Informal mobile-health: Potential and pitfalls for community health workers

A study with community health workers in Ghana, Ethiopia and Malawi has found most are using their own mobile phones to do their jobs, but at considerable personal cost. Could this pave the way for a new approach to m-health? 

What is the research about? 

Researchers surveyed and interviewed around 2,200 community-health workers in Ghana, Ethiopia and Malawi to find out if and how they use their own mobiles to carry out their work.  

Why is this research important? 

For the past decade, a lot of money and effort has gone into mobile health (sometimes called ‘m-health’ or e-health) schemes to improve health services, particularly in rural areas where there are fewer facilities. But an over-reliance on donors has resulted in pilot projects that don’t reach many people and stop after a few years. So, this study examines what health workers are already doing with their own phones and what the advantages and disadvantages of this are. 

Understanding this might provide ways to improve health services using personal mobiles, but in ways that mean health workers do not bear the costs. 

What did they find out? 

Health workers and their clients were positive about using mobile phones for health care and said that they were essential for community health work. 73% of community health workers in Ghana, 87% in Ethiopia and 64% in Malawi said their work would be very difficult or impossible without a working phone. 

Yet only 15% were involved in formal m-health schemes run by governments or NGOs. Almost every community health worker had a personal mobile and used it in their work. Around 90% did this on a daily basis. 

Community health workers used their mobiles for work in the following ways: 

• Communication: They used voice calls, text messages and WhatsApp groups for sharing information on meetings and training, for coordinating work activities and getting advice on difficult cases.  
• Information: Some used the internet and apps to find out about health conditions and treatment. 
• Other uses: Some used cameras to document paperwork or take pictures of symptoms, calculators for dosing, stopwatches to take pulses, and torches to examine patients. 

Four advantages of using personal mobiles for health work 

1. Efficiency: Most said mobile phones made their workloads more manageable. They talked about how wasted journeys no longer happened, saving both time and money.  
2. Quality: Mobile communication had improved understanding and trust with patients. It also helped with confidentiality, as people could call in private to talk about sensitive matters. 
3. Health outcomes: 98% said their use of a personal mobile had directly improved patient health, and 85% said it had saved someone’s life as they could call for medical back-up. 
4. Patient experience: Patients also reported advantages – they could call ahead to check a health worker’s availability before travelling to see them, or check whether they needed a face-to-face meeting at all. 

Four disadvantages of using personal mobiles for health work 

1. Connectivity: It was a daily challenge to keep phones working due to poor network connectivity and unreliable electricity supplies, particularly in Ethiopia and in rural places. More than two-thirds of health workers said their phone had stopped working in the last year. This had affected patient care, and 3% said this even contributed to a patient’s death.
2. Costs: Many community health workers made sacrifices like missing meals to cover the cost of using their own phones for work (95% in Malawi, 72% in Ghana and 48% in Ethiopia).  
3. Workload: Around two-thirds got work-related calls outside working hours, often at night, particularly those in rural areas.  
4. Confidentiality: Around one-quarter kept confidential patient information on their phones. As some health workers shared their phones with other people (67% in Ghana, 41% in Malawi and 25% in Ethiopia), they were worried about confidentiality. 

What does this mean for HIV services? 

It is important to find ways to build on informal m-health practices, so that using a personal mobile is fair for the health worker and doesn’t bear negative impacts. To do this, community health workers need to be central to discussions. 

If you are working on an m-health scheme or with community health workers, it is worth considering the following:  

• Find out how your community health workers use their mobile phones for work. This will avoid duplication: for example, if there is already a WhatsApp group there may be no need to create a new one.  
• Provide support for community health workers to use their own phone rather than giving them new ones. 
• Cover the costs through direct cash transfers or by adding a small amount to salaries.
• Develop guidelines and training on phone use. For community health workers, topics should include storing confidential data and assessing online information. For patients, training should cover managing expectations about health worker availability.