Mobile consulting as an option for communities with minimal healthcare access in low-resource settings

There is rapid growth in the use of mobile communications technology in low and middle income countries (LMICs), including Bangladesh, Kenya, Nigeria, Pakistan and Tanzania. In these countries, where our study will take place, over 70% of people have mobile phone subscriptions. Mobile technology brings possibilities for improving access to quality health care and strengthening health systems, particularly in communities where people have difficulty finding quality services because they do not exist, they are not available when needed, they are too far away or they cannot afford the service. Mobile consulting ("mConsulting") is when someone with a health need consults a healthcare provider using mobile communication technology, e.g. consulting with a community health worker, pharmacist, nurse or doctor using a mobile phone. The enabling potential of mConsulting is important globally and locally, given the pressing need for creative, innovative ways to make quality health care available to everyone who needs it, regardless of who they are, where they come from or their ability to pay. But not enough is known about what mConsulting services are already available, who uses them and why in such contexts. There are well-known corporate providers in each country but with the availability of mobile money transfer, individuals and small organisations may also be providing mConsulting. In our study, we want to explore how mConsulting is used and provided and its perceived impact in urban slums, remote rural areas and refugee camps in five LMICs in Africa and Asia so that we can generate ideas for health policy and build an evidence base for future research. Working with stakeholders, we aim to propose an intervention in mConsulting to improve health care access and strengthen health systems for future implementation and evaluation.

In this Foundation Grant project, we will interview experts and review policies about mConsulting. We will search the internet, social media and use word-of-mouth to identify available services in the communities where we are working. We will hold community workshops and mini-interviews to ask community leaders, local healthcare workers, pharmacists, shop and drug vendors, traditional healers and other community members about mConsulting services - what is available, used and why? We will explore their perceptions of its impact on users and the wider health system and hear their ideas about mConsulting as an option to strengthen access to health care. We will interview mConsulting providers about their purpose, history, size and coverage, operating systems and costs. Towards the end of the study, in each site, we will bring together stakeholders from within the community, public sector, mConsulting services and non-governmental organisations for a consensus-building workshop to discuss our findings, develop ideas for health policy and for future research.

Out of this Foundation Grant, we will achieve an understanding of the opportunities for and dilemmas created by mConsulting in communities with minimal healthcare in low-resource settings. We will develop a proposal to refine, implement and evaluate a mConsulting intervention in collaboration with existing providers and develop case studies on mConsulting to inform teaching in all participating institutions. Our work will be guided by project advisory groups in each site, made up of community representatives, on-the-ground healthcare providers, and mConsulting providers. They will ensure our work is locally relevant and responsive. Members of our interdisciplinary team are also part of the NIHR Global Health Research Unit on Improving Health in Slums and the Digital Health for Healthworkers project from which we will draw expertise, engagements and data to complement this study. In each site, we have included junior co-applicants to work alongside seniors, as part of building research capacity in health systems within LMIC contexts.

Extensive availability of mobile communications in low and middle income countries (LMICs) presents an opportunity to strengthen health systems. Mobile consulting (mConsulting) enables healthcare consultations between providers and care-seekers using mobile technology. mConsulting has potential to fill gaps in provision of quality healthcare for low-resource communities.

Despite extensive research on mobile health, recent reviews indicate little empirical evidence about mConsulting service availability, use and impact on the user and wider health system, particularly in low-resource communities.

In this Foundation Grant project, we will explore provision, use and perceived impact of mConsulting in urban slums, remote rural areas and refugee camps in Bangladesh, Kenya, Nigeria, Pakistan and Tanzania. Data will be collected through cyber-mapping, document review and, participatory community workshops and interviews with community members, mConsulting providers and other decision-makers. Analysis will result in conceptual understanding of the opportunities for and dilemmas created by mConsulting in communities with minimal healthcare access.

In each site, a consensus-building workshop with key stakeholders will result in ideas for policy and a co-designed mConsulting intervention for future implementation (in collaboration with existing providers) and evaluation. We will develop case studies to inform our teaching in all participating institutions. Project advisory groups comprising community representatives, on-the-ground healthcare providers, and mConsulting providers will guide our work in each site. We will draw on existing collaborations, expertise and data from the NIHR Global Health Research Unit on Improving Health in Slums and the Digital Health for Healthworkers project to complement this study. Our junior co-applicants will work alongside seniors, as part of our commitment to building capacity in health systems research in LMICs.

National and international policy makers will gain an understanding of the role of mConsulting in the health economy of low-resource communities and how it might be best harnessed (or not) for the benefit of low-resource communities. This will inform policy in fields such as health provider regulation and training of health workers, regulation of healthcare provider organisations, healthcare finance including health insurance systems, telecommunications.

Local policy makers and planners responsible for improving access to healthcare for low-resource communities will benefit from insights into the role of mConsulting and its impact on local health economies. This may enable them to undertake local initiatives that increase healthcare access.

mConsulting providers who are considering or already filling gaps in health service provision in low resource communities will benefit from understanding how they are perceived and the key access issues and priorities for (potential) service users.

Community members/groups will benefit from understanding the penetration of mConsulting in their community, how it is used and, perceived benefits and disbenefits. This will arm them with information to help them to work with mConsulting providers and local healthcare authorities to provide services that are accessible and meet their needs.

Community members, service providers and other stakeholders will gain experience of participatory approaches to the development of ideas for policy and the development of research. This will result in research of relevance to the health systems in their low-resource contexts. Individuals may gain in skills and confidence to contribute to debate and planning through this experience.

Research team members will enhance their research knowledge and skills through participation in the project. They will build on the study results to design further research to be submitted to the MRC Health Systems Research Initiative Call 6.

Likely time scales of impact will differ according to beneficiary:

Researchers who are participating in the project will benefit from the outset through working on the project.

Local and national decision makers (policy makers, mConsulting providers, health service providers, community leaders) will benefit as the project proceeds through their involvement in stakeholder workshops and particularly when the findings are available.

Global decision makers are likely to benefit when the findings become widely available through briefing papers and the journal article.

Community members who live in the study site and engage with the project will benefit during the project. More generally, individuals who live in the study sites may benefit from the use of study results by community representatives to engage with mConsulting providers and local authorities about provision of accessible healthcare services.