February 1, 2012

The following is a full transcript of FedCentral’s interview with Dr. Mwendwa Mwenesi, mHealth Coordinator, Tanzania Ministry of Health and Social Welfare and Dr. Michael Cowan, Director, Deloitte Consulting LLP conducted by Jane Norris on February 1, 2012. To listen to the full interview go to http://www.deloitte.com/us/fedcentral.

Jane Norris
Welcome to FedCentral brought to you by Deloitte, a program where executives and federal government leaders talk about the issues and initiatives that are making a real impact on the business of government today, to help government help America.

Today we’re talking about the use of mobile and wireless technologies to support health objectives. It’s sometimes called mHealth, and it has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change, and these include rapid advances in mobile technologies and applications and new opportunities for the integration of mobile health into existing eHealth services and the continued growth in coverage in mobile cellular networks. There are now over 5 billion wireless subscribers, and commercial wireless signals cover over 85% of the world’s population. That’s quite a reach, so today we’ll discuss how the world is using mHealth to expand access, improve quality, and decrease costs in healthcare.

So we welcome two experts in the field. We welcome Dr. Mwendwa Mwenesi, mHealth Coordinator from Tanzania’s Ministry of Health and Social Welfare; and Dr. Michael Cowan, Director, Deloitte Consulting, LLP who join us today. Let me give you a little background.

Dr. Mwenesi is the national mHealth coordinator at the Tanzania Ministry of Health and Social Welfare and an internationally recognized leader in the area of mHealth. A medical doctor by profession, Dr. Mwendwa worked to scale up and improve the healthcare profession and the impact of existing mHealth initiatives. In addition, she’s currently leading the development of the world’s first national-level mHealth strategy, which she recently presented at an mHealth summit in Washington DC. Before joining the ministry, Dr. Mwendwa was in charge of the HIV care and treatment clinic at Tanzania’s National Hospital. Welcome and thanks for joining us.

Dr. Mwendwa Mwenesi
Thank you very much.

Jane Norris
Dr. Cowan is a director in Deloitte Consulting’s Federal Health practice. He’s responsible for clinical leadership in healthcare, social services, and federal health consulting. Formally Dr. Cowan spent 33 years in the US Navy, and he was selected as the 34th naval Surgeon General chief bureau of medicine and surgery. Dr. Cowan, nice to see you.

Dr. Michael Cowan
Thank you, Jane. It’s a pleasure to be here.

Jane Norris
So let’s start with mobile health or mHealth. What is it, Dr. Cowan? Can you explain what this is about?

Dr. Michael Cowan
I think so. There are many complicated definitions and explanations but basically, it’s using communications to deliver healthcare services. If you talk to your doctor on a telephone or if you receive instructions over an email, that’s mHealth. That’s reaching out beyond the doctor’s office, beyond the face-to-face encounter to provide services.

Jane Norris
So how is that overlapping into the work that you’re doing in Tanzania?

Dr. Michael Cowan
The work that Deloitte is doing in Tanzania has been to reach out to a remote population. You know, one of the problems in medicine is the tyranny of geography. It can be so hard to get into see a doctor that people don’t or can’t, and we reached out and partnered with the Ministry of Health and NGO and others to deliver healthcare services in Tameka, which is a fairly remote region of Tanzania. The project has just ended and we are in the process of evaluating the results but it’s very clear that we were able to provide many services virtually and continue to provide those services that people would simply not have gotten had they had to go to the doctor’s office.

Jane Norris
And Dr. Mwendwa, tell us a little bit about the program and how it’s working in Tanzania?

Dr. Mwendwa Mwenesi
Okay. Thank you very much. Actually in Tanzania, we have several programs. As Dr. Cowan was saying, we have those that are related to reproductive and child health, and at the Ministry of Health and Social Welfare, we implementing four programs, one of which is on the reproductive and child health, and it’s actually dealing with educating and creating awareness to pregnant women, especially on the importance of attending the clinic and making sure that they make all the visits that they are supposed to make during their pregnancy and also educating them and creating awareness on how they should take care of their newborns and they put us also over the post natural care.

And also we have another one which is dealing with Millennium Development Goals (MDG) reporting. That is reporting of the MDG indicators; the maternal mortality rates, the child mortality rates, the newborn mortality rate from the health facilities, and also we have another one which is involving the reporting of the disease of outbreaks; that is Integrated Disease Surveillance and Response (IDSR) and also we are now working with other non-government organization to implement the project on how can we track drugs talks in the health facilities.

Jane Norris
So Dr. Cowan, given those objectives, how is mhealth being merged together and used?

