Director of Health, Mobile for Development at GSMA, Dr Craig Friderichs, talks about the impact mHealth can have on South Africa’s healthcare landscape and what needs to change to realise its full potential.
Firstly, how do you define ‘mHealth’?
The definition that we use at GSMA is that mHealth is any health service within the health system that can be delivered by mobile technology. That includes a mobile phone as well as the broader mobile ecosystem, such as network infrastructure.
mHealth solutions are currently being used as tools for data collection, business intelligence, communication and clinical decision support. Tell us about the maturity of mHealth in light of these usage trends.
At GSMA, we’ve been looking at the market over the last four years with a very specific purpose of stimulating scale and sustainability of services. We’ve tracked upwards of 1,600 mHealth services across 30 data points, primarily across Africa. We have seen evidence of safety, efficacy, health systems benefit and user adoption and interesting upward trends in the availability of published materials.
We’ve seen little, if any, evidence of the economics of mHealth services. Without this information there is no way for procurement managers to seriously consider integrating mHealth services into long-term fiscal budgets. For example, introducing a new drug in the pharmaceutical sector requires evidence of cost and impact. Without a comparator of those two elements against their current drug or health intervention, decision makers cannot realistically consider investment.
Would you say that placing far more priority on the cost component before going into development is the key message for developers and entrepreneurs in the mHealth space?
There are three key messages: the first is to have a very clear understanding of who the customer or end user is. The second is to understand who the payer is. If we follow the flow of money in healthcare we’ll quickly realise that the end user in the majority of cases does not pay for services. 86% of Total Healthcare Expenditure exists in an indirect payment mechanism, meaning that someone else is paying for your and my health services. These indirect payers and providers can be governments, NGO’s, faith based organisations, medical insurance companies or other third party providers. Developers and entrepreneurs often confuse the end user and the buyer of these services.
The third message is around the introduction of new payment mechanisms, facilitated by and through mobile technology. We’re expecting the recent announcement by Apple launching their health research platform and suite of healthcare services across the US and Europe to help shift the market towards mobile payments, reimbursements and enable results based financing solutions.
What else can we learn from Europe and the US to guide the growth of the local mHealth sector?
We’re seeing a lot of movement in the European and US markets from a regulatory and policy standpoint, an example of which is the recent finalisation of the FDA’s guidelines on medical applications.
We’re also seeing a number of mHealth companies successfully accessing a reimbursive payment mechanism. This stems from a well-established reimbursement environment and enabling policy and legislation that allows for innovative, new technologies and services to be integrated into the health system. These mHealth companies are also more focused on the dynamics of market access, or as mentioned before, providing the right proof points that enable procurement managers to make investment decisions.
What are some of the pressing healthcare issues that mobile can address in this country?
In South Africa, it’s worth thinking about the mention of the e-wallet during the President’s State of the Nation Address. This highlights the fact that we’ve seen explosive growth in mobile money solutions throughout East and Southern Africa and that mobile is fast becoming front and centre in the delivery strategy of basic services by governments around the world.
Very specifically, we think that mHealth will have a major role to contribute towards implementing National Health Insurance (NHI). There are three areas that stand out for us: patient identification; very simple but transformational information services which can be used to increase the reach of quality, timely information to end users who previously did not have access it; and lastly, if we were to go a little further and make some hypothesis about the private health sector in this country, we would put money behind Machine to Machine (M2M). We are starting to see the evolution towards a very user-centric approach to mHealth, i.e. personalised health and devices.
What are your thoughts on data collection and how it’s being used?
There are some key questions that need to be addressed before we can even start looking at data. Safety and security are key issues that are keeping regulators busy in the European Commission but in emerging markets around the world the more critical component are the resource constraints that big data creates. Who will manage this data? Who will respond to it? How flexible is a national treatment plan to real-time data feeds and potentially local, community level requirements?
This is a major burden on government, NGOs and other organisations because they don’t have the capacity or the resources to react to the findings in the data being collected. So the conversations around data privacy, data security and privatisation of data are actually secondary questions.
In terms of the mobile industry’s ability to select and manage that data, there is a very interesting conversation underway to create one central patient record across a group of East African countries that would enable cross-border access to medical and health information. In Kenya health records are actually being stored by one of the biggest telecom operators in that country.
In Europe, Orange recently won the tender to manage the case records for the French Ministry of Health. So there’s definitely an increasing acknowledgement that the mobile industry has the capability, expertise and the resources to not only work with that data but also to manage it in a very private and secure environment.
We need to work on how that data will be managed in terms of a responsive capacity. At the moment it’s very much a one way flow of information. What we need is an understanding of who will respond, how they will respond, and how that will influence a localised, epidemiological health response.
What do we need in place to be able to realise the potential of data as you’ve talked about?
This might be slightly controversial in terms of the question of ownership, but GSMA’s position is that certain portions of that data should be openly accessible – obviously with very strict privacy and security measures in place. We also believe portions of that data should be owned and managed by local regulators or health authorities, whether the ministry of health or a higher national body.
However, we should also be conscious of the economies of scale in terms of the cost and efficiencies that the private sector can bring into this debate. From the example I gave of Orange earlier, we are seeing a huge value add to the healthcare system from mobile players able to work with public sector stakeholders to provide a much needed service.
How should government treat mHealth solutions?
Government needs to act as an enabler of mHealth, which can be accomplished by facilitating policy and legislative changes, whether it be through health regulation, the HPCSA, or the National Health Act itself which needs revision in terms of mobile, ICT and other technologies.
I think a lot of policy and legislative input is needed for government to provide a fair, equitable open market environment to encourage participation from potential partners. Ultimately, we would like to see a fair and open tender process being implemented across the country.
What is your vision for how mHealth will be used in healthcare?
Mobile is not the silver bullet, but we are seeing global organisations like WHO, the UN and the International Telecoms Union (ITU) using mHealth to disseminate information, such as appointment reminders and patient alerts, as part of their central strategies because they have a proven cost benefit to the health system. So again, I think that providing proof points around the economics will be the catalyst for mHealth service integration into the health system.
In South Africa, there are three very interesting areas for me and that is: health financing or how we can leverage the banking and mobile industry to facilitate that in a number of different scenarios. Second would be a health identifier or central register to create a first engagement point in the healthcare system, and standardising that with some sort of mobile identifier, such as a phone number.
And then thirdly, which has sparked debate over the last few weeks, is around point of care diagnostics. We’ve seen a lot of traction around HIV, malaria and TB with specific software algorithms that are run though a mobile device, and we are now also starting to see actual point of care devices being integrated into software and hardware solutions. This technology would significantly reduce costs for the public sector especially.
So these are the three areas I would say will have the greatest impact and benefit on the South African healthcare system.