Systematic review on what works, what does not work and why of implementation of mobile health (mHealth) projects in Africa

Strengths: what is working?

mHealth projects are highly reliant upon the characteristics of the technology available. Its low-cost, ease of use and wide-spread availability were frequently cited as the main drivers for implementation [18, 22, 26, 43, 49, 50, 56, 58],[59, 62, 63]. An increase in access to mobile phones has motivated researchers and project managers towards seeking innovative ways in which healthcare can be provided, particularly in areas that current infrastructure and technologies cannot possibly reach.

The majority of the projects reported successes and positive outcomes of mHealth in Africa. Some these results were: support to patients in requesting services (e.g. generating appointments) [27, 34, 62], reduction in communication delays and improvement on data collection and reporting [14, 18, 38, 46, 47, 49–51, 54, 56],[63], reduction in patient burden to transportation time and costs [49, 51, 62], improvement on health workers’ compliance to treatment guidelines [17, 22, 34, 37], increase in patient uptake of counseling and disease testing [22, 31, 50], and improvement on the patient adherence to treatment [21, 22, 30–32, 37].

Benefits of mHealth projects were described at every level within the healthcare system, from governments to clinic staff, and on to patients. Governments may, for instance, benefit from increased support of patient management [20] and increased direct communication with stakeholders in rural areas [45, 50]. Health workers may receive support through professional networks, or can prioritize efforts in areas where they are most needed (e.g. rural areas uncovered by specific programs or interventions) [37, 56], and increase their role in active case detection using disease surveillance systems [49]. Finally, patients benefit by saving money from regular consultations, and can also have increased attention and receive more support from health providers, as discussed in previous sections. SMS alone has been proven to help bridge the communication gap in the health sector between health workers and patients, different managerial levels, and between MoH and facilities in the peripheral areas [17, 21, 22].

A main reasons given for a highly positive perception of mHealth projects by health workers, staff and patients were a high acceptance [16, 18, 33, 34, 47, 49, 56, 63] and familiarity of use of mobile phones [31, 34, 38, 47, 59, 62]. This is understandable given the large reach that mobile phones have had in recent years in Africa. The acceptance of the technology itself may have an effect in the overall acceptance of the project. In Botswana and Uganda for example, the technology was highly accepted and project outcomes were valued positively overall [34, 35].

Another characteristic of mobile phones is that it may reduce the feeling of being observed, particularly in situations that might create stigmas. For instance, results show tha patient’s perceived value of the use of mHealth for consultations proved to be more acceptable in sensitive situations where it was more difficult for information to be discussed in face-to-face consultations e.g. HIV-infected patients [62]. The use of mobile phones allowed the patient to keep her privacy.

Other benefits of mHealth are more related to the technology itself. When compared to other technologies (e.g PDAs or laptops), mHealth projects benefited from the fact that mobile phones proved to be less subject to theft and breakage [17, 22, 25, 28, 34, 54, 63].

Although successes have been reported, mHealth integration into the healthcare system is critical to achieve the maximum benefits. Projects have proved to be successful when they have been adapted to the local context and language [31, 62], when the government has an existing mHealth or eHealth strategy and has an interest or willingness to set-up a system to integrate mHealth projects [47], and when the project has been developed and implemented by public-private partnerships (e.g. participation of local private service providers) [25, 37][47]. Regarding the latter, findings include examples of collaborations between Universities in developed and developing countries, research institutes, non-profit organizations, private sector, public and private hospitals and public sector.

The management of the project is not a simple task and cannot be minimized. Management remains a core component of an mHealth project to ensure that outcomes and goals are achieved. Several factors related to the management and project design were important drivers of project success. Examples include providing adequate incentives (e.g. airtime credit) to ensure a high response rate to the project [21, 22] and providing training for staff and users [32, 52]. These factors cannot be disregarded by the project manager. Additionally, there are two important factors that characterize management of mHealth projects. Firstly, mHealth projects require minimal human resources and training required is normally simple [32, 54]. Secondly, mHealth requires the collection of data during the project implementation, which allows manager to provide real-time supervision and monitor work rate, attendance and working hours of the staff involved [47, 50].

Despite the positive conclusions of the studies here presented, it must be noted that the projects are all still small-scale and success of similar large-scale projects is not guaranteed. Fortunately, due to the characteristics of the technology, the estimated low-replication costs and the high adaptability to local cultural settings [51] increasing the potential of these projects for scaling-up [32, 47, 56], particularly if targeting remote and resource-limited areas [49]. Pilot studies, such as those discussed here, will allow managers to assess impacts prior to scaling-up [27].

On a small-scale, findings from this review show that as accessibility to mobile phones increases, the potential of mHealth to improve healthcare delivery in Africa is also increasing remarkably fast; however, there are weaknesses and challenges that must be considered and addressed for mHealth to fulfill this potential.

