On a cold winter morning in New Jersey, I wait for sun to rise in California. My Skype interview with Pamela Riley, makes me look forward to 9AM – a little more than the usual. My questions for Pam are around a topic that has garnered tremendous attention in healthcare industry around the world – the role of mobile technology in public health. Mobile technology is all around us, but what exactly is its potential when it comes to healthcare? What are the challenges and where are the opportunities? Fortunately, Pam agrees to answer my questions through her wide and vast experience.
Pamela Riley is a Principal at Abt Associates where she where she leads activities to leverage mobile technology to improve health outcomes in developing countries. Over the years, she has contributed in the digital health space covering various domains such as, maternal, child and and reproductive health and HIV AIDS. She brings a unique combination of private and public sector background. . She has worked in various geographies including Bangladesh, Ghana, Kenya, Uganda, Eastern Caribbean, and West Africa. She is currently based out of California.
Click here to listen to the full interview.
Audio podcast by Dr Lily Lee – In conversation with Pamela Riley
Written and transcribed by Connected Health Quarterly
Lily: Pam, you have been a part of several important digital health programs. How has this journey been?
Pam: My career started in the mobile phone industry as a strategist for Vodafone – 9 years ago, I made the shift to International Public Health with Abt Associates, as digital health advisor. My work is now is mainly around –
- Behavior change applications for general populations – caregivers, patients and consumers
- Health worker tools for education, training, supervision, and decision support that are critical for strengthening first line providers
- Program management which focuses on data collection and analysis on good decision making in health programs
- And finally, digital financial applications through mobile money which brings in accountability and transparency in the healthcare financial system
Abt Associates is a large social science research and implementation organisation working across 40 countries. Most of my work is taken place within two USAID global health projects that have enabled us to explore such a wide range of digital interventions. These are:
- Sustaining Health Outcomes through the Private Sector (SHOPS Plus mission is to harness the full potential of the private sector and catalyze public-private engagement to improve health outcomes in family planning, HIV, child health, and other health areas. To increase access and use of quality products in the private sector (e.g. clinics and pharmacies), SHOPS Plus has incorporated digital applications that connect isolated facilities, strengthen dialogue between governments and private providers, and address training gaps.
- The Health Finance and Governance project focuses on strengthening the public health system by improving the backbone health information system that is so essential for data driven resource allocation and decision making.
Lily: There are various words out there — mHealth, ehealth, digital health. It means different things to different people. How would frame them to set a context for today’s chat?
Pam: I agree. The terminology has always been confusing. There has been much debate about those and other terms: telehealth, telemedicine, connected health. Conventions are changing.
e-health: traditionally, an umbrella term and pertains to any health information or resource in digital form; so all the computers, servers, networks and databases that make up the backbone health information system are called e-health
m-health: is a subset of e-health and refers to the last mile applications that are delivered via phones or tablets for collecting or disseminating data.
Globally, stakeholders in this space are just referring to them together as digital health.
Lily: You have been working in this field for a while now. Tell us a little bit about how has d-health evolved overtime.
Pam: One thing that stands out is how digital health implementers have rallied around what we call the 9 principles for digital development. These 9 principles have been endorsed by hundreds of organizations, and they are so simple really and also serve as foundational principles for development generally. . A few of the key ones:
- Design with the end user: this will ensure a usable solution, such as having right level of literacy
- Understand the ecosystem: e.g. where will users charge their phones?
- Reuse and improve on what’s already there: avoids waste and duplication such as burdening health workers with enter data on multiple devices
- Build for sustainability: who will pay to maintain the system after it is up and running?
- Be collaborative; partnering with local institutions and other funders will improve results. There are so many cases where different projects are funding digital solutions in the same community, with one sending malaria messages and a second sending family planning messages. This is wasteful and does not serve the families well.
While digital health is maturing and improving, it is not a silver bullet that can solve all challenges related to inequity, efficiency, unavailability and cost! But it can be a powerful tool to achieve objectives.
Lily: What are the examples of success and failure stories and factors that contribute to it?
Pam: Where Digital health has had greatest measurable impact is efficiency gains. Solutions can be consumer facing or health system facing and use different metrics for success. For health system applications money saved becomes the most important positive impact since it frees up resources to do other inputs. Mobile technologies cannot deliver babies or clean the dirty drinking water or end gender violence but it can help health programs do other day to day things faster, more accurately, and save costs, and therefore impact lives.
There are studies show that SMS appointment reminders sent to patients increase adherence to treatment through follow up care. Mobile applications for tracking and ordering drugs prevents stock outs and protects lives. We did a small study in India in our SHOPS project that improved the percentage of women who continued with injectable contraceptives. By scheduling a simple phone call timed for two weeks after the injection, when side effects typically occur, clinic staff were able to counsel the women at a critical time. Such simple interventions have impact.
With regard to the impact of digital on population health, the evidence is weaker. There are qualitative studies that show the use of mobile decision tool support used by health workers improves the perception by the patients about the quality of care given, providing credibility and statusto health workers, and can strengthen that relationship.
