By John A. MacDonald, Anita M. McGahan, Will Mitchell, & The T-HOPE Team
For generations, the model of how people in the developed world access health care services has involved face-to-face encounters between doctors and patients in brick-and-mortar medical facilities. The contours of that model are well known: A
patient arrives in a clinic, registers her insurance at the front desk, and waits. Then a nurse or an aide ushers her into a sterile room, takes her
vital signs, and hands her a paper gown. Some minutes later, a doctor in a white coat enters the room, asks her questions for 10 minutes or so,
and conducts a brief physical examination. The doctor issues a diagnosis, writes a prescription, and sends the patient off to make a copayment.
Afterward, the patient will drive to a local pharmacy to purchase medication. She is one of 40 patients whom the doctor will see that day.
In developing countries, that model of access is structurally
untenable. According to the World Health Organization, there is a
global shortage of 4 million health care providers; in 57 countries,
by the WHO’s reckoning, that shortage amounts to a “crisis.” 1,2
The WHO also estimates that 30 percent of the world’s population
lacks access to essential medicines.3 Rural clinics in the developing
world are scarce and ill supplied, and using better-equipped urban
medical facilities often requires patients to make a two-day journey.
Even within cities, travel to and from a clinic through jammed
streets can take several hours. Urban clinics, moreover, are typically
overwhelmed by patient demand. Alternative providers such
as local pharmacists are well meaning, but they tend to have limited
training. In place of insurance, people must rely on family savings
to cover health care expenses. Medications are often counterfeit,
serving as placebos at best and causing considerable harm at worst.
Across large swaths of the globe, a lack of supporting infrastructure
and appropriately trained personnel undermines any hope of
replicating the Western model of health care.
But a new breed of innovators who work in startup companies,
multinational corporations, NGOs, and government agencies are
responding to this challenge by using information and communication
technology (ICT) to reinvent health care access. Consider:
In a remote area of a developing country, a patient walks not into
a medical clinic, but into the home of a local woman. Trained as
a health worker, the woman asks a few questions in the patient’s
native dialect, takes the patient’s temperature and blood pressure,
and then picks up a mobile phone. Within seconds, a paramedic
is on the line. Using one of 70 algorithms in a clinical decision-making
software package, the paramedic works through another,
more targeted series of questions. The local health worker then
holds the line as the paramedic, via the Internet, sends a brief summary
of the case to a physician for review. The summary includes
a diagnosis and a proposed treatment plan. The physician agrees
with the diagnosis but suggests a longer course of antibiotics, and
signs off. The paramedic comes back on the line to explain the
diagnosis and the treatment plan, and the local health worker offers
to provide medications directly to the patient. Meanwhile, the
physician turns his attention to the next case summary that appears
on his screen—one of 400 that he will review that day. That’s not
a theoretical scenario. That’s the reality for patients enrolled in
eSwasthya, a program offered by the Health Management and
Research Institute, a nonprofit organization based in India.
ICT has the potential to topple or at least lower the geographic,
financial, and cultural barriers to access that dominate the health
care landscape in low-resource environments. Spurred by a rapid
diffusion of mobile telephony and by a sharp increase in Internet
penetration, many organizations in the developing world are building
health programs that hinge on the use of mobile phones, Internet-enabled
computers, and other ICT devices. In some cases, these
programs complement existing hands-on health care services. In
other instances, they present ambitious and innovative alternatives
to traditional care.
The new frontier of health care access has many striking features:
a radical reinterpretation of what it means to see a health care professional;
a redefinition of skill on the front line of care; an amplification
of each professional’s productivity; and a vast extension of
geographic reach. Yet by far the most significant feature is an intensive
focus on the needs of the patient. Programs such as eSwasthya
make significant use of ICT, but their primary focus is on providing
members of their target population with access to needed care.
The Center for Health Market Innovations (CHMI), based in
Washington, has amassed data on 1,200 for-profit and nonprofit
health programs.4 The Results for Development Institute launched
CHMI in 2010 with funding from the Bill & Melinda Gates Foundation,
the Rockefeller Foundation, and UKaid. Since then, the CHMI
database has emerged as the world’s leading repository of information
on global health innovation. We are all members of the Toronto
Health Organization Performance Evaluation (T-HOPE) team, and
in that capacity we scoured the CHMI database for programs in
the developing world that prominently feature the use of ICT. We
focused our attention on programs for which detailed information
on organizational strategy and operational results is publicly available.
