learnt are very similar to most of the other players in the mHealth space. As Arjen identified in his presentation, when working in the mobile health space, one needs to:

• (Re-)consider their own resources
• Set realistic timelines
• Get the content right
• Incentives work!
• Involve the right mix of communication channels, with a combination of broadcasting through traditional media and narrowcasting with new media. Or, as Marcus Sigurdsson from McCann Health said in a separate presentation, ‘Success is not dependant on technology! Healthcare is a medical challenge. Health is a communications challenge.’
• Technology is a tool, not a goal in itself. Oscar Gómez also addressed this during his presentation, saying, ‘Technology is a key to improve healthcare models… but it’s not sufficient!’

Text to Change’s Main Recommendations:

• Understand where and with whom you work
• Take time to develop a comprehensive program design
• Create partnerships for the most impactful service by searching for synergies and stick to your expertise
• Plan multiple moments for M&E. Be flexible and adjust where required
• And above all, Keep it simple!

A Strong Foundation for Partnerships

Kirsten Gagnaire, the Global Partnership Director for the Mobile Alliance for Maternal Action (MAMA), also shared key learnings in her presentation: Health: Achieve Scale through Partnerships. She discussed partnership building, with a focus on building a strong foundation for partnerships and lessons learnt.

According to Kirsten, a strong foundation for partnerships has:

• A common vision
• Common goals
• Governance
• Clear roles and responsibilities
• Shared values, and
• MOUs

As Kirsten stressed, when work with partners it is very important to:

• never underestimate time that needs to be invested into building and maintaining relationships
• understand an ROI expected from partnership of each partner
• understand partners’ culture and how to effectively interact and communicate
• understand and clearly outline financing, funding, streams and associated fees, and
• obtain written MOUs with clear commitments including how and when commitments will be executed

The importance of partnerships was echoed by Oscar Gomez, in his presentation ‘Partnering with the Customer’. According to Oscar, ‘Building partnerships is a key to deliver’ However through his eyes, the most important partner is THE CUSTOMER.

Putting it all together

Even though the mHealth industry recognises the above lessons and recommendations as important elements in creating sustainable mHealth services, I find that often these are not put into practice. Organisations that overvalue their own resources, set unrealistic timelines, or do not use a mix of communication channels are not rare. Also not rare are examples were too little effort is put into the content itself, too much in the technology and no incentives are considered.

mHealth is challenging! However, as we all know by now, the opportunity to create a sustainable mHealth service is great! This opportunity requires a lot of effort in all the elements mentioned, including: partnership creation, promotion, content, technology and incentives.

Co-hosted by the mHealth Working Group and the mHealth Alliance, this online discussion forum aims to gather input from the global community about their opinions on and experience with scale-up and sustainability. The discussion follows the recent Skoll World Forum debate series on Moving beyond Pilotitis.

Experts representing a variety of organizations will address the following questions:

• What does it mean to design for scale and sustainability?
• Does designing for scale and sustainability alleviate ‘pilotitis’?
• What are the drawbacks of designing for scale and sustainability from the beginning (particularly for new mHealth programs)?

Some of the experts participating will be:

• Kirsten Gagnaire, Mobile Alliance for Maternal Action (MAMA)
• Alain Labrique, Johns Hopkins University School of Public Health
• Garrett Mehl, WHO
• Steve Ollis, D-TreePamela Riley, Abt Associates
• Kelly Keisling, NetHope
• Shariq Kohja, mHealth Alliance
• Jon Payne, mHealth Alliance
• Jon Jackson, Dimagi
• Merrick Schaefer, World Bank
• Brendan Smith, Vital Wave

The upcoming forum will expand on the mHealth Working Group’s discussion forum from earlier this year. The active, five-day discussion centered on themes of the draft brief “mHealth: Emerging High-Impact Practices for Family Planning.” Community members shared their experiences with mHealth projects and traded tips and links to helpful tools and resources. A total of 37 participants representing more than 12 countries and 22 organizations made 52 contributions to the discussion.

To participate in the forum from March 18-22, 2013, simply reply directly to any forum-related emails. If you’re not a member of the mHealth Working Group listserv, sign up at knowledge-gateway.org/mhealth. If you have any questions about how to participate, email Allison Bland at abland@jhuccp.org.

