Peter Benjamin, a self-described “geek with a cause” and the General Manager of Cell-Life in South Africa, may be on the verge of producing the first empirical evidence that an mHealth system can scale to a national level and provide clear benefits across an entire healthcare ecosystem.

With the ink barely dry on a contract with the South African National Department of Health, Peter and his team of programmers, network engineers, business analysts, and trainers are already elbow deep in planning a National mHealth System that will enable facilities across the country to test 15 million people for HIV by June of this year.

Peter took an hour away from his Gantt Charts to explain how Cell-Life grew from a probing question among colleagues to a non-profit organization equipped to build the nation’s first mHealth system.  He also explained how cell phones have the potential to transform healthcare systems of developing nations, but that mHealth itself might be a transitory period that lasts only another year or two.  Below is an edited version of our conversation.

Q: What drew you to mobile phones as a way to address logistical challenges in South Africa’s healthcare system?

A: We started as a project of the University of Cape Town University Electrical Engineering Department about a decade ago, in 2000, when we asked ourselves: can we use cell phones and other tech do so something socially useful rather than just make money?

Just to throw some numbers at you, in South Africa there are 5 million landlines (telecom lines) but there are 42 million cell phones — an order of magnitude different.

The country has a population of about 48 million people so you’re talking about 90% of all youth and adults using cell phones.  Yet, only 5 million people have access to the internet through a normal computer, but double that number — 10 million — use the internet through a cell phone, WAP or mobi sites.

If we can turn this electronic, always-on device, in the hands of 90% of all youth and adults into a way to access healthcare, we have the potential to make a very significant change to the way the health system works in South Africa.

Basically for a decade, the Dept of Health has been failing to get the Internet into all the health facilities.   Of the 4,300 health facilities, only about 1,200 have a working email address. With Internet access growing out of cell phones, it’s possible to actually get a functioning health informatics system working and that’s quite fun. That could change the environment in which we’re playing in South Africa.

Q: How did you come to offer the mobile services you provide at Cell-Life?

A: One of the main things we do with cell phones is data capture which basically means filling in a survey or form or something like that by using your cell phone.   We’ve been doing bits of cell phone data capture since the start in early 2001.  We did a cell phone data capture system for the paramedical people who go from clinics to the houses of people with AIDS to support them and to report back.

It’s developed a lot in the past decade or so and the acronym we have for this project today is EMIT, Evaluation and Monitoring Information Tool.  It’s mainly used by NGO’s reporting on their different HIV activity, particularly community training where you report saying today I trained 30 people in how to use condoms at this particular clinic, etc.

The other area we’re involved in with mobile phones is Cell Phones for HIV.  It involves trying to think through how a whole range of cell phone technology can be of use to the wider HIV sector, both clinically with respect to the Department of Health, but even more so with other social players from big community organization to HIV agencies, support groups, etc.

In December we were given the first big mHealth project led by the National Department of Health in South Africa and the plan is to use cell phones for monitoring their HIV Counseling and Testing campaign (HCT).  After receiving 15,000 cell phones from the biggest operators in the country, this project became the flagship project of the Dept of Health.  They want a cell-phone-based system that will allow them to meet their goal of testing 15 million people for HIV by June of 2011 and enable all clinics and other HIV testing sites to report regularly.

Cell-Life was awarded the contract last month in December, which is wonderful but also quite terrifying.  They want to do this at all 7,080 health facilities around the country. That includes all the 4,300 public facilities plus quite a lot of private ones — like general practitioners’ offices, some street pharmacies and even supermarkets and mines that have agreed to do HIV Counseling and Testing.

This project is a different order of magnitude to the previous projects we’ve been doing.   We’re a small non-for-profit NGO in data and we’re now being asked to set up a National mHealth System and have it working in 7000 health facilities.  My desk is full of plans, Gantt Charts of how we’re going to train 14,000 people in 7,000 health facilities between now and Easter.  So it’s doable but it’s more than we’ve done and, to my knowledge, more than anyone else has done in South Africa and probably anywhere in Africa.

The fun part is that the infrastructure needed to get this HCT monitoring system working, is more or less the exactly the same infrastructure you need for any clinical and mHealth application you can think of, from information management to stock ordering to lab results, tending to remote diagnosis to training health professionals to epidemic outbreaks and other epidemiology.  If it goes well, it could start convincing the Dept of Health that mHealth actually can work.

Q: Can you talk a bit about some of the more interesting ways you’re using mobile technology?

A: Have you heard of MXit?  MXit is an absolute phenomenon in South Africa. It enables users to send an instant message over a cell phone system.  To use it, you have to download a little applet and then you can connect to the MXit server and communicate immediately with anyone else on MXit.

