Fighting the Health War on Two Fronts

As any student of history will tell you, the surest way to lose a war is to fight on two fronts. For decades, developing countries have been fighting a war against persistent poverty, famine, and disaster-related illnesses like cholera and diarrhea. Resources were stretched to the breaking point in many countries as they struggled to build a health system that is responsive to a well-established set of health problems. So it probably came as welcome relief when economic fortunes turned rosy, and developing-country governments could allocate more resources to infrastructure and public services like health and education. Until, of course, the spoils of rapid economic development began to spoil.

Health systems across the developing world are suddenly dealing with a range of health issues that hitched a ride with prosperity: diabetes, hypertension, obesity, and heart disease - to name only a few. It turns out that a sedentary fast-food lifestyle is as unhealthy for the Chinese as it is for Americans. In fact, the Overseas Development Institute, a UK-based think tank, calculated that the number of overweight and obese people in developing countries has quadrupled to one billion people in only 30 years.

In newly prosperous countries, this is not a transition; it's an addition to the normal roster of water-borne and tropical diseases which are still thriving in remote, rural areas. The opening of a new, unfamiliar front in the health war presents opportunities for both the development community and the private sector (e.g., pharma). With many years of data on the long-term cost of chronic diseases in developed countries, there is a compelling argument for even modest investment in nutrition, wellness and preventative programs. Such modern illnesses can by addressed by mobile-based information campaigns, digital reminders, and remote reporting and diagnostics. It's not very sporting to capitalize on another's misfortune. But mature-market providers can chalk it up to helping the new kids learn from past mistakes, and giving them a fighting chance in a historically uphill battle.

mHealth - a New Level of Maturity?

The who's who in mHealth gathered a few weeks ago at the second annual mHealth Summit in Washington, DC. Organized by the National Institutes for Health and the mHealth Alliance, the event featured globally-known keynote speakers including Bill Gates, Ted Turner and Dr. Judith Rodin (President of the Rockefeller Foundation). The mHealth Summit also attracted 2,400 attendees from 48 countries, 125 exhibitors and several hundred members of the media. This represents a dramatic change from just a few years ago when mHealth gatherings were small-group discussions and workshops on how to put this nascent field on the global radar. Yet it begs the question: has mHealth reached a new level of maturity, or just a new level of attention?

 

Collaboration with the broader eHealth community (of which mHealth is a sub-set) is a good indicator of maturation in the mHealth space. Indeed, eHealth and mHealth leaders are coming together to establish common principles and standards for implementations in the space. Another notable development is the increasing focus among mHealth organizations on Maternal and Child Health. This focus was inspired by the need to accelerate progress on the Millennium Development Goals. It has also prompted discussion on how mHealth could be used to improve the health of poor men, which is linked to maternal and child health indicators as well as to markers of community well-being. This subject was the topic of two recent workshops organized by the Collins Center for Public Policy.

Despite these achievements, true maturity of a field like mHealth can be measured by one concrete achievement: scale. From the inception of organizations like the mHealth Alliance and the mHealth Initiative, the goal of scale has been top-of-mind but elusive. mHealth pilots abound, but scale is necessary for market-driven sustainability of mHealth. Such drivers will come from private-sector involvement motivated by credible impact assessments and proof of potential profits (or at least financial sustainability). The development community and private sector alike would benefit from focusing on mHealth impact assessments, cost saving analyses, and market sizing, as well as the application of these research outputs to motivate the investments necessary for scale.

Collaboration Shaping Demand for Health Technologies in the Developing World

A consortium of international health stakeholders just issued a call for collaboration to expand the use of technology in reducing maternal and newborn mortality. The call was issued by the Partnership for Maternal, Newborn and Child Health (PMNCH), an international alliance of 280 governments and development community members working to reduce maternal and infant mortality. This group has garnered the support of high-profile organizations such as the mHealth Alliance, a cross-sector organization launched in 2009 by the Rockefeller, UN and Vodafone Foundations. When organizations such as these collaborate, they are actually shaping how governments will use and demand technology in the future.