Weaknesses: what is not working?

One of the major weaknesses of studies on mHealth projects lies in the fact that the claimed benefits are unclear and long-term results remain uncertain [16, 32, 37, 46, 61, 63]. Often, studies report that cost-effectiveness is unknown [29, 61], and in some cases studies mention that the evidence is weak, and the external validity and study design are limited [20, 21, 27]. The studies report that, while mHealth projects aim to resolve challenges of data collection, during implementation some problems are still faced. These include difficulties in monitoring text message content [23], data under-reporting [37, 46], and the possibility of receiving biased responses from participants (e.g. anxiety due to receiving delicate information on the phone) [14, 61].

The participation of the government, via the Ministry of Health, is a fundamental aspect for success of mHealth projects. Failure may happen when there is a lack of integration into the healthcare system and, particularly, when there are unclear roles and responsibilities at the various different hierarchical levels (government to managers to health workers) involved in implementation and operation [45]. For example, mHealth outcomes are highly dependent on clinical training, practice and experience of health workers [49, 63]. If they are non-existent or provided by the government actors, the project is unlikely to achieve its expected goals.

Project design is also an important task for managers of mHealth projects. In this sense, manager and planners, in particular, have a strong role to play to ensure the success of the project. A major condition of the design is on its adaptability to the local context or tailored to the population’s needs. Projects have an increased risk of failure when they have not been designed for or adapted to the specific context [32].

There are also other important factors related to the project design that need to be looked at closely. For example, planning costs and logistics are essential elements that, if not assessed accordingly, may affect the delivery of the intervention (e.g. timely responses or project coverage) [14, 33, 61]. Lack of planning may also affect resources available for the implementation. For instance, without adequate planning, there could be occasional shortages of resources, such as staff available, during the project lifespan [22]. This might result in overwhelming staff that have to deal with an increased workload due to the number of messages or calls received [50].

Ease-of-use, familiarity with and access to the technology were important factors mentioned for implementation success. However, in some cases it was reported that, despite the relative ease-of-use, a lack of the skills required to use the technology was a barrier that limited staff in responding and acting promptly to text messaging requests [43, 62]. To overcome this problem, some patients asks for support from their relatives or friends, but this may bring other problem particularly when talking patient’s data privacy. In terms of use and acceptability of mobile technology, issues regarding phone ownership such as high phone sharing, lack of money to top-up a phone and male control over household phone ownership may also limit results of a project [32, 37].

The capacity of mHealth projects is defined by the capacity of the technology itself. There are for instance, only a limited number of characters that can be sent using text message [18], thus limiting the application of these projects to specific types of interventions. Thus, the use other technologies to replicate or imitate the same mHealth project may not result in similar outcomes [21, 25, 54]. Other technology-related problems are poor data quality and transfer [18, 37], network loses, phone maintenance costs [17], risk of theft and loss [19], poor handling and use [57], a lack of software flexibility and adaptability, and risk of human errors in the program [63].

In addition to these technical challenges, legal issues arise in terms of privacy and security measures to be taken for obtaining, handling and transmitting data. As a new concept that has gained popularity in recent years (most of the studies are from 2009 onwards), little was found mentioned in terms of legal factors, standards and regulations surrounding the use and application of mHealth for healthcare services. For instance, privacy concerns exist when a patient is not the direct owner of the mobile phone [34, 56]. In this sense, two possible solutions were found in the results: firstly, the use of coded information for confidentiality protection and data security [63], and the integration of SMS guidelines into broader clinical and healthcare processes [50]. Though during project implementation some measures were taken by researches (e.g. a security PIN code to protect patient data), these concepts remain highly unfamiliar and very poorly understood by users [37, 54]. Moreover, user expectations in terms of confidentiality and privacy remain very variable even within the same population [32].

Threats: why is it not working?

In Africa, mHealth projects may face external barriers and limitations that might cause project’s failure. Limiting factors need to be considered from early phases of the project. So far, it was discussed that the project design and the adaptation to the local context were critical issues that, if not thoroughly assessed, could result, worst case scenario, in a complete project failure. These are factors internal to the project, and can be controlled by the project manager, researcher or planner.

The limited research and knowledge available on mobile phone applications in health [22], and the scarce knowledge of the long-term effect of mHealth intervention on health outcomes in low-resource settings [15, 62] are two external factors that may limit potential impacts of mHealth interventions. There are other factors that may also threaten project sustainability and delivery of results. These include the limited funding opportunities available for long-term implementations [56] and the dependency of external factors unrelated to the project itself, such as the duration of patient treatment that may influence adherence and motivation to participate [18, 63], user’s illiteracy and high workload for facility staff or health workers [38, 54].

