Tag Archive for eHealth

If somebody had a crystal ball: The paradox of a self-defeating health policy.

When I was a new graduate student of health policy, I was once asked by a professor whose class I took, why I had left clinical practice to study health policy. I replied naively, ‘I migrated from clinical practice because I don’t like the idea of working in a place where I can make one mistake and kill a person.’

‘I see,’ he said, ‘so you decided to come over to policy and kill thousands?’

His response, delivered in jest, was tacitly instructive about the importance of getting health policy right, because of the scale at which the impact can be felt. Indeed, one of the central tenets of governance in healthcare is the identification and rectification of problematic policies (WHO, 2017).

Even after learning at graduate school that policy work tends to be an arduous, convoluted and often contentious process, I still intuitively considered policy work to be safer, more elegant and less stressful than clinical work. It was experiences ‘from the trenches’ that revealed otherwise. Within a year of completing my masters, I was battling to pilot an intervention aimed at mitigating the undesirable effects of a well-intentioned health policy that has outlived its relevance in its context; a process which was the diametric opposite of ‘elegant and less stressful’!


When a health policy endangers health

Pharmacies in Zimbabwe, a low income country in Sub-Saharan Africa plagued by a protracted economic recession and a dilapidated health system (Meldrum, 2008), are prohibited by law from advertising their inventory to the general public unfettered like conventional businesses do (Health Professions Act, 2004; Medicines and Allied Substances Control Act, 2001; Pharmaceutical Professional Conduct Regulations, 1989). Given the information asymmetry characteristic of a typical healthcare market, and the potential severity of the consequences of such asymmetry, advertising restrictions are rightly intended to protect members of the public from product claims they are unequipped to evaluate objectively. However, to the extent that advertising restrictions interfere with information provision and transparency when accessing health care, they themselves are a health hazard and this is what the medicine advertising regulations in Zimbabwe have become. The fine line between availing information about care and protecting the public from exaggerated claims should be carefully navigated. Interventions which mitigate the deleterious effects of health information control policies can and should be developed.

In well-served health systems, restricting advertising in and of itself does not constitute a problem because a patient can reasonably expect to find the medicine(s) s/he requires after only one stop or at most few stops at pharmacies in his/her vicinity. However, in Zimbabwe today, systemic economic challenges are causing generalised medicine shortages. These challenges are, in the main, beyond the control of the pharmaceutical sector. As a result, the largest referral hospitals suspended elective surgeries (United Bulawayo Hospitals, 2016; Harare Hospital, 2016). Pharmacies that happen to have a particular medicine that is in short supply everywhere else, are precluded from overtly advertising this fact. Patients therefore have to rely on door-to-door enquiries at multiple pharmacies, serendipitous coincidences, intuition and the benevolence of some pharmacists who sometimes offer to help by contacting colleagues within their professional networks on behalf of patients. Electronic prescribing is not yet widely used in Zimbabwe so patients or their carers are the ones tasked with transmitting prescriptions between prescribers and the pharmacies that will ultimately dispense them. They therefore bear the transaction cost of this process and have to trudge from one pharmacy to the next until they eventually get to a pharmacy that can fill their prescriptions. When pharmacists turn away prescriptions but offer no additional information about where patients can get those prescriptions filled, they become the human face of a system that seems unresponsive to the plight of the ill. Once, I remarked to my colleagues, ‘If somebody had a crystal ball, they would be the oracle that informs patients where exactly to go to get their prescriptions filled and reduce the burden of medicine access.’


The intervention: Controlled democratisation of pharmaceutical inventory information

Accessing medicines should not depend on unsystematic methods of search and we most certainly shouldn’t have to look to clairvoyance to make health systems more efficient and transparent – especially when advances in health informatics and Web 2.0 coupled with the ubiquity of portable information and communication devices have increased the interconnectedness of actors and rendered faster sharing of information across large networks possible. After a content analysis of the statutory instruments governing the practice of pharmacy in Zimbabwe, with the view to finding a legal workaround for the advertising rules, I discovered a loophole. While advertising inventory to the general public is prohibited in Zimbabwe, advertising to another health professional is not. Therefore, if a vertical search engine that is populated by real-time crowdsourced inventory data from retail pharmacies all over the country was set up, and if the back-end of that search engine was managed by a pharmacist, then it could be used by that pharmacist to advise patients, on a case by case basis, even remotely via the internet, about the exact locations of pharmacies stocking specified medicines. A prototype meant to achieve this was designed and the three statutory bodies that regulate healthcare practice in Zimbabwe were approached for approval before launch.