Maternal and child health has captured broad attention throughout the development community. Reducing maternal and child mortality is the stated goal of Millennium Development Goals (MDGs) 4 and 5, and they are the goals that have seen the least amount of progress. The recognition that insufficient progress has been made in these areas is illustrated by the emergence not only of the consortium, but of other organizations such as Advanced Development for Africa (ADA), a new foundation dedicated to scaling African health programs with a focus on maternal and child health as well as communicable diseases. And The Bill & Melinda Gates Foundation recently announced $1.5 billion in funding over the next five years for maternal and child health, family planning and nutrition.

Multinational companies seeking to expand the reach of their technology solutions in the developing world can advance their goals by getting involved with the development community early. By identifying and mobilizing resources towards key issues, the development community is influencing the health agenda and ultimately the technologies that governments procure. For instance, a new partnership between the Carlos Slim Institute for Health, the Gates Foundation, the Government of Spain and the Inter-American Development Bank promises $150 million to Mexican and Central American governments to support maternal health, nutrition, vaccination, anti-dengue and anti-malaria campaigns. Joining forces with leading organizations and emerging alliances in public-private partnerships can help multinationals get a seat at the table and shape the new demand for healthcare technologies.

Obesity and chronic diseases - A part of development?

by Karen Coppock
_________________

Obesity is rapidly increasing in China - 30 - 50% per year - and in developing countries across the globe as incomes improve, people work in more sedentary jobs and eat more processed food. With obesity comes diabetes, heart disease, high blood pressure and a variety of other chronic diseases and illnesses. In addition to obesity, longer life spans - which are also associated with economic development - also increase the likelihood of suffering from a chronic disease. Are chronic diseases a part of development?

Professors James Kahn, M.D., M.PH. and Joshua Yang, Ph.D. seem to answer yes to this question. In a report they wrote - The Relationship among Economic Development, Health, and the Potential Roles of mHealth - for a conference on mHealth in Bellagio, they note that:

• "Reducing chronic disease often requires rejecting behaviors associated with greater wealth (e.g., tobacco use, high-fat and high-sugar diets, and decreased physical activity) and thus relinquishing their perceived status value."

Since it is unlikely that most people will reject these behaviors (as evidenced by the US and the increasing obesity rates in China and other countries), technologists should continue to focus on how to use technology for behavior change as well as for the tracking, treating and assisting people who end up with these chronic diseases. The success of these efforts are essential for the cost-effective care of those already ill and to stem the tide of future sufferers of these diseases.

Augmented Reality and Health...Institute for the Future workshop

by Karen Coppock
____________

The Institute for the Future was generous enough to invite the Mobile Health 2010 participants to a half-day session on augmented reality (AR) and mobile health yesterday. Popular topics were using AR for preventative health, user interfaces, sensors and chronic care management. A few themes cut-across several of the topics and echoed some of the key take-aways from the Mobile Health 2010 event the day before, including:

Less is more

• Actionable information and knowledge is better than raw data and dense charts and graphs
• Simple and very easy-to-use user interfaces are essential - especially when dealing with elderly populations, which tend to have the highest incident of chronic health conditions
• Images can be extremely powerful and persuasive

Personalization may go hand-in-hand with AR

• Individuals may be more likely to be motivated to respond to AR when it is personalized. Motivational messages from grand-kids to give cancer survivors the strength to continue treatment, reminders from a recording you made yourself about how crummy junk food makes you feel may help you walk past - and not into - a McDonalds, the ability to block out food choices in a grocery store that are not aligned with your particular diet plan will help keep you on plan and images of yourself 10 pounds lighter may motivate you to continue on with your workout plan

AR applications for mobile phones will take a while to mature and start to be used in health and well-being initiatives in the developed world. It will take them even longer to reach the developing world given the levels of sophistication required from mobile device and networks. And just as with basic mHealth applications, the effectiveness of AR with regards to improving health and well-being outcomes will need to be proven and new business models created.

Mobile Health 2010 - Day 2

by Karen Coppock
_______________

Day two of the Mobile Health 2010 conference was even more action packed than day one...from discussing FrontlineSMS Medic's use of mobile phones to find survivors (and then rebuild the country) after the earthquake in Haiti to the low-hanging fruit application area (drug compliance).

