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Objective: Remote or mobile consulting is being promoted to strengthen health systems, deliver universal health coverage and facilitate safe clinical communication during coronavirus disease 2019 and beyond. We explored whether mobile consulting is a viable option for communities with minimal resources in low- and middle-income countries. Methods: We reviewed evidence published since 2018 about mobile consulting in low- and middle-income countries and undertook a scoping study (pre-coronavirus disease) in two rural settings (Pakistan and Tanzania) and five urban slums (Kenya, Nigeria and Bangladesh), using policy/document review, secondary analysis of survey data (from the urban sites) and thematic analysis of interviews/workshops with community members, healthcare workers, digital/telecommunications experts, mobile consulting providers, and local and national decision-makers. Project advisory groups guided the study in each country. Results: We reviewed four empirical studies and seven reviews, analysed data from 5322 urban slum households and engaged with 424 stakeholders in rural and urban sites. Regulatory frameworks are available in each country. Mobile consulting services are operating through provider platforms (n = 5–17) and, at the community level, some direct experience of mobile consulting with healthcare workers using their own phones was reported – for emergencies, advice and care follow-up. Stakeholder willingness was high, provided challenges are addressed in technology, infrastructure, data security, confidentiality, acceptability and health system integration. Mobile consulting can reduce affordability barriers and facilitate care-seeking practices. Conclusions: There are indications of readiness for mobile consulting in communities with minimal resources. However, wider system strengthening is needed to bolster referrals, specialist services, laboratories and supply chains to fully realise the continuity of care and responsiveness that mobile consulting services offer, particularly during/beyond coronavirus disease 2019.
In theory, mConsulting can be provided from anywhere in the world. However, the pragmatics are likely to be shaped by the needs of particular populations and the regulatory, technological and health system contexts in which mConsulting takes place. 8 To gain analytical traction on the interaction of digital processes with context, we studied mConsulting in remote and spatially marginalised communities in Pakistan, Tanzania, Kenya, Nigeria and Bangladesh: five LMICs facing pervasive structural barriers to growth and development, with low-income levels, socioeconomic inequities and wide disparities in health outcomes and access to services 30 (Table 1). National policy and digital landscapes in Pakistan, Tanzania, Kenya, Nigeria and Bangladesh. DHS: Directorate of Health Service; ICT: Information and Communication Technology. In the last two decades, each country has made progress in increasing life expectancy, improving maternal and child health outcomes and reducing malnutrition. However, malnutrition remains the biggest risk factor for death and disability in all, 56 and maternal mortality rates in Nigeria, Kenya and Tanzania are substantially higher than the WHO/Sustainable Development Goal of 140 per 100,000 live births. 57 All five countries are working towards universal health coverage, 39 but face challenges of weak health systems, shortages in skilled health workers 36 and a growing burden of non-communicable disease, alongside an already-high burden of communicable disease. 56 There are differences in health system financing and service arrangements but all are pluralist, involving a complex mix of public and private sector services, spanning individual/small for-profit, commercial and not-for-profit stakeholders. International development partners are key funding stakeholders, particularly in Pakistan, Bangladesh and Tanzania, including for digital health. 58 Public sector primary care is free at the point of use in Pakistan, Kenya, Nigeria (mostly) and Bangladesh, while user fees (with some exemptions) apply in Tanzania. Out-of-pocket healthcare expenditure is high in Bangladesh (74%), Nigeria (77%) and Pakistan (60%), lower in Tanzania (24%) and Kenya (24%). 40 In Kenya, almost 7% of the population is pushed into poverty annually, as a result of direct payments for healthcare and associated transport costs. 59 Health insurance is negligible in Bangladesh and Nigeria, while various social and voluntary health insurance schemes have some traction in Tanzania 60 and Kenya, 61 including in rural areas. A micro health insurance system to support ‘under-privileged citizens’ to access needed healthcare, has recently been introduced in Pakistan’s Khyber Pakhtunkhwa Province. 62 Additional country contrasts include infrastructure and access to electricity (e.g. in Tanzania, access is 32.8% national/16.9% rural 41 compared to 93% national/89% rural in Pakistan 34 ) and diverse sociopolitical history and culture. In keeping with global trends, 45 mobile phone subscriptions are high in all five countries, ranging from 75% of the population in Tanzania and Pakistan, to almost 100% in Kenya and Bangladesh (Table 1). Internet penetration is lower in all – between 23% in Tanzania and just over 40% in Nigeria, Bangladesh and Kenya. 45 In each country, there are gender and location differences in mobile phone ownership and internet usage, indicating less independent access for women and rural residents. For example, 93% men and only 39% women own mobile phones in Pakistan. 34 In urban Tanzania, 82% men and 62% women own mobile phones compared to 74% men and 40% women in rural areas. 35 In all five countries, technology-enabled healthcare delivery is embedded in national policies, including on information and communication technology (ICT) (Nigeria 52 ) and digital futures (Pakistan, 46 Tanzania49,58 and Bangladesh54,63). Specific electronic/eHealth and mobile/mHealth policies are in place in Tanzania, 47 Kenya50,51 and Bangladesh 53 (Table 1). Kenya has developed standards and guidelines for mHealth systems (2017), 50 and in Nigeria, there are efforts to incorporate and regulate ICT through existing health policies, including those that govern face-to-face consultation (e.g. professionalism and confidentiality). Regionally, as members of the East African Community, Kenya and Tanzania are guided by the Health Sector Investment Priority Framework (2018–2028), which promotes investment in digital health technology. 55 Within the five countries, we undertook a scoping study of mConsulting: in remote rural areas in Pakistan and Tanzania, and urban slums in Bangladesh, Kenya and Nigeria. These sites were purposively selected as low-resource communities with minimal access to healthcare services, located in rural–urban contrast. The five urban sites form part of the National Institute of Health Research (NIHR) Global Health Research Unit on Improving Health in Slums study. 