The mHealth Working Group is a collaborative forum for sharing knowledge and developing promising practices on mobile technology for health. Founded in 2009 with global health organizations, the Working Group frames mHealth within global health strategies and standards. The mHealth Working Group is facilitated and supported by USAID’s K4Health Project. The Working Group holds regular meetings in Washington, DC, to discuss promising approaches, challenges, and lessons learned. The group promotes approaches that are appropriate, evidence-based, interoperable, scalable, and sustainable in resource-poor settings. Over 950 representatives of more than 200 organizations in 45 countries participate in the mHealth Working Group.

The mHealth Alliance advances mHealth through policy research, advocacy, and support for the development of interoperable solutions and sustainable deployment models. Working with diverse partners, the mHA sponsors events and conferences, leads cross-sector mHealth initiatives, and hosts HUB (HealthUnBound), a global online community for resource sharing and collaborative solution generation. An idea that emanated from a July 2008 conference in Bellagio, Italy on the future of mHealth, the mHealth Alliance was ultimately launched at the GSM Association Mobile World Congress in February 2009 by the United Nations Foundation, Rockefeller Foundation, and Vodafone Foundation.

Photo: Courtesy of m4RH program

Health played important role on the conference side. With two seminars in the main conference programme and four additional seminars on Thursday, a lot of buzz was created around health and mobile health. It was interesting to see how newcomers to the field were still discussing how mobile can improve access to health, reduce costs and increase efficiencies, and how existing players already spoke about challenges and how to create sustainable business case.

One of my favourite presentations was from Sara Chamberlain, the Head of ICT in India for BBC Media Action, who discussed mHealth in the context of their recent Mobile Kunji and Mobile Academy project [1] launch in Bihar, India. Her presentation, ‘Making a living from mHealth isn’t easy…’, covered everything from how challenging mHealth is even though ‘the scale of opportunity is huge’ to presenting how BBC Media Action overcame these challenges with their project.

If I were to summarise Sara’s presentation it would cover three things, opportunities, challenges and recommendations:

OPPORTUNITIES:

• Over 103 million people in Bihar, India, including 27 million women of child bearing age;
• 80% of 15-49 year old men and women have access to a mobile phone
• 63% of men and 32% of women own a mobile phone
• 100% of community health workers have access to a mobile phone

CHALLENGES:

• Old, used, damaged, or basic mobile phones, where the majority of these ‘grey market’ copycat handsets do not support local language fonts
• High illiteracy level: 70% of women in rural Bihar are illiterate
• Low mobile literacy and very recent adoption of mobile technology: 91%  of those surveyed have never sent an SMS
• Low disposable income to spend on phone calls: 53% of Bihar’s 103 million people live below the poverty line

RECOMMENDATIONS to achieve sustainable scale:

• Make it cheap, share revenue to cover costs and create value for advertisers
• Demonstrate value to the public sector
• Develop partnership for scale

Given that the above is only a snapshot from a huge learning that BBC Media Action achieved in Bihar, I highly recommend reading Yvone MacPherson and Sara Chamberlain’s recent Policy Briefing: ‘Health on the move: Can mobile phones save lives?’

Not too long ago an article was published by our good friends from Johns Hopkins University and the WHO entitled: “H_pe for mHealth: More “y” or “o” on the horizon?” They offer a tempered, yet somewhat optimistic view of the scientific landscape of mHealth evidence. That’s great for the medical community and tracks the historical evolution of medical devices globally. Here at the GSMA we’ve set ourselves a goal in 2013 for taking this a step further and trying to demonstrate the business case for mHealth in emerging markets. After a year spent identifying, validating and testing the value drivers amongst public and private stakeholder groups we know what this looks like in a spread sheet. We can finally argue a long term, shared value proposition.

But now the real challenge is taking those business cases, aligning to country specific health needs, negotiating with the consortia of partners, building out the win-wins for everyone involved and supporting the launch of services to a critical adoption rate. Mount Everest seems an easier mountain to climb. Watch this space in 2013 for stories of how organisations and companies move mountains to incentivise public and private stakeholders in emerging markets with oftentimes broken health systems to mainstream mHealth.