A study titled Mobile Health (mHealth) in Low- and Middle-Income Countries (LMICs) has been published and addresses one of the key issues that has emerged during the COVID-19 pandemic: digital health equity.
Mobile Health in Low- and Middle-Income Countries analyzes the potential and challenges associated with the growing use of ubiquitous mobile phones and the ever- increasing connectivity globally to reach remote or otherwise disengaged populations.
The review study talks to the body of evidence that indicated the huge potential of digital health to transform health systems but also highlights the many challenges: connectivity, ownership of mobile technology, privacy issues around data collection, access to technology.
The paper talks to the growing demand for mhealth technology in the growing middle classes of LMICs where the on the ground hospital system is not able to meet demand.
The sharing of mobile data has emerged as a complex issue with the dawn of the COVID-19 pandemic; tracer apps are being widely used as tools for monitoring social mobility and contact tracing. As mobile phones become a source of public surveillance, with direct and immediate implications for health security, there is increasing pressure on telecommunications, mobile network operators, and governments to join forces.
The importance of the simple mobile phone as a source of data for real-time consumer behaviour for public health planning and crisis response cannot be underestimated or, importantly, under-resourced. The review concludes that regulations are going to be necessary to promote the ethical use of mobile phone data while utilizing its currency in response to public health crises in the future. The paper strongly supports private-public partnerships.
It highlights the advantages that private sector investment offers to the field: value through enhanced capacity, advances in technology and the ability to meet increasing consumer demand for real-time, accessible, convenient, and choice-driven health care options.
It cites the example of a start-up called Babyl, a service providing remote consultation services and a self-diagnosis app for health care consumers in Rwanda via the UK, as indicative of where the digital healthmarket is headed but at the same time highlights some of its shortfalls such as privacy and overall cost effectiveness, factors it says might mean that access to digital heath will not reach those vulnerable populations who most need it.
The review also cites Img, an Indian company, that provides an extensive range of services, including an online pharmacy and lab testing services directly to consumers . The company has received some 200 million in investment in recent years including from the Bill and Melinda Gates Foundation (https://www.1mg.com).
The paper argues that more needs to be done to ensure that, in the haste to respond to consumer needs and wants, intrinsic values that underpin the right to affordable, accessible, appropriate, and quality health services remain the ethical benchmark for future advancements.
At the same time, the authors raise questions around whether transparency, local ownership, equity, and safety are likely to be supported in the current environment of health entrepreneurship.
Although mHealth in Higher Income Countries (HICs) is becoming increasingly mainstream, evidence of scaled-up, sustained initiatives in LMICs are not as well established. This discrepancy is a likely product of a tendency still toward investment in pilots that fail to reach scale (and are not published) without sustained resourcing owing to a lack of longer-term funding arrangements.
From the analyses undertaken to date, mHealth in LMICs has been focused largely on two areas: the use of mHealth to support health workers in health service delivery and the use of mHealth to deliver health information directly to consumers and to support behavior change in disease management interventions.
However, this is about to change. Large, underserved, and consumer-savvy middle classes in the emerging economies combined with the gaping vacuum in consumer choice for health care during the COVID-19 pandemic has only fueled growth in mHealth in LMICs.
The authors highlight the importance of the WHO Digital Health Strategy (2020–2025) and several of its core principles which remain relevant for mHealth in LMICs, in particular, the need for a sound regulatory framework for activities based on capacity building, equity, ethics, accountability, and governance.
One-way and two-way messaging remains the most used modality, with a gradual shift to the use of apps and social network sites (Facebook messenger, WhatsApp, and WeChat).
A major barrier to mHealth implementation in LMICs remains a lack of technical capacity and capability, with technical support being outsourced in some countries, leading to limited potential for sustainability. Moreover, local investment, especially when donor investment is backing the initiative, is a critical factor in determining translation from pilot to a domestically funding scaled-up program.
This transition, which is part of the broader agenda in global health financing, is likely to have significant implications for the sustainability of other interventions that fall outside primary service goods and services infrastructure until the translation of value (of digital health) is costed, tested, and accepted (as no longer an adjuvant to mainstream health service delivery)
The review points out that possibly the greatest brake on the optimism surrounding mHealth is the issue of equity: who gains access and reaps the benefits. It suggests that groups with greater access to resources (technical as well as financial capital) are more likely to be early adopters of new technologies and cites the rollout of electric cars as a similar scenario.
The most obvious and well-described risks, the review suggests, is related to the safety and confidentiality of sharing data or personal health information via mobile devices. Tracer apps on mobiles during the COVID-19 pandemic are a good example.
In light of these challenges together with the growing evidence of the growing market potential in LMICs including scale (large), human capital (young, growing populations), relatively weak regulations, and a growing middle class, the review further argues that the future of digital health in LMICS may very well be tied to securing public-private partnerships (PPP).
