mHealth: Achieving Equitable Healthcare In Emerging Countries Using Mobile Technologies
by Theresa Dawson
Access to quality healthcare plays a critical role in the economic growth of developing countries. The growing field of mobile technology in healthcare, known as mHealth, has potential for enhancing the healthcare delivery systems of these emerging markets. The benefits and value propositions of mHealth are illustrated in global use case models. The healthcare system of Belize, a developing country, is examined utilizing a SPELIT analysis (Schmeider-Ramirez & Malette, 2007) of the social, political, economic, legal, intercultural, and technological aspects as well as the World Health Organization Health Services development framework. Economic policy changes are recommended, and the addition of an mHealth strategy to the Belize national healthcare vision is proposed.
Global health challenges are significant barriers to global economic development in developing countries, particularly disease and lack of prevention, epidemics, and the spread of communicable disease, combined with a shortage of healthcare workers. The quality of citizens’ health and well-being affects the human capacity needed for a country to progress (Vital Wave, 2009). Indeed, common indicators of a country’s development, as measured by the United Nations Human Development Index (2016), include assessments of a country’s birth and death rates, life expectancy, health, and education. As part of an initiative to develop solutions to meet these challenges, since 2010 the World Health Organization (WHO) has formally asked for manufacturers, institutions, universities, and individuals to submit innovative health technology solutions for low and middle-income countries (WHO, 2016). This has resulted in a comprehensive compilation of innovative technologies and worldwide use cases for solutions using mobile communications that have potential to improve and meet healthcare needs in those countries with inadequate resources (WHO, 2015). Consequently, the use of mobile communications to deliver health-related services has resulted in the field of mobile health known as mHealth. Thus, mHealth is beginning to play a key role in transforming the global healthcare delivery system by providing technological solutions to enhance healthcare provisions in developing countries.
What is mHealth?
mHealth refers to the use of mobile technologies for facilitating the delivery of healthcare services. There are 900 global mHealth products and services, and this global mHealth market is expected to exceed 30 billion in U.S. dollars (Lauler, 2013). Key areas of mHealth employment include improved access, education and awareness, remote data collection, disease tracking, remote monitoring and treatment support, and communication and training for healthcare workers (Gorski et al., 2016; Vital Wave, 2009). The 2009 United Nations and Vodafone mHealth report (Vital Wave, 2009) described worldwide evidentiary mHealth use cases. Gorski et al. (2016) posit that such use cases are important in illustrating strategies and sustainable value propositions for mHealth implementation.
As an example, distance and access can be a barrier to care. Many citizens in rural areas must travel long distances for healthcare. Lack of transportation, travel, and wait time makes seeking health services in urban areas challenging. Using hotlines, connecting doctors to patients via phone, text, video, or utilizing screening applications for patients to self-monitor their condition can alleviate and reduce time traveling and waiting for health services. This approach provides a broader reach in serving and meeting the needs of those requiring medical care.
When short messaging service (SMS) was used in Africa for campaigns to provide HIV/aids awareness, the improved awareness helped individuals understand conditions of disease and alternatives for prevention and treatment. Subsequently, there was an increase of
40% of citizens who elected to undergo testing for HIV, seeking treatment as needed, thus reducing the spread of the disease (Vital Wave, 2009).
In Uganda, healthcare workers used personal devices to collect data for the Uganda Health Information Network (Vital Wave, 2009). Because those that live in rural areas may not visit health facilities regularly, data collection in the field is important to assess need and efficacy of healthcare services provided by the government. Additionally, tracking disease and outbreaks using mobile phones and web-based technology can help in decision making for containment and prevention of outbreaks.
Remote monitoring plays an important role in preventing complications for chronic diseases by assisting with adherence to treatment plans that might otherwise put a patient at risk for complications. Specifically, healthcare workers can call patients to monitor their medication regime, or patients can use their phone to remind themselves to take medications or to record and track their blood sugar or blood pressure. This recorded data can be provided to the local health clinic for patient monitoring. Remote monitoring can be especially effective for a disease like tuberculosis (TB), where proper medication compliance can cure the disease. In South Africa, healthcare workers used SMS monitoring for TB medication compliance resulted in a 90% medication regime compliance, over 20% to 60% without the reminder (Vital Wave, 2009).