Some of the threats for mHealth lie in the health system and government themselves. The role and level of involvement of governmental organizations is fundamental for project success during its lifespan. However, for the integration of mHealth into the current systems, care delivery processes as they stand today need to be redesigned (e.g. change to electronic records and data) [22]. Healthcare providers need to develop the cultural and organizational capacity required to manage digital health information [63]. The lack of these capacities may lead to late reporting, lack of feedback and incomplete data collection [63]. Mechanisms to use data collected are also required at the district and national levels [17, 32, 43, 46, 56]. Evidence shows that there are wide gaps in the understanding of the complexities that health systems may face in large scale implementations of mHealth projects [55], or the standards required for monitoring and evaluating them [21, 34]. A lack of guidance and policies from the Ministry of Health and inexistent financial support from governments to deploy mHealth projects are regarded as reasons for failure [49].

Probably the major limitation for implementation of mHealth projects is the coverage and accessibility of the technologies. mHealth is highly dependent on infrastructure availability in the area where the project is being deployed, hence a reliable network, internet and electricity access [19, 32, 34, 37, 38] are prerequisites. Access to mobile phones in Africa is extensive, but not necessarily reliable. Moreover, the technical or expert knowledge for maintenance and development of platforms (software and hardware) may be limited or not available locally [37, 56], and when available, the lack of expertise may slowdown implementation as technical training will normally be required [49, 57, 62].

It was previously mention that acceptance was a reason for the success of mHealth project. However, even if a pilot project may have been perceived as valuable by the user, there are still questions regarding acceptance of the technology by the communities as receptiveness is limited by socioeconomic and sociocultural factors, geographic barriers and quality of care [19, 20, 32, 33, 49]. For instance, in some places SMS interventions may fail due to high illiteracy levels and/or user preferences for making voice calls or personal appointments [14, 17, 62]. In addition to all these factors, little is known in regards of data protection, and the feasibility and acceptability confidentiality methods [62].

Due to all the external factors that may threaten success of mHealth project, it is important to point out the relevance of the role that management has before, during and after implementation. The unknown cost-effectiveness of deployment and maintenance [49, 56, 63], particularly on a large-scale [32], and the challenges of management of mHealth projects remain underestimated [26]. As we gain more knowledge on mHealth interventions, opportunities need to be carefully assessed for further implementations.

Opportunities and recommendations

Opportunities to increase implementation and expand applications of mHealth in Africa are vast, but future steps need to be taken cautiously. Tomlinson et al.[64] have recently published a review where they discuss the lack of evidence regarding mHealth effectiveness and efficacy [64]. The authors argue that an mHealth project is likely to work if there is a follow-up of the project, if it has been designed for specific contexts, and if high consideration has been given to the frequency of the message delivery, wording and content of the message. While mHealth projects face challenges and threats, there are also many opportunities. The major opportunity for mHealth is the increasing mobile phone coverage. As coverage to mobile phone networks expands and new communication technologies are developed (e.g. cheaper smartphones), opportunities for mHealth applications remain high [14–19, 22, 26, 28, 31, 34, 37, 40],[43, 49, 56, 62]. For instance, innovations for automated text messaging and partnerships with mobile technology developers may improve scalability [37, 39, 49]

However, large-scale or nationwide coverage of mHealth projects were rarely reported in the literature. While, potential for scaling them up was frequently mentioned [32, 47, 56], the lack of secure funds for scaling-up [19, 32], the potentially high set-up costs and unknown cost-effectiveness [43, 63], and the lack of evidence of effectiveness to assess, for instance, the applicability of mHealth to other diseases [24, 40, 44, 54, 62] are factors that just allow small scales and limited interventions.

Solutions for the challenges faced by the health systems in Africa are very much needed. As previously discussed, opportunities are high where the application of mHealth can support drug supply and stock management [43], stock forecasting [15, 47, 49], collect and disseminate health data in remote areas [33, 58], support different national disease control programmes and provide access to data for an evidence-based approach [47, 50], utilize health workforce (e.g. health workers) [19, 47, 49] and provide specialized care/mentoring in rural areas [26, 50]. Considering that these projects may be highly attractive and acceptable for private or commercial partners and governments (MoH) [21, 29, 49, 50], future projects should consider larger-scales and the full integration into the healthcare systems.

Recent research into health outcomes of mHealth interventions have been increasing rapidly. According to the findings of this study, the major threats to mHealth projects include cultural perception, language, limited resources in rural settings, weak health systems and external financing schemes. Whilst factors may be setting-dependent, Figure 2 provides an overview of the fundamental elements identified that could lead mHealth projects to succeed in Africa and integrates the findings of this study into a tabulated SWOT analysis.