Ultimately, we identified 40 programs that meet those criteria.
They cover a wide range of applications—from public outreach on
sexual and reproductive health to the use of biometric identification
cards in microinsurance plans. But all of them aim to extend
and improve health care access.
A Framework of Innovation
To make sense of the many ICT-enabled health programs that have
emerged in recent years—and to identify worthwhile candidates for
investment or emulation—funders, government officials, and program
managers need to have a clear analytical framework. In this
article, we introduce a simple yet compelling classification scheme.
We believe that the best way to look at innovations in health care
access is through the lens of demand: Who will benefit from implementing
such programs, and what form will that benefit take? In
that spirit, we focus first on the potential users of health technology
and then on the uses to which that technology might be put.
When it comes to ICT-based health access, there are two groups
of core users: patients and providers. The first group includes not
only patients and their families, but also members of the general
population who have an interest in disease prevention and wellness.
The second group encompasses a wide variety of health care professionals.
This category includes, for example, rural physicians in
India who access continuing medical education through Narayana
Hrudayalaya, a large hospital chain that delivers training via satellite
and fiber-optic technology. But it also includes local entrepreneurs—
many of them former tuberculosis patients—who run mini
TB clinics under the auspices of Operation ASHA, a program that
uses a biometric patient-record system. (Operation ASHA began in
India but now operates in Cambodia and Vietnam as well.)
The uses of ICT in health care fall into two broad categories: educating
people about healthy living or medical practice, and empowering
people to access or deliver treatment. The first use category covers
initiatives that aim to increase the knowledge of those who dispense
or receive health services. It includes activities that range from issuing
SMS bulletins about safe sex to producing online modules that
teach new techniques to primary care providers. The second use
category involves applications that directly or indirectly affect patient
care. It includes (among other uses) telemedicine kiosks, clinical
decision-making software, and supply-chain management tools
that improve access to medication.
A dual focus on users and uses
yields a two-by-two framework that
encompasses four broad categories
of ICT-based health care innovation.
(See “ICT in Health Care
Access: A Survey of Innovation,” below.) This framework brings order
to the seemingly chaotic landscape
of this growing sector. It serves as a
map to a fast-changing terrain that
will enable decision-makers to evaluate various innovations. ICT is
changing what it means to be a user within a system of health care
access, and it’s changing the range of potential uses as well. Categorizing
and comparing programs from around the world helps us
identify where and how that transformation is unfolding globally.
A Survey of the Field
The framework has utility for investors, donors, policy makers, and
program managers. For investors and donors, it offers a tool for comparing
organizations that apply for funds with peer organizations
that target a similar set of users and uses. Similarly, policy makers
can deploy the users-and-uses framework to assess public health
programming, to allocate scarce resources, and to encourage private
investment in a given area. (Many of the examples in the CHMI
database represent public-private partnerships, and many others
began as private projects that government health departments then
took over.) Program managers can categorize their own efforts by
referencing the framework. Doing so will help them with strategic
planning, and it will also help them to avoid the pitfalls that other
organizations have encountered in serving particular user groups
or in implementing particular uses.
Now, with this framework in place, we can survey the rich
variety of ICT-enabled health programs that populate the CHMI
database. (Several of these programs operate in multiple areas
of the framework; they serve multiple users and uses. But we categorize
them here according to the domain where their impact is
especially salient.)
Educating Patients | Two programs in the database offer examples
of using ICT to provide accessible health education to the
general population.
mDhil, a venture-backed startup based in Bangalore, India, leverages
mobile telephony and the Internet to reach its target audience—
urban young adults in New Delhi and Mumbai—at a fraction of the
cost of traditional education initiatives. In its first year in operation,
mDhil attracted 150,000 paid subscribers to its SMS health messaging
service. The service costs 5 cents per health tip or 60 cents per
month by subscription. Since its founding in 2009, mDhil has aggressively
expanded its Internet presence. Its full-featured website
covers health issues that range from weight loss to cancer. It also publishes
a series of video clips on YouTube that has attracted more than
10 million views. The videos feature recurring personalities who
answer questions about various topics; the most popular clips are
those that address sexual health concerns. The ability of mDhil to
conduct an Internet-based marketing strategy on a large scale distinguishes
it from most other programs
that aim to broaden health care access.
Marie Stopes International (MSI),
based in London, targets men and
women in need of sexual health services.
