The arduous path to make mHealth work at last

Life-saving mobile apps may be coming of age.艾尔温tracks their lofty promises and messy reality.

For a few months in 2016 community health workers working withchildrenin northern Malawi had a helping hand.

A smartphone app led them through a standard protocol of examinations helping to boost both the accuracy of diagnoses, as well as their confidence. They toldresearchersthey liked the app because it reassured them that their decisions were solid [1].

But, after eight months, the project was over and the app removed for fear that — with thefundinggone — it could soon become out of date.

This is hardly an isolated incident. mHealth makes a tantalising offer: to plug gaps inhealthprovision in impoverished countries using cheap, widely available tools. Butacross Sub-Saharan Africa, Asia and South Americahundreds — perhaps thousands — of mHealth experiments done in the hope of improving healthcare disappear after a year or two.

2016年reviewcast a harsh light on mHealth [2]. Led by Alain Labrique, a public health professor who heads the Global mHealth Initiative at Johns Hopkins University in the United States, it concluded that — with some exceptions — “the strength of the findings to support the use of mobile interventions over alternate strategies is still limited”.

The review found that many interventions go undocumented; many are designed without academic rigour, making it hard to gauge their success; and often the chosen outcome measures mean they cannot be compared with other studies.

Caroline Perrin, a PhD student in telemedicine at Geneva University in Switzerland, says that instead of measuring outcomes, studies tend to measure how much health professionals like their new apps, and are often too small to have the statistical sensitivity to detect a fall in mortality, for example.

And this, she says, adds to the difficulty of demonstrating that a single digital element woven into a complex health system actually makes a difference.

Perrin’s professor, Antoine Geissbühler, adds that rigorous evidence is important not just to prove effectiveness, but to avoid harm. Even at pilot stage, he says, training sessions that focus on one health activity can eat up time and distort priorities. And governments need to make hard decisions between deploying eHealth and other activities, such as running vaccination campaigns. “Some countries cannot do [it] all.”

Few studies ever get scaled-up because they cannot prove to donors that they are effective, says Labrique’s review. And many projects are simply unscalable due to poor choices during the design phase.

Choice of software, for example, is crucial, says Garrett Mehl, a specialist in digital health at the World Health Organisation (WHO). A bespoke bit of standalone software might be fine for a few villages. But could it withstand the demands of 100,000 health workers — the help desks, the training and re-training, the ‘community of knowledge’ that’s in the background, keeping it ticking over?

“The reality is that unless they are using software that’s a ‘global good’ it’s unlikely to be able to scale,” he says. But even then, other factors may come into play.

Take the app that proved useful in diagnosing children in northern Malawi — theSupporting LIFEAPP（疾病控制的低成本干预）。“Even though the software was open source, the ministry of health just doesn't have any internal capacity to roll out the software or even maintain it,” says project’s coordinator John O’Donoghue, now an eHealth specialist at University College Cork, in Ireland.

“实际上，如果要修改和维护和实施该项目，我们可能每年都在谈论数百万欧元的努力。”

数字和卫生社区正试图找到更好的方法来利用MHealth的承诺。

For example, Perrin is helping researchers choose useful outcome measures when they set up pilots. Although a study may be too small to spot a drop in maternal or neonatal mortality, it might be able to detect an improvement in another parameter shown to decrease mortality.

She has identified 70 such variables, all of which can be influenced by digital interventions — having four check-ups during a pregnancy, for example, or identifying danger signs that predict neonatal illness.*

唐格说,这样的代理是必不可少的pporting LIFE. “Thankfully,” he says, “no child passed away during our study”, so they measured hospital referral rates for evidence that the digital system improved the accuracy of health workers’ referrals.

Adding to efforts to impart rigour to mHealth pilots, a few years ago the WHO, with the International Telecommunications Union,已发表的建议on how to scale mHealth non-Communicable Disease projects. The agency has also developed alexiconfor both health and digital specialists, whose first version was released earlier this year.

Meanwhile,Principles for Digital Developmentwritten by a group of donors and implementers were endorsed by many international organisations in 2015, and a supportingforumlaunched last year.

And the WHO produced theMHealth评估和规模计划（地图）工具包in 2015, which has been adopted by the newMalawi eHealth Research Centre奥多诺格（O’Donoghue）帮助发现的Mzuzu大学。

这意味着任何提议MHealth干预措施的人都必须进入中心，并花几天时间对地图工具包进行评估。如果未能证明它可以满足人力资源，金融和技术能力等领域的需求，并且找不到解决方案，则该提案被放弃了。

Toolkits and better study design may improve pilots and perhaps allow some scale-up. But if mHealth is to make a real difference in the developing world it requires scale-up to national level.

Many people fail to grasp how formidable that challenge is, says Mehl. “It requires the enabling environment of policies, the infrastructure, the tools — and knowing which work and which don’t — and the training.”

作为成功的罕见例子，他强调了印度政府的消息传递服务Kilkari, designed by BBC Media Action, which delivers free audio messages about pregnancy, childbirth and childcare to women from the second trimester of pregnancy and continues until the child is one year old. Developed and tested in the state of Bihar in 2013, it went on to reach two million subscribers within 12 months of its launch. The government went on to adopt it in 2016, footing the bill for call costs and rolling it out in 13 states.

Sarah Chamberlain, director of digital for BBC Media Action India, highlights three factors in its success. First, the government had already invested in registering pregnancies and births, and it saw Kilkari as a way of incentivising women to supply this data; second, long-term and “patient” investment by donors; and third, spending years cultivating a relationship with the Ministry of Health. “You cannot imagine how much energy it takes to nurture a relationship with a national government,” she says. “You can't just fly in and fly out.”

Mehl还认为，从地方规模转移到国家规模需要文化变革和信任的飞跃：部长必须说服抛弃纸进入数字机器的价值。这与培训，帮助桌，硬件和软件茶点的长期资金有关。

He says Tanzania’s Ministry of Health is “exceptional” in having undergone just such a journey. Working with the international health organisation PATH, in the更好的免疫数据（BID）计划, it is using mHealth to improve the tracking of immunisations in a way that is compatible with other digital health interventions.

该系统已扩展到坦桑尼亚的四个地区，并计划尽快到达十个地区。非洲和数字健康区域总监Henry Mwanyika将其成功归因于健康等级的咨询，并“打破语言障碍”，以便工程师，政客和卫生工作者可以相互交流。

What most impressed Mehl was the early recognition by the ministry that the project would take at least five years of “burn-in” — meaning “understanding and absorbing and tweaking and optimising”.

这可能表明国家正在唤醒MHealth的复杂性。这反映在resolutionthat was adopted by member states at the World Health Assembly this May, and is widely seen as a milestone for catalysing progress in the field, says Mehl.

The resolution seeks a global strategy, technical assistance for scale-up, and information on best practice and developments in digital health.

mHealth may be emerging from its Wild West phase. Indeed, the term itself is being abandoned in favour of ‘digital health’, to convey the joined-up thinking required for success.

But we might need to subdue our hopes. “The expectation that it’s going to have massive impacts early in the phase of adoption is unrealistic,” Mehl says. “It’s largely helping people to do what they are already doing but a little bit better, faster and more effectively.

“It’s going to be a slow transformation.”

*This piece was amended on 3 September 2018. An earlier version of the article stated that a set of 70 variables that can be influenced by digital interventions are set to be adopted by WHO as part of upcoming guidance on digital maternal health interventions. This statement was incorrect and has been removed.