Dr. Michael Cowan
Each of these projects has its own merits, and one of the values of mHealth is that a health system can solve a specific problem and then using that same infrastructure go solve another problem. So mHealth is a tool that allows outreach and contact between patients and providers. Unlike many systems like the electronic health record for a large population where everybody sort of has to do it at once, mHealth is very incremental. So innovations come one at a time, but because we’re using the same basic architecture, the same basic tools, the cell phone, the Smartphone, and some cases email, these incremental changes can add up to an entirely new system.

Jane Norris
And Dr. Mwendwa, do your healthcare providers have access to cell phones? Do they have the coverage they need to use those tools in order to improve healthcare in Tanzania?

Dr. Mwendwa Mwenesi
Oh, thank you very much. Actually in Tanzania, that’s one of the areas that are very successful. Most of the healthcare is mobile because they have cell phones and the good thing is that telecommunication and network coverage, especially mobile phone is very good in the country. You can find that even in most remote areas, there is network coverage. So most of the healthcare is mobile because they have cell phones.

Jane Norris
As you start to report back communicable diseases to track women who are pregnant to make sure that they’re checking in, are there other applications that you see using mobile technology that will drive healthcare in Tanzania even further into the use of mobile technologies and therefore benefit a wider population?

Dr. Mwendwa Mwenesi
Yes, definitely because the use of mobile phones in reproductive and child health areas is very important because you can find there are some healthy facilities which are very remote, and the availability of mobile phone helps the healthcare workers to phone, for example, the district hospital to call for an ambulance, for example. And this helps a lot because sometimes you’ll find out that many women would have died because there was no way of communicating because in Tanzania the landline communication is not reliable. But by using mobile phones, it has helped a lot, especially in reducing maternal mortality rates.

Dr. Michael Cowan
And there are two ways of looking at the advantages of mHealth. The first is that it allows the health system to reach out to patients who otherwise would not receive services or would be under-served because of geography or immobility or unavailability of health services where they are. So there’s a quality of care aspect.

There’s also a cost aspect. In America, for example, about half of the total cost of healthcare, which is, as we all know, spiraling out of control, is for primary care, and many advocates of mHealth will say that half of primary care or more, but at least half of the episodes of primary care that most people receive could be done virtually – that is, could be done with mHealth. So the number of expensive doctor’s visits that are required to maintain one’s health goes down with mHealth and the ability to reach services out to those patients at the same time and provide a better range of services is increased.

All that said, not everyone supports mHealth. We have a model in the United States – frankly throughout the world – where healthcare is delivered in the office, face-to-face, one-on-one between a doctor and a patient, but we now know that properly administered and properly delivered that very good healthcare can be delivered virtually.
Jane Norris
Is that your experience, too, Dr. Mwendwa?

Dr. Mwendwa Mwenesi
Yes, I think the experience is almost the same but you know, in developing countries, you know that technology we are still a little bit back. So we are still working. For example, the Minister of Health will have a telemedicine unit whereby we are trained to see how we can go into the clinic. For example, a doctor in a dispensary in a village can communicate with doctors at the peripheral hospital in case the doctor has a patient of whom he doesn’t know, maybe he is sort of stuck with the diagnosis. Then he can phone the doctors at the peripheral hospital and they can help him in making the diagnosis by guiding the treatment of that patient.

Jane Norris
So it sounds like this is already had good success, right? Are you optimistic that there will be more programs down the road that could benefit from mobile health technologies?

Dr. Michael Cowan
I certainly am. The technologies – almost all of the technologies that are needed for – at least for primary care already exist under very ubiquitous. We don’t have to gamble on some new technology or some expensive technology to become affordable, and we’ve seen the results both in Tanzania, other places around the world, and we’re beginning to see movement within the United States. So yes, I’m very enthusiastic and positive.

Jane Norris
Dr. Mwendwa?

Dr. Mwendwa Mwenesi
Yes, definitely, there is a great potential with the technology that we are having now, especially the use of mobile phones because as I explained before in the geographical nature of the country -the network coverage that we’re having with the phones, it helps accessibility and it’s also cost-effective, especially to healthcare workers and to patients.

Jane Norris
So what’s the ratio of healthcare workers to patients in Tanzania? Do you know?

Dr. Mwendwa Mwenesi
Of course I’m not very sure now what the ratio is because we have so many universities in the country now. I think there are more than five universities, so we have, like, so many doctors being produced. So I cannot give the exact number, but I remember it was like 1 to 10,000; one doctor to 10,000 patients. But now I’m not very sure because we have some doctors that are being produced by the universities.

Jane Norris
And what’s the doctor to patient ratio in the United States, Dr. Cowan?

Dr. Michael Cowan
To be honest Jane, I have no idea. I do know that qualitatively speaking, we’re projecting insufficiency of primary care providers five, ten years into the future, and frankly one of the answers to that is not to produce more primary care providers but leverage them better and mHealth is a way to do that.

