ICT4Health 2015 - J Watkins

The Vutivi Studye/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

ICT4HealthTygerberg Hospital, Stellenbosch University

24th November 2015

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

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.

What is e/mHealth?

Collect dataCount eventsConnect individualsCompress 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

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)

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

District Health Managem

ent Inform

ation System

National Development Plan - National Health Insurance - The National Health Act

Relevant South African Policies

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

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

200120072013

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

Participant Chart

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

‘Lucy’ the Fieldwork Vehicle

My Mama Miriam, the impetus for this study

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

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 SupportInformation, protocols, algorithms, checklists

7 Provider-to-Provider CommunicationUser 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?

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

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/

Johnson & 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/Consumers (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 AfricaResults • Landscape of

e/mHealth in South Africa – different players/stakeholders involved

Topic 1

South Africa mHealth Stakeholder High Level Overview

Results: Topic 2

Patient Health WorkermHealth Examples: mHealth Solutions Taxonomy:

MomConnect

Nkateko Phone Call Reminders

District Health Information System





Topic 2

• Communication between Patient and Health Worker


MomConnect National Department of HealthmHealth Project at scale



Topic 2

Pregnant women at the clinic opting into receiving staged-based educational text messaging (SMS)

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


“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)



District Health Information SystemDigitizing 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

Results: Case Study 3Health Worker Health WorkermHealth Examples: mHealth Solutions Taxonomy:Vula Mobile (eye)

Stop Stock-outs (drugs)

Thumela Mobile (referrals)

Web Literacy (Google)

Clinical Associates Students







Topic 3

Communication between Health Worker (at the ‘coal’ face/remote) and Other (website/app/specialist clinician etc.)

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



Topic 3

VULA Mobile App Mobile phones with diagnostic capabilities for eye healthcare where issues of rurality are a problem

2 Sensors & Point of Care DiagnosticsEye Test

Connect to specialist – Chat – Information = Remote Diagnosis

Pupil Check

Topic 3

THUMELA Mobile ReferralsConnecting health workers to improve referrals and remote diagnosis


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


Topic 3

Mobile Web Literacy of Nurses

Littman-Quinn



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)

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)


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

management5.) Nurses use of

computers 8.) Digital solution to

drug stock-outs 11.) Future use of

mHealth

6.) Phones used to support doctors’ work

practices7.) 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)

Ove

rarc

hing

Th

emes

/Issu

esB

arrie

rs/B

enef

itsK

ey

Exam

ples

Rec

omm

enda

tions

ConclusionsInterpretations, 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

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.

Thank you for listeningInkomu Fambani Khale

Thank you to the Vutivi participants, my supervisors & funders

All images, unless stated are J.O.T.A.Watkins