Posted on Saturday, February 2, 2013
Alain B. Labrique, PhD, MHS, MS, MACE Director, Johns Hopkins Global mHealth Initiative
- Assistant Professor, Department of International Health/Epidemiology (jt) Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA Department of Community-Public Health Johns Hopkins School of Nursing (jt)
- Director, Johns Hopkins Bangladesh, Ltd
- Visiting Professor, Xiamen University, Fujian, China
Date/Time: Tuesday, Feb 26, 7:10 pm Location: ITE 459, UMBC
Abstract: In these final months leading to the 2015 Millennium Development Goal deadline, we find ourselves redoubling efforts to bend downward the trajectories of change, striving to reach the UN targets set in September 2000. Over the past decade, these shared goals have galvanized the global community, across national boundaries and political agendas to strive for certain universal targets – from dramatically reducing global poverty and improving equitable access to education to achieving substantial reductions in infant, child and maternal mortality. Between October 2011 and March of this year, these ambitions were further challenged by a global population that finally exceeded 7 billion, further straining efforts to reduce inequities. These challenges start at the very beginning of life – providing a clean and safe birth, attended by competent care–providers – through childhood – ensuring timely vaccination against major causes of death – into adolescence – providing education that prepares young men and women for a productive future. Into adulthood, these encompass access to employment, appropriate financial remuneration, competent and affordable healthcare, access to adequate nutrition and protection from disease.
With a denominator of 7 billion, it is not difficult to rationalize both why inequities in health, education or gender equity persist and why national or global institutions fail to deliver on promises. Populations, rural and urban, socially or economically disenfranchised, have been characterized as the "bottom billion" or the "ultra poor" –where incomes stagnate at less than US$1.25 per day. One basic component linking these challenges is that of measurement – making every life count, irrespective of where a child is born or when a pregnant woman dies. This has remained a lofty, unattainable goal – until now. By the end of 2010, the International Telecommunication Union (ITU) estimated that over 90% of the world's population lived within reach of a mobile phone network, with over 143 countries having access to high-speed Internet services. In 2011, this UN agency estimated that 5.9 billion mobile phone subscriptions reflected a 79% penetration in the developing world alone. Of the one third of the global population using the Internet, 62% are residents of the developing world. In the last fiscal quarter of 2011 alone, 180 million new mobile subscribers were registered, reflecting the rate of the near-exponential growth in this sector.
This rapid, market-driven technologic revolution has spawned a sea change in global development. Initially, organizations like the Grameen Bank capitalized on mobile technology as an innovative small enterprise solution for landless women to provide connectivity to their villages. These business models are rapidly becoming obsolete as mobile penetration increases and access to phones becomes ubiquitous. In the past decade, entirely new fields of research and implementation science have emerged, prefaced by an 'm', representing the novel 'mobile' facet of their approach: mHealth, mBanking, mAgriculture, and mLearning.
Mobile technologies are also rejuvenating the domain of telemedicine and electronic health (eHealth), which were previously largely "tethered" systems, focused on facility–based record—keeping, supply chain monitoring and sometimes, decision-support. Mobile technologies serve to untether these systems from their facilities. They widen the reach and versatility of the eHealth infrastructure to support frontline health workers, where and when they need access to patient information, while also allowing them to contribute to the clinical record from the field.
This is, to many of us, the most exciting endgame for mobile health, or mHealth – a pragmatic and now, tested, series of solutions to help us bridge that Last Mile, to accelerate progress towards the MDGs by 2015 and beyond. Over the past 5 years, hundreds of pilot projects across the globe have tested mHealth strategies to increase the capacity of community health workers and improve the quality of care received by the populations they serve. From this field of a thousand flowers of innovation, a healthy bouquet of solid enterprise solutions have emerged and are being used in countries at regional and even national levels. These systems enable tasks that were previously thought to be logistically impossible – enumeration of populations; registration of pregnancies, births and deaths; scheduling of antenatal, postpartum, and immunization visits with accountability for missed or delayed contacts; and providing at least a rudimentary health record. Importantly, these systems also provide a means to improve system efficiencies, from worker management to monitoring supply chains (including identifying counterfeit medications), as well as real–time monitoring and reporting of vital events and system performance. Most importantly, the most vital function of mobile phones, often lost in the whirlwind of innovation–voice communication – is a central facet of the mHealth revolution, allowing workers to access peer and supervisor guidance when and where they need it.
Frontline health workers who are often the first and only point of care for most of the 'bottom billion' and the world's rural poor, have been disconnected from the parent health systems they serve. Their isolation and often rudimentary training, limited the capacity of this cadre to provide little more than basic care, often disjointed from the broader health system within which they function. Mobile systems now exist to address gaps which, until recently, seemed intractable. Strategies exist that provide continued skills development and training to frontline health workers, and that integrate them as full-fledged members of their health systems. mHealth systems have empowered families with the information they need to maintain their health, and knowledge about services they should expect from the government or health providers. Exciting strategies that bridge the worlds of mHealth and mFinance offer novel approaches to demand–side financing and performance–based incentive schemes.
In 2012, we find ourselves armed with functional mHealth systems, with a growing evidence–base for what works under various conditions. Mobile technologies continue to grow in sophistication and shrink in cost, providing fuel to several visions. We can imagine, in the not-too-distant future, a mobile phone being part of the core set of tools provided to every new community health worker, or a temporary phone, connected to essential downstream services and health information, being given to pregnant women as part of their antenatal services, as banally as an Iron-Folic Acid supplement. Through these visions, we build on the legacies established by public health giants John B. Grant, whose work established the models for training China's "barefoot doctors" in the 1960s and 1970s, and Carl Taylor, founder of the academic discipline of International Health and proponent of the vision that empowered communities and frontline health workers can shape their own futures. Without mHealth, these leaders changed the delivery of care to disconnected populations across the globe – imagine what is possible to accomplish under a new paradigm of universal connectedness. In the next decade, if these mobile-enhanced systems have not been integrated as mainstream approaches to delivering health, financial, education and legal services across socioeconomic boundaries, it will not be because we weren't able to do so, it will be because we will have chosen not to.
Dr. Alain Labrique is the founding director of the Johns Hopkins University Global mHealth Initiative, a multi-disciplinary consortium of over 70 faculty and 150 students engaged in mHealth innovation and research across the Johns Hopkins system. An infectious disease epidemiologist, with training in molecular biology and over a decade of field experience running large population-based research studies, Dr. Labrique serves on the faculty in the Global Disease Epidemiology and Control Program of the Department of International Health. He holds joint appointments in the Department of Epidemiology, Bloomberg School of Public Health and the Department of Community-Public Health in the School of Nursing of the Johns Hopkins University. He is lead investigator in several research projects measuring the impact of mobile information and communications technologies on improving maternal, neonatal and infant outcomes in resource-limited settings, primarily in South Asia. Dr. Labrique was recognized as one of the Top 11 mHealth Innovators in 2011.
In addition to developing training curricula for mHealth education, Labrique serves as an mHealth advisor to several international and global health agencies, including WHO, USAID and the mHealth Alliance. In addition to teaching and mentoring students at the Bloomberg School, Dr. Labrique and his team are working to understand the "trajectories to mortality" in resource-limited settings experienced by women of reproductive age and infants, to identify novel opportunities for intervention. Dr. Labrique is also actively engaged in designing, exploring and validating appropriate diagnostic and public health technologies, and is the inventor of a number of diagnostic and anthropometric devices.