The promise and pitfalls of global mHealth ========================================== * Miriam Shuchman More than three-quarters of the world’s nearly 7 billion mobile-cellular subscribers are in developing countries, a statistic that drives excitement around mobile-health technology or mHealth, despite a paucity of evidence. Alain Labrique, who chairs the World Health Organization’s Review Group on mHealth says he imagines a future where a mobile phone is a basic tool for community health workers. And the promise of mHealth goes beyond phones to mobile platforms where health workers access clinical algorithms or maintain electronic records and to handheld mobile labs. But critics say the technology is overhyped, and a 2013 series of papers in *PLOS Medicine* alleges the field is plagued by a lack of rigorous evaluation and a failure to use interoperable systems. Alexander Tsai of the Center for Global Health at the Massachusetts General Hospital and coauthor of one critique, stated in an email that “mHealth-type interventions have great appeal” in the developing world due to resource constraints. “But I still think that the enthusiasm is outpacing their demonstrated utility.” Over the past six or seven years, some strategies using cell phones “have stood the test of time,” says Labrique, leading to current efforts to scale up “the most promising solutions.” But the field of mobile technologies is lacking in high-quality evidence. Its foothold on Canada’s foreign aid owes less to hard data and more to the keen interest of nongovernmental organizations and governments, including our own. Canada ranks in the top four funders of the technology along with Norway, the United States and the Gates Foundation, according to Labrique. The Harper government has championed mobile systems for birth registration, so a chunk of the $3.5 billion the government pledged during the recent Summit on Maternal, Newborn and Child Health is expected to go to mHealth. This seems even more likely after a recently announced revision to Canada’s international aid scheme, with more money going to 25 priority countries and an increased emphasis on accountability. The latter is an area where mHealth is likely to have a role, as mobile data services replace paper-and-pencil for reporting health indicators, but it’s unclear how much money will become available. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/186/15/1134/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/186/15/1134/F1) Community health workers in Bangladesh learn to use an app that will help them conduct breast exams in the privacy of women’s homes. Image courtesy of Ophira Ginsburg Amy Mills, a spokesperson for the Department of Foreign Affairs, Trade and Development, stated in an email to *CMAJ* that the government is developing its 2015–2020 aid commitment and “the proposed accountability mechanisms or what technologies will be used are still under assessment,” but added that the government supports “game-changing solutions.” Mobile health was “definitely the buzzword” in post-summit Ottawa after Ban Ki-moon, secretary general of the United Nations, emphasized it in his keynote, said World Vision Canada’s Melani O’Leary. With close to $8 million from the government and private Canadian donors invested in mHealth globally, World Vision heard from “a lot of people looking to do mHealth for various things, rightly or wrongly,” she said. Given the government’s interest and the recent critiques, *CMAJ* scanned a few of the projects Canada is supporting. Stigma-busting video: More than half of all deaths from breast cancer occur in low- and middle-income countries, but at a breast clinic in rural Bangladesh, oncologist Ophira Ginsburg of the University of Toronto discovered that stigma and fear are huge obstacles to care. Women from rural villages came to the clinic only when they had advanced cancer, and even then, often didn’t return. Working with a Bangladeshi tech company, Ginsburg developed an app to guide female health workers in examining women in their homes, scheduling clinic appointments and showing a video of interviews with women who received care, the crucial piece, they told Ginsburg. Use of the app led to more women coming for care, according to a Jan. 6, 2014 article in *The Oncologist*. But the project is now at a standstill, a common situation in mHealth that Labrique refers to as “‘pilotitis’ — the proliferation of pilot projects that unfortunately don’t scale.” Texting to improve adherence: Richard Lester, director of the University of British Columbia’s Neglected Global Diseases Initiative, found that AIDS patients in Kenya take antiretroviral medication more regularly and reach higher rates of viral suppression if clinic staff text “Mambo?” (“How are you?”) in Kiswahili. The “WelTel” trial was published in *The Lancet* in 2010, and this year Lester received $2 million to scale up across rural Kenya. Labs on chips: The idea of a lab-on-a-chip — automated chemical analysis using microfluidics to measure a droplet of spit or a pinprick of blood in a space smaller than 1 square millimeter — was first described in 1990, but development has proven difficult. The potential for low-income countries is enormous says James Fraser of ChipCare, a University of Toronto engineering spin-off working on a hand-held blood analyzer that health workers could use to do CD4 counts required for ongoing AIDS treatment. Like other global health innovators, Chip-Care engineers are Grand Challenges Canada beneficiaries, raising over $2 million last year from Grand Challenges and other investors, but the road from the lab to the village could still be long.