What's Ailing Mobile Health?

Introduction

The world is abuzz about the potential of mobile communications. When the number of mobile subscribers topped 3 billion earlier this year, it was widely noted that more than half of these people were in emerging markets. With mobile coverage expanding further in poor countries every day, development experts and business people alike are excited about what mobile phones might do.

Many expect that mobiles will provide users with much more than phone calls. In the same way that the spread of PCs and internet connections have changed everyday life for those in rich countries, mobile phones and GSM networks are beginning to do the same for the poor. Banking, education, trade, governance, healthcare—services which have been traditionally paper-based and in-person—are all now poised for a mobile transformation. The exciting outcome is more efficient, affordable and accessible services targeted for low-income users.

Of these service areas, mobile banking is the most advanced to date. Early success stories such as Safaricom’s M-PESA service in Kenya, and Globe and Smart’s competing services in the Philippines have contributed to a growing number of mobile banking startups across the developing world. It is estimated that there are now over 10 M people in emerging markets regularly using mobile banking services.

By comparison, mobile health has yet to blossom. Though the concept of using mobile networks to increase the reach of healthcare in developing countries has been tested repeatedly over the past decade, there is yet little scale to show for it.

This week I'm in Italy at a small conference on mhealth for the poor, hosted by the Rockefeller, UN and Vodafone Foundations. One of the research reports issued in advance of the conference, by Vital Wave Consulting, estimates that less than 100,000 people in developing countries have used mobile health services to date, and that of 50 known pilot projects around the globe, the majority have been discontinued.

What lessons can mBanking offer mHealth?

The success of mobile banking has led many here to ask "what can mhealth learn from mobile banking?" Even more specifically, folks are looking for an early success story that can catalyse market activity and awareness, asking "what is going to be the M-PESA of mHealth?"

I believe the catalytic model may be already underway in several markets, but it may have been overlooked because these models are quite simple and very commercial. Healthline in Bangladesh, Teledoctor in Pakistan, and MediCallCentre in Mexico each offer a simple consumer proposition: "Call a Doctor." For a premium but affordable call rate (or a monthly subscription fee in the case of Mexico) individuals can simply dial a number and speak with a doctor in a call centre. Healthline, relaunched 9 months ago, claims to have circa 10,000 callers per day, while Teledoctor - which started about 6 months back, has up to 2,000 per day. Meanwhile MediCallCentre in Mexico, which started in 2001, had 1M customers after 5 years but ballooned to 7M in 2007/8 due to changing their billing structure to charge households a fee on their fixed line bill (admittedly, not a pure mobile service.)

I presume that these medical call centre services, not included in the Vital Wave report mentioned above, and largely unknown to the people I've met at this mHealth conference, haven't been consider as bona fide mHealth. By comparison, most of the donors and public health organizations are focusing on more sophisticated services like disease surveillance, remote diagnosis, etc. which are predominantly built for institutions (hospitals, NGOs, Ministries of Health) rather then for consumers.

Furthermore, Healthline and TeleDoctor may violate taboos that make them less attractive to the public health community:

o Clients paying

o Profiting

o Care provided is “helpful” but not complete

o Taking doctors away of hands-on work

o Patient –generated (rather than doctor or PH generated) action

But I am enthusiastic about these services, both on the merit of their own value (validated by each customer who decides to call back) and in terms of the building block that I believe it could represent for a more sophistocated mHealth industry. I say this because they mimic many of the characteristics of early-stage m-banking platforms:

o Leverage strong & widescale mobile operator brand

o Provide easier access to clients

o Low-cost delivery of service

o Not panacea or terribly robust service at the beginning – just a simple consumer proposition marketed to the "person on the street."

Predictions

We need many more of these models to come to market to catalyse the mobile health market in developing countries. mHealth will take off when services are:

(1) designed for end-user needs

(2) simple service offerings (i.e. "Call a Doctor")

(3) affordable compared to existing alternatives

(4) can scale profitably

Finally:

(5) The services will get more sophisticated later

(6) They will be controversial (but shouldn’t be)

The Unintented Consqueneces of Top-Down

It is popular to say that good development efforts - and market-based development efforts in particular - should be "bottom up" as opposed to "top down."

It is less common to articulate, with examples, why. A recent article about the current political crisis in Zimbabwe by Stephanie Nolen of Canada's Globe and Mail newspaper provides a haunting one.

(For those unfamiliar with Stephanie - she is Canada's leading journalist on Africa and international development. Some-myself included-would say she is one of the world's best.)

