Mobile-First in Africa: How Mobile Phones are Changing Health Care in Africa

Africa is quickly becoming a mobile-connected continent: mobile phones are often the only technology available, especially in places where it is hard to find power lines, fixed-line telecom infrastructure, or personal computers. This technological explosion is changing people’s lives in several ways to an even greater extent than in developed countries and opening up a wealth of new opportunities.

This series will focus on several African projects that are leveraging existing mobile technology to have a significant impact on people's lives, from education to banking, from health to conflict outburst handling, and more. Articles in this series will not only cover the available technological ground of those projects but also try and explain their impact on African society.

This InfoQ article is part of the series “Mobile-First In Africa”. You can subscribe to receive notifications via RSS.

In little over a decade, Africa has gone from being a region where it was, and still is hard to find power lines, fixed-line telecom infrastructure, and personal computers, to being the second most mobile connected continent where about 15% of the billion inhabitants owns a cell phone.

This technological explosion is having a far larger impact than merely connecting people, says Seth Berkley, CEO of the GAVI Alliance, since it is creating a very large, low-cost distributed sensor network that has the potential to completely transform global health care:

"Historically we have had very little solid real-time disease surveillance and monitoring data on Africa, and as such have had to rely upon a few sentinel sites and modelling estimates to track the spread and prevalence of disease […] Cell phones are changing that. For the first time we are seeing good quality data that can tell us who is dying and from what, who is sick, and where clusters of disease are occurring. […] With 630 million cell phone subscribers in Africa, and 93 million already using mobile internet, we know the data is there.”

Monitoring health data can have a strong impact on health policies and help improve them on several accounts:

Disease spreading: cell phones are instrumental in the fight against diseases, such as in the case of malaria.

Counterfeit drug detection: cell phones are also being used to detect fake or stolen drugs. This reduces health risks for people and helps authorities fight counterfeit drugs spreading.

Drug supply: cell phones can be easily used to monitor the level of vaccine supply in remote facilities, making it possible to prevent stock-outs and helping to ensure that vaccines are available when required.

Birth registration: sadly, many infants are born and die without ever being registered. Cell phones can help parents to register the birth of their child, which allows governments to better plan health policies. For a fuller analysis of birth registration, see InfoQ’s Mobile-first in Africa: Education, Birth Registration, Banking\.

In this article we will review a few projects in the above listed areas that have been changing the healthcare landscape in Africa.

The fight against malaria

Malaria is a big issue outside of the developed world, as it is attested to by the following WHO figures:

• About 3.2 billion people are at risk of malaria worldwide.
• There were an estimated 198 million malaria cases worldwide in 2013, mostly children.
• In 2013, malaria claimed an estimated 584 000 lives, i.e. 1,600 malaria deaths per day.
• About 90% of malaria deaths occurred in WHO Africa region, mostly among children under 5 years of age. As a matter of fact, the situation is even worse than that, since WHO Africa region does not include either Somalia or Sudan, which both are countries affected by malaria.

The cost of malaria does not only sum up to its death toll. Even more striking is the effect that malaria has on African society. According to Malaria No More (MNM), a nonprofit organization that aims to end death caused by malaria in Africa, it is estimated that malaria costs Africa $12 billion a year in lost productivity. Indeed, according to MNM, “malaria accounts for half of preventable absenteeism in African schools, causing up to 10 million missed days each year.” No other disease is so efficient in keeping children out of school. Furthermore, while malaria is less likely to be deadly for adults, it is still true that the disease forces adults out of work and thus causes a reduction in disposable income for families.

Mobile tech can be a key factor in the fight against malaria, says Martin Edlund, MNM's founding member and CEO:

Of all the tools in the malaria fight (including the obvious ones such as nets, testing, treatment and spraying) mobile phones may be the ones that tip the balance toward ending this disease. That’s why at Malaria No More we’ve been bold in proclaiming that malaria can be the first disease beaten by mobile.