The unfavourable response received from them, was unexpected. An email communication was circulated to all the registered practitioners, cautioning them against what the chief regulatory institution considered an ‘illegal project’ that was tantamount to advertising. I was explicitly informed that I was risking censure by setting the ball rolling with it and was sufficiently intimidated. Of all the illegal things a health professional in Zimbabwe can do, outside of malpractice, experimenting with advertising is considered the most negligent because it is so easy to avoid. It is seared onto our minds right from pre-qualification training that advertising by health professionals is simply not acceptable, so it is almost a reflex response for healthcare providers to stonewall anything that bears advertising connotations.

Regulators were re-engaged because their endorsement is crucial. Without this it is not possible to persuade pharmacies to volunteer the essential crowdsourced data needed to populate the vertical search engine that drives the intervention. Although they acknowledged unreservedly the existence of the problem that the advertising policy has given rise to, regulators remained steadfast in their position that the proposed vertical search platform solution was illegal and ‘was not in the best interests of the public’. The judiciary arm of the state was therefore invoked in the hope that it could rule on the legality of the proposed intervention.

The intermediate goal became to obtain a court judgement that would compel the regulatory bodies to allow this intervention to be tried. A High Court application (Herald, 2016a) citing the health minister and all three relevant regulatory entities as respondents, was filed. We currently await a judgement pronouncement but continue to keep the discussion about the matter alive, for example through the press (Herald, 2016b). Meanwhile, one of the regulatory bodies has responded to our court application with a counter-suit for costs because according to it, we ‘brought a case before the Court prematurely.’


The Future

Towards the end of 2016 a press announcement notified the public of the healthcare regulators’ intention to relax draconian advertising policies (Herald, 2016c), having recognised the need for the public to access information about healthcare providers and services. I count this a small victory and look forward to the green light to implement the ‘Crystal ball’ project with much optimism. Lessons from its implementation could bode well for health systems facing similar governance problems.

Determined to build my credibility with policymakers and take forward my academic studies, I enrolled for a PhD with the Global eHealth research group at the University of Edinburgh and am now 10 months into a three-year programme. Taking this parallel pathway, whilst continuing to fight the case for better information sharing about community pharmacy stocks in Zimbabwe, has forced me to critically examine my assumptions and proposition and to mentally separate my personas as an objective researcher of eHealth innovation and as an innovator/entrepreneur. It has provided an opportunity take an in-depth look at the technical and legal feasibility of alternative approaches, and their ethical, legal and governance implications, as well as to study a wider range of innovative digital approaches for supporting pharmacy practice and strengthening health systems. This transition has been guided and encouraged by my PhD supervisors Dr Claudia Pagliari and Dr Raluca Bunduchi, who have kept my feet on the ground and combine expertise in health technology assessment, health policy and innovation studies. Our new opinion piece in BMJ Global Health (June, 2017), aims to draw wider attention to the challenges facing Zimbabwe and seeks ideas and opinions from researchers, policymakers and practitioners facing similar problems elsewhere in the world.


By Dudzai Mureyi, Global eHealth PhD student

Dudzai Mureyi is a first year PhD student on the Global eHealth programme at the University of Edinburgh, supervised by Dr Claudia Pagliari (eHealth Research Group) and Dr Raluca Bunduchi (Entrepreneurship and Innovation Group).