MSI has been in operation for
more than 30 years, and it currently
has centers in 40 countries. Its program
in Bolivia, a country with limited
communication infrastructure, offers
mobile clinic services, finances health
care for low-income families, distributes contraceptives, and provides
public education on sexual health issues. To promote reproductive
health education, MSI Bolivia established a confidential phone line
through which adolescents and young adults can ask questions that
they find too embarrassing to bring up in a public setting. Trained
university students field questions on the line six days a week. If necessary,
they refer callers to an MSI clinic for medical care. The cost
of each call is about 21 cents, and MSI Bolivia and the caller share
the cost equally. MSI plans to expand its service by creating a Web
portal for patients and providers, and by enabling patients to book
clinic appointments through its confidential hotline.
Educating Providers | The database features two programs that
expand access to care by using ICT to improve the training of local
health care workers.
Health[e] Foundation, based in Amsterdam, has a simple mission:
to deliver state-of-the-art medical information to resource-limited
regions of the world. Founded in 2003 by the Dutch physician Fransje
van der Waals, Health[e] Foundation offers a blended curriculum that
combines brief, periodic on-site training sessions with three-month-long
e-learning modules that participants can take online or offline
(via USB memory stick). The modules address a broad range of topics,
including HIV and AIDS, tuberculosis, and mental health. At the end
of each module, participants receive a certificate, along with access to
course updates and continuing-education materials. Medical experts
from around the world help to create and curate this educational content.
Health[e] Foundation operates on every continent except North
America and Antarctica, and it presents its course material in multiple
languages. Each year, about 1,000 physicians, nurses, and other health
workers receive training through the foundation.
Narayana Hrudayalaya, based in Bangalore, India, supplements
its core health care services by operating a highly advanced provider
education platform. The Narayana facility in Bangalore is one of the
world’s premier cardiac surgery centers. It has 5,000 patient beds, and
it’s best known for offering a low-cost ($2,000) coronary artery bypass
procedure. Recently, Narayana began a less publicized venture into
continuing medical education and telemedicine. It joined the PAN
African e-Network, a multiorganizational initiative that uses satellite
and fiber-optic technology to bring Indian expertise in education
and health care to sub-Saharan Africa. Initially, the network focused
on providing remote consultations and ECG readings to in-country
health care workers. But Narayana, which is leading the health care
aspect of the project, quickly recognized the potential of the network
to deliver educational content to African physicians. Today, Narayana
offers remote educational services in 16 African nations.
Empowering Patients | Several ICT-enabled programs in the
database augment the ability of low-income patients to access standard
health care services.
Rashtriya Swasthya Bima Yojana (“National Health Insurance
Program”), based in India, uses portable biometric data collection
and other ICT methods to support a nationwide insurance plan.
The program has helped establish affordable access to care for about
34 million poor Indian families. It’s a public-private partnership in
which the Indian government serves as the payer, third-party insurers
provide risk coverage, and contracted administrators manage
enrollment and claims. The federal government covers 75 percent
of the cost of premiums, and state governments cover the remaining
25 percent. Each participating family pays a one-time fee of 30 rupees
(about 70 cents) at the time of enrollment. The head of each family
and four other family members have their fingerprints and picture
taken at a terminal that immediately adds them to a central database
and generates a chip-enabled smart card. At that point, family
members may use the card to access about $600 worth of hospital
services. Several features of the plan help patients to avoid delays
in care. The authentication, claims, and authorization processes are
tied to a patient’s smart card, and they are completely paperless. The
plan also offers preapproval and fixed pricing for 750 procedures and
claims. To participate in the service, hospitals must have a reliable
Internet connection, and they must install fingerprint and smartcard
readers. The service closely monitors hospitals for possible
fraud and quickly removes offending institutions from the program.
Changamka Microhealth, a Nairobi, Kenya-based insurer that began
operation in 2008, also issues smart cards. The organization targets
people who have some income but are unable to open a savings account
at a traditional financial institution. With a Changamka card,
users can visit a doctor or buy medicine at more than 30 accredited
establishments in Nairobi, Kikuyu, Mombasa, and Naivasha. Changamka
has negotiated discount rates with each of those providers.
Patients can use the cards for outpatient treatment, maternity care,
third-party payment, or in-house services that their employers provide.
