e/mHealth Solutions in Rural South Africa for both patients and health workers: A Critical Analysis

1. The Vutivi Study
e/mHealth Solutions in Rural South Africa
for both Patients and Health Workers:
A Critical Analysis
Jocelyn Anstey Watkins
PhD Candidate in Health Science, Warwick Medical School
Supervisors: Prof Frances Griffiths, Dr Jane Goudge and Dr Francesc Xavier Gómez-Olivé
ICT4Health
Tygerberg Hospital, Stellenbosch University
24th November 2015

2. Contents
• Background to South Africa’s Health System
• Conceptual Framework
• Research Site
• Methods
• Results with Examples from the Field
• Interpretations, Implications and Recommendations
• for Policy and Practice

3. Background and Health System Challenges
South Africa presents a relevant case study to examine where and
how e/mHealth may play a role within the care cycle and assist
rural communities in the barriers faced in accessing healthcare.

4. What is e/mHealth?
Collect data
Count events
Connect individuals
Compress time
Create opportunities to improve
health
Mobile Health (mHealth) is the use of mobile and wireless technologies to support the
achievement of health and is a component of Electronic Health (eHealth)
Source: HealthEnabled
Mobile phones are ubiquitous in South
Africa – they are a utility rather than a
luxury

5. Theoretical Framework
- Normalisation Theory (May)
- Realism (Pawson and Tilley)
- Capability Approach (Sen)
- Behaviour Change Wheel (Michie)
- Access to Healthcare (Levesque)
- 12 mHealth Solution Framework
(Labrique)

6. The National Integrated ICT Policy Green Paper
The South African Connect Broadband Strategy
The National mHealth Strategy
The National eHealth Strategy
National Health Normative Standards Framework
Protection of Personal Information Act
DistrictHealthManagement
InformationSystem
National Development Plan - National Health Insurance - The National Health Act
Relevant
South African
Policies

7. MRC/Wits Agincourt Health and Socio-Demographic
Surveillance Site
Mpumalanga, South Africa
Fieldwork was conducted over
12 months from
September 2013 to 2014
Annual census for last 20 years
Population Size: n= 107,500
Area Size: 420 km2 study site
Number of Households: 16,000
Villages: 32
Cell phone Penetration: 93% of
households own a cell phone
(2014 census stats)
Households are reliant on migration for work, social grants
and subsistence farming

8. Percentage of households owning cell phones in Agincourt HDSS research
site
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Percentage of households with cellphones in Agincourt HDSS research site
2001
2007
2013

10. Research Design:
Methods of data collection
Methodology:
• Mixed-methods
• Case study design
Qualitative research methods:
- In-depth interviews with participants
- Focus group discussions
- Prolonged engagement in non-participant
observations in district hospital, clinics and within
the community (ethnography)
Secondary Quantitative data analysis of annual
demographic census
- Descriptive stats e.g. migrations, education
status, asset status, healthcare utilisation and food
security

11. Participant Chart

12. Sampling and Population
Sampling: Clinics and hospital randomly sampled.
Health workers were purposively sampled for diversity of
duration, type of experience, work role & context.
Patients recruited from the chronic disease queue and
interviewed whilst they waited for their consultation.
Sampled for diversity of locality of residence, age and
gender, and long-term conditions.
Demographics:
 Equal ratio of male to female patients aged 18-90
 Range of chronic diseases – TB, HIV/AIDS, Diabetes,
Hypertension, Epilepsy etc.
 Patients were from both South Africa and Mozambique
 All patients owned a basic cell phone (phone sharing
was rare)
 2/3rds of patients had no airtime at the point of
interview

13. ‘Lucy’ the Fieldwork Vehicle
My Mama Miriam,
the impetus for this
study

14. Data Collection & Analysis
• All data audio-recorded,
transcribed verbatim
(Xitsonga to English) and
analysed thematically
• NVivo utilised to
manage and code data
• Consent: thumbprint or
signature guided by
senior multilingual
QualitativeAgincourt
Fieldworker
• Ethics: WMS, Wits and
Mpumalanga Province
Fieldworker assisting patient with inked thumbprint on consent form

15. 2 Sensors & Point of Care Diagnostics
1
Client Education & Behaviour Change
Communication
3 Registries / Vital Events Tracking
4 Data collection & Reporting
5 Electronic Health Records
6
Electronic Decision Support
Information, protocols, algorithms, checklists
7 Provider-to-Provider Communication
User groups, consultation
8 Provider Work Planning & Scheduling
9 Provider Training & Education
10 Human Resource Management
11 Supply Chain Management
12 Financial Transactions & Incentives
12 Common mHealth Application Framework (Labrique, 2013)
How does mHealth impact on quality and efficiency in terms of improving
service delivery processes, strengthening health systems and health outcomes?

