This paper describes a journey toward successful scale in digital health interventions. Along the journey, use of digital tools for health will shift from being a disruptive innovation to being institutionalized as common practice. Our vision is a world where we no longer refer to mHealth or eHealth services, but rather take as a given that digital tools are incorporated seamlessly throughout health systems, enabling greater health impact.
To achieve this vision, we believe the digital health community should deliberately and clearly define that we are working towards a common goal of institutionalization and develop an
investment strategy to achieve it. This paper is intended to stimulate debate on the following questions:
• What does the goal of institutionalization mean for scale?
• What levers enable institutionalization?
• How can we work together to reach institutionalization?
Like most long and arduous journeys, reaching our destination will require time, investment, and collaboration. We recognize that our collective effort to deliver meaningful health impact using digital interventions could be transformational to the communities we serve.
In the mid-1990s, Bill and Melinda Gates read a New York Times article on the widespread death of children in developing countries from diarrhea caused by rotavirus. As Bill Gates put it, this was a killer disease that could be treated for about the same price as a US citizen would spend on a cup of coffee. The story stimulated the Gates family to act. They shifted the mission of their Foundation to include global health, and both Bill and Melinda Gates began to work full-time on the challenge.
The Gates Foundation may be the world’s largest philanthropic foundation, but even its resources are too small to radically reduce infant mortality and improve maternal health around the world. Success demands progress on many fronts. Invention, such as the production of new vaccines, is a given. Innovation, to make effective prevention and treatments applicable to the diverse contexts in which children and mothers die around the world, is another.
Fundamental to success is the idea of scale. It is not enough to beat the rotavirus with one child, or a village of children, or even tens of thousands of children. To stop diarrhea claiming the lives of children under five it is necessary to beat the rotavirus half a million times every year in at least two continents. Since diarrhea is just one preventable cause of death for eight million children under five each year, the task is bigger still.
1. Ask how the system feels, not just how it works.
Design isn’t just about making something work: it’s about asking what something feels like when it does work. Many brilliant systems fail because they feel stupid, humiliating, or dull to the humans who use them.
2. Recognize that a good system is often the best influencer.
Sticky systems keep people interested and coming back, and each visit is an opportunity to have your actions change their actions.
3. Let the user close the loop.
A system’s recipients will either make it a success or a failure. Letting them influence and shift the system dynamically means they can buy into the system, and that’s what will make it work over the long run.
4. Go micro with the human factors.
Human values matter, but vague isn’t helpful: specific human insights give real clues for changing behaviour.
5. Start with hope, and take the long view.
Systems that are purely reactionary (as opposed to visionary) fail, or worse, they limp along, alienating everyone from staff to customers and communities.
There are over 6 billion mobile phone subscribers and 75% of the world has access to a mobile phone. Service and care providers, researchers, and national governments are excited at the opportunities mobile health has to offer in terms of improving access to health care, engagement and delivery, and health outcomes. Interventions categorized under the rubric ‘‘mobile health’’ or ‘‘mHealth’’—broadly defined as medical and public health practice supported by mobile devices—span a variety of applications ranging from the use of mobile phones to improve point of service data collection, care delivery, and patient communication to the use of alternative wireless devices for real-time medication monitoring and adherence support.
A recent World Bank report tracked more than 500 mHealth studies, and many donor agencies are lining up to support the ‘‘scaling up’’ of mHealth interventions. Yet, after completion of these 500 pilot studies, we know almost nothing about the likely uptake, best strategies for engagement, efficacy, or effectiveness of these initiatives. Currently, mHealth interventions lack a foundation of basic evidence, let alone a foundation that would permit evidence-based scale up. For example, in Uganda in 2008 and 2009 approximately 23 of 36
mHealth initiatives did not move beyond the pilot phase. The current enthusiasm notwithstanding, the scatter-shot approach to piloting mHealth projects in the absence of a concomitant programmatic implementation and evaluation strategy may dampen opportunities to truly capitalize on the technology. This article discusses a number of points pertinent to developing a more robust evidence base for the scale up of mHealth interventions. The issues raised are primarily conceptual and methodological.
World Health Organization
The mHealth Assessment and Planning for Scale (MAPS) Toolkit is a comprehensive self-assessment and planning guide designed to improve the capacity of projects to pursue strategies that increase their potential for scaling up and achieving long-term sustainability. MAPS is designed specifically for project managers and project teams who are already deploying an mHealth product, and who are aiming to increase the scale of impact. External parties seeking to understand the maturity and value of mHealth projects may also find value in using the Toolkit jointly with projects.
The Toolkit covers six major areas (referred to as the “axes of scale”) that influence the scaling up of mHealth: Groundwork, Partnerships, Financial health, Technology & architecture, Operations, and Monitoring & evaluation. The axes of scale reflect the key concerns, activities and decisions that relate to these six areas.
MAPS allows users to assess where projects stand in relation to each of the axes of scale, and to track progress as activities evolve and progress. The Toolkit will help project teams to identify areas that require further attention, and then to devise strategies to overcome any challenges or obstacles to progress. MAPS is designed to be used periodically at several time points throughout a project’s trajectory, guiding projects through an iterative process of thorough assessment, careful planning and targeted improvements. These steps facilitate successful scaling up of mHealth products.