Technology and health care in the developing world

Jennifer Manne and Walter Curioso look at innovative projects that exploit the potential of mobile phones, personal digital assistants, and the internet

The design and implementation of interventions to improve poor health and increase access to health care in the developing world has long been a difficult challenge for health professionals and policy makers alike. In search of sustainable, effective answers to the complex health conditions of low and middle income countries, researchers have begun to explore technology driven solutions to such problems, with interesting endeavours taking place in Latin America, Africa, and parts of Asia.

Biomedical informatics

The use of telecommunications technology, such as the internet and mobile phones has increased greatly in much of the developing world. The growth of the internet and use of mobile telephones has taken place in Central and South America as well as parts of Asia and Africa (see table). This knowledge has encouraged many clinical researchers to explore the use of information and communications technologies, commonly called health informatics, as a cheap answer to the difficult challenges facing these healthcare systems.

Source: www.internetworldstats.com and www.infoplease.com/ipa/A0933605.html

As a result, researchers and clinicians have undertaken biomedical informatics projects that innovatively employ the internet, computers, mobile phones, and personal digital assistants to improve the quality and accessibility of health care. These projects often take the form of infectious disease interventions that can improve access to health information and care in rural areas; among discriminated populations; and regarding sensitive topics, such as gender and sexuality.^w1

One example of such projects comes from Ann Kurth at the University of Washington and colleagues. This team is currently implementing an informatics project that uses personal digital assistants to improve adherence to antiretroviral drugs and provide safer sex behavior support to HIV positive patients (box).^w2

In addition, Kurth and colleagues have received a grant to implement a similar intervention titled "Pambasuko Palm" in Mombasa, Kenya. Funded by the University of Washington's Center for AIDS Research, this intervention will evaluate the feasibility and effectiveness of palmtops to deliver training to HIV clinicians and to collect data about patients.

Health informatics includes the development of electronic medical record systems that can improve management of information and so provide better support for treatments. For example, Fraser and colleagues have described web based medical record support systems to improve the management of HIV and tuberculosis in Haiti.^w3 Such systems are capable of tracking the results of drug sensitivity tests; patterns of sputum smear and culture results; and time to conversion from positive to negative cultures. Similarly, large non-governmental organisations, such as Partners in Health, are currently using web based electronic health record systems in poor countries to further the process of antiretroviral rollout.^w4

Finally, health informatics technologies are being used increasingly in the developing world for public health surveillance, especially to try to monitor transmission of HIV and sexually transmitted infections and improve services for patients. For instance, "computer assisted self interviews" technology is being used by medical doctors and researchers to increase patients' reporting of potentially stigmatising, risky behaviours, by ensuring anonymity in the reporting process. The technology has already been used in many developing countries, including Brazil, India, and Kenya, and preliminary studies from the National Institutes of Health show positive results.^w4 Similarly, informatics tools including mobile phones and the internet are being used extensively to improve diagnosis and treatment of HIV and sexually transmitted infections as well as in partner notification for new patients.^w4

The case of Peru

An excellent example of the application of medical informatics has taken place recently in Peru. Despite improved political stability and economic advancement, Peru, a middle income Latin American country, still faces considerable challenges to improving health for its people. Much like other developing countries, Peru has experienced high rates of maternal and under 5 mortality as well as epidemics of infectious disease, such as multidrug resistant tuberculosis and malaria.^w5 Moreover, challenges such as geographic barriers and stark ethnolinguistic differences present challenges to healthcare professionals who seek to increase access to health care among rural Andean and isolated jungle populations as well as poor urbanites.

Use of technology in Peru has recently grown. It is estimated that there are more than 10,000 internet cafes and almost 10 million internet users in Peru.^w6 Seizing the opportunity presented by this trend in technology use, a research team from Universidad Peruana Cayetano Heredia, in Lima, Peru, began to investigate the use of technology driven health interventions as a route to establishing safer, cheaper health care with the hope that this would not only be a solution to Peru's health challenges but also useful in many developing countries.

The Cell-Preven project provides an excellent example of a successful health informatics project that the team designed and implemented (fig 1).^w7 The heart of the project is the creation of a Spanish language, real time surveillance system. Trained healthcare workers, as members of mobile teams, travelled to three target communities, where they provided on-site screening, treatment of sexually transmitted infections, and medical care for female sex workers. The health workers captured data in real time about adverse events to metronidazole, a drug used to treat bacterial vaginosis, and sent this information to the system for compilation and analysis. In the case of severe adverse reactions, the health workers were able to communicate with doctors directly by text message and give the patient immediate medical support.

The system improved the treatment and data collection in the three locations where it was used. This method of diagnosis and data capture eliminated many of the complications caused by paper records while allowing doctors to respond immediately to medical events in a group of women who might otherwise have been excluded from accessing care.^w8 Also, the information collected through the system was stored in a secure internet database and so could be analysed immediately, greatly increasing the efficiency of the research process. Moreover, the health workers who were part of the mobile teams gave uniformly positive feedback about the healthcare improvements afforded by the system. This project offers great promise for a simple technology based system-involving only the use of mobile phones in the field and the internet-as a means of providing sophisticated solutions for overcoming geographical barriers in the provision of better healthcare. Furthermore, this technology is not only useful for reporting and monitoring adverse reactions to treatment for sexually transmitted infections but might also be used during vaccination campaigns, infectious disease outbreaks, and other settings where geography or language introduces a barrier to accessing care.