  1. Harare Central Hospital (2016). Internal memo: Suspension of Elective Lists-Drug Shortages. Harare. [WWW] Available from https://zimnews.net/zimbabwe-suspends-surgeries-harare-hospital/ Accessed 06 February 2017.
  2. Meldrum A, (2008). Zimbabwe’s health-care system struggles on. Lancet 371(9615); 1059-1060.
  3. Parliament of Zimbabwe (2001) Medicines and Allied Substances Control Act [15:03]. Harare. Parliament of Zimbabwe.
  4. Parliament of Zimbabwe (2004) Health Professions Act [27:19]. Harare. Parliament of Zimbabwe.
  5. Parliament of Zimbabwe (1989) Statutory instrument 232 Pharmaceutical Professional Conduct Regulations. Harare. Parliament of Zimbabwe.
  6. The Herald (2016a). Pharmacist Seeks Court Order for private pharmacy stocks database. [WWW] Available from  http://www.herald.co.zw/pharmacist-seeks-court-order-for-private-pharmacy-stocks-database/  Accessed 06 February 2017.
  7. The Herald (2016b). When regulation is outpaced by technology. [WWW] Available from  www.herald.co.zw/when-regulation-is-outpaced-by-technology/ Accessed on 06 February 2017.
  8. The Herald (2016c). Zimbabwe: Govt relaxes Medical advertising rules. [WWW] Available from http://allafrica.com/stories/201611280215.html Accessed 06 February 2017
  9. United Bulawayo Hospitals (2016). Internal memo: Cancellation of Elective Surgical Operations. [WWW] Available from http://www.africanews.com/2016/10/15/drug-shortage-hits-zimbabwe-hospitals-suspends-some-surgical-operations// Accessed 06 February 2017.
  10. WHO (2017) Governance. [WWW] Available from http://www.who.int/healthsystems/topics/stewardship/en/ Accessed 06 February 2017.
  11. Mureyi D, Pagliari C, Bunduchi R (2017) Drug advertising riles and the patient safety paradoc in Zimbabwe. BMJ Global Health (Opinions), June 8th 2017 http://blogs.bmj.com/bmj/2017/06/08/dudzai-mureyi-et-al-drug-advertising-rules-and-the-patient-safety-paradox-in-zimbabwe/ Accessed on 10 June 2017

Preferential Software for the Poor

Millions of families who have never accessed the Internet, used landline telephones or even postal service have now begun using mobile phones. Increasingly governments, charities and tech companies see this new infrastructure as an opportunity to re-imagine the way that we deliver health care. While this field is young and riddled with disappointments, some mobile health, or mHealth initiatives have yielded impressive results. For example, inexpensive text messaging programs have improved quality of care for children with Malaria (study), increased adherence to HIV medication (study), and made community-based support as much as 137 times faster and four times less costly (study).

I wish that I could say such studies prove that communication technologies boost health outcomes, but sadly I cannot. Perhaps this field’s most inconvenient truth, observed again and again by practitioners and scholars, is that technologies that are effective in one setting often have very different effects in other settings. It is not difficult to see what makes mHealth so complex; the daily routines by which people make use of technology as well as the technologies themselves are diverse and continually changing. It is more difficult to determine how we might cope with unpredictability and make the most of mHealth opportunities. Currently popular prescriptions include selecting technology that is scalable, fostering collaboration and planning for financial sustainability from day one.

I would like to suggest that we begin by listening to the poor and marginalized individuals who stand to benefit from our work. Listening is a matter of such practical importance that I often think of it as the core competency of the team at Medic Mobile, the mHealth social enterprise I co-founded. We begin by making time for long conversations with people from each of the groups any new initiative might touch. No project moves forward until we have listened long enough to begin seeing the central strengths and constraints of each group from their point of view. Hearing of their daily concerns goes hand in hand with imagining alternative futures, and we always draw sketches of how our collaboration might change their community. By ‘we’ in this case I am also referring to the beneficiaries because sketching and brainstorming is collaborative wherever possible. When we sketch what a future service might look like, we consistently receive more detailed and often more critical feedback than through conversation alone. Making it easier for people all over the world to give feedback on our intentions forces us to listen not only more patiently but also more pragmatically. The number of times we have thrown away old sketches and drawn new ones, always based on feedback, is a reasonable gauge of how well we have listened.