Some cold water was poured over the idea of mHealth by a few industry players and VCs who said things such as "this isn't a business" and "we are a $20+ billion dollar business, will your mHealth innovation make a difference in my revenues - unlikely." Yet some organizations, BabyCenter being an excellent example, are reaching scale and likely profitability. BabyCenter is used by nearly half of all pregnant women in the US and has expanded to serve pregnant women and young mothers in 22 countries. BabyCenter's business model is threefold: advertising revenue, premium paid services and patient reimbursement. In countries such as India, BabyCenter content is often delivered via mobile phones as the percent of the population that owns a PC is very small. BabyCenter's VP of International astutely noted that advertising is still a viable model in India as a mobile phone purchase is the first step into the middle class and hence mobile-phone owners are a compelling market for advertisers.

In the final panel, Dave Marvit of Fujitsu Labs of America nicely summarized three parting thoughts:

1. Don't forget sensors when thinking about mHealth 
2. It's not about the data, it's about knowledge or actionable information
3. Focus more on health and less on technology

Thank you BJ Fogg and all of the conference speakers/participants - was an excellent two days.....however, there is still a lot more work to do to transform interesting mHealth pilots into viable businesses with proven health outcomes.

Mobile Health 2010 - day 1

by Karen Coppock
_________________

Mobile Health 2010 started off with a bang today with more than two dozen speakers ranging from academics to medical professionals to NGOs and technologists....long breaks were scheduled throughout the day to encourage interaction and networking and the participants were just as interesting as the panelists.

The day started with discussions about behavioral science (e.g., BJ Fogg presented his behavior grid) moved into text messaging for health - I learned that more than 1.5 TRILLION text messages - or approximately 220 per person on earth - were sent in 2009 alone. This was an approximate 50% increase in the number of text messages sent in 2008. SMS is a very compelling platform to use for health education, monitoring and drug compliance.  Unfortunately, Frank Bailey from AARP noted that as folks age and their health worsens, they are less likely to use text messaging (only 23% of adults over 60 years old with two or more chronic medical conditions used text messaging technology.)

Later in the day, the urgency behind mHealth was discussed. Richard Adler of the IFTF cited a depressing CBO statistic that if cost increases remain constant, health care expenditures will equal 99% of GDP in 2082. A less dismal scenario was that health care expenditures would only equal 50% of GDP in 2082. Either way, it is clear that innovation and alternative business models will be required moving forward and there is a great deal of hope for mHealth.

The main question remains - does it work? Will it "bend" the cost curve while also dramatically improving health outcomes. Much more work needs to be done to answer this question and there is a great deal of optimism that the answer will indeed be yes...

mHealth for the masses...

by Karen Coppock
________________

MIT's Technology Review highlighted an ultra inexpensive microscope - just $3 - that can be attached to a mobile phone to conduct basic medical diagnostics such as generating blood counts and identifying disease cells and bacteria.

The key to its low price is the use of software, rather than an expensive lens for the medical diagnostics. Aydogan Ozcan, an academic and entrepreneur at UCLA, is the brain behind this solution and he is forming a venture, Holoscope, to continue to refine and then commercialize this solution.

I was very pleased to see that one target market for this low-cost microscope is educational institutions. While in Uganda a few months ago, the research organization where I was doing some volunteer work (Conservation Through Public Health) lent its microscope to the local hospital and schools as neither had access to a microscope (not even the hospital!). Even the most resource-constrained schools may be able to find a way to come up with $3 and most teachers that we met - even in very rural areas - owned mobile phones.

One critique of the $3 microscope was that the images were not clear enough and that doctors would be hesitant to use them. Many public high schools in remote areas in Africa (and likely Latin America and Asia) have no microscopes, so I imagine that low-quality images are a tad better than no images. Regardless as to if this particular solution succeeds or not, the most important take-away is that engineers are beginning to design very low-end, low-cost solutions so that the masses in emerging markets (and low-income segments in developed countries) will be able to benefit from the power of mHealth applications.