Finally, training a healthcare workforce is critical, and mobile technology can be used to provide information and education for healthcare professionals. In Coban, Guatemala a nursing school used a combination of mobile phones, landlines, and telegraphic devices that transmit handwriting, to train nurses residing in a rainforest (Innovation and Technology for Development Centre, 2014). Mobile technology can allow workers to communicate with one another to provide additional support for diagnosis and treatment. Utilization of mobile apps and use of artificial intelligence can provide reinforcement and empower patients to take responsibility to monitor their own health.
Why mHealth in Emerging Countries?
While quality healthcare is often difficult to obtain in developing countries, cell phones and wireless devices are becoming more commonly used, according to the International Telecommunication Union (ITU). The ITU reports there are over six billion wireless subscribers with over 70% of them residing in low- and middle-income countries (WHO, 2011). The growth of this technology, particularly in low-income settings, can compensate for the lack of infrastructure that hinders access to quality healthcare. Wireless technology can connect patients to healthcare workers, help patients monitor their own conditions, and allow healthcare workers to communicate with one another. There is great potential in using this technology as a solution for providing improved global health resources and for facilitating patient centered care.
mHealth as a Solution for Improving Equitable Healthcare Access in Belize
Belize, a Central American country with a population of approximately 360,000, is located on the Caribbean coast of Central America. Belize borders Mexico in the north and Guatemala to the west and south. The Caribbean Sea is to the east. Forest covers 60% of the country, making the terrain difficult to access. Agriculture such as bananas and sugar cane are located in the low-lying areas. Offshore, the Belize Barrier Reef is the second longest barrier reef in the world. Belize achieved full independence from British Colonial rule in 1981 (Central Intelligence Agency [CIA], 2018). Male and female distribution is equal and approximately 55% of the population lives in rural areas. The population is young with just 6% over the age of 60 (Ministry of Health, 2014).
In Belize there has been increased report of non-communicable diseases, such as diabetes mellitus type2, heart disease, cardiovascular disease, cancer, and depression. The leading causes of death are heart disease and complications related to diabetes (Ministry of Health, 2014). These preventable and treatable diseases are contributing to a reduction of overall life expectancy. Additionally, there are incidences of communicable diseases such as dengue, vector borne malaria, and HIV (Ministry of Health, 2014). These problems are associated with high costs and an increasing need for healthcare workers.
The use of mHealth as a solution for potentially improving the healthcare delivery system in the country of Belize was explored using a social, political, economic, legal, intercultural, and technological (SPELIT) approach (Schmeider-Ramirez & Malette, 2007), to examine the environment of the issue of healthcare access in Belize. Incorporated into the SPELIT analysis was the use of a strategic healthcare analysis tool, the World Health Organization (WHO) System Assessment Framework (WHO, 2018). The WHO framework is comprised of essential building blocks required for an effective healthcare delivery system. These system building blocks include leadership and governance, healthcare financing, health workforce, medical technology, service delivery, and health information systems.
Environment of the Issue (SPELIT)
Social determinants of Belize healthcare
Where an individual resides and grows up are social elements that impact one’s health and well-being. Poverty, access to clean water, quality of housing, education, and lifestyle choices all have an effect on health. According to the World Fact Book, approximately 41% of Belizeans live below the poverty line (CIA, 2018), and the Caribbean Development Bank’s (2009) poverty report emphasizes that in Belize there is a high correlation between lack of income and health and well-being. Over half of the population lives in rural areas, 99% have access to drinking water, and 90% have access to improved sanitation conditions (CIA, 2018). While education plays a role for disease prevention, health literacy is also a key to wellness. Many Belizeans have limited access to education, as high costs prohibit them from attending high school; therefore, formal education and science-backed information about health and wellness is often lacking.
While there are private medical care associations in Belize, the government implements a national insurance plan overseen by the Ministry of Health. This national insurance plan provides affordable healthcare to the citizens of Belize. National funding is concentrated on urban areas, and these areas are served by hospitals. Those living in poor and remote areas have fewer resources and might be served by a small health center with a nurse as the primary point of care, with a weekly visiting physician (Belize Ministry of Health, 2014). There is additionally the presence of non-governmental organizations that provide healthcare services to underserved areas (Pan American Health Organization, 2009).
Physicians are trained in the UK, Cuba, US, Guatemala, and Mexico. There are offshore medical schools, and the University of Belize has a nursing school. Locally trained professionals are in high demand and are often recruited to practice out of the country. As a result, the government has formed agreements with Cuba and Nigeria to supply nurses to Belize (Belize.com, 2018; Pan American Health Organization, 2009).