“However, we do not have strong evidence yet that investment in digital health is changing health outcomes.”
There was an evaluation of World Health Partners asocial franchise in telemedicine model in India, in which clinicians were on call to guide health care and answer questions. It found no impact on health outcomes in the regions where the service was employed. There was no change in health seeking behaviours, no improvements in caregiving protocols by providers.
SHOPS project evaluated another digital health service in Kenya to assess the impact of text messaging in family planning knowledge and use. We did find an impact on knowledge but we did not find impact on contraceptive use. We surmise that could be due to the dose. The evidence shows that for behaviour change interventions to be successful, they need to be a part of a broader campaign such as mass media campaigns, education at the point of care, and other complementary efforts. If someone gets a text message on use of contraception, it is unrealistic for this single intervention to change the behaviour. That said, knowledge in itself is a step towards behaviour change.
One of the lessons World Health Partners provides is the cost of under-investing in the design phase. Back in 2011, World Health Partners assumed that making high quality diagnostic care available at a very affordable price would attract users of the service. But in fact, demand was very low.. A user centric design process helps to identify barriers such as price or habits that can improve uptake of services. .
Another lesson that studies have shown is to pay attention to the incentives for using technology. In some cases, clinic staff have been trained on use of mobile data collection tools to improve the timeliness of their service delivery data. But if governments have not yet given up mandatory paper forms (to ensure there were back-up records), this doubles the reporting work of the clinicians.
Lily: True, we need to have this dose intensity and multi-prong approach. Design is not a technology component, but much more holistic in nature.
Pam: It is important to establish a realistic time horizon, we are in a hurry for results with digital health. .In one example, there is a large-scale program in India called “Kilkari“, which sends voice messages to enrolled pregnant women to provide health advice through each stage of pregnancy and child birth. This program took 4.5 years to design, refine and roll-out. The government has now integrated the platform into the public health system, thus reaching millions of women each year. It’s important to do it right rather than doing it fast!
Lily: You also have lot of experience in collaboration. Could you talk about examples of working with public-private partnerships (PPP)? Does m-health feature anywhere?
Pam: Digital health presents a unique opportunity to bring different parties together to collaborate. One example where this is highlighted is in mobile health insurance. This model was pioneered by a social enterprise named MicroEnsure, who convinced mobile operators to offer their mobile subscribers free insurance via their phone. This benefits the mobile operator because it increases customer loyalty. This model is scaling across the world.
These initiatives start out with simple life insurance policies, and then evolve to include hospital cash policies if someone is hospitalised. By offering these free mobile policies, millions have been exposed for the first time to benefits of insurance to protect them from losses during health events. This paves the way the sale of more complex health insurance services.
A key challenge with digital health applications is financing them after donor funding ends. Philanthropy is not sustainable, there needs to be a business model. The key is to consider and build in benefits for all partners- a win-win model.
An example of that is what we are doing with SHOPS Plus in India. We are developing partnerships with MTV and Tinder, to provide family planning messaging to lower barriers on use of contraceptives. . Both of these partners have national scale, allowing us to reach millions. Commercial companies are motivated by profits and in this case, new content areas increases their exposure to new advertisers.
Lily: What is your advice to organizations working in the space of leveraging technology in public health.
Pam: Most importantly, address the gap that exists due to lack of evidence by building in rigorous evaluation studies that can be replicated. I recommend using WHO’s m-ERA checklist to help build a systemic case for investment. There are also many global resources and tools available to help guide implementers, such as m-Health Assessment and Planning for Scale. This provides a process for designing interventions that take into account many intersecting issues including financing, technology selection, and partnerships.
Lily: What do you foresee as major changes we can expect in this field?
Pam: Well there are really mundane changes and then there are these exciting, sexy changes. Let’s go with mundane changes first.
- A lot of work is happening to integrate health databases, many of which exist in silos and don’t allow decision-makers to see the big picture. Abt Health Finance & Governance project helping the Indian state of Haryana connect for the first time information related to health work force, drug supply, and services delivered .
- Another trend is what is an increasing us audio information, which has traditionally been more costly than text. But new technologies are driving down the cost of voice messages, and it has so many advantages – it is warmer, you can capture local dialects, and it can tackle low literacy issues.
- Improved visualisation of data is also important. New tools help decision making by providing visually appealing guides and maps.
There are also some more cutting-edge technologies that are being applied to development challenges. These include the use of drones and remote sensors o map the changing coastlines that are happening due to climate change or track refugee population movements, which contribute greatly to epidemics and poor health.
I thank Pam for sharing her insight and experience on the subject that, no doubt, will continue to drive the passion and imagination of anyone interested in the intersection of health and technology.
Dr Lily Lee is the President of Almata. Trained at University of California, Berkeley, Lily has over 30 years experience in the healthcare industry in senior roles. She is also co-founder of an NGO in education & healthcare China for the last 28 years. Currently, Lily is a Professor of Global Social Impact at the University of Pennsylvania.
Also published on Medium.