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It’s time to look holistically at the costs and benefits of introducing and scaling up eHealth and mHealth initiatives.
In 2008, the Bellagio eHealth Call to Action called upon the global health community to stop rearranging health care to try out the newest or sexiest technology, and to start working together to integrate technologies into improved health service delivery practices, to focus on sustainability, and to ensure interoperability.
We have come a long way.
Coalitions of practitioners and researchers, such as the mHealth Working Group, are building on what works. These groups are continually advancing the field so that new technologies respond effectively to needs with sustainable solutions. We have guidelines and tools such as the World Health Organization mTerg’s mHealth Evidence Taxonomy, which categorizes mHealth interventions and innovations against a framework of health systems constraints.
We also have the mHealth Evidence database by K4Health, a clearinghouse of technology-related interventions and research information.
And we have the USAID ASSIST mHealth Systems Strengthening Framework for leveraging mHealth to strengthen health systems.
These are just some of the guidelines and tools that global experts have developed to build the evidence base and improve research on how mHealth can best support improving health services for low- and middle-income countries. But we still have a way to go.
What will be the full cost if the program is scaled up to a national level compared to current costs?
Costing is one area where we are just starting to break ground. We are already calculating some costs: the costs of phones, airtime, training, program development, IT support, and even policy changes and technology upgrades. Some developers itemize the costs of information systems per provider or per patient.
But to what are we comparing these costs?Comparisons that count are important. What will be the full cost if the program is scaled up to a national level compared to current costs? And what about the lives saved and improved health outcomes? What are the financial and health costs of doing nothing?Policymakers need to quantify the value added to make informed planning decisions and to define mHealth priorities and policies. Thorough costing of mHealth programs is still uncommon, and contextualized costing that assesses those costs within the parameters of national health accounts and links these investments to health and economic gains is almost nonexistent.
An app called mSakhi presents us with an opportunity.
mSakhi is a smartphone application developed by IntraHealth International for frontline health workers in rural India. It provides illustrative and audio reminders and guidance that helps accredited social health activists (or ASHAs) to counsel and educate the families they serve. ASHAs also use mSakhi to record data on the mothers and newborns they visit.
ASHAs are trained to reach some of the most remote and impoverished communities in the country to provide pregnancy counseling and health education, to accompany women in labor to skilled delivery care, and to promote immunizations and appropriate newborn care.
We were especially excited to learn that ASHAs who use the app are much better able to recall health warning signs and have significantly better counseling skills than those who don’t use it. They also completed official registration—that is, birth certificates—of more births (100% versus 78%) and identified five times more sick newborns requiring referral (53 versus 9 sick newborns) than ASHAs who underwent the same training but did not have the added benefit of mSakhi.
Now the Government of Uttar Pradesh is investing 3 million USD to scale the mSakhi technology to cover five districts—home to 15 million people—and to provide a wider suite of services.
Improved health may come at a higher cost, but appropriate, effective technologies can multiply the return on investments.
mSakhi can now store and forward client information, process diagnostic algorithms, schedule and track appointments and care processes, and track supervision visits for ASHAs. The app is robust enough to provide immediate health service delivery improvements and flexible enough to advance easily and become more sophisticated alongside the country’s technological capabilities.
ASHAs and a variety of other frontline health workers will be using mSakhi for prenatal and antenatal care and other integrated services.
As the project scales, IntraHealth will further explore the costs of mSakhi within the context of health costs, human resources for health costs, and the health accounts of the Indian State. And we will help our colleagues in the Ministry of Health to quantify the wider improvements gained in strengthened systems, workforce stability, widened access to services, and quality of care. Over time, we hope to expand our support to the Indian government to track the improved health outcomes due to mSakhi.
We can save lives and improve health with new technologies. But we must understand when these applications statistically improve care, whether they are cost-effective, how they contribute to the national health system, and whether they can be sustained over time. Improved health and saved lives may come at a higher cost, but appropriate, effective technologies can multiply the return on investments. And diligent cost analysis can determine the value return on these investments. All of us in the global health community—including donors, governments, the private sector, and NGOs—need to hold each other accountable in assessing cost effectiveness, cost sustainability, and quantifying the return on investments we make in mHealth and eHealth. We think the results will be impressive
.Innovators, roll up your sleeves. Your mission has just begun.
IntraHealth’s team in India developed mSakhi in collaboration with the Government of Uttar Pradesh and with funding from the Bill & Melinda Gates Foundation. The authors thank Girdhari Bora, ICT Advisor for IntraHealth’s India programs, for sharing information on his team’s innovative work with mSakhi. We also thank Lesley-Anne Long, the Global Director of mPowering Frontline Health Workers, for challenging the global health community with the question of mHealth costing at the mPowering meeting last month. The meeting was sponsored by mPowering Frontline Health Workers, with support from Futures Group, Intel, and IntraHealth International. The workshop results will feed directly into work that the One Million Community Health Workers campaign is doing with the Government of Ghana to design and cost a mHealth system for planning a national community health worker program.
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