Political aspects of Belize healthcare
The government of Belize is a parliamentary democracy (National Assembly) under a constitutional monarchy with a system of English common law (CIA, 2018). The Ministry of Health, located in the capital city of Belmopan, is run by a Chief Executive Officer who works with a Director of Health Services to oversee the Belize healthcare system. Services are organized by region, overseen by a Regional Manager and Deputy Regional manager. The National Health Information Steering Committee leads the strategy and advises the Ministry of Health. This committee is comprised of 13 members of the Ministry of Health and various government officials (Belize Ministry of Health, 2010). This Steering Committee makes decisions about health needs of citizens, issues of public and private healthcare delivery, government healthcare policies, regulations, and service quality standards (Ministry of Health, 2014).
Economic factors affecting Belize healthcare. Major economic industries are agriculture, tourism, and fisheries. The service industry and tourism account for 55% of the country’s GDP (Ministry of Health, 2014). High unemployment, debt, and a trade imbalance contribute to the economic issues that account for the cause of poverty. The country lacks training programs for job creation; it lacks infrastructure support for education, community development, and social programs (CIA, 2018).
Approximately 5.8% of the GDP is spent on healthcare (CIA, 2018). The total health expenditure is primarily from public sources. The Belize Health Care Sector reform program was a 30 million (U.S. dollars) project intended to provide universal health access to all citizens (Belize Ministry of Health, 2014). While this universal healthcare plan was intended to make healthcare accessible for all citizens of Belize, there is an inequitable distribution of resources, with rural regions receiving less investment.
Legal considerations for Belize healthcare. There are legislative proposals pending for regulating medical and dental care, including nursing, midwifery, and distribution of pharmaceuticals and medical equipment. The legislation is intended to provide the Ministry of Health with the constitutional authority for regulating the health care system (Ministry of Health, 2014). While there was a national e-government policy formulated in 2008, it appears there are no national laws or regulations for electronic health systems that establish a system of privacy protections for consumers.
Intercultural influences of Belize healthcare. Belize is comprised of an ethnically diverse population containing four ethnic groups: Creole, Maya, Garinagu, and Mestizo (CIA, 2018). Culture plays a part in the high incidences of non-communicable diseases such as diabetes and hypertension, as these are related to diet and lack of awareness of nutrition and its effects on disease.
Current use of healthcare technology. In 2004, the government invested in a Health Information System, an IT solution with a goal to expand health information to rural areas and to improve data and reporting of information. Utilizing an electronic medical record system allows portability of healthcare information among the regions (Belize Ministry of Health, 2010). However, challenges such as weak IT support, lack of standards, and poor interoperability have rendered this system inefficient. Wasden (2014) reports that to take advantage of mHealth in providing service delivery, a market needs an electronic health record system. He further posits that integrating electronic healthcare records to communicate within a system with hospitals and physicians is a prerequisite for a successful mHealth strategy. While the system is not efficient, it is a strength that Belize has the infrastructure in place and is working towards effective use of the electronic system. Furthermore, 63% of Belizeans have mobile phones and 44% are internet users (CIA, 2018), making use of mobile technology for healthcare delivery to be a feasible option.
Belize suffers from healthcare deficiencies, including a rise in the incidence of non communicable diseases such as diabetes, heart attack, stroke, and depression. Furthermore, Belizeans have poor awareness and education about the prevention and consequences for these diseases. Consequently, there is needed improvement in overall education, particularly in the areas of health awareness, nutrition, and disease prevention. In addition, there is an inequality in healthcare access for all citizens, with those in rural and poor areas lacking consistent access to physicians, nurses, and medicine. Finally, a shortage of healthcare workers results in an infrastructure that cannot meet the needs of the people.
Key Economic Principles That Have an Effect on the Quality of Healthcare in Belize
Production, resources, and scarcity. Healthcare can be viewed as a service that can be produced, with resources being personnel required for delivery of those services. Production of health care workers in Belize is limited to a few in-country training institutions and import of workers from other countries. By not supporting a high school educational system, the government is in effect limiting the number of students that can enter the university system to produce a pool of needed health care resources in the communities of Belize. The shortage of healthcare workers, or scarcity of personnel resources, results in unmet needs of the Belizean people. Furthermore, by not supporting healthcare workers with an efficient system, workers are enticed to practice in other countries.