Listening meaningfully is also a great intellectual challenge because appreciating the circumstances of any poor person involves understanding global poverty. The first time that a community health worker in Malawi told me that he had to walk 15 kilometers and spend a third of what he would earn in a typical day just to charge his phone, I understood that an mHealth initiative designed for him would need to reimburse for electricity and use phones which hold a charge for a week or two. Having now heard similar stories from dozens of health workers, it frustrates me how the mHealth community obsesses with fancy smartphones that need to be charged everyday. I have had similar conversations with facility-based staff who lament that the internet is slow, unreliable or absent from their clinics. These are the clinics most in need of support, and yet nothing is more in fashion than to boast that one’s mHealth application is “cloud-based.” International development agencies often write requests for proposals that explicitly call for cloud-based apps because they are deemed ‘more scalable,’ which in turn pressures charities that rely on such grants to write cloud-biased proposals. After many cycles of such investment, it should not surprise us that cloud and smartphone apps are among the most ‘tried and true’ tools in the global mHealth community. Neither should it surprise us that when the ‘best tools’ excel in more urban and middle-income environments, the tools themselves come to incentivize organizations to focus not on the poorest, but on middle-of-the-road needy communities where the tools are likely to be relevant.

To be sure, smart phones and cloud servers can be tremendously helpful in many settings. It seems almost counter-intuitive to suggest that we could ever go wrong by maximizing ‘value for money’ with technologies that are ‘cost-effective’ enough to ‘go to scale’ nation-wide. No one seems to be intentionally marginalizing the poorest. An alternative view may only emerge when we not only listen to the poor, but spend enough time in their company to appreciate that they are subject to a perpetual train of abuses and unfair disadvantages. The most difficult to perceive are the abuses which are nobody’s fault, the suffering which seems inevitable because it flows not from evil people but from patterns of society that have long been taken for granted. Some use the term ‘structural violence‘ to describe such social arrangements that tend to put specific groups in harm’s way. Revisiting this concept has helped me attend to who gets left behind when we design technologies with a utilitarian focus on the characteristics of the average needy community. Many who call attention to structural violence have also argued that the only means of addressing such systemic unfairness is to build a preferential option for the poor. What would preferential software for the poor look like? Perhaps I can explain this most clearly with an example.

My first mHealth project was with a rural Catholic hospital in Malawi called St Gabriel’s. We gave phones to about one hundred community health workers so that they could exchange logistical information such as “Mary Banda in Msangwa village might have Tuberculosis and I want you to come test them.” The project was successful enough that many other organizations asked us to replicate it, but they wanted to use more quantitative data in more complex ways than our initial approach to simple prose text messaging. At the time, industry experts referred to durable, inexpensive and long-battery-life phones as “dumb” or “SMS-only” phones because they “couldn’t run apps” that would support forms-based data collection or menu-based decision support. Bucking conventional wisdom, I fixated on the idea of putting apps on $20 phones because it seemed the only way to move beyond the limitations of text messaging without leaving behind communities like St Gabriel’s.

During a trip to Kenya I learned of the popular mPesa mobile banking service. It involved simple menus and worked on the cheapest phones–it was possible! How ironic that the experts in my field had neglected to discuss a technology that 70% of adults in Kenya were using. I learned that mPesa was installed not on the phone itself but on the SIM card, so I began talking to mobile network operators about putting health apps on their SIM cards. I was told again and again that it simply would not be possible unless I were prepared to pre-order a custom batch of 10-50 thousand SIM cards (and my funders said that would be impossible). More than a year later I discovered a small Eastern European manufacturer of paper-thin ‘parallel-SIM’ cards that slide underneath a typical SIM card. Using this technology, we could install our apps on the parallel SIM and keep using ordinary SIMs to connect to the mobile network. Medic Mobile soon began developing a parallel SIM card app called Muvuku, which means ‘to listen’ in Chichewa, one of the indigenous languages of Malawi. Since then we have used it in more than a dozen countries and it has won a few awards. Conveniently, it also works well for programs that could afford more expensive phones and that do have access to electricity and local smartphone suppliers. It was harder and took much longer to develop than an Android app though. It was only worth the effort because of a commitment that has more to do with who we are than it has to do with maximizing impact or going to scale. While we’re open to working in any setting that would benefit from our support, we design our core technologies in partnership with, and to suit the circumstances of poor and marginalized communities.

