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Is digital health just for the rich?

Despite COVID-19 forcing the hand of digitally reticent governments and health organizations to update, upskill and adopt digital health tools, evidence of scaled up mobile phone health (mHealth) initiatives being accessible to the poorest and those most in need, is so far, thin on the ground, according to the review released today in the Annual Review of Public Health. Annual Reviews today announced plans to make all of its 51 journals open access using a new model.

"Mobile Health (mHealth) in Low- and Middle-Income Countries (LMICs)" analyzes the potential and challenges associated with the growing use of ubiquitous mobile phones and the ever-increasing connectivity globally to reach remote or otherwise disengaged populations. It highlights the advantages that private sector investment offers to the field: value through enhanced capacity, advances in technology and the ability to meet increasing consumer demand for real-time, accessible, convenient, and choice-driven health care options. At the same time, the authors raise questions around whether transparency, local ownership, equity, and safety are likely to be supported in the current environment of health entrepreneurship.

Although mHealth in Higher Income Countries (HICs) is becoming increasingly mainstream, evidence of scaled-up, sustained initiatives in LMICs are not as well established. This discrepancy is a likely product of a tendency still toward investment in pilots that fail to reach scale (and are not published) without sustained resourcing owing to a lack of longer-term funding arrangements.

From the analyses undertaken to date, mHealth in LMICs has been focused largely on two areas: the use of mHealth to support health workers in health service delivery and the use of mHealth to deliver health information directly to consumers and to support behavior change in disease management interventions.

However, this is about to change. Large, underserved, and consumer-savvy middle classes in the emerging economies combined with the gaping vacuum in consumer choice for health care during the COVID-19 pandemic has only fueled growth in mHealth in LMICs.

The authors highlight the importance of the WHO Digital Health Strategy (2020–2025) and several of its core principles which remain relevant for mHealth in LMICs, in particular, the need for a sound regulatory framework for activities based on capacity building, equity, ethics, accountability, and governance.

One-way and two-way messaging remains the most used modality, with a gradual shift to the use of apps and social network sites (Facebook messenger, WhatsApp, and WeChat).

A major barrier to mHealth implementation in LMICs remains a lack of technical capacity and capability, with technical support being outsourced in some countries, leading to limited potential for sustainability. Moreover, local investment, especially when donor investment is backing the initiative, is a critical factor in determining translation from pilot to a domestically funding scaled-up program. This transition, which is part of the broader agenda in global health financing, is likely to have significant implications for the sustainability of other interventions that fall outside primary service goods and services infrastructure until the translation of value (of digital health) is costed, tested, and accepted (as no longer an adjuvant to mainstream health service delivery).

The review points out that possibly the greatest brake on the optimism surrounding mHealth is the issue of equity: who gains access and reaps the benefits. It suggests that groups with greater access to resources (technical as well as financial capital) are more likely to be early adopters of new technologies and cites the rollout of electric cars as a similar scenario.

The most obvious and well-described risks, the review suggests, is related to the safety and confidentiality of sharing data or personal health information via mobile devices. Tracer apps on mobiles during the COVID-19 pandemic are a good example.

In light of these challenges together with the growing evidence of the growing market potential in LMICs including scale (large), human capital (young, growing populations), relatively weak regulations, and a growing middle class, the review further argues that the future of digital health in LMICS may very well be tied to securing public-private partnerships (PPP).

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