16. Four Topics
Topic 1
• Landscape of e/mHealth in
South Africa – different
players/stakeholders
involved
Topic 3
• Communication between Health
Worker (at the ‘coal’ face/remote) and
Other (website/app/specialist clinician
etc.)
Topic 4
• Use of portable mobile
ultrasound for pregnant
women
Topic 2
• Communication between
Patient and Health Worker

17. Content
Aggregators
using social
media platforms
(Mxit Reach)
Service &
Content Providers
(Department of
Health (DOH) via
Management &
Clinical Staff)
Donors as
implementers and/or
Funders
(USAID/NORAD/Johns
on & Johnson)
Public Health
System
(DOH responsible
for
implementation,
monitoring &
evaluation)
Doctors as
Designers &
Developers
(Vula &
Thumela)
Digital Providers:
Technology and
Software
Developers/Stakehold
ers
(Private: Mobenzi,
Dimagi; NGO: Cell Life)
Front-end
Users/Consum
ers (Patients or
Health
Workers)
Policy Advocates
and Advisors
(Technocrats:
district, provincial,
national DOH &
GSMA)
Research
units as
Experts to
Advise (CSIR,
Wits RHI)
Mobile
Operators
(MTN,
Vodacom,
Telkom)
Content
Producers
(MAMA)
Medical
Device
manufacturer
(GE)
Topic 1. e/mHealth Landscape in South Africa
Results • Landscape of
e/mHealth in South
Africa – different
players/stakeholders
involved
Topic 1

18. South Africa mHealth Stakeholder High Level Overview

19. Results: Topic 2
Patient Health Worker
mHealth Examples: mHealth Solutions Taxonomy:
MomConnect
Nkateko Phone Call Reminders
District Health Information System
1
Client Education & Behaviour Change
Communication
3 Registries / Vital Events Tracking
4 Data collection & Reporting
5 Electronic Health Records
Topic 2
• Communication
between Patient and
Health Worker
1
Client Education & Behaviour Change
Communication

20. MomConnect
National Department of Health
mHealth Project at scale
1
Client Education & Behaviour Change
Communication
3 Registries / Vital Events Tracking
Topic 2
Pregnant women at the clinic opting into receiving staged-based educational text messaging (SMS)

21. S.Charles
The Nkateko Trial: Hypertension Project:
Lay Health Worker Mobile Phone Call to Patient Mobile Phone as a Appointment
Reminder to attend clinic for vital signs checked & collect treatment
1
Client Education & Behaviour Change
Communication
“I can’t read, but when the
children are at home, I do ask
them to read it for me and tell
me the message.
And I cannot see very well.”
(Martha, female, aged 58, hypertension)
Topic 2
Reference: Thorogood et al. Trials 2014, 15:435
“The nurses don’t put much effort into collecting the data
because they are not using the data themselves they are
just capturing it to be used at the national level and
analysed there. They are feeding the data in but getting
nothing out.” (Key Informant, male)

22. 4 Data collection & Reporting
5 Electronic Health Records
District Health Information System
Digitizing health indicators from paper graphs as a
precursor to electronic patient files.
“If you can’t get basic health care, you can’t
get basic equipment, you cant feed your
doctors in theatre more than bread and
butter, I am sure that trying to organise a
digitalised interlinking computer system that
is maintained and people are trained on is
impossible.”
(Doctor, male, District Hospital)
Topic 2

23. Results: Case Study 3
Health Worker Health Worker
mHealth Examples: mHealth Solutions Taxonomy:
Vula Mobile (eye)
Stop Stock-outs (drugs)
Thumela Mobile (referrals)
Web Literacy (Google)
Clinical Associates Students
2 Sensors & Point of Care Diagnostics
6
Electronic Decision Support
Information, protocols, algorithms, checklists
7 Provider-to-Provider Communication
User groups, consultation
8 Provider Work Planning & Scheduling
9 Provider Training & Education
11 Supply Chain Management
Topic 3
Communication between
Health Worker (at the
‘coal’ face/remote) and
Other
(website/app/specialist
clinician etc.)

24. Stop StockOuts Campaign
Using mobile phones to alert others of out of stock
medication at clinics and hospitals
“Our women can’t afford a taxi [public
transport on mini bus] to town to buy
iron tablets because we have run out
here at the hospital.
They get worms from eating soil; had a
small tapeworm delivered post-
caesarean in theatre yesterday.
We also have stock-outs of Ampicillin,
Pethidine, Fentanyl, injectable
Morphine, paracetemol”
Doctor, male, District Hospital
“We have stopped
initiating HIV + kids
on Anti-retrovirals
because of the
Abacavir stock-outs”
Nurse, female, Primary Health
Clinic
7 Provider-to-Provider Communication
User groups, consultation
11 Supply Chain Management
Topic 3

25. VULA Mobile App
Mobile phones with diagnostic capabilities for eye healthcare
where issues of rurality are a problem
2 Sensors & Point of Care Diagnostics
Eye Test
Connect to specialist – Chat – Information = Remote Diagnosis
Pupil Check
Topic 3

