Sandhu stopped by CHMI’s Washington hub at Results for Development recently to discuss his piece, which highlights six innovative mobile services from emerging market that could be translated to industrialized countries. Sandhu’s article also describes existing barriers to bringing mHealth models seeded overseas to the United States, including lack of evidence, unclear regulation, and market failures endemic to the American employer-based health care system.
The focus on translating innovations coincides with the new Ashoka Changemakers contest Innovations for Health: Solutions that Cross Borders (the subject of a Twitter chat on Monday, December 12). Here are a few takeaways from our chat with Sandhu for people designing mHealth programs.
Live in a high-income country? Look south for ideas to expand access and cut costs. “The goal should not be to copy programs exactly, but rather to adapt global innovations for the developed-world market,” writes Sandhu. There is evidence that mHealth models from developing countries are already taking root in the states: Maryland governor Martin O’Malley announced recently that the state will adopt HMRI’s health hotline model—which promises to improves health access and efficiency—in Prince George’s County. “It’s not about reverse innovation—it’s about cross-learning,” said Sandhu, noting that the flow of ideas needs to go in both directions. Read more about Maryland’s partnership with India here.
Understand how people use their phones around the world. Sandhu meticulously observes the way people interact with their phones. “The focus in mHealth has been on SMS, but we often forget that the most basic use of a phone is to make phone calls,” said Sandhu. CHMI’s analysis of profiled mHealth programs shows that phones are the most commonly used information technology device in health programs; Our data show that programs may be as likely to use phones for simple voice communication as for SMS. Encyclopedic knowledge of phone plan offerings in a country of operation is essential for mHealth program designers, since usage of programs will depend on cost to users. “People know exactly how much things cost, say, in Kenya to call from Orange to Safaricom at a certain time or to send a text out of network.”
To avoid calling fees, which can be very high, people invent solutions. “In Mongolia where I lived for a couple of years people call and hang up after one or two rings—they describe the practice with the verb dohi, which literally means ‘to signal’. Such ‘flashing’ solutions have emerged in many other contexts around the world.”
Use mHealth applications to attract new mobile phone customers. Companies offer a slew of promotional benefits to get new consumers to sign up for new mobile plans, like games, ringtones, free minutes, bonuses, and “please call mes”—a way of formalizing “flashing,” or giving people missed calls to signal that you want them to call you back. “HealthLine in Bangladesh is at a reduced cost but available only to Grameenphone subscribers,” says Sandhu, “It is used to attract and retain customers.”
Money saved on mobile phones can be used for health. Changamka is a health savings scheme in Kenya we’ve written about before. “When you can’t touch the money [except to spend it on health services], it will work better than if you just ask people to save up,” Sandhu said, “The savings are enabled by the technology.” CHMI has a fledgling category for these mHealth payment programs, often facilitated by mobile money transfer services like the DFID-seeded, 8-year old service M-PESA.
mHealth for chronic diseases? Check back in a few years. “With chronic care, we’re very early on in the innovation cycle,” Sandhu explained. CHMI has profiled only a few programs using phones to target chronic disease. Because chronic diseases are tied to lifestyles, Sandhu noted that the omnipresence of consumers’ mobile phones in their day-to-day life offers unprecedented data about behavior. “We haven’t had access to information about what people do in their home,” said Sandhu. “You get a much more granular and intimate view of people and their interests in nonclinical environments: Where people are, who they connect with,” he said, pointing out that the data generated can yield insights about how to design programs to effectively prevent or manage chronic diseases.
“With Type 2 diabetes patients, you’d want to use phones to monitor eating habits and insulin levels,” he said, “the idea is that people would change their behavior if they saw how what they ate affected blood sugar levels.” Project HealthDesign, funded by the Robert Wood Johnson Foundation, examines how patients can use personal technology to track “observations of daily living” (ODLs). Based out of the University of Wisconsin, Project HealthDesign is in turn funding multiple concurrent efforts to explore applications of this concept. And now Ida Sim from UCSFand Deborah Estrin from UCLA through an initiative called Open mHealth are working to establish a standard set of tools to be used by mHealth application developers, primarily to take advantage of these ODLs. They are geared towards US-based applications, many of which focus on chronic disease, but there may be global implications down the road.