The cards are available at supermarkets and other retailers, patients
can add money to the cards at a cellular-connected terminal
or through a mobile phone, and the cards do not expire. Changamka
has partnered with GA Insurance, a Kenya-based company that acts
as both underwriter and fund manager for the organization.
Empowering Providers | Finally, several programs in the database
deploy ICT systems to enhance provider-side efficiency.
World Health Partners (WHP), based in New Delhi, offers an
example of ICT-enabled remote primary care. WHP, a nonprofit
partnership, began as an 18-month pilot in the Indian state of Uttar
Pradesh, and more recently it has expanded to Bihar, one of India’s
poorest states. WHP recruits pharmacists, local health workers,
and other informal care providers and sets them up in franchised
“clinics” under the WHP brand. The clinics mainly handle primary
care complaints, but patients can visit them for preventive medicine,
for tuberculosis treatment—or for anything in between. As
with eSwasthya, patients first consult a local WHP franchisee and
then connect via telephone or videoconference to a remote physician.
After the consultation, the physician can send a prescription
to the clinic via SMS. WHP maintains laboratories for blood work,
X-rays, and ultrasound tests, and it runs WHP-branded pharmacies
as well. Patients pay less than $1 per visit, of which 60 percent
goes to the franchisee and 40 percent goes to WHP. There are 250
telemedicine centers in the WHP network, and thus far WHP providers
have served about 750,000 people. Today, WHP franchisees
operate in 4,000 villages in Bihar. But the partnership is adding
villages to its network at a pace of 400 per month, and its goal is to
serve 20,000 villages by 2015.
SMS for Life, a system for improving supply-chain management,
shows that provider-side ICT implementation can go well beyond
enabling telemedicine. The project began as a pilot program in
Tanzania, a country with endemic malaria. About 93 percent of
the population is at risk of malarial infection, and there are an
estimated 60,000 deaths annually from this preventable illness. To
prevent stock-outs of antimalaria medication (among other crucial
supplies), the Tanzanian Ministry of Health and Social Welfare partnered
with Novartis, IBM, and several multinational organizations
to develop a system for monitoring supply levels across the country.
Each Thursday, health facility workers receive an automated
text message that asks them to report on their stock levels. If they
don’t reply within 24 hours, they receive a reminder message. The
next Monday morning, a district officer receives a summary report
of supply levels throughout a given region. The officer can then order
additional supplies or redistribute supplies from one facility to
another. Within six months of the start of the pilot, the stock-out
rate in Tanzania declined from 79 percent to 26 percent.
Assessing the Data
Sorting the ICT projects in the CHMI database in accordance with
the users-and-uses framework helps shed light on areas of health
care where the application of ICT has been fairly robust—and on
areas where there are notable opportunities for further innovation.
A large number of these projects, for example, focus on empowering
either patients or providers. They target populations that
traditional services have been unable to reach, and they do so by
overcoming limitations related to geography, transportation, and
the high cost of delivering on-site services. These examples provide
other organizations with models for bringing together traditional
and nontraditional providers to enable services that do not require
brick-and-mortar facilities or face-to-face interaction.
There are also multiple entries in the CHMI database that fall
within the patient education domain. These services, which often
rely on cell phone and SMS technology, take advantage of the explosion
in mobile telephony that is occurring in even the poorest
communities around the world. These services have one other advantage:
The organizational infrastructure needed to initiate them
is relatively simple.
By contrast, we found notably few examples of ICT-based innovation
in the provider education domain. The reason for that gap is
twofold, we believe. First, training providers is a highly technical
undertaking—considerably more so than, say, launching a mass SMS
campaign to teach the general
public about condom use. It requires
both medical and educational
expertise, along with
a deep understanding of local
provider practices. Second, although
many Western medical
schools are working with
schools and governments in
the developing world to improve
provider training, the
standard approach continues
to focus on delivering such assistance
on-site and in person.
These barriers are surmountable.
We expect to see
slow but significant growth
in ICT-enabled provider education,
especially as ICT infrastructure
becomes more
prevalent in the developing
world and as educational institutions
there become more
sophisticated. Established
schools such as Stanford University
and startup ventures
such as the Khan Academy (a
nonprofit video-based education
service) are already demonstrating
that educators can
conduct large-scale knowledge
transfers—even entire university
courses—via the Internet.
It’s only a matter of time
before similar approaches to
educating providers begin to take
hold in developing countries.