Jane Norris
I’m telling you, it’s very interesting. All right, we’ll be back with more on this in just a moment. We’re talking today to Dr. Mwendwa Eunice Mwenesi. She’s the mHealth Coordinator for Tanzania’s Ministry of Health and Social Welfare and Dr. Michael Cowan, a Director in Deloitte Consulting LLP’s health practice, Federal health practice, and you’re listening to FedCentral on Federal News Radio 1500 AM. I’m Jane Norris.

You’re listening to FedCentral brought to you by Deloitte, and today we’re talking about mobile health technologies and how they are improving healthcare worldwide or have the potential to do that at any rate, and my guests today here on Federal News Radio – we welcome Dr. Mwendwa Eunice Mwenesi. She’s the mHealth Coordinator, Tanzania Ministry of Health and Social Welfare and Dr. Michael Cowan, a Director at Deloitte Consulting in the Federal health practice.

So I’d like to ask both of you and start with Dr. Mwendwa. What’s the potential for this kind of mobile health technology for Tanzania and even for the world?

Dr. Mwendwa Mwenesi
There’s a great potential of mobile health in Tanzania and in developing countries because the use of mobile phones and electronics also has helped a lot to reduce the costs—especially in the communication between doctors and the communication between health facilities and peripheral hospitals. I think the most important thing is the devices and if the mobile phones and all the electronic equipment that are used can be affordable to the government because we are depending on external resources. But what we can expect in the future, most of these programs, because they are having a great impact on healthcare, they can be absorbed into the government and therefore we are hoping that we’re going to have devices that are cost-effective and can be used by the healthcare workers, even those with very low levels of education, especially at the remote facilities.

Jane Norris
Well because, you know, Smartphone’s, you can Google information and it can bring it up and, it might be, you know, an education tool for the healthcare provider who may not be a doctor like you to give advice or information to the patient that may be sitting in front of them. Is that the idea?

Dr. Mwendwa Mwenesi
Yes, exactly, but you know, the problem is also the accessibility of networks, especially if you talk about internet. Yeah? That is possible in big cities and the places where the least accessibility of network but in most of the area, especially those outside the cities, it’s very difficult to – to get network and therefore sometimes to Googling and sort of accessing information from the internet is very difficult, but those who are within the cities, that is definitely very good.

Jane Norris
So Dr. Cowan, you must have a different view. Obviously not a developing country, but does a developed country like the United States still have potential for mobile health expansion?

Dr. Michael Cowan
Oh, of course. Let me back up just a little bit and put it in context. The practice of medicine has been relatively passive patients and sort of know-all clinicians. Now that’s an exaggeration, but frankly people couldn’t get to medical libraries; they couldn’t learn about their health. We’re seeing a real revolution at many levels right now in the United States. Number one, we are building a nationwide health information network. It’ll consist of regional health information organizations that will eventually make medical data ubiquitous and easily transferred around the country.

The second part of this revolution is the availability of information on the internet. You can learn a lot about any medical condition on the internet with good, vetted information. That’s become a very good source and layman can actually know. All of that is combined with the fact that we really in medicine, have come to the realization that having passive patients who are kind of in the dark about their own conditions is not the right way to do it. We want patients to know, well, who they are and what they have. We want them to be partners in their healthcare, and mHealth is sort of the last step of this network that will all come together to empower patients, actually empower clinicians and their teams at the same time, and to what I think will be a quite new and improved model for how we deliver healthcare as well as population health service.

Jane Norris
Is cost driving that, as well?

Dr. Michael Cowan
Partly so, but it is a good, clinical principle that a patient, as a knowledgeable partner in their healthcare with their medical team is going to have a better outcome. Many of the diseases that Americans suffer from are what we call self-inflicted diseases. They are diseases of poor exercise, poor eating, and the more patients understand and become engaged and responsible for their health, the better off we all are.

Jane Norris
And Dr. Mwendwa, what are the challenges that stand in the way of this expanding?

Dr. Mwendwa Mwenesi
I think the biggest challenge is the cost. That is one, and also the level of knowledge of the healthcare workers who are using mobile phones and we expect them to use the internet services. We know that the level of education, especially those healthcare workers who are working in the dispensaries and health centers is very low and therefore we need a lot of investment in training. Also making sure that we provide mobile phones and devices that are easy to use, not complicated advanced mobile phones and I think we have programs that have experienced that. Even a simple mobile phone can be used, for example, in data tracking or the community health workers, a simple device can be used, which is cost-effective. So I think the first thing is the cost and because after some time, then the government has to take over some of these projects that will have an impact on health. So I think those are the challenges.