What does it mean to make preferential software for the poor? I do not mean to argue that the solution lies with any one technology or in dealing with any particular constraint, be it electricity, usability, adaptability or local availability and appropriateness. Rather, it means standing with the poor, spending time in their company and appreciating their strengths and constraints—as they see them—before attending to technical or financial concerns. I believe this matters because engineers and economists too often advocate for their expertise in ways that make the aspirations of the poor seem impossible, or even a waste of resources. In recent decades we have heard that HIV prevention is ‘cost effective’ but treatment is not and that patients who do not respond to the cheaper classes of Tuberculosis drugs are ‘untreatable.’ Today many still argue that poor community health workers can volunteer while their bosses receive comfortable salaries and that the ‘dumb phones’ which have proliferated all across the African continent are not ‘smart’ enough to extend the highest standard of medical care. These social fictions stem from a poverty of imagination about what is possible. They stem from a traditional deference to the expertise of foreign technical elites over the lived experience of beneficiaries. To be sure, spending time in the company of the poor will not render all problems easily solvable. But listening patiently and with a deep sense of humility is a decent place to start.


Isaac Holeman, Medic Mobile 

Isaac Holeman is a designer and a scholar striving for global health equity. Through ethnography and innovation, his work is about seeing through the eyes of the poor and marginalized and responding pragmatically. He has pursued this work as a cofounder of the mHealth social enterprise Medic Mobile, as an Echoing Green Fellow and as a Gates Cambridge Scholar.

mHealth and User Centered Design in low resource settings

Walk into almost any corner store in India, Pakistan, Zambia, Mexico, or Tanzania and you will find cell-phone top-up cards for sale. Corner stores and markets and even street vendors understand that mobile phones mean business. There are now more than six billion wireless subscribers in the world, and more than 70% of them reside in low- and middle-income countries. The Global System for Mobile Communications Association (GSMA) reports commercial wireless signals cover more than 85% of the world’s population, extending far beyond the reach of the electrical grid.

As global health NGOs join governments, health care, and donors begin to build the foundations for a cancer control strategy in places such as sub-Saharan Africa, we need to incorporate mobile health strategies and monitoring mechanisms to unleash the potential of those six billion mobile users to further awareness, advocacy, and behavior change goals.

A 2011 WHO report on mHealth states: “The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks.” If we intend to
improve access to cancer control strategies known to be effective such as HPV and Hepatitis B vaccines, and cervical cancer screening, into our global mission to fight cancer in low and middle income countries then the use of mHealth will certainly form part of the tools to accomplish those goals.

Most patients in sub-Saharan Africa walk away from the clinic visit with a cell phone in hand, but lack access to resources about treatment, work-related issues, and transportation to receive the treatments. If they are fortunate enough to have access to treatment, they may have no way to communicate problems or questions as health facilities could be miles away by foot from where they live. Mobile technologies could help bridge the gap for patient support services. As a global health community, we should support adequate resources for more research and development of effective mobile strategies to urgently address cancer and other other non communicable diseases, the cause of 63% of global deaths.

There are few global foundations underwriting programs to support the understanding and development of mHealth in cancer interventions. If foundations, governments and private individuals were made aware of the
potential impact that mobile based Cancer applications could have on their dollars already invested in health services there is little doubt that they would get behind the deployment of such technology.

Medic Mobile is partnering with the University of Edinburgh on the creation of a series of courses focused on mHealth and User Centered Design in low resource settings.


Jay Evans, Regional Director , Asia for Medic Mobile
Jay Evans TH





Twitter: @jaymedicmobile