Men, women, mobile phones and reproductive health...

by Karen Coppock
__________________

Yesterday I moderated a fascinating live chat on Gender, Phones and Reproductive Health - transcripts for the session are now available under the Discussion Boards link in the Conference Hall on the eConference website. I encourage you to review the transcripts and continue the conversation on the Discussion Board.

More than three dozen participants - from across the world - contributed to a very lively and informative discussion on using mobile phones in reproductive health and differences in targeting men and women. Organizations are taking very different approaches to gender differences - participants in the chat noted the following examples:

• "In a pilot family planning project called Saathiya, in India we established a helpline with two separate phone lines for men and women served by same-gender operators. This approach proved to be very effective for men to be very comfortable asking wide range of questions on sexual health and FP"
• "the audience is not necessarily just the target women, but often many other influential people in the community...." This approach was taken in Rwanda - "an SMS in Kinyarwandan in 2006 [was sent] to all registered mobile phone users to announce the child health campaign with bed nets, immunization, and deworming. It went out 2-3 days before the campaign"
• "In using mobile phones, what is the role of women versus the role of community health workers. In
  a rural Nigerian setting, we need CHW to be intermediaries...process and interprete into local language, do reports etc"...CHWs [community health workers] in Nigeria are often, in my experience, the entry point into the household, past husbands, and can reach the wives. I agree with Ego in the importance in that setting to look at the relationship between the two."

Many more topics and issues were raised in the chat, but one theme was consistent throughout the discussion....sustainability and scale has not yet been achieved, but "People are really thirsty for information!" so we need to figure out the most effective method of quenching this thirst and mobile phones could be a very viable solution.

eConference, May 5th, 11am session on Gender, Phones and Reproductive Health 2pm EST

Vital Wave Consulting will be moderating a live chat on Gender, Phones & Reproductive Health on Wednesday, May 5th, from 2-3pm US Eastern time - please join us!

The discussion is a part of the Using Mobile Technologies to Improve Family Planning, Maternal Health & Newborn Services in the Developing world and is sponsored by USAID, the mHealth Alliance and SHOP. The session will revolve around a recent Vital Wave Consulting report, Women & Mobiles: A Global Opportunity, and will cover how gender issues will impact mHealth design, use and outcomes.

To register for the free conference, please click here.

According to conference sponsors, the conference is "intended for health program implementers with little or no experience using mobile technologies such as cell phones and PDAs to achieve public health goals."

The Women & Mobiles report - as well as several other Vital Wave Consulting reports - can be downloaded from the Resource Center section of the eConference, as well as from Vital Wave Consulting's website.

Mobile World Congress Puts the Spotlight on Maturing mServices

The 2010 Mobile World Congress, held last month in Barcelona, featured the usual array of cutting-edge devices and new service offerings from handset makers and operators from around the globe. While Microsoft's launch of its new mobile operating system got the biggest headlines, some of the most intriguing discussions that took place centered on the increasing maturity of mobile services aimed at emerging market consumers. Gavin Krugel, the GSM Association's director of mobile banking strategy, noted at the event that one billion people in the world have access to a mobile phone but not a bank account. And Krugel said that there are now 40 million people worldwide using mobile money, a number that is growing daily. In Uganda alone, 18,000 people join the ranks of mobile money users each day.

The development of mServices has long held great promise, but the lack of a clear business case has hampered their growth - until now. Mobile money, despite regulatory hurdles, is leading the way. And the plethora of mHealth applications on display at the Congress demonstrates that it too is beginning to take off. The case has been furthered by reports such as Women & Mobile: A Global Opportunity, authored by Vital Wave Consulting and sponsored by the GSMA Development Fund and the Cherie Blair Foundation for Women. The study, which included surveys of over 2,000 women in developing countries, found that nearly half of women (and two-thirds of women business owners), are interested in services such as money transfers via their mobile phones, a number that is even higher in countries such as Kenya where knowledge of these services is widespread.