The challenges to informatics

Although the benefits of low technology solutions for the health sectors of poor countries are promising, limitations exist. Potential areas of concern include the widespread perception that both mobile phone and internet technology employed will prove too sophisticated for developing country settings. Moreover, the question of technological maintenance and support for such projects in poor countries has also created cause for concern.

Some critics have expressed concern about the pervasiveness of mobile phones in the developing world, especially in medically underserved areas. They claim that the widespread implementation of interventions dependent on mobile phones will be limited by the lack of phones in certain regions and may demand additional training for healthcare providers in these areas. Although mobile phones are increasingly being used even in remote or poor communities, this concern is certainly valid. For instance, interventions that employ mobile phones require the presence of a signal in target areas, a condition that can be difficult or expensive to remedy.

Similarly, the feasibility of web based interventions because of lack of access to the internet and proficiency in use of the internet in poor communities is also a concern. This concern is debatable based on the results of recent research collected by Alva and colleagues that showed that most HIV positive patients (60%) from a large HIV/AIDS treatment centre in Peru reported recent use of the internet, and use of the internet as a means of obtaining health related information.^w9 Nevertheless, further research and wider proliferation of favourable results are required regarding mobile phone and internet accessibility in developing nations.

A final concern surrounding technology driven health interventions is the associated costs. Some critics of health informatics argue that building capacity for technology use in poor communities is too expensive to warrant serious attention. The Cell-Preven project partnered with the company Voxiva and thus was successful in reducing the cost of building and using appropriate technology. In addition, a recent preliminary analysis of a mobile phone surveillance system called Alerta that was used in Latin America, showed that the use of mobile phones reduced the operating cost of the health intervention by 40% while increasing reporting coverage by three times, compared with a paper based intervention.^w10 So, although preliminary evidence about the cost of these interventions is favourable, more research is needed.

Many poor countries face the challenges of limited resources for the healthcare sector, severe shortages of healthcare providers; inadequate training programmes and continuing education for practising providers; as well as geographical and ethnographical barriers to providing adequate care. Low technology solutions, such as Cell-Preven, tackle these public health challenges in a creative and efficient manner, with the potential of better health for all.

Competing interests: WHC was involved in the design, implementation, and evaluation of Cell-Preven.

Provenance and peer review: Not commissioned; externally peer reviewed.

This work was supported in part by a grant from the FIC/NIH (R01TW007896)

Jennifer Manne, Research Professor, School of Medicine and School of Public Health, Universidad Peruana Cayetano Heredia, Lima, Peru
Email: jmanne@hsph.harvard.edu
Walter H Curioso, affiliate assistant professor,Division of Biomedical and Health Informatics, School of Medicine, University of Washington, Seattle, Washington


Student BMJ 2007;15:427-470 ISSN 0966-6494 | December

1. Banerjee I, Leong Hsi-Shi C. Internet in the war against HIV/AIDS in Asia. In: Murero M, Rice R, eds. The Internet and Health Care: Theory, Research and Practice. Mahwah, NJ: Lawrence Erlbaum Associates, 2006, pp. 357–373.
2. Kurth AE, Curioso WH, Wolpin S, Segura P, Cabello R, Berry D. Personal Digital Assistants for ART Adherence and Safer Sex Behavior Support: A Novel Intervention in Peru. 2nd International Conference on HIV Treatment Adherence. Co-hosted by the International Association of Physicians in AIDS Care (IAPAC) and the National Institute of Mental Health (NIMH). March 28-30, 2007
3. Fraser HS, Jazayeri D, Nevil P, Karacaoglu Y, Farmer PE, Lyon E, Fawzi MK, Leandre F, Choi SS, Mukherjee JS. An information system and medical record to support HIV treatment in rural Haiti. BMJ. 2004 Nov 13;329(7475):1142-6.
4. Curioso WH, Kurth AE, Blas MM, Klausner J. Information and Communication Technologies and HIV/STIs. In Holmes KK. et al., ed. Sexually Transmitted Diseases, 4th edition; NY, McGraw-Hill; 2007 (In press).
5. Frisancho, Ariel. “The Right to Health in Peru,” in Comparative Studies and the Right to Health, edited by Marks, Stephen. Cambridge: Harvard University Press, forthcoming October 2007.
6. Curioso WH, Blas MM, Nodell B, Alva IE, Kurth AE. Opportunities for Providing Web-Based Interventions to Prevent Sexually Transmitted Infections in Peru. PLoS Medicine 2007;4(2):e11.
7. Curioso WH, Karras BT, Campos PE, Buendia C, Holmes KK, Kimball AM. Design and Implementation of Cell PREVEN: A Real-Time Surveillance System for Adverse Events Using Cell Phones in Peru. AMIA Annu Symp Proc 2005; 176-180
8. Curioso, WH. “New Technologies and Public Health in Developing Countries: The Cell PREVEN Project,” in The Internet and Health Care: Theory, Research and Practice, edited by Murero, R and Rice, R. Lawrence Erlbaum Associates, May 2006.
9. Alva I, Blas M, Cabello R, Garcia P (2005) Risks and benefits of Internet use among people living with HIV/AIDS in a resource-contrained setting. 3rd IAS Conference on HIV Pathogenesis and Treatment; 24–27 July 2005; Rio de Janeiro, Brazil. Available: http://www.iasociety.org/Default.aspx?pageId=11&abstractId=2177398. Accessed 23 June 2007.
10. Prahalad C. The Voxiva Story. The Fortune at the Bottom of the Pyramid: Eradicating Poverty Through Profits. First printing ed. New Jersey: Wharton School Publishing; 2005:361-379.

       

 Printable version    Download PDF    E-mail this to a friend    Respond to this article