Human capital. Human capital refers to the knowledge and skills of people. The knowledge and skills provide economic value. Human capital is related to economic growth as measured by investment in education, resulting in higher earnings and higher spending (Nickolas, 2018). Health expenditures are also an investment in human capital (Chang & Ying, 2005). To improve health, it is important to reduce the disparity of quality health services in the country. Lee, Kiyu, Millman, and Jimenez (2007) state that research shows a strong correlation between a strong national health system and health outcomes. They posit that strong human and social capital can be created by developing a national health care system strategy of strengthening communities through service delivery in health care centers and clinics and by improving education in schools.
Investing in education and an equal distribution of health care access will improve disease prevention and life expectancy, thereby preserving human capital for working and contributing to the economy. Establishing mHealth education and training programs for building a workforce will be an investment in human capital.
Efficiency and equity. Economic maximization of resources can be viewed according to efficiency and equity. Efficiency is a means to the greatest production, and equity is how those resources are distributed fairly across a population (Parkin, 2017). The quality resources for health education, diagnosis, and treatment in Belize are not only lacking but not used efficiently and equally in urban and rural areas. Most healthcare professionals are located in urban areas, and there are gaps in staffing and distribution of medical equipment in the regions (Pan American Health Organization, 2009).
The WHO states that there is inequity in healthcare in emerging countries. There is not a fair and equal distribution of healthcare services throughout the world, and in particular, those in emerging countries suffer from a shortage of healthcare workers. Belize should include reduction of healthcare inequalities as a goal of the country’s health policy and strategy in order to maximize service delivery, focus on prevention, and reduce overall costs associated with disease.
The use of mHealth is a viable alternative and adjunct to the current healthcare delivery system of Belize. There are many key benefits to the implementation of a mobile health access program, specifically in the areas of access, quality, education, and training. For those patients that live in remote areas, where education about a condition or access to care is difficult to obtain, health and wellness information can be delivered via mobile phones. Accordingly, physician services can be delivered via mobile solutions such as monitoring of blood sugars associated with diabetes or blood pressure levels associated with hypertension. Moreover, data can be collected at the nearest health center and integrated into an electronic health record system to monitor patient status. Subsequently, quality of care can improve when sharing of information between patients and healthcare professionals is done efficiently and securely. Access to electronic information can additionally help to make better diagnostic and treatment decisions. Equally important, mobile health tools can provide learning and training for healthcare professionals. These mobile health approaches can allow patients to be educated and to take control over managing their health, thus decreasing risks associated with a chronic disease.
Objectives and Action Needed for Implementation
Involvement of Key Leaders and Stakeholders
There are multiple stakeholder interests for mHealth implementation in Belize. For the patient, improved care and taking responsibility of care is needed. For the healthcare provider, delivering quality care efficiently is paramount. For the government, equitable delivery of a national health system is a priority. For the mobile tech companies, there is great potential in emerging countries for providing equipment services and platforms.
For mHealth to be a viable solution for an emerging country such as Belize, it will be important to engage these healthcare stakeholders to develop a national strategy. Support will be needed from the Ministry of Health, given the government’s role in overseeing the national health care system. Support will also be needed from private healthcare companies, health educators at the universities, health care center workers, and regional overseers. Additionally, support from the Belize telecommunication providers such as Speednet or BTL Belize Telemedia Limited could not only assist with network connectivity, but these companies have a customer base and knowledge of consumer habits that will allow them the ability to market any new mHeatlh technologies with a large distribution network (Accenture, 2014). Additionally, mHealth technology companies are eager to enter and invest in emerging markets to provide products that focus on disease prevention, education, and data collection.
An mHealth implementation plan in Belize can be strategically designed using resources from the WHO’s (2012) “National eHealth Strategy Toolkit.” This toolkit provides a strategic framework for developing and implementing healthcare technology solutions on a national level. First and foremost, it will be important for the government to develop a national vision for mHealth. The Ministry of Health will be required to implement leadership and invest in technology and workforce training. It will be essential that the Ministry of Health forms alliances with technology companies and health workers to provide healthcare services using mobile devices. For example, mobile devices such as smartphones and tablets can be given to healthcare workers. Once a national strategy is developed, the government, private sector, and organizations working to bring development to Belize can pilot an mHealth program and move to a scalable solution for equitable healthcare.
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