A recent article in WHO bulletin identified important challenges to make M Health initiatives sustain beyond demonstrations and pilots. (http://www.who.int/bulletin/volumes/90/5/11-099788/en/index.html). For the first time I saw some systems thinking evolving as the world begins to develop understanding of delivering healthcare at the bottom of the pyramid.
Disconnected development of applications in absence of significant alignment with healthcare delivery models, financing models and supply chain of goods and services is most likely to remain limited in its impact. I have attempted to express my views taking on board the lessons learnt from small pilots and looking towards a promise of better healthcare delivery system.
1. M-health needs to move towards sustainability and then develop an evidence base: It is desirable to build an evidence base for a new way of doing things but the real challenge is to ask the right research questions and measure the right things. Evaluating isolated systems not built on systems thinking may show some positive outcomes when compared to no intervention. Something will always be better than nothing, but does that provide answer to a range of issues and problems? Is the intervention scalable? Is it compatible with existing healthcare system and its drivers and does it align with regional/national agenda? How will a limited intervention (e.g. focussing on HIV or malaria or smoking using mobile phones) look like in light of bigger picture where equally important illnesses/contributing factors would need to be addressed?
What I am trying to emphasise is – it would be far better and perhaps sustainable for funding agency to support M health initiative as a part of larger drive to achieve a sustainable healthcare delivery system and then perform a rigorous evaluation to develop an evidence base. I don’t think an M Health intervention to support antenatal care and another to support HIV medication use and a third to track institutional delivery would deliver value as against a seamless one. Having a systems approach and collection of evidence in itself would still be limited if we cannot compare and Meta-analyse results across regions/countries. Therefore measuring similar parameters in standard format is perhaps the best way forward.
2. M-health systems should be interoperable with existing e-health initiatives and M-health should adopt and implement the same standards already present in e-health: These are essentially two sides of the same coin. There is no interoperability without standard based communication. If we continue to develop patchwork of interventions one for every disease and do not follow standards based coding then we will have the same problems as rest of the healthcare system, but probably even worse given lack of incentives and funding support post pilot. Moreover, many interventions tend to offer solutions without bringing physicians and hospital based systems into the loop. It may be harder in situations where private healthcare providers work independently, but again standards based design could easily enable opening of information pipelines as the model moves towards integration.
3. M-health should take an equitable and participatory approach: It is not only about patient’s participation in managing information but also provider’s participation is equally important. The issue becomes critical in developing world where illiteracy and disempowerment stand as barriers to patient participation. In such cases often intermediary health workers need to get involved. An ideal solution would enable transmission of data multidirectional between patients, providers, health workers and managers of the healthcare system. Such an approach will help to develop clinical and analytical grunt to the designing and planning and delivering services. Furthermore, participatory approach could be extended to the design process. Including potential stakeholders right from the start and designing while addressing each one’s needs would probably deliver a more sustainable intervention. A good healthcare system delivers for every one not just of the rich or the poor.
4. M-health needs to focus on health, not on the technology: Often the systems get designed with technology in forefront given the excitement of innovation. In healthcare, technology has always remained as an enabler of service provision - not a provider of services in itself. Ignoring this important principle has led to siloed, disconnected and incomplete solutions. Conceiving the services first and using workforce, technology, financing mechanisms and supply chain issues to seamlessly form a synthetic whole to design a healthcare delivery mechanism, is probably what we need. Technology has been tested, it will continue to evolve and become more reliable but in itself it will deliver limited advantage unless one sees technology in larger perspective of larger healthcare system.