Until recently, program managers
with an interest in ICT-enabled strategies
to improve health care access had
few examples to follow. Fortunately, as
the programs in the CHMI database
indicate, promising examples are now
emerging. The next challenge will be
to evaluate the long-term viability
and the outcomes of such programs,
and that will require looking beyond
simple metrics such as the number of people who have been treated
or trained. A working group that includes CHMI, T-HOPE, and the
Global Impact Investing Network is developing a set of metrics for
investors and funders to use in assessing new health care projects.
But that effort will take a significant amount of time to unfold. Meanwhile,
tools such as the users-and-uses framework help to illuminate
the variety and the depth of activity in this emerging field.
Assessing the Future
Numerous limitations continue to affect the implementation of ICT-based
health care solutions. Internet connectivity is still nascent in
much of the developing world. The instability of electrical supply
in developing countries presents a massive challenge as well. And
although mobile-phone service is becoming ubiquitous, high rates
of illiteracy limit the usability of SMS-based programs in many
parts of the globe. In a recent post at SSIR Online, Ken Banks noted
that organizations continue to push technology—mobile technology,
in particular—into low-resource settings without fully taking
into account local needs.5 The use of ICT in health care is still in its
infancy, and we shouldn’t let its novelty distract us from the need
to assess its relevance to target communities. Health care technology,
in short, cannot surmount all barriers to health care access.
Despite those obstacles, there are substantial opportunities to
expand ICT-enabled health care services. Most developing countries
now have the telecommunications infrastructure to support at least
basic ICT services, and those services can readily improve access to
health care treatment and education through the deployment of voice
and SMS applications. More sophisticated services, meanwhile, are
emerging in countries that have both a strong technical infrastructure
and a sophisticated organizational infrastructure. Fortunately,
more and more countries do have that combination of resources.
What’s more, the potential scalability of ICT-based services offers
an opportunity for organizations to extend their programs beyond
individual countries. After all, many developing countries suffer from
similar gaps in health care access and face similar infrastructure
limitations. At least five of the 40 programs that we identified in our
survey are transnational in scope. We have already discussed four
such programs: Operation ASHA, which sponsors TB clinics in multiple
Asian countries; Health[e] Foundation, whose provider education
platform reaches physicians in Asia, Africa, and South America;
Marie Stopes International, which offers sexual and reproductive
health services in 40 different countries; and Narayana, an Indian
organization that participates in the PAN African e-Network. In
addition, a program called Dentista
do Bem coordinates the efforts of
volunteer dentists in Portugal and
in numerous countries throughout
Latin America. Other ICT-enabled
approaches—with due allowance
for the need to make cultural and
linguistic modifications—have the
potential to extend across national
borders as well.
The innovative programs in the
CHMI database reflect a disruptive
model of care that has not yet spread from developing countries to
more resource-rich settings. The broad use of advanced telemedicine
and clever smart-card-enabled insurance schemes are rare
or nonexistent in much of the developed world. Yet the potential
benefits that those services could bring to the operation of, say, an
American HMO (health maintenance organization) or a Canadian
LHIN (local health integration network) are immediately apparent.
Indeed, given their relative freedom from technical obstacles and
their high literacy rates, developed countries present an environment
in which ICT-driven health care clearly might flourish. One
place to start would be in the use of long-established mobile technologies—
an area where “advanced” countries have lagged behind
their less-developed counterparts. SMS-based payment and health
education applications have become commonplace in many developing
countries, for example, even as people in the developed world
focus on creating medical smartphone apps that have struggled to
find broad utility.
In all parts of the world, the largest barrier to implementing ICT-based
health care is not a lack of technology or a lack of medical skill.
Instead, it is the belief—prevalent in both the developing world and
the developed world—that high-quality health care services require
hands-on, person-to-person engagement within a traditional brick-and-mortar medical facility. As that mindset changes and as organizational
and logistical capabilities continue to improve, we are
likely to see rapid growth in demand-focused, ICT-enabled services
that address the needs of both patients and providers. Technology
that can improve access to health care now exists, and it’s becoming
ever more widely available. We simply need the motivation and
the courage to use it.
We wish to thank Ameya Bopardikar, Jieun Cha, Earl D’Almeida, David Leung, Leigh
Pharand, and Jason Sukhram for providing research support for this article. We are also
grateful for the financial support provided by the Center for Health Market Innovation,
the Results for Development Institute, and the Canadian Social Sciences and Humanities
Research Council.