Malaria No More is pursuing a strategy based on three traditional pillars of the fight against malaria: early diagnosis, mosquito nets, and vaccine management. In all cases, though, they count on mobile phones to make those strategies radically more effective. "Malaria thrives on bad information," said Edlund at the 2013 Social Good Summit. "Good information is how we are going to save lives […] and it starts with two simple devices: a rapid diagnostic test and a mobile phone."

A rapid diagnostic device is a 60 cents device capable of predicting malaria with a 99.5% accuracy. According to Edlund, health operators distribute 230 million such devices in Africa each year. The outcome of a diagnostic test is either a 0 or a 1, i.e., a single bit of information. "This becomes really exciting when combined with a mobile phone," since it allows one to identify malaria outbreaks and to better plan for medical intervention.

Mosquito nets are another fundamental weapon against malaria. The biggest issue with them is showing people how to use them and also getting them to do it. As Ray Chambers, UN special envoy for malaria, declared to Reuters: "The average, it appears, in Africa, (is that) one out of two people will not sleep under a net unless they are reminded, encouraged." For this reason, reminders and other kinds of messages, inviting people to or explaining how to use mosquito nets, are usually broadcast on the radio. Many people at risk, though, live outside the area reached by television and radio, and sometime even electricity, and getting them the right information is a challenge in itself.

This is where mobile phones can help, thanks to their large penetration, even larger than radio or electricity. SMS messages are highly effective as a means for delivering information and reminders about malaria control, and to remind families at risk to sleep under nets and seek timely testing and treatment when specific symptoms appear.

One specific example of this use of mobile phones is MNM’s NightWatch initiative, which is engaging mobile platforms and African leaders, from international music icons to local sports heroes and African presidents in countries such as Cameroon, Chad, Senegal, and Tanzania. A study by HL Bowen evaluated the impact of such a campaign in Cameroon and found a 6.6% increase in last-night net use among respondents and a 12.0% increase in last-night net use among children under five.

Another interesting use of mobile technology aims to evaluate how "human movements contribute to the transmission of malaria on spatial scales that exceed the limits of mosquito dispersal." A paper published in Science in October 2012 explains how cell phone data were used to analyze the travel patterns of nearly 15 million individuals over the course of a year in Kenya. The study could demonstrate the existence of stable routes for both human and parasite movement and this led to the identification of settlements which were acting as a major source of parasites, and those that were most vulnerable to importation, depending on local factors like the availability of vectors (mosquitos) for the further spreading of the parasites.

Caroline Buckee, one of the authors of the study, highlighted the importance of combining massive amounts of data coming from cell phones with detailed information about malaria incidence to understand the spread of the disease.

Counterfeit drugs

In many African countries, the spread of fake or stolen drugs is a real risk. The World Health Organization estimates 30% of drugs in emerging markets are fake and may be very harmful to consumers. Governments make an effort to combat that through several global tactics, such as strengthening supply chains, investigating etc., but also through directly getting in touch with consumers. As we have already seen in other cases, in Africa mobile phones are one of the best ways to make that direct connection.

Several initiatives exist to help identify counterfeit medication. One such is Ghana-based mPedigree GoldKeys, another is Sproxil, an American company based in Cambridge, Massachusetts. In both cases the system is based on the following steps:

A security label with a scratch-off panel is placed on all protected products.

Consumers scratch off the panel at point of purchase to reveal a unique one-time use code.

The code is sent via a free SMS or mobile app to a country-specific short code, and the consumer receives a reply almost instantly indicating whether the product is genuine or suspicious.

A useful consequence of this is that authorities can tell where a fake batch of drugs has entered the market, or when there is a spike in activity. They can also locate and trace stolen goods or illegally diverted medication.

The mPedigree platform entered testing in 2008 in Ghana, to be eventually approved by several Ghanaian authorities and organizations in 2014. At the end of 2010, two pharmaceutical companies started to roll the service out for their medicines in Nigeria and Ghana. Finally, in 2011 the Kenya drug safety regulator announced its support for it.

