Scaling SMS for healthcare.

There is certainly no shortage of coverage of the mobile revolution in Africa.   Mobile phones have undoubtedly ushered in a new era of amazing innovation and, more importantly, access to Africa. They've brought financial services to millions of unbanked Kenyans, empowered citizens to take an active role in promoting social change, supported humanitarians responding to crises, helped epidemiologists control disease outbreaks, and the list goes on. The mobile phenomenon is so well established that the initial enthusiasm of early adopters is now giving way to more constructive criticism. Which is not to say that we've exhausted our collective imagination on how to put this platform to use for the developing world.  Indeed, there are endless opportunities to use mobile technology to support health, financial, education, agriculture, and governance sectors in Africa.  But more importantly, many of these innovations have yet to reach their full potential.  With the exemption of Safaricom's mobile money transfer service, M-PESA and now, M-KESHO,  the majority of the mobile innovations you've probably read about are only reaching a minority population.  The time for scaling mobile services has come.  And I can think of no better place to start scaling mobile innovations in the healthcare sector than one of Sub-Saharan Africa's largest HIV/AIDS control programs - AMPATH.

First, a bit about the region in reference here - western Kenya.  At 300 kilometers west of Nairobi we're a world away from the shiny towers of Safaricom and burgeoning tech community of Nairobi.  This is a predominantly rural region where maize, malnutrition, and election fueled malevolence reign supreme. Nonetheless, nearly 50% of the population we serve owns a mobile phone. And since phone sharing is very common in these parts, nearly everyone has access to a mobile phone.  But upon arriving here a year ago I was surprised to learn that relatively little has been done to utilize the ubiquity of mobile phones and the affordability of SMS text messaging to improve patient care. From conversations with colleagues across Kenya, I learned that our program is no exception.  It seems that despite the fever pitch of the blogosphere, the reality on the ground is that SMS is widely revered as a potential communication channel for healthcare but, on the whole, it is still rather rarely deployed.  

There are loads of opportunities to utilize SMS in healthcare.  Personally, I'm most interested in patient facing interventions.  Programs that help nudge people towards healthy behaviors.  I just finished my third concept paper and pilot program design for such patient facing SMS interventions here at AMPATH.  All three rely on open-source and elegantly simple software from Frontline:SMS.  And all three could be easily adopted and implemented at other healthcare facilities.  All you need is a mobile phone, netbook, and mobile signal (the latter of which is suprisingly ubiquitous across much of the continent).  Assuming these pilots prove effective, we plan to swiftly scale these services to reach the entire population they are designed for.

Outreach:SMS. AMPATH now has over 100,000 HIV-positive patients enrolled into care.  And with our current door-to-door HIV counseling and testing campaign these numbers are expected to increase exponentially over the next 12-24 months.  Like all HIV programs, appointment adherence is critical to our ability to maintain the health of our patients and minimize their ability to transmit the virus to others.  But with nearly 1 in 3 of our patients not attending clinic within a 10 day window of their scheduled appointment there's clearly considerable room for improvement.  Our Outreach:SMS program aims to reduce the rate of missed visits by sending patients appointment reminders via text message.  Big thanks to @bikobiko and @dalezak for developing the ReminderManager plug-in for Frontline:SMS (this nifty feature will significantly reduce the staff time required to operate the program).  Reminders will be sent two days and one day before the patient's scheduled appointment to help address common reasons for missed visits - forgetfulness and failure to plan ahead.  The objective of our program is two-fold: 1) maintain the health of our patients through improved appointment attendance and 2) reduce current program costs associated with follow up on patients who fail to attend clinic.  And here's the kicker, this intervention will result in an overall cost savings for our program if it is able to reduce the number of monthly missed visits by 30% or more (which studies have shown is eminently feasible).

SMS for Heart Health:  While much of Africa is overwhelmed by efforts to control infectious and nutritional diseases, non-communicable chronic diseases like heart disease are emerging as the next major threat to global health.  Aggressive action is now needed to test, treat, and educate our patient population before yet another epidemic takes hold.  We are about to begin an ambitious program incorporating hypertension screening into our door-to-door HIV counseling and testing campaign.  All people identified with systolic blood pressure (SBP) over 160 will be put on hypertension drugs.  People with SBP between 140-159 are given six months to change their lifestyle to try to self-regulate their blood pressure before they are started on drugs.  This six month window offers us the greatest chance at an affordable means of preventing heart disease.  But promoting behavior change requires frequent and consistent support - far more than what occasional clinic encounters can offer.  We plan to use SMS text messaging to routinely educate this particular patient cohort on heart healthy habits and facts about heart disease to encourage them to make the lifestyle changes required to reduce their risk for heart disease. 

SMS for ANC:  This program is a blatant rip-off of text4baby.  Text4baby was launched in the U.S. in February of this year with backing from the White House, the U.S. Department of Health and Human Services, and a broad coalition of public and private organizations.  It is an SMS based information service that sends health tips that are timed to the mother's stage of pregnancy or the baby's age.  But while text4baby was launched in a resource-rich country, we believe a similar program could significantly aid our efforts to improve reproductive and mother and child health here in Kenya.  Indeed, one resource Kenya is not lacking in - mobile phones - is practically the only resource needed to implement this intervention.  And more importantly, the need is arguably more severe in this region where the majority of women give birth at home and over 70% deliver without professional medical help.  We will rely on community health workers (CHWs) to identify pregnant women, refer them to antenatal care (ANC), and capture their mobile phone numbers.  We will then enroll all those who own a phone or share a phone with their spouse into an SMS program that will send text messages to encourage ANC attendance and help address patients' chronic lack of information on maternal health.

None of these programs are revolutionary.  That's not our goal.  We're just utilizing the most pervasive and most effective communication channel available in this region to promote behavior change.  As detailed in MobileActive.org's white paper, Scaling Mobile Services for Development, our programs clearly fit the criteria of m-Services ready to scale.  We're relying on existing technology and established infrastructure.  We have a very simple and compelling value proposition.  We put the needs of our users - our patients - first.  Our aim isn't to get published.  Our aim is to quickly pilot these programs and take them to full scale as soon as possible. But perhaps most importantly, we have a clear understanding of how to achieve sustainability.  These SMS services will be free to our patients.  But that doesn't mean they'll result in a net increase in our program's operating costs.  Rather, if they successfully change the designated behavior they should provide a net savings.  Less patients who fall out of care means less patients to follow up.  More patients self-regulating their blood-pressure means less patients on hypertension drugs.  And more pregnant women attending ANC means less unanticipated delivery complications and costly emergencies. Indeed, as we look toward scaling these services across our entire two million person catchment area we will assess both the health and economic outcomes of these programs.  We're hopeful that it won't be long before we're able to demonstrate a clear return on investment for scaling SMS interventions for healthcare.  

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