26. THUMELA Mobile Referrals
Connecting health workers to
improve referrals and remote
diagnosis
8 Provider Work Planning & Scheduling
Example:
District Doctor
photographs an
X-ray image of the
lungs and sends it via
WhatsApp to a
Specialist at the
Tertiary Hospital
“I try to use the hospital telephone system,
which can be frustrating, you wait for ages
before the Operator answers often after several
minutes and then you give up.”
Surgeon, male, District Hospital
2 Sensors & Point of Care Diagnostics
Topic 3

27. Mobile Web Literacy of
Nurses
Littman-Quinn
6
Electronic Decision Support
Information, protocols, algorithms, checklists
9 Provider Training & Education
Example:
Doctors receiving
blood tests results
from the National
Labs direct to their
phones during the
consultation
instead of waiting
for patient files
Example: Nurses searching for health info on
search engines such as -
Topic 3 Doctors accessing
Digital Blood
Results
“The expectations to put a system in place, where you may have
staff who are not particularly computer literature is scary at best, so
there needs to be a whole change management programme that
goes with this with concerted levels of training.” (Key Informant, male)

28. Topic 4
• Use of portable mobile
ultrasound for pregnant women
GE Healthcare Vscan portable ultrasound (pocket sized)
“The new ultrasound machine has arrived but I
understand that was 5-6 years of requesting
later. And the older one is held together by
bandages!” (Doctor, male)
“Yes because at our clinics we don’t have sonars,
you have to go to the private doctor to consult. I
went to the private doctor to know if I am really
pregnant.” (Pregnant woman, 30-39)
2 Sensors & Point of Care Diagnostics

29. Street level bureaucrat:
Patient self-management
Health workers
e/mHealth use
Accessible digital
health information for
patients and health
workers
Local opportunistic
implementation
of the use of
e/mHealth
Management of
resources and
maintenance
equipment
Health system
dimensions
1.) Access to health
information
2.) Web literacy of
patients and health
workers
4.) Phones to support
chronic disease
management
5.) Nurses use of
computers
8.) Digital solution to
drug stock-outs
11.) Future use of
mHealth
6.) Phones used to
support doctors’ work
practices
7.) Local digital
innovation by doctors
3.) Adolescent phone
use (informal)
14.) Barriers to
e/mHealth
10.) Landscape of
e/mHealth in South
Africa
12.) Policy
environment/financial
stability
13.) Health system
dimensions
15.) Policy debate
Unreliability of airtime
because of financial
instability further
marginalises some people.
Increased access to digital
sources can empower the
patient and improve
understanding
Decide who
monitoring would be
best for as it still may
marginalise few
without phones/poor
eye sight and no proxy.
Normalisation of nurse
computer nurse to
become part of
everyday work
practice.
Informal mHealth by
patients and doctors.
Shift in doctor’s
personal device use for
work practice. Greater
exposure may lead to
innovation. Though
inequity emerges.
Current maintenance
strategy does not bode
well for future
e/mHealth technology.
Needs buy-in from all
levels who will support
new ICT systems.
Committed working
relationship with
external stakeholders
increases knowledge.
Continued
government
stewardship.
Collaboration for
evidence-based website
mHealth reminder and
monitoring system using
personal phones. Nurse
computer training.
mHealth practices for
work e.g. referrals
adheres to standards.
NDOH to encourage
doctor innovations.
Nurses trained in
obstetric ultrasound for
primary care.
Informed maintenance
strategies with back-up
plan.
Financial investment if
all other
recommendations are
adhered to.
Greater legislation and
regulation for health
worker use of
WhatsApp for work.
Intended outcomes: Recommendations may lead to more efficient work practices by health workers, enhanced health service delivery and
improved patient outcomes (greater support/information networks)
Overarching
Themes/Issues
Barriers/BenefitsKey
Examples
Recommendations

30. Conclusions
Interpretations, Implications & Policy and Practice Recommendations
• Context of health delivery in South Africa is
not completely ready for e/mHealth but there
is a definite need to try if the the ability to
communicate is created or the quality of the
communication is improved.
• e/mHealth between health workers and other
specialists is feasible & acceptable and to
some degree is already in use.
• Enhancing healthcare through the use of
digital networked communication has
potential, where its implementation is
integrated within this normalisation.
• Need to understand the unanticipated
consequences of implementing everyday
technology: cell phones for different purposes
from their intended function.
Source: Agincourt website

31. Conclusions cont.
• A NDOH health website for patient and health
workers is recommended.
• Maintenance and management strategies for
e/mHealth
• Legalisation over the use of WhatsApp with
patient data or more secure messaging
platform
• Support local innovation and implementation
• There has been a lack of commitment to
addressing rural technological deficits but the
tide is changing.
• Development from within – the doctors are
becoming the developers because they know
what they need to improve work practices.
• The South African health system
has many systemic problems and
e/mHealth will not be a
standalone solution but it may
enhance health service delivery
through improved communication
channels.

32. Thank you for listening
Inkomu Fambani Khale
Thank you to the Vutivi participants, my supervisors & funders
All images, unless stated are J.O.T.A.Watkins