Effectively it sends SMS-type messages through GPRS, which makes the cost of a text message of let’s say 100 characters, less than 1 South African cent (or 1 tenth of a US cent).  It makes text messaging effectively free.

We have created a sort of website within MXit.  The MXit jargon is calling it a BOT.  In this space we provide all the usual HIV content, information, interactive quizzes and things like that.

Probably the cutest thing we’ve done with MXit is linked it to the National AIDS Help Line.  The National AIDS Help Line call center is free for people calling from a landline but its normal price from a cell phone — which means it’s often too expensive for most people to call it.

Now that we’ve linked MXit to the National AIDS Help line, someone can be texting away on MXit and it goes through to the computer screen of professional HIV counselors at The National AIDS Helpline.  Those counselors type back and it goes back to the users cell phone screen.  It’s, if you like, text counseling.  I can’t remember the exact number but somewhere around 22,000 text counseling conversations have been done over the last year and half.

We also use Please Call Me (PCM) a lot.   PCM is a way for someone with no money for airtime to send a free message to someone else to ask them to phone them back.  It basically came up because most people with a cell phone in South Africa don’t have money to make calls (air time). Cell phone companies set up these calls as a way for poor people to have some of their friends phone them back.  It drives cell phone traffic and that also helped the operators make money.

We use PCM, not necessarily for people to call back, but as a way for people to raise their hands and request various things like SMS subscription services.  For example, one way people can subscribe to our HIV SMS subscription services is to send a Please Call Me to a particular number. In advertisements we say various things like “if you want to get information around the Treatment Action Campaign send a Please Call Me to this number.”  Or, “if you want to find out where your local HIV clinic is, send a Please Call Me to that number.”  Using PCM like this creates a way to make the services, literally, completely free (not even the cost of an SMS).

We also do a small amount of stuff on Cell Book, which is basically a downloadable Java app over GPRS that allows you to download a reasonable amount of information, like a hundred A4 pages of information to a GPRS phone.  That’s a way to disseminate large volumes of HIV information, treatment guidelines and that’s sort of thing.

Q: In October 2009, in an article that appeared in This is Africa (a publication of the Financial Times Ltd.), the journalist said you argued that there “is a lack of clear evidence that demonstrates the practical and monetary benefits of mobile healthcare”  Do you feel the evidence is there now?

A: No, the evidence isn’t there.  Basically mHealth seems to be overwhelmingly about the “m.”  It’s ‘look at how we can do things with cool little add-on devices to the iPhone,’ or a hundred other tech things and not that much to do with health.  There’s a standard way to check if any intervention in health has done something.  Currently almost none of the systems can actually show a health benefit.  Until they can, there isn’t a reason for the health profession to take much interest in this stuff.

On top of that, there are very few systems that have gone to any scale.  Almost all the systems that I’ve read about or heard about, are basically at the level of one clinic or a handful of clinics testing a particular intervention or service.  The only two that I’ve known that have gone through a bigger national scale are TrackNet Data Reporting in Rwanda and various Text4Baby things in the US and other countries.  Those are massive projects but neither has proven health benefits. That is why the HCT project with the 7000+ health facilities we’re doing in South Africa could be quite interesting this year.

To my knowledge no system has shown a business model either.  Everything is still pilot.

I’m absolutely NOT saying there isn’t a benefit to this stuff but I think this is an empirical point rather than principle point.   We have yet to see any clear evidence to demonstrate a tactical and monetary benefit of mobile healthcare. I can say dozens of things about how I think it can, or it’s reasonable to suspect, or there’s a coherent hypothesis that this can be a benefit, but we haven’t proven it yet.

Q: Do you feel there is pressure to provide empirical evidence?

A: There are lots of people running around trying to find answers to this stuff,  in particular the mHealth Alliance.  They’re actively trying to hype this stuff and that’ s their job.

Separately, there’s the GSMA, which see mHealth as potentially the next big thing that the operators can make money on. There’s a big conference in June in South Africa in which they’re going to bring together 100 governments and 150 different operators to build an industry around this stuff.  They’re desperately searching around to find a few examples that a) have medical benefit; b) can go to scale c) show a business case.

So yes, there are lots of people trying to find this stuff but no one has cracked it yet.

I think mHealth as an area doesn’t have much than 1 or 2 years in it.  What I mean by that is if it is shown to be effective then it won’t be called mHealth anymore.  It will just be the obvious way to do healthcare.

Tagged as: cell-life, mhealth, Mobile Health, peter benjamin