Mobile health unproven but not without potential in South Africa

JOHANNESBURG, South Africa – Towering over downtown Johannesburg is a huge cylindrical skyscraper, a red banner at its crown with one word printed in white, ‘Vodacom’—the name of the largest telecommunications company in South Africa. The tower reminds onlookers of the importance the telecommunications sector plays in this nation of 53 million citizens, where there are more active mobile SIM cards then there are people.

The dominance of mobile technology is hard to miss in South Africa. The country has one of the highest mobile subscriber penetrations in sub-Saharan Africa. Advertisements for companies like Vodacom litter the airwaves and online. In a city like Johannesburg, there are few residents who aren’t connected to the rest of the world through a cellphone. 

For South Africans, having a cellphone means more than just socializing. It also means having a portal to access information and connect with health services.

Young Africa Live, a mobile platform designed to facilitate discussions among young South Africans on sex, relationships and HIV/AIDS, is just one example of a program geared to improving health outcomes using mobile technology in the country. The project has over 1.8 million users. 

Young Africa Live is part of a broader global effort called ‘mHealth,’ which uses cell phones for projects ranging from monitoring stock supplies of medicine in rural areas to sending test results to health workers from labs. According to GSMA mHealth Tracker, a project launched by a London-based global telecommunications industry trade group, there are nearly 100 mHealth projects in South Africa—the country has one of the highest concentrations of mHealth projects in the world.

The key to understanding the popularity of these programs in South Africa, and elsewhere around the world in the health sector, is the changing social dynamics behind what is making them possible, said Ananya Raihan, executive director of Dnet, a non-profit organization in Bangladesh committed to tackling poverty through technological innovations. Raihan was in Johannesburg this month for a global conference on maternal health. And while his work in the mHealth field is in Bangladesh, his perspective holds true for South Africa as well. 

In Bangladesh, he said, the promise and spread of technology reach even the most remote villages, where people transport car batteries and use solar power to charge their phones. A smartphone can cost $65 USD, he said, which can be a whole months salary in Bangladesh. But people are willing to prioritize that purchase over other life necessities such as having food three times per day, he said. In the capital city, news reports show that sales of smartphones have reached around 40 percent in mobile phone shops.

Raihan said this kind of tradeoff happens in many countries across the global south, including South Africa. For this reason, the public health community has been aggressive in its effort to leverage mobile technology for health. 

But just because people have phones and are connected to mHealth projects, it does not necessarily mean the health projects are effective. While reporting in Johannesburg, I’ve discovered that one of the primary issues facing the mHealth community is proving that the projects actually work and bringing them to scale. 

Many mHealth projects boast of how many people have signed up for the program, but fall short in evidence on whether those people behind those numbers have had their health improve. One of the problems is that gathering evidence often takes long periods of time, according to Smisha Agarwal, an associate at Johns Hopkins Bloomberg School of Public Health. In the case of mHealth, sometimes the technology advances at a quicker pace than researchers are able to study them. According to some people I spoke with, the projects are also not well-integrated into the broader health efforts across the country. 

“There are so many initiatives and no coordination between them,” said Thembeka Gwagwa, general secretary of the Democratic Nursing Organisation of South Africa, a national trade union. Local stakeholders, like her trade union, are often not consulted before projects are launched, she said. 

Even some of the biggest proponents of the mHealth sector agree. Patricia Mechael, executive director of the mHealth Alliance, a coalition of organizations aimed at advancing mHealth programs around the world, told me that there are thousands of mHealth projects globally, but many of these fail, never reaching a point where they are brought to scale. To Mechael, who was also in town for the maternal health conference, working in the mHealth field “like flying and building a plane at the same time.” 

“MHealth is still such a new field that when you start to engage these programs at a larger scale, and integrate them with larger health systems, it’s not always clear from the outset what is going to work, how it is going to work and why it is going to work,” she said. 

On one of my last days in the country, I spent the day with Sikhomzile Sibanda, a young mother of two who received text message support during her pregnancy and post-pregnancy through one of these mHealth projects, called MAMA. As we sat in Sibanda’s one-bedroom apartment she began reading to me some of the messages she had recently received. 

“There is this one. It says: ‘Think about what to take with you when you give birth. You may need things like sanitary pads, pajamas, toiletries and clothes for the baby,’” she told me. “I like that one.” 

Sibanda had her child seven weeks ago, and had brought all the recommended items to the hospital. 

Gwagwa’s and Mechael’s words of caution linger in my mind. But in my two weeks of reporting here I’ve seen that mHealth, for the time being, is a way to reach mothers like Sibanda. 

After spending an entire day with her, I saw that there were just a few things she kept glued to her side: her two sons and her cell phone, which she continuously wiped out of her pocket, checking for updates from family and friends.