64 Their inclusion gave us access to secondary data from household and adult surveys (conducted in 2018–2019), which asked questions on mobile phone access, internet access and digital health-seeking behaviour.65,66 Table 2 provides a description of each site, including contextualising information for the urban sites from the NIHR Global Health Research Unit on Improving Health in Slums.66,67 Study sites: low-resource communities with minimal access to healthcare. CBD: Central Business District; NGO: non-governmental organisation. Set within the seven study sites described in Table 2, our scoping study involved: (1) policy and document review; (2) secondary quantitative analysis of data from household and adult surveys, undertaken by the NIHR Global Health Research Unit on Improving Health in Slums 64 in the five urban study sites; followed by (3) qualitative interviews and workshops with key stakeholders in all study sites (urban slums and remote rural areas). For the urban sites, we were able to mix our methods in explanatory design, 73 first identifying the extent of mConsulting through the surveys and then exploring with stakeholders how representative the survey findings are. 74 For all study sites, we designed our qualitative engagements to include multiple perspectives from within mConsulting systems; (4) our approach was guided by project advisory groups (PAGs), comprising community representatives, local health workers and mConsulting providers, in each country; (5) in our interpretation, we integrated our findings both within this scoping study and with our review of current evidence, in an effort to capture a wider ‘picture of a system’ – a complex, adaptive mConsulting system – informed by multiple perspectives. 74 Ethical clearance and approvals were obtained from all relevant bodies in each partner institution and study site. All participants provided informed consent. Between 2018 and 2019, household and adult surveys were conducted by the unit in the five urban slum sites, using a geospatially referenced study design and survey methods that have been described elsewhere.65,66 Administered by fieldworkers trained in the ethics and techniques of survey-based data collection, in the language preferred by the respondent, household surveys were used to collect demographic and socioeconomic data, while individual surveys (administered in each participating household to a randomly selected household resident aged over 18 years), collected health-related information. For our study, we used data collected about household access to mobile phones, internet and airtime; and adult digital health-seeking behaviour (see Appendix 2). We purposefully selected participants for their role in the mConsulting system: policy-makers and digital health experts, telecommunication providers, mConsulting providers, health workers and community members. We identified mConsulting service providers and users through internet searches, our organisational networks, site contacts and word-of-mouth. Health care workers were drawn from cadres active in local care provision in public and private sector employment, including clinical officers, doctors, nurses, pharmacists and community health workers. We selected residents for the diversity of age, gender and religion, choosing different times of the day across the working week/weekends, and different parts of each site to reach people ‘at home’. In the urban study sites, we used the findings from our secondary analysis of the surveys to contact trace community members (who had used their mobile phones to receive health information/advice and who had agreed to participate in follow-on studies). These participants were invited to participate in mini-interviews and community workshops. Health workers and decision-makers were identified through previous engagements, site contacts and, in the urban sites, from the previous mapping of healthcare facilities undertaken as part of the NIHR Global Health Research Unit on Improving Health in Slums. 64 We reviewed policies about mConsulting and interviewed policy and digital experts. We held community workshops and interviews to ask community leaders, local healthcare workers, pharmacists, shop and drug vendors, and other community members about mConsulting services, exploring what is available, used and why? We interviewed mConsulting providers about their purpose, history, size and coverage, operating systems and costs. With all participants, we explored their perceptions of the impact of mConsulting on users and the health system and sought their ideas about whether mConsulting is an option to strengthen access to healthcare. Towards the end of the study, we brought together community members, health workers, mConsulting service providers and decision-makers for consensus-building workshops to discuss our findings and develop ideas for health policy and for future research. Interviews and workshops were carried out at venues convenient and accessible to participants, in their preferred language. They were conducted by researchers trained in the methods and ethics of qualitative engagements, including taking of consent. Semi-structured interview guides were piloted and refined following feedback. Regular debriefing sessions were held with researchers to identify issues for further exploration and to manage any unanticipated problems. For community level mini-interviews, informed verbal consent was sought from participants and noted in field notes. Field notes included the participants’ role in the community and any mConsulting services mentioned. These were typed up and expanded by the researcher in English, as soon as possible, after each interview. For the semi-structured interviews with healthcare providers, key informants and policy/decision-makers, informed written consent was sought, including to audio-record the interview. All identifiers were removed from transcripts and quality checked by research team members. Data were encrypted and stored on a secure server at the University of Warwick for analysis. Researchers in each country team (MA, NC and PK) tabulated data from the relevant sections of the household and adult surveys (mobile phone, internet, airtime access and use of technology for healthcare seeking) (Appendix 2). For each site, the total sample for that site was tabulated against the total number of respondents for that particular question per site. Interviews and field notes were transcribed and translated into English where necessary. Transcripts were reviewed by team members (BC, MA, PK and RA) against audio recordings to ensure accuracy of translations and consistency. These were analysed thematically, 75 guided by our understanding of access as a dynamic interchange between mConsulting users and providers across a digital communication platform.10,11 Researchers in each country team (BC, OF, MA, PB, PK, NR and NC) coded the transcripts along key access dimensions of acceptability, availability and affordability, while allowing for emergent themes. In consultation with the wider team, codes were reviewed, then developed into initial themes and refined through further coding. Themes were compared across countries and according to participant type. At the beginning of our community-based research, we consulted with community leaders at each site. Community members are part of PAGs in each country team. The PAGs have advised us on our research approach, process and plans, including dissemination of results. Community members were recruited to fieldwork teams in Nigeria, Kenya and Bangladesh. Members of the community, including people with healthcare needs, were included as study participants.
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