International mHealth Innovations and Applicability to Developed Countries – 9/23/11

I’ve intended to write a post about international mobile health for some time now, specifically mobile health in developing countries. I’ve even been jotting down notes for it in Evernote. 

I’ve had interesting conversations with US healthcare executives about international mHealth. In many ways, the developing world is ahead of the US, both in terms of impact and scale. It’s also possible, even with all the US hype about mHealth, that mHealth is getting more hype internationally in terms of potential to revolutionize health and wellness.

There are many reasons for the differences in stage and potential of mHealth between developed and developing countries. US healthcare executives I’ve talked to seem to get the potential of mobile health when they see it applied overseas, to the point international concepts and work I’ve done have directly resulted in at least one US partnership agreement and grant application.

Earlier this week, I came across a spectacular article specifically on mHealth lessons and limitations from international models. Yes, it was spectacular. The author, Jaspal Sandhu, has an impressive resume and I’m sure he’s written similar reports for some of his recent clients that include Microsoft, Clinton Health Access Initiatives, and the mHealth Alliance.

It’s worth a read if you want a good, concise picture of international mHealth innovation, both in terms of fit and lack of fit for the developed world. It covers a lot of the more well-known mHealth projects and players and has some cool tidbits, like that GlowCaps was an imitation of a South African medication adherence system. I’ll try not to repeat too many points that Mr. Sandhu made in his story and will try to expand on the subject based on personal experience and research.

My personal journey in international mobile health is based on experience with a for-profit mobile health company from founding to first contract. My co-founders and I felt strongly that a for-profit model was essential to scale and go beyond the current environment of grant-driven programs.

The company was launched as a joint venture with a global licensing agreement for a mobile, SMS-based platform that runs on feature phones, about 200 different models. Feature phones are low end, non-smart phones, or dumb phones, by extension. The platform was built to bring a smart phone-like experience to mobile services on low-end devices. It was also natively SMS to provide certain remote push capabilities as well as security features.

Our idea was to license the platform, which is still pretty new though it is on about a million devices in Africa and India, for healthcare. That seemed like a good pitch for scale, especially given the newness of most mHealth companies and technology, and also made development and startup costs very low. We also forged a partnership with a smallish hardware maker in Africa to offer a bundled package to organizations.

The initial idea was a community health worker phone, both hardware and software, that would integrate with OpenMRS, the most widely used EMR system in the developing world. We found this pitch to be too hard to sell, especially as we were not academically affiliated and had missed the Gates Challenge that had funded two similar companies. As we were told by an mHealth Alliance board member, we were much further along in terms of OpenMRS integration and links to mobile payments, but Gates money had already been spent and those organizations would be hard to unseat. That seemed understandable.

We transitioned from community health and clinical offerings to retail health, something that is growing in Africa, and eventually settled on mobile supply chain and monitoring and evaluation (M&E) services specifically for healthcare organizations.

The contract we eventually got, right before I decided to step back into an advisory role, was with a health delivery organization in Uganda that is using the platform and modules we designed to track clinic data in aggregate and health-related supplies (meds, bed nets, reproductive health) from the national level down to clinics and small pharmacies/retailers. I actually don’t think it’s terribly innovative, but we had a good USAID connection in Uganda that sealed the deal. The vision is much bigger than the initial contract, so hopefully it will evolve into something extremely novel and valuable. We’ll see.

I was planning on writing this post with lessons learned that can be applied to the US, but I’ll use what Mr. Sandhu wrote as a starting point. His five lessons learned are below.

Go Beyond Apps

I could’t agree more. The article cites the same Pew Internet data I’ve mentioned before, but comes to a slightly different conclusion. I think text messaging and interactive voice recognition have very limited applicability to impact health and wellness in the US. It might work for basic functions such as med adherence, which I acknowledge is a major problem.

My opinion, though, is that text messaging for chronic disease care is not a viable way to create behavior change because it is such an isolated, static event, not giving the patient access to their full health picture and status on an ongoing basis. To create change and engage patients, they need to know, at all times, what happened previously or what is going to happen in the future.

