Improving care for non-communicable diseases: There’s an App for That!

By Professor Vivekanand Jha – Executive Director of George Institute for Global Health India

Over the last 25 years, the global burden of diseases in terms of mortality and morbidity has inexorably shifted from infections, neonatal deaths and pregnancy complications to noncommunicable diseases (NCDs).  In India, the contribution of NCDs to deaths increased from 37.9% in 1990 to 61.8% in 2016. This change requires a fundamental shift in the health system response to manage this transition, in part due to pauci-symptomatic nature of these conditions and the long-term management and medication availability requirements. The fact that the affected individuals and families are not ill enough to be forced to approach the healthcare system, and the need for periodic reassessment and treatment modification require novel approaches, especially to cover the needs of population living in remote rural areas.

In recent years, interventions that use mobile devices and wireless technology have been thought to be key to improving healthcare delivery for NCD management by reducing response time (by using trained non-physician health workers), providing immediate treatment decisions, minimizing variability in the quality of care, and optimizing monitoring and patient engagement. Lumped under the generic term ‘mHealth’, these solutions have been popping into the market with remarkable regularity around the world. India has been an early adopter of technology, and to some extent was a leading participant in the ‘tech-boom’ of the 1990s and early 2000s. The number of mobile connections in India has grown to over 1 billion, with 42% of subscribers living in rural areas. It is not surprising, therefore that a number of mHealth have been released to the Indian market.

The World Health Organization (WHO) recommends the “building blocks” framework to track system performance and evaluate progress. The components or blocks are: service delivery, health workforce, health information systems, access to essential medicines, financing and leadership/governance.

Image credit: http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

We did this systematic review to ascertain the ‘fit’ of the mHealth initiatives targeted to NCD management in India with the aforementioned building blocks. This review was limited to published literature that contained primary data. We ended up with a total of 318 articles, most of whom were published in the last 5 years. A majority of the reports came out of Southern Indian states. Over 80% of the interventions were limited to one or two building block domains, with service delivery being the focus in over 50%. The least frequently covered blocks were Health Information, Leadership, Governance, and Financing. Client education was the most frequently used tool. We were struck by the relatively poor quality of the studies – with issues related to sample size calculation, experimental design, methodological rigour, and narrow focus, with neglect of the efficacy, user acceptability, and cost-effectiveness. A large proportion used non-validated instruments (surveys and questionnaires).

An important caveat that must be pointed out is that this review is limited to published studies – we did not evaluate interventions that are available through app stores or on the web but have not undergone scientific testing or submitted to academic journals.  

It seems that developers of these mHealth solutions have been approaching healthcare delivery as an engineering problem, and try to develop a technical solution, without addressing the system-wide needs. The term ‘pilotitis’ has been used, where solutions are launched without robust evidence around usability, efficiency, efficacy, cost-effectiveness and/or scalability. To achieve scale, these innovations should be evaluated in a real-world context and integrated within existing and emerging health systems

Appropriately conceptualised solutions supported by technology can have lasting impact on long-term community-based management of chronic conditions, reduce inefficiencies caused by disease-specific silos of healthcare delivery and narrow health outcome disparities. mHealth community should recognise the need to design solutions with health systems building blocks in mind,  evaluate them using validated methodology powered on relevant end-points, and include user-acceptability and cost-effectiveness. Finally, all of these should be integrated with reforms in medication delivery, financing and governance at all levels of care.

 You can read the full paper here: https://mhealth.jmir.org/2018/10/e11440

 

Questions:

• Do you think mHealth solutions should be developed after a proper health system needs assessment? If yes, who should do it and what should they look for?
• What kind of testing should a new mHealth solution undergo before being released to the market?
• Have you been impressed by any mHealth solution? If yes, can you share the distinguishing features of the solution(s)?

 

Bio:

Professor Vivekanand Jha is the Executive Director of George Institute for Global Health India, Professor of Nephrology at the University of Oxford and Adjunct Professor of Medicine at University of New South Wales, Sydney. The current focus of Professor Jha’s research is in using multi-disciplinary approaches and innovations to address the system level health and economic challenge posed to humanity by non-communicable diseases.