Alan Gelb

How do you develop a patient centred healthcare system that serves vast numbers of transient poor people? India has an answer: Rashtriya Swasthya Bima Yojna (RSBY), which has won plaudits from the World Bank and the United Nations as one of the world's best health insurance schemes.

RSBY combines state-of-the-art technology and incentive structures. It is paperless, does not use cash and provides affordable health insurance to millions of people. The overwhelming majority of who, are illiterate, transient people living below the poverty line.

RSBY employs cost effective, scalable technologies to help satisfy the health needs of a significant proportion of India’s poor. Enrolment of families into the scheme, biometric smart card generation, pre-authorization of admissions, as well as claim submission and approval, all occur electronically. Beneficiaries can use their smartcards in any empanelled hospital across India and therefore travel is no barrier to receiving healthcare. Patient data are transferred electronically between empanelled hospitals and insurance companies and claims are settled automatically. The scheme lowers costs, increases efficiency and reduces fraud.

A postnatal care program using biometric identification has been developed in Cross River State, Nigeria. Since power supply in that region is quite unreliable, the electronics to run it is powered by solar panels. This is a relevant example of how new technology can be transported and used in rural areas and in environments that we would normally consider difficult.

Mobile telephony has spread very rapidly in developing countries, one reason being their seriously deficient fixed line systems.According to the International Telecommunications Union there are some 5 billion wireless subscribers in the world today and over 70% of these reside in low and middle income countries. In 2011, Africa held its first mobile health summit in South Africa and firmly put mobile telephony at the centre of improving healthcare in poor countries. A 2011 WHO global survey of the use of mobile telephony in healthcare; mHealth, reported that commercial wireless signals cover over 85% of the world’s population. Eighty three per cent of the 122 countries surveyed in the Report used mobile phones for free emergency calls, text messaging and pill reminders.

Mobiles can be useful in a number of ways: farmers, for instance, are able to get information about the prices for their products (so they can sell them at the right moment at the right price). For health it has been used to deliver information to pregnant women, to enable local health providers to ask questions about particular cases to central facilities, to track and monitor treatment.

Kenya is beginning to exploit its mobile telephone infrastructure to send and receive health information to educate girls and women about labour, contraception and birth. Kenyan women are monitored during their pregnancy via their mobile phones. They receive regular calls from an automated system, which asks them questions to monitor their health condition in order to check that they do not have antenatal complications. The aim of the project is to extend this mobile screening and triage service to those hard-to-reach patients in rural areas.

One of Zambia’s biggest successes has been the liberalisation of its telecommunications infrastructure. Today there are over 8.2 million mobile telephone subscribers in Zambia, which has a population of some 13.8 million. This suggests Zambia might consider exploiting its mobile telephony network to provide a cost effective and scalable means to educate girls and women about contraception, labour and child birth.

Mobile telephony has become an important vehicle for improving the quality of understanding of health issues and of tailoring treatment for individuals.

Technology can't do everything to help poor countries manage their disease burden, but it could enable more efficient systems that can be built around individuals. A good example is the tracking system developed in some African states for patients who follow treatment regimes for tuberculosis.

In Chad digital biometrics are being used to monitor the health status of nomadic populations, who might not keep or understand any form of paper ID. Official identification in most developing countries is relatively low: overall something like 50% and in Zambia only 9% of the population have official birth certificates.

 Although developing countries are low on traditional official identifications such as birth certificates, they are one of the biggest uses of biometric identification. The comparative advantage of developing countries is that they have fewer legacy systems, relative to the developed world, and can therefore implement and benefit from emerging technologies far more easily.

 Africa is the fastest-growing mobile telephone market in the world and the biggest after Asia. Over the past five years the number of subscribers on the Continent has grown some 20% each year. By the end of 2012 it is projected that Africa will have 735 million mobile subscribers.The nature of Africa’s mobilemarket is also changing. Today, smart phone penetration rate in Africa is estimated to be about 18%: almost one in five and projected to reach 40% by 2015. While patchy, mobile penetration rates in Sub Saharan Africa, where the disease burden is greatest, are not low and the rate of smart phone penetration is estimated to be about 20%.

 In 2007 Sarafaricom, a leading mobile phone network in Kenya, launched M-Pesa, a mobile phone‐based payment and money transfer service for people too poor to have a bank account. M-Pesa spread quickly and has become the most successful mobile phone‐based financial service in the developing world. Today there are some 17 million registered M-Pesa accounts in Kenya. It is only a small step to offer a mobile health information service for all M-Pesa account holders.

 Africa’s new highways to carry healthcare information are virtual rather than physical. They already exist, they are extensive and, over the course of the next five years, are projected to rapidly expand and improve. With such an infrastructure one teacher can educate millions of people, which is significantly more cost effective and sustainable than traditional healthcare programmes.

One of the difficulties that many developing countries face is poor information on the health status of their population, on the incidences of specific diseases and how they can relate the data from periodic health surveys to actual clinical information, arising from the operation of the health system.

One way of merging medical information with the demographic and health database is to have a much stronger focus on the individual. For instance, a patient who suffers from a particular disease can be tracked along with that patient’s health information. Other details, such as age, gender and provenance can be added and fed into the system to create a significant database.

Modern technologies have the scalability to provide the basis for Africa to develop country-congruent health policies that are locally applicable. Technological systems such as mobile telephony, the internet and biometric identification, which are appropriately implemented, have the capacity to empower individuals and encourage them to take care of their own health. Further, such technologies have the capacity to improve targeting, reduce fraud and increase access to healthcare. Technologically based healthcare strategies offer Africa an opportunity to leapfrog its ineffective traditional healthcare systems and begin to manage the enormity of its disease burden and, in turn, may benefit the whole world by demonstrating the benefits of patient centred healthcare.