Dr. Michael Cowan
And I would add the challenge of culture. We in the medical profession have adopted a culture where it’s okay for patients to be passive and where the physician is the single point of contact for all services, and it won’t be easy for people to give these things up. Culture change takes time, but I think it’s inevitable because the value is there, and you mentioned cost. The cost value is going to be every bit as important as we look forward for the next ten or twenty years as the clinical value that this can bring.

Jane Norris
So talk to me about the way that Deloitte is working with Tanzania to make this happen. Is this a model that might help other countries to employ similar technologies?

Dr. Mwendwa Mwenesi
Yes, definitely. The Ministry of Health and Deloitte are basically in the process of developing a mHealth strategy. We are expecting this to be a guideline on how mHealth initiatives and projects in the country should be implemented, what procedures are followed, and how can we monitor and evaluate the impact of these projects in the country with so many other issues. Like issues of standards, data security, and interoperability—we expect them to be well-addressed in the strategy. So basically we are working with Deloitte to develop an initial mHealth strategy that can also be used and adapted in other developing countries.

Dr. Michael Cowan
And the greatest value that I think Deloitte brings to this is that while all the pieces for successful mHealth programs exist, bringing those pieces together in a meaningful, programmatic way so that they work well and become the new norm and make the culture change – that’s something that we do. That’s one of the sweet spots of our business, and so I think that’s one of the major things that we bring to this.

Jane Norris
And how do you think the experience Tanzania is having will translate back into the United States?

Dr. Michael Cowan
I think the same pieces are available around the world and the same problem exists in bringing them together into being a coherent system. Right now, if you think about patients with diabetes living in far remote areas, perhaps elderly and poor, don’t have cars, that’s a common problem and often being dealt with piecemeal one or two patients at a time, but we have the technology, we have the phones, we have the instant messaging services bringing together a process with an expert center that makes it easy for the clinicians and the patients to make contact is the essence of what needs to be done for mHealth, and there’s nothing magical about it. It’s just doing it.

Jane Norris
Do you think the adoption in Tanzania was actually easier because they isn’t the doctor-patient ratio that the United States or the model in place that the United States has, and is that something that can be overcome? You know, just because of the culture that Dr. Cowan talks about, do you think in the United States or in other countries will face a similar sort of resistance be – by practitioners?

Dr. Michael Cowan
Oh, I think they’re exactly the same. If you listed the 20 things that had to happen in Tanzania, they’re the same things that would have to happen here. It may be that item number three’s a little easier and item number seven’s a little harder. I think they’re exactly the same. I think this is a very universal issue.

Jane Norris
So Dr. Mwendwa, tell us about other countries that have contacted you or other places in the world where this might be expanding.

Dr. Mwendwa Mwenesi
Basically, Kenya. During the past week we had a conference at the mHealth Global Summit. I came across an mHealth coordinator from Kenya and actually she was very impressed with what is going on in Tanzania and I think she learned a lot. She was on the panel and we have agreed that we can see how we can collaborate and she can also have some lessons to learn from what Tanzania’s doing. So basically that is the contact that I’ve managed to speak to.

Jane Norris
But you’re planning to do outreach on this to try to get others involved or let them know at least the benefits of the work that you’ve done.

Dr. Mwendwa Mwenesi
Definitely.

Jane Norris
And so that will pay in dividends, I’m sure, in healthcare in the long run. I may be talking to two of the pioneers of mobile health technologies in the world.

Dr. Michael Cowan
That’s possible. We just shared working on this panel at the mHealth conference, and this was the third annual mHealth conference. The first one two years ago was quite small. The second one was 2,000 people. This one was close to 4,000, so this is clearly a very rapidly developing field with a great deal of worldwide interest and is very exciting.

Jane Norris
It is very exciting.

Dr. Mwendwa Mwenesi
Yes, and also the opportunity that we got during the summit that occurred last week as Dr. Cowan was saying, of having a panel to express interest in what we are doing in Tanzania. Actually we have received a lot of compliments from different countries that what you’re doing is very important and actually lots of the countries are trying to follow the path that you’re taking. Yeah, so, it was definitely a very good compliment from most of the partners that we met.

Jane Norris
Well, I thank you both for sharing your insights today. It’s fascinating talking to you about this, and I hope I get a chance to do it again. We’ve been talking to Dr. Mwendwa Eunice Mwenesi. She’s the mHealth Coordinator for Tanzania’s Ministry of Health and Social Welfare and Dr. Michael Cowan, Director, Deloitte Consulting LLP about mobile health and how it is changing the world.

Thanks very much for joining us. You’ve been listening to FedCentral on Federal News Radio 1500 AM. I’m Jane Norris.

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