Often, village doctors also own a pharmacy and dispense medications without fully understanding their proper uses or hazards. The problem of a lack of proper healthcare, trained doctors and health professionals is not confined to Chakaria, a rural district with a population of around 400,000 located on the south-east coast of the Bay of Bengal. About 75% of Bangladesh’s population live in rural areas and suffer similar shortages.
But Chakaria, like the rest of rural Bangladesh, has one thing going for it that health workers hope will help deliver better medical care – a high penetration of mobile phones. Some 61% of households have at least one mobile phone. In an illustration of the take-up of the technology, not just in Bangladesh but also throughout the developing world, three years ago the equivalent figure was 55%.
In a practice known as mHealth, conventional healthcare is supplemented by the use of mobile phones for communicating with patients and doctors, delivering expert advice, collecting information in public health campaigns and even self-testing by patients. Proponents of the practice say it can provide some aspects of healthcare to a greater number of people in the developing world than could be done physically, as well as helping to conserve scarce health resources.
For instance, when treating tuberculosis (TB) in India, SMS messages are sent to patients every day, reminding them to take their medicines and the patient has to text back a confirmation that they have taken their dose. Ensuring the medicine has been taken is particularly important in the treatment of TB, because if medicines aren’t taken regularly, the disease can become multi-drug resistant, making treatment more difficult.
This simple procedure – an exchange of text messages – eliminates the need for a health worker to pay the patient a personal visit and brings about huge cost savings.
Making it Work
Fatema Khatun, a PhD student at the University of New South Wales (UNSW), is assessing community readiness for mHealth in rural Bangladesh. In conjunction with the university's Asia-Pacific Ubiquitous Healthcare Research Centre and the Bangladesh-based International Centre for Diarrhoeal Disease Research, Bangladesh, she is gathering socio-economic data on households, including mobile phone penetration, with the ultimate aim of identifying how best to use mHealth.
The researchers are assessing the effectiveness of a program whereby village doctors in Chakaria use mobile phones to supplement their own work, by contacting qualified doctors in the city to seek advice and confirm their diagnoses. Patients who elect for their village doctor to use the heavily subsidised service pay 30 takas – around 40 cents, and about one-fifth of what it would cost to travel to a city to see a doctor. The qualified doctor can also send back a prescription via SMS.
The program, however, has not been without its hitches, including a lack of acceptance by some village doctors and a dispute with the telecommunications carrier supplying the service, and so take-up has been slower than was hoped for.
Nonetheless, in her interviews with potential patients, Khatun has found considerable enthusiasm for the idea, attracted by the speed with which they can access medical expertise at night or during an emergency. Patients also like the idea of visiting a doctor for an initial consultation, then following up via mobile phone. Some village doctors also acknowledge the benefit of having a trained doctor supplement their knowledge.
Khatun, a medical doctor with a masters degree in international health, had feared the cost of the mobile service might deter potential patients. Although paltry by Western standards, the call costs are not insignificant in a country with a per capita annual income below A$1000. But patients compared the call cost to the price of a face-to-face consultation and decided it was good value.
Pradeep Ray, a professor of information technology at the Australian School of Business, is the founder of the International Initiative for Ubiquitous Healthcare, which aims to exploit mobile broadband communication technologies for healthcare.
He says Bangladesh has an advantage over many other developing countries when it comes to rolling out mHealth initiatives because of a successful legacy of commercialised mobile phone-based services in public health, a sector in which non-government organisations are able to operate in that country without many bureaucratic constraints.
“Bangladesh is leading the world in providing these mHealth-based services,” Ray says. “We expect this to be of great, great use in many developing countries – Africa, South America, the Asia-Pacific.”
The healthcare difficulties created by the lack of funding, hospitals and qualified professionals in the Third World are compounded by a lack of information and communications technology infrastructure in the health system. “In Australia, the doctors and hospitals have got very well developed computer networks and various types of devices, but in developing countries that’s not the case,” says Ray.
This makes mobile phones all the more important and, according to Ray, the penetration of mobile phones in the developing world is between 60% and 80% of the population, depending on the country, compared with the penetration of internet-enabled computers of just 10% to 15%.
“That is why mobile technology has so much to offer in terms of providing access to healthcare,” he says.
Despite the potential of the technology, there are still significant socio-economic and cultural difficulties to be overcome. The program to remind patients to take their HIV or tuberculosis medicines via SMS has run into problems because not everyone can read, even when the messages have been converted into the local language and script. And where a household has only one phone, usually the male breadwinner takes it with him to work. This can make it hard to get a message to a female sufferer.
Developed World Applications
The problem of scarce health resources is particularly acute in the developing world. But governments and health authorities in the developed world are also struggling with how best to allocate their resources as an ageing population places increased demand on the health system.
Tina Campbell, managing director of Melbourne-based RealTime Health, uses mobile phones to distribute videos of patient and carer experience to other patients and carers. She says research shows that hearing other patients’ experiences of managing chronic conditions improves a person’s motivation and confidence to engage in appropriate self-care behaviours.
“We have a fantastic channel to a large and receptive audience,” she says, noting that mHealth can change patient behaviour and provide tools to help people better manage their health. “We’re living in an age where chronic conditions are a major concern to health systems globally and health systems are struggling to keep up with demand,” says Campbell. “It’s very important people learn to manage their chronic conditions more effectively.
“Apps that enable people to monitor their health, and give them tools to manage their conditions, have the potential to have a flow-on effect to the broader health community and reduce the burden on the health system.”