The full article is well worth a read particularly if you are puzzled by the unexplicable ups, downs and delays of the resolution on Zimbabwe's Presidential election in May. But for those short of time, here is the quick synopsis:

> The International Criminal Court has been set up over the past few years, at great expense, to bring international war criminals and despots to justice.

> The threat of extradition and prosecution by the ICC creates even more incentive for despots to cling to power, since they cannot simply flee or buy their way to safety after losing their grip on power.

> Mugabe himself was ready to concede to the MDC in the days following the general election, but dozens of powerful henchmen in his inner circles - who have been responsible for committing crimes against Zimbabwe's citizens - fear so greatly about the ICC coming after them that they have not let Mugabe and ZANU-PF go down.

> The violence (most brutal in the past few days) is more than a party lashing out for political survival; it is a group of powerful, nasty and desperate people fearing for their lives.

What a twisted outcome. The notion that Western-led efforts to bring justice and safety to protect innocent citizens ends up backfiring by making it harder for perpetrators to let go.

This is a powerful lesson for us trying to make the world a better place: oftentimes the pursuit of what we believe to be "better" ends up making things much worse. It shows that it is particularly dangerous to apply Western-style ideas (in this case about justice; but I think the same is sometimes true of health care, communications, financial services, social progress, etc.) to developing country-contexts in an effort to help without a full understanding of ground-level realities and/or an unwillingness to compromise Western values, which we think should be universal.

I've long thought that "goodwill makes sustainability harder." It needs to be isolated and eventually weaned out of market-based development efforts in order for them to succeed in the long run. But this article makes me think goodwill is even worse; not just leading to unsustainable outcomes but to unintended consequences that make a situation even worse.

If only those worse consequences were unsustainble.

Innovation Edge

In London at "the innovation edge" conference hosted by NESTA (group w/ the mandate to encourage innovation in the UK.)

Tim Berners-Lee is speaking (inventor of the web) and just said two really interesting things: (1) (paraphrasing einstein) - if we knew what we were going to get at the innovative process, it wouldn't be called research. (2) Advice to grantmakers - don't ask those who you give money to tell you exactly what they'll get at the end of the process. (Otherwise you'll kill the innovative potential of what they're doing.)

Here here.

Cambodian taxi rank

Cambodian Kudos to twitter ...you've got to be impressed by a tool that instantly uploads messages to your blog when you’re in a country that doesn’t have mobile data services.

That said, my goodness mobile is prolific here. I was in Cambodia once prior in 2004 and don't recall seeing much evidence of any mobile network. Now 7 companies are competing. And people are all calling at will: In just over an hour since I arrived, an unconnected group of 3 taxi drivers have organized themselves via mobile phone. First the fellow selling rides at the airport called his mate in the parking lot who brought around a car to pick me up and ferry me to a nearby café, stationed on the side of the highway heading down to the coast. He called someone at the café who, ahead of our arrival, started flagging taxis that were passing by to find one that was already planning to go to the coast so that he could pick up a return fare and provide the other guys with a commission for their work. Efficiency!

Q: Can the Cellphone Help End Global Poverty?

A: Yes.


The New York Times Magazine asked a terrific question this weekend. And provided an even better answer in the form of a long feature story. Tremendous article; well worth a full read.

NYTimes: "Can the Cellphone Help End Global Poverty?"

But if you're pressed for time, the best paragraph explains why mobiles are different in developing countries than in the West.

"...forget for a moment about your own love-hate relationship with your cellphone, or iPhone, or BlackBerry. Something that’s mostly a convenience booster for those of us with a full complement of technology at our disposal — land-lines, Internet connections, TVs, cars — can be a life-saver to someone with fewer ways to access information. A “just in time” moment afforded by a cellphone looks a lot different to a mother in Uganda who needs to carry a child with malaria three hours to visit the nearest doctor but who would like to know first whether that doctor is even in town. It looks different, too, to the rural Ugandan doctor who, faced with an emergency, is able to request information via text message from a hospital in Kampala... There’s the live-in housekeeper in China who was more or less an indentured servant until she got a cellphone so that new customers could call and book her services. Or the porter who spent his days hanging around outside of department stores and construction sites hoping to be hired to carry other people’s loads but now, with a cellphone, can go only where the jobs are. Having a call-back number, Chipchase likes to say, is having a fixed identity point, which, inside of populations that are constantly on the move — displaced by war, floods, drought or faltering economies — can be immensely valuable both as a means of keeping in touch with home communities and as a business tool. Over several years, his research team has spoken to rickshaw drivers, prostitutes, shopkeepers, day laborers and farmers, and all of them say more or less the same thing: their income gets a big boost when they have access to a cellphone."