http://www.arcade-project.org

ICTs: opportunities and challenges Henry Lucas- Brighton, UK. All course materials are published by the ARCADE Projects under the Crea:ve Commons A<ribu:on Non- commercial- ShareAlike 3.0 Unported license.

PART FOUR: Possible relevance in resource poor contexts

What do we mean by Resource-poor contexts? Complex health markets with multiple providers Cash for services situation even in public sector Absence of high level accredited providers public or private (doctors, nurses, midwives, pharmacists, technicians) Reliance on: CHWs/VHWs/HEWs Proliferation of unaccredited providers: UAPs, drug sellers (markets, shops), alternative and traditional, faith healers, etc

Is self management the only option?

Where there is no possibility of adequately funding a provider-based model of care full self-management facilitated by expert patient networks and smart phone technology is one of the few options for those with chronic conditions. (van Olmen et al, 2011)

[In India it would be impossible] to simultaneously focus on NCDs and communicable diseases;... such a utopian argument ignores the political and economic constraints that shape resource allocation (Subramanian et al, 2013)

There are multiple ICT interventions targeting low resource environments Free to use data: Mobile for Development Impact [GSMA: mhealth products & services in the developing world (673) : 2013

Diverse range of interventions Health messages SMS (FP, MCNH, AIDS, Obesity) Targeted SMS (Diabetes, Reproductive Health) Monitoring systems (Patients, Providers, Drugs) Job aids for CHWs (Florez-Arango et al. 2011). Guides and training materials: Where there is no doctor mobile app Mobile Academy Mobile advice/consultation/prescription HealthLine Bangladesh Meradoctor, Mediphone India Photo: UNICEF Guinea, cc license Photo: DIVatUSAID, cc license

Self-management Many of the above interventions could be seen as contributing to a health information environment that is supportive of selfmanagement Photo: FHS, permission to use For example, much of the material and many of the tools being developed for use by CHWs could equally well be used by patients or carers. There are also a limited number of interesting initiatives which address the networking and support components of selfmanagement.

Approach One: Basic - icddr,b With almost no resources, ICDDR,B encouraged the formation of community based clubs for those with diabetes and/or hypertension in the Chakaria region of Bangladesh Provided with initial support in terms of diagnosis and advice Most have remained active since late 2010, with members checking blood glucose and blood pressure at regular meetings and consulting qualified physicians by mobile phone when needed. (Hoque et al, 2014)

Approach Two: Going to scale - MoPoTsyo Almost 140 patient information centres for individuals with diabetes in Cambodia Run by peer educators under the supervision of program managers who are also diabetic Identify diabetics, provide targeted advice and information, and assist health status monitoring Assisted access to qualified doctors and pharmacists when required Central database of patient records including time series health status monitoring data Routine mobile phone contacts maintain network - MoPoTsyo- http://www.mopotsyo.org/

Approach Three: Social Enterprise- TRCL/ AMCARE Patient at home and home medical devices and mobile phone Image adapted from: Chronic illness initiative of Telemedicine Reference Centre Limited http:// www.amcare24.co m/welcome.php Patient s immediate family members Chronic disease management portal Medical consultant (Endocrinologi st & cardiologist) 24/7 medical call centre(access to trained doctor)

Approach Three: Social Enterprise- TRCL/ AMCARE Diabetes & hypertension management service Mobile phone access to qualified doctors Electronic prescription via SMS & SMS Alerts Home monitoring & home care services Access to Bangladesh Diabetes Association in-patient facilities Registration: $10/year $10-20/month home care Source: Chronic illness initiative of Telemedicine Reference Centre Limited http://www.amcare24.com/welcome.php

Hope or Hype? Are we talking about empowerment or abandonment? Will services be good enough (disruptive innovation) or better than nothing? All three initiatives were driven by one or two key individuals. Can they be readily translated and taken to scale? Much of the academic discussion relates to a handful of chronic conditions: AIDS, diabetes, hypertension, asthma, etc. Are we abandoning the notion of an integrated healthcare system?

More generally In under-regulated, multiple provider health systems with no trusted authority: is it true that knowledge is power for patients with chronic conditions? Effective gate-keeping functions are central to health systems in advanced market economies: how can the chronic sick or their carers distinguish experts from quacks who are trying to extract what little money they have?

Who might be trusted? Candidates: National/local government agencies National/International NGOs (BRAC, Gates) National/International healthcare companies Professional bodies of health workers Drug companies, telecoms companies Is there is a viable business model that would incentivise private companies to provide appropriate, reliable health information and support services to the poor/poorest? To what extent could technology be used to enhance regulation?

SOURCES Slide 6: van Olmen (2011) @The growing caseload of chronic life-long conditions calls for a move towards full self-management in low-income countries. Global Health. 2011 Oct 10;7:38. doi: 10.1186/1744-8603-7-38. Slide 7: Subramanian, SV, Malavika A Subramanyam, Daniel J Corsi and George Davey Smith (2013). Rejoinder: Need for a data-driven discussion on the socioeconomic patterning of cardiovascular health in India. International Journal of Epidemiology 42:1438 1443. Slide 8: Free to use data: Mobile for Development Impact [GSMA: mhealth products & services in the developing world (673) : 2013 https://mobiledevelopmentintelligence. com/products Slide 9: top photo: Getting the word out via SMS by UNICEF Guinea, cc license; bottom photo: Dimagi, by DIVatUSAID, cc license Florez-Arango, J. F., M. S. Iyengar, et al. (2011). "Performance factors of mobile rich media job aids for community health workers." Journal of the Amerucan Medical Information Society 18: 131-137. Slide 10: Photo- FHS, permission to use. Slide 11: Hoque, Shahidul, Ariful Moula, Mohammad Iqbal, SMA Hanifi, Mijanur Rahaman, Abbas Bhuiya (2014). Clubs for Diabetics and Hypertension in Later Life: Bangladesh. Conference presentation: Geneva Health Forum April 15-17 2014. Slide 13: Image adapted from: Chronic illness initiative of Telemedicine Reference Centre Limited http://www.amcare24.com/welcome.php (date accessed: 29.08.14)