Technology works, people don't
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Study of pilot project using mobile phones for healthcare in Africa finds that technology works, but implementation, management and human factors are real hurdles.
Bridges.org has conducted an in-depth investigation of a pilot project by the Cape Town Health Directorate that tested innovative uses of mobile phone technology to improve the treatment of Tuberculosis (TB) in its clinics. This is part of the City's efforts to find better, and more cost-effective, methods for enhancing patient adherence to treatment regimes. The treatment of TB in Cape Town offers a good setting to explore whether and how mobile phones can be used in healthcare. South Africa has one of the most alarming TB epidemics in the world. And the damp climate, poor living conditions and high prevalence of HIV/AIDS make Cape Town a hot spot for TB. At the same time, South Africa's mobile phone market is large; in June 2004 there were 18.7 million registered mobile phone subscribers out of a population of 46 million. Further, mobile phones are widely used by low income groups, although usually only for receiving calls and text messages (which is free with a basic service plan). Examining TB treatment is not only useful because of the impact of the disease, but also because lessons learned from successful systems for TB treatment adherence could be applied more broadly to other diseases. For example, one of the problems with HIV/AIDS treatment is that it requires lifetime adherence to drug regimes. The bridges.org report provides a practical, objective look at the technological, management, and human factors involved in implementing technology in a developing country clinic environment. The study was supported by the International Development Research Council. THE TECHNOLOGY PILOT Patients that do not take their TB medication on time (or miss doses) hinder efforts to control the spread of the disease. The World Health Organisation recommends the Directly Observed Therapy System (DOTS) for treating TB, where health workers watch patients take their medication each day. DOTS has been shown to produce the best results for treatment adherence, but places a heavy burden on already over-stretched health services. It also can be costly for patients who must travel to a clinic every day, and threatens fragile livelihoods if it impinges on working hours. The Cape Town Health Directorate is implementing a proactive strategy to control TB, including exploring new methods for enhancing treatment adherence. In this pilot, the technology solution was provided by On Cue, a small company offering a Compliance Service that sends short text messages to patients via mobile phones to remind them to take their medication at pre-determined times. Patients with mobile phones are selected to use the service if health workers consider them candidates who are likely to take their medication without direct supervision. The bridges.org study looked at the effect of the use of the Compliance Service on TB cure rates and treatment completion rates in Cape Town, and identified related social and economic impacts resulting from the use of the technology. It also assessed whether, and how, best practice principles for project management were implemented. KEY FINDINGS Bridges.org found the Compliance Service to be a suitable adjunct to DOTS that will help improve TB treatment adherence in Cape Town and beyond. The technology works and it is effective. And on face value, it also provides a more cost-effective and convenient treatment adherence option, both for the health service and the patient. However, a number of obstacles limiting the effective use of the service were identified -- notably, poor administrative procedures. Although patients and healthcare workers were enthusiastic about the service and able to use it, a significant number of patients did not use it as instructed. An overall lack of ownership of the project at the clinic limited the proactive participation of staff, and there was no one on-site to take direct responsibility for implementation. This was exacerbated by the fact that clinic staff schedules are tight and many staff members feel that they are already over-worked. City and clinic bureaucracy limited the add-on functionality that would expand the usefulness of the service. And issues of privacy, data protection, and security will affect the widespread use of technology in healthcare in Africa over the long-term. The Compliance Service is only a viable option if adherence levels are at least those of clinic-based DOTS. The patients enrolled in the service showed rates for TB cure and completion similar to those using clinic-based DOTS at the clinic; however, the results cannot indicate the effect of the service on adherence levels because of the problems with pilot implementation. CONCLUSIONS The pilot demonstrated the power of mobile technology to address a critical developing world need. Yet no technology is a silver bullet to solve the problem of patient adherence: it is all down to the way in which it is implemented. Successful integration of technology in healthcare requires a clear understanding of where technology use ends and care-giving begins. The lessons learned in this study are informing decision-making about the future use of the Compliance Service in Cape Town clinics, and the Health Directorate should be applauded for having the courage and vision to share these findings with the rest of the world. This study unearthed important issues around technology use in primary health care -- shedding light on the practical realities of the developing world context -- which could inform other efforts. Over the long term, innovative technology uses like this are likely to play a critical role in the rollout of treatment for HIV/AIDS and other diseases in the developing world. But they will only make a difference when patients and healthcare workers embrace new systems and implement them effectively at ground level. |
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