Elsevier

Health Policy and Technology

Volume 1, Issue 3, September 2012, Pages 155-164
Health Policy and Technology

From pilot to scale: Towards an mHealth typology for low-resource contexts,☆☆

https://doi.org/10.1016/j.hlpt.2012.07.009Get rights and content

Abstract

The paper classifies mobile phone based solutions for Health Information System (HIS) in low-resource contexts into four types: interactive voice response (IVR); plain-text SMS; locally installed handset and SIM-applications; and browser-based solutions. The resulting reference typology details the strengths and disadvantages associated with each solution type along four dimensions: robustness to low-resource contexts; flexibility for organisational and functional change; usability; and financial cost. The paper demonstrates how the strengths and disadvantages associated with each solution type become more evident when implementations are intended to scale in low-resource settings. Early decisions about whether or not to leverage health workers own handsets, initial arrangements with mobile operators and requirements regarding the solution's capability to support offline work may shape the choice of solution type and have long lasting implications. The typology is produced through involvement with longitudinal action research projects, including the statewide implementation of an application-based solution in one Indian state.

Highlights

► Typology of mHealth solutions for Health Information Systems in low-resource contexts. ► Solution types measured according to robustness; flexibility; usability; and cost. ► Solution type strengths and disadvantages become more evident in low-resource settings. ► The typology is produced through longitudinal action research.

Introduction

Considerable efforts are made by national governments and international aid agencies in order to alleviate human deprivations such as rampant communicable diseases, starvation and malnutrition, and high rates of maternal and young child mortality.1 The availability of timely and accurate health information is, as noted in [24], required for the “strategic planning and setting of priorities; clinical diagnosis and management of illness or injury; quality assurance and quality improvement for health services; and human resource management” ([24], p. 161). The appropriate use of information and communication technologies (ICTs) can improve timeliness, strengthen data quality, and facilitate evidence-based decision making for health [4], [13], [21]. However, as is pointed out in [26], the majority of health information users in less developed economies have not had access to the infrastructures required for adopting and utilising computers and landline Internet connectivity.

The extensive and swift rollout of mobile telecom infrastructures has triggered an avalanche of health related digital innovations, commonly referred to as mHealth, encompassing all kinds of mobile devices from wireless chip-based solutions to portable computers. In particular, low-end mobile phones bear some important characteristics that make them suited for mHealth initiatives in low-resource contexts. These characteristics include widespread domestication of affordable and robust handsets, high levels of low-end mobile phone literacy, local competencies on servicing and repairing handsets, low proneness to theft, and low consumption of battery power.

Unlike laptop computers and PDAs, mobile phones feature effortless sociability as its core functionality, which may make them less likely to be left broken or abandoned in dusty corners or desktop drawers [19]. Within health care, mobile phones show promise in facilitating efficient capture and transmission of data for routine health decision making, disease surveillance, and beneficiary tracking throughout health programmes. A growing number of digitised health information systems (HIS) are now being extended to the communities through free and open source frameworks like Rapid SMS, FrontlineSMS, and DHIS-Mobile (reported on in this paper). The on-the-spot digitisation of health data also promises to free up overburdened health workers' time and limited resources spent on data transfer, from paper registers to paper forms, and from paper forms into national computerised HISs for aggregation and analysis.

Despite the promising potential of mHealth and other ICT innovations, a World Bank report [14] suggests that many ICT-for-development initiatives are seeded as short-term donor-funded pilots without regard to scalability and sustainability. The anticipated impact and benefits deteriorate as soon as pilot funding is discontinued or key activists resign from the projects. In particular, the benefits of interventions in public health can be limited unless they scale to inform evidence-based decision making and resource allocation for whole administrative regions [22].

Existing research into the topic of how sustainable mobile phone based interventions in health can be effectively deployed and scaled in developing countries is limited [6], [11], [15], [20]. Despite the breadth of current mHealth projects, recent reviews suggest that most of the innovations have so far failed to scale or sustain beyond the pilot stage [5]. Consequently, there is an urgent need for the identification of elements that can promote the successful scaling-up of mHealth initiatives [12].

The contribution of this paper is a classification of mobile phone based solutions for HIS interventions in low-resource contexts into four empirically derived types: interactive voice response (IVR); plain-text SMS; locally installed handset and SIM-applications (e.g., J2ME, Android, SIM Toolkit); and browser-based solutions (e.g., WAP, HTML). IVR services let the user call a number and type digits or use voice recognition in response to voice prompts. Plain-text SMS solutions allow users to send SMS messages to a service number, and receive responses back via SMS. Locally installed applications support graphics and an interactive user interface, while allowing offline data entry in areas without mobile coverage. Browser-based services are generally maintained and updated on online servers, but are accessible through mobile phones using mobile browsers.

In section ‘An mHealth typology for low-resource contexts’, the four solution types are presented in a reference typology that details the strengths and disadvantages associated with each type along four dimensions: robustness to low-resource contexts; flexibility for organisational and functional change; usability; and financial cost. This paper shows how the strengths and disadvantages associated with each solution type become more evident when implementations are intended to scale in low-resource settings. In particular, early decisions about whether or not to leverage health workers' own handsets, initial arrangements with mobile operators and requirements regarding the solutions capability to support offline work may shape the choice of solution type and have long lasting implications. The paper aims to identify a vocabulary that allows aspiring mHealth initiatives to synthesise and share experiences and manoeuvre in the mHealth solution space in a dynamic development context.

Section snippets

Conceptual framework

The concept of installed base cultivation [10] captures the idea that very large and complex information systems, also referred to as information infrastructures, are never designed or built from scratch, but always evolve through the extensions and improvement (cultivation) of what is already in place (the installed base) [8], [9].When we consider the extension of digitised HISs to the community level through mobile phone based interventions, the installed base refers broadly to the whole

Research approach

The three authors are involved with the Health Information System Programme (HISP), an international research network doing open source development and implementation of the District Health Information Software (DHIS2) in a range of countries in Africa and Asia, including whole states in India. The dots on the map in Figure 1 indicate where DHIS2 is used as the national HIS data warehouse, or is in the process of becoming the national standard. The DHIS2 software is used for reporting,

Pre-study of plain-text SMS solution in Andhra Pradesh

In order for the start-up DHIS-Mobile project to gain initial insights from an ongoing mHealth initiative, a short study of a plain-text SMS-based reporting system for Integrated Disease Surveillance & Response (IDSR) was conducted in February 2009. The solution was implemented in six districts in Andhra Pradesh (India). The solution supported weekly reporting of data through SMS with alpha-numeric codes. Data of the prescribed IDSR formats were sent from the reporting health workers to a

An mHealth typology for low-resource contexts

This section presents the reference typology as a tool for manoeuvring in the space of possible mobile phone based solutions (Table 1). The reference typology consists of four distinct types of solutions, each suitable for different deployment situations. These are: interactive voice response (IVR); plain-text SMS; locally installed handset applications (e.g., Java J2ME, Android, and SIM Toolkit); and browser-based solutions. In the typology, the locally installed applications are again divided

Conclusion

The lack of sustainability and scalability has been a serious problem with mHealth pilots in low-resource contexts [5], [12]. We have proposed a reference typology, with the aim of identifying a set of dimensions and a vocabulary for the sharing of experiences in between ongoing projects, and assist initiatives in manoeuvring in the vast mHealth solution space in a dynamic development context. The typology identifies the strengths and disadvantages of each solution type along the four

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    A shorter version of the paper was published in proceedings from European Conference on Information Systems 2012.

    ☆☆

    Research funded by the Norwegian research council (Forskningsrådet).

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