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Mobile phones to speed up healthcare delivery in EastAfrica

Sunday July 10 2011
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The mobile phone is now set to be the information portal for health workers, many of whom work in remote areas where access to reference materials is limited.

Renowned economist Jeffrey Sachs has called the mobile phone “the single most transformative technology for development.”

Mobile applications have revolutionised the way information is spread in developing countries, finding a wide range of functions in such diverse sectors as agriculture, personal banking and cash transfers.

The mobile phone is now set to be the information portal for health workers, many of whom work in remote areas where access to reference materials is limited.

An emerging set of applications will shake up the delivery of health care in the region, which has been long plagued by staff shortages and lack of funding.

A new report by the iheed Institute and Dalberg Global Development singles out “mHealth Education” or “mHealthEd,” a novel set of mobile applications thatcould ease the skills shortage in the health sector by providing training, testing, support and supervision of health care workers. The applications can also be used to remind patients to take their medication, or keep an appointment at the local health centre.

Workers can learn new treatment procedures, test their knowledge after training courses and take certification exams, look up information in medical reference publications, and trade ideas on crucial diagnostic and treatment decisions, all through their mobile phones.

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For example, the Health Education and Training in Africa (HEAT) Programme in Ethiopia is a comprehensive online bank of freely accessible learning resources, designed to be easily downloaded for printing and distribution. eMOCHA is another application that is gaining ground in Afghanistan and Uganda; it stands for “electronic mobile open-source comprehensive health application.”

In addition to data collection and communication tools for health workers, the eMOCHA application provides multimedia courses and lectures recorded in MP4 format, followed by quizzes to test users’ knowledge of the information. In Kenya and Uganda, “Text to Change” provides HIV/ Aids information to individuals via SMS.

In East Africa, the shortage of trained health workers is dampening prospects of achieving the health-related Millennium Development Goals (MDGs). According to the WHO, East Africa is suffering from a serious shortage of doctors — there is only one physician per 10,000 of the population in Kenya and Uganda; the figure drops to less than 0.5 in Tanzania. The global average is 14 physicians per 10,000 of the population.

Even when low-income countries go to great expenses to train doctors and nurses, they often have a difficult time retaining them because of low salaries and poor working conditions. The reality on the ground is that nurses and community health workers provide the bulk of health services to patients, particularly in the rural areas.

Uganda has an estimated 26,000 enrolled nurses, Tanzania has an estimated 11,000. Kenya has about 34,000 enrolled nurses, but Dr John Ouma Odondi, head of primary services at Kenya’s Ministry of Health says that the country is still suffering a staff shortage.

“We should have hired an additional 35 nurses in every constituency annually from 2009, but we haven’t been able to fill the numbers,” he says.

Dr Odondi says that a major challenge is retention of staff, and that the ministry is working on strategies to retain talent and skills. About $335,000 is allocated by the ministry to training every year.

“We have short-term courses delivered in institutions as well as in-service training, but admittedly, this portfolio is thin,” says Dr Odondi.

The iheed report cites a 2007 study by McKinsey which estimated that if sub-Saharan Africa continues to rely on professional doctors and nurses, then closing the gap in healthcare human resources would require a total of $33 billion in spending between 2007 and 2030, together with the addition of 300 new medical schools to the 90 that are there today, and 300 new nursing schools, approximately doubling the number today.

The report asserts that, “Community health workers offer a more realistic path to rapidly strengthening the healthcare workforces in low-income countries.”

Unfortunately, community health workers typically receive little training and have high staff turnover.

The mobile applications are thus mainly targeted at nurses and community health workers, whose effectiveness is often hampered by lack of comprehensive information on diseases and treatment procedures. The apps are not intended classroom-based training, but rather to supplement it with mobile refresher quizzes, quick access to reference materials, real-time feedback, and updates about new or improved treatment procedures.

Investing in community health workers has been shown to reap tangible and long-term rewards. Community health workers provide many of the same services that physicians and nurses perform at a lower cost. They also require less training than professional doctors: 2-3 years, compared with the 5-8 years that it takes for a doctor to be licensed and allowed to practice without supervision.

The report says, “Improved training and ongoing learning, especially of community health workers, mean better diagnosis, treatment and improved health outcomes.”
When healthcare workers are better trained, there are marked declines in maternal mortality, infant mortality, and the overall burden of widespread disease.

Training of midwives has been shown to reduce maternal deaths and infant mortality by significant margins. It is estimated that training and supporting midwives to provide a package of select neo-natal interventions could prevent 38 per cent of newborn deaths, or 1.3 million babies per year.

A recent WHO study found that training community health workers in Bangladesh reduced maternal mortality by two-thirds and still births by 40 per cent— results which, if applied globally, could save the lives of 120,000 mothers and 96,000 babies per year.

One mHealth Education pilot project has been undertaken in the Millennium Villages Projects, which includes the villages of Dertu in north eastern Kenya; Mbola in western Tanzania; and Ruhiira in south western Uganda. In these villages, community health workers are responsible for 100-200 households each, conducting home visits, routine and preventative check-ups. During evaluation, community health workers reported that having a mobile reference point eliminates the need to carry a heavy manual or constantly call a nurse for support.

The report highlights that a major problem is the small storage capacity of the phones, limiting the length and number of modules that can be stored, particularly for non-English versions. The fact that not all phones have the Java technology required to download the modules could also limit the project’s reach.

However, the technology is gaining ground. Anne Kamene, a former enrolled nurse at the Kangundo district hospital in Kenya said: “I [now] interact a lot with patients and give them more attention than before. Even the doctors respect us. Before, we were just there to follow instructions, but after seeing what we’re able to do, they listen to us and even consult us.”

The report is emphatic that the goals for mHealth Education must be ambitious, because the challenge is so great. It is estimated that in order to achieve the health-related Millennium Development Goals, the training of over 2.1 million current healthcare workers must be improved, and about 2.6 to 3.5 million new workers must be trained and deployed in developing countries.

Instead of developing several more pilot projects, the next step should be selecting a successful project and scaling it up to district or even national level.

Gustav Praekelt, whose foundation developed the Young Africa Live portal in South Africa, underscores the obligation to scale up: “Don’t do it unless you can reach at least one million people.”

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