Mobile services are positioned to become highly strategic for scaling business and programs in emerging markets. This will likely be the case for technology companies and a range of vertical markets (such as financial institutions, agricultural firms, and even governments). Yet mServices are still a nascent arena. Successful scale requires careful planning up front and an understanding of the conditions in each individual market. For example, where banks hold significant political and economic power it may be necessary to include those institutions in any mFinance services offering. Otherwise, those banks may view mobile banking as a threat. Taking a hard look at the market dynamics - including industry, regulatory or competitive barriers - can make the development of a successful mServices strategy that much more likely.

mHealth Interview at Mobile World Congress

Brooke Partridge and Karen Coppock were interviewed about mHealth by Karma Peiro Rubio of 3cat24 - the information service for Catalunya based in Barcelona.

Click here to read the interview in Catalan (you can use Google translate to read it in Spanish or English, although the English-language translation is a bit rough).

Vital Wave Consulting at Mobile World Congress

Vital Wave Consulting will be at the Mobile World Congress in Barcelona next week - come by one of our sessions and say hello.

Monday, Feb. 15th - Launch event for “Women & Mobile: A Global Opportunity”, the first global market sizing report of its kind highlighting the gender disparity in mobile ownership and usage in low and middle income countries. Report is authored by Vital Wave Consulting and sponsored by the GSMA Development Fund and the Cherie Blair Foundation for Women. Vital Wave Consulting's CEO, Brooke Partridge, will be a speaker. (invitation only)

Wednesday, Feb. 17th - mEducation - Liberating the Classroom, 2:00 - 3:30 pm. Vital Wave Consulting's VP of Consulting, Karen Coppock, will be a panelist.

Thursday, Feb. 18th - mHealth – Collaborating for Universal Care, an mHealth Insight developed with the mHealth Alliance, 2:00 - 3:30 pm. Vital Wave Consulting's CEO, Brooke Partridge, will be a panelist.

Hope to see you in Barcelona!

mHealth Initiative West Coast Seminar

by Karen Coppock
_____________

The mHealth Initiative hosted a very interesting West Coast Seminar on How New Communication Patterns Will Change Healthcare in San Francisco last Friday.

Interesting tidbits from the various speakers throughout the day:

• EMTs in San Diego spearheaded the introduction of a mobile health application that would allow them to begin to administer treatment and access patient records (i.e., allergies to medications, etc.) on the way to the emergency room.

• The European Unions ultra-strict privacy and medical-oriented regulations make mHealth almost impossible in Europe....shame as Europe is so much more advanced than the US in terms of adopting text messaging.
  

• Walmart and CVS are not competing (successfully) for primary care physicians. One doctor mentioned that if hospitals alienate primary care doctors by requiring that they work after hours to answer patient emails and SMS queries, that they may jump to Walmart and CVS - reasonable working hours, decent pay...new competitive threat.
  

• Doctors categorically DO NOT want patients to send them SMS or email them directly - the doctors fear that they may not receive the message until it is too late and the patient has experienced a "negative event" (e.g., landed in the ER room or died). Doctors prefer for these communications to occur at the practice/group-level where a timely response can be better assured. Not so much a legal liability issue as a ethical one for them. They DO want to communicate amongst themselves, using any and all communication modes possible (e.g., voice, email, IM, video)

• One mega provider's virtual care data (2008): 24 million eVisits, 6 million secure emails, 6 million electronic prescription refills and 17 million electronic transmissions of lab results. In their SMS trials they found that after stating their name (~20 characters) and a mandatory opt out statement (~25 characters), they only had ~120 characters left in their SMS message - not much to work with

Was a great event - slides for the speakers - including the Vital Wave Consulting slides I presented on SMS-based mHealth applications in emerging markets - will be posted on their website soon - look for them here.

Market Sizing Approaches

by Karen Coppock

The mHealth Alliance's most recent eNewsletter - the mPulse - highlighted a Vital Wave Consulting report: Sizing the Business Potential of mHealth in the Global South

From the eNewsletter:

Sustainable business strategies are essential to the successful scaling of mHealth projects everywhere, yet only a handful of companies have begun making significant investments in mHealth. A report written by Vital Wave Consulting, which has worked closely with the mHealth Alliance, identifies critical success factors for stimulating cross-sector collaboration and proposes three methodological approaches to sizing the mHealth market.