Betty Enyonam Kumahor, who is Managing Partner at The Cobalt Advisors, and was previously regional managing director of Pan-Africa for ThoughtWorks, andworked on mPedigree. She describes it as an example of "frugal innovation, [since] it doesn’t require anything fancy to do it. It’s really just with an SMS and a simple backend system that you are able to verify if your medication is safe or not” Still, frugal innovation is able to save lives.

Health education

Health education is an important topic, as Tina Rosenberg, of the New York Times’ Fixes column, suggested at the 10th annual Global Health and Innovation Conference in 2013, where she claimed that “the biggest fix in global health in the coming years will be “harnessing the power of peer pressure” to get people to adopt healthy behaviours.” And again, mobile phones prove to be of high value as a means to spread medical information among people who are under-connected in conventional terms, but own a mobile phone.

Mobile health education and awareness programs (known as mHealth) use SMS messages to send health information to its intended recipient on a variety of subjects, such as test methods, treatments, health service availability, and so on. The biggest advantage of SMS messages in this case, besides their capacity to reach people in rural areas that would be otherwise hardly reachable, is their unobtrusiveness and confidentiality, which is of critical importance in environments where disease is often taboo. A study in BMC Research Notes by Kivuti-Bitok & colleagues (2013) found that mobile phones were helpful in identification of cervical cancer in Kenya and hinted at mobile phones being able to “play a great role in advertising and encouraging screening, which many patients were reluctant to go through with due to embarrassment and cultural expectations.”

Preventing medication stock-out

In many African countries, supply chain problems make it difficult to get medicines to patients, especially malaria drugs. It is not uncommon that a patient, after detecting the first symptoms of an illness and going to the nearest health center, is turned away because there is no medication available. Things are worsened by the relatively low density of health centers, which means that it is not easy for the patient to reach one of them, let alone trying her luck a second time by going to another after being turned away.

SMS for Life is a project aimed at "harnessing everyday technology to eliminate stock-outs and improve access to essential medicines in sub-Saharan Africa." According to Novartis, one of the partners in SMS for Life, factors that contribute to high rates of drug stock-out at health centers include:

• Zero visibility to district management on the medicine stock levels in their facilities.
• Extreme difficulty in forecasting demand for the drug.
• Inconsistent reporting of consumption and sporadic, paper-based ordering.

SMS for Life tries to leverage technology already available to health workers to set up an effective workflow that has proven to greatly improve the availability of drugs and, in the Democratic Republic of the Congo, also other medical supplies, including blood supplies. The system works in the following way:

A six-month pilot program held in Tanzania showed "impressive results":

Stock-outs were reduced from 79% to less than 26% in the three districts.

• At the beginning of the pilot, 26% of the facilities had no dose form of the Novartis ACT and by the end, this figure had been cut to less than 1%.

Next Article in Series

The next article in the series will focus on crowdsourcing services, like those based on the Ushahidi platform, that have been used to monitor elections, to report problems about water supply quality, or map violence outbursts in political crisis.

About the Author

Sergio de Simone is an iOS Independent Developer and Consultant. Sergio has been working as a software engineer for over fifteen years across a range of different projects and companies, including such different work environments as Siemens, HP, and small startups. Currently, his focus is on development for mobile platforms and related technologies.He tries to be a successful iOS independent developer and he is always on the look for challenging and new endeavours as a consultant. In his spare time he is waiting for his twins to grow up a bit so he can teach them some programming. You can find a few pointers about him on his contact page.

Africa is quickly becoming a mobile-connected continent: mobile phones are often the only technology available, especially in places where it is hard to find power lines, fixed-line telecom infrastructure, or personal computers. This technological explosion is changing people’s lives in several ways to an even greater extent than in developed countries and opening up a wealth of new opportunities.

This series will focus on several African projects that are leveraging existing mobile technology to have a significant impact on people's lives, from education to banking, from health to conflict outburst handling, and more. Articles in this series will not only cover the available technological ground of those projects but also try and explain their impact on African society.

This InfoQ article is part of the series “Mobile-First In Africa”. You can subscribe to receive notifications via RSS.