Text messaging services overseas, for things like medical education games, are perfect because they provide users with relevant information to which they otherwise would not have access. We have regular access in the US to healthcare information and consumers are increasingly going online to get it.

OK, so I realized I didn’t answer what else needs to be done to go beyond apps. I think it involves connected health devices, like MedApps and Telcare and others that will be launching very shortly. I also think it involves suites of solutions and services instead of individual offerings in isolation.

Target the Underserved

Well said. I know Denver Health has some promising results related to mobile health for an underserved, Cricket-using population (Mr. Sandhu mentioned Cricket in his article as well.) A Denver Health  presentation out there somewhere (I think by Andy Steele, MD, or Susan Moore) gives more info about the SMS trial, but I can’t find it. Is there anybody that has it and can send a link?

The article discusses, although not in terms of relevance to underserved groups in developed countries, is the use of mobile incentives. Mr. Sandhu writes about the promising links between health and mobile money or incentives internationally. I also found a proposal by his company that is largely based on mobile incentives to improve health, so I’m sure he’s very well versed in this type of incentive.

Why not use the same thing in the US with underserved groups? You submit your weight (or glucose or blood pressure or steps or whatever) each day and at the end of the month, if you meet some goal for self reporting, you get a bunch of Cricket credits. I guess you could do the same thing with smart phone users if you used things like iTunes credits. I’m not sure about regulatory limitations on incentives like this, but it sounds like it would be worth trying. Does anybody know anybody doing it?

Engage Smaller Operators

I think this is the same as the lesson above. The article differentiates by looking at smaller wireless carriers as great partner targets for mHealth service providers because health services represent new streams of revenue in a very competitive environment. Good points. I think this is how GreatCall operates.

Mix Digital and Tactile

Again, great lesson. The examples of Sproxil and X Out TB are perfect. I imagine there are some very cool imitations of X Out TB that could be used in the US. The issue again is incentives. I’m not sure who would pay for it in developed countries, but you do need incentives, such as free supplies or lower premiums, to get people to use services like this.

Completely Rethink Business Models

Internationally, many mHealth business models are dependent on mobile incentives, mobile money, or mobile payments for things like micro-insurance. Mobile incentives alone will not work for all populations in developed countries, though underserved groups might be a good group to target if you wanted to copy the international model.

I think the point made earlier in the article, "multiple stakeholder groups might also collaborate to pay for a single service", is extremely relevant here. Healthcare financing in developed countries, most especially the US, is extremely complex. It is not as easy as getting the big funder, like USAID or PEPFAR, to sign on. I think many sustainable business models in the US will engage multiple entities to fund individual services.

Other Challenges

I think there are a couple of other challenges in developed countries that companies operating internationally don’t face. First, regulation and policy related to security and privacy, while generally well-intentioned, hinders innovation. We sold a mobile platform for patient data collection in Africa without any discussions about Meaningful Use or patient privacy. The only concession was that the servers had to be housed in Africa and not with Amazon.

This is probably not ideal at this extreme, but the point is that new mHealth offerings are a lot easier to test and roll out without such high penalties and such ease of legal action. This is why we’re seeing such a dizzying array of offerings internationally.

Second, the centralized nature of health funding in developing countries makes who you know very important. Of course who you know and have access to in the US is important, but generally one organization cannot push mobile health programs onto others.

Well, I guess HHS did it with Voxiva and text4baby in the US, so I know that there are exceptions. But from my experience, getting the number of signoffs for a sale with a health system in the US is considerably more challenging than having the org that funds 100% of operations for another local org tell that local org that some mHeath program should be a part of the next budget.

I hope this was interesting and I’m sorry if it went long. I do find the subject fascinating and wish developing countries weren’t so hard to commute to. I’d love to hear from others that have had experience with international health tech work.


Travis Good is an MD/MBA involved with health IT startups.


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