Homing in on three countries – South Africa, Turkey and Vietnam – the report samples healthcare data and expenditures to identify where there is information missing that is necessary to assess the size of the mHealth market. Recognizing that the early stages of mHealth present challenges for collecting primary data, the report stresses the importance of including input from health experts in the developing world and identifies available secondary data.

Suggested methodologies for building effective market sizing entail top-down and bottom-up approaches, including: (1) top-down estimates from health budgets with needs-based segmentation; (2) top-down analyses from health ICT or eHealth budgets; and (3) bottom-up calculations from health care program cost and the volume of potential data. A fourth section compares the three methodologies and the quality of their results.

Developed for professionals across sectors and industries, the report helps to lay the groundwork for building the multi-sector engagement necessary to deliver on the promise of mHealth to improve health care delivery in countries facing even the gravest public health challenges.

Download and read the full report at www.mhealthalliance.org under “Resources”.

Expecting the unexpected: technology in emerging markets

Vital Wave Consulting’s CEO, Brooke Partridge discussed the market dynamics across the developing world and how they shape the unprecedented innovation and impact of technology use in these emerging markets at a PARC Forum event on July 23rd in Palo Alto.

Mobile, particularly mobile services (mServices) were a lively topic of discussion. mServices includes things like:

• mobile money (i.e., immigrants and migrant workers sending money back to their families)
• mhealth (i.e., using SMS messages to remind people with TB to take their medicine or people with diabetes to do a glucose test)
• mAdvocacy (i.e., Greenpeace Argentina has used SMS messages to ask people to call their legislators to lobby for policy action, to immediately alert people about urgent environmental issues)

There are literally hundreds of mServices projects being pilot tested across the globe, but even some of the most visible (i.e., M-PESA in Kenya) have not achieved scale. Some of the obstacles are regulatory (particularly with regards to cross-border transmissions), financial (solidifying the business case) and some are in the nature of the projects themselves. Many of the projects were set up just as that – projects – and were not structured to become viable, scalable businesses. Management teams, business models and the service itself often all need to be transformed in order to bring solutions to scale and that is not trivial undertaking. Time is also required and many of these are very new initiatives.

Would be interesting to return to the PARC Forum in July of 2010 and repeat this conversation – hopefully there will be many examples of successfully scaled mServices at that time.

mHealth Alliance Launched in Barcelona

At the Mobile World Congress in Barcelona this week, attendees saw fewer new product announcements than in years past. But some exciting opportunities were still to be found. One such opportunity was the timely announcement of the global mHealth Alliance to be launched in the coming year. The organization is intended as a collection of private-sector companies, governments, health organizations and non-profit foundations that aim to support mobile health initiatives through research, funding, advising and promoting common standards. The mHealth Alliance is spearheaded by global founding partners including Vodafone Foundation, Rockefeller Foundation and the United Nations Foundation.

Vital Wave Consulting played a role in the creation of the mHealth Alliance, facilitating an international mHealth conference in Bellagio, Italy last July and authoring the United Nations Foundation and Vodafone Foundation Technology Partnership’s mHealth for Development report. Research on early mHealth initiatives showed overwhelming interest and support among all participants – public health practitioners, government officials, NGOs and corporate managers. It also revealed a promising industry that has the opportunity to achieve sustainability and broad geographic impact while addressing some of healthcare’s more critical issues such as a global shortage of healthcare workers and the continuing spread of communicable diseases. Industry leaders interviewed as part of the report agreed that scale is essential and its potential is dependent on the services’ ease-of-use for healthcare workers, adaptability to low-end handsets, and the ability to install and maintain on operator networks. Without scale, such programs have the potential to be relegated to corporate social responsibility programs rather than revenue-generating enterprises.

To accelerate the growth of mHealth and fully unleash the potential of its applications, dynamic multi-sector collaboration is needed between groups as diverse as governments, multilateral organizations, and the private sector. Joint action such as the mHealth Alliance has the potential to create a global mHealth infrastructure that lays out common standards and guidelines, and serves as a repository for shared resources and best practices. Private-sector stakeholders in mHealth, mBanking and other mobile service areas would do well to participate in emerging alliances to support the scale of applications, services and business models that have clear social benefits and tremendous potential for profitable returns.