Josh Nesbit is creating connected and coordinated rural healthcare systems, transforming the efficacy of decentralized rural public health by reinventing the role of the locally-based community health worker thanks to smart and simple mobile phone-based solutions.
The New Idea
While doing research on children’s access to HIV/AIDS medicine in rural Malawi, Josh—at the time, an aspiring doctor—was struck by two trends. On the one hand, he observed volunteer community health workers who could not respond effectively to a high demand for public health services due to distance, isolation, and a lack of communication infrastructure between the field and medical facilities. On the other hand, he observed the prevalence of mobile phones in even the most remote regions of the country. Putting two and two together, Josh realized that mobile phone-based communication had the potential to turn a fragmented rural healthcare quagmire into a coordinated health system where community health workers (CHWs) living and working in rural communities would be able to respond to patients’ needs rapidly and efficiently. More rural patients could receive better healthcare simply by improving communication among the players that already existed within the system.
Josh saw an opportunity to expand and improve healthcare to rural patients without relying on an influx of more doctors and nurses. Rather, he saw an opportunity to maximize the potential of existing human resources. Using affordable, scalable, and easy-to-use mobile technology, Josh is creating connected and coordinated health systems where locally-based community health workers can serve their communities with minimal dependence on distant medical facilities. In other words, he is building a system for “just-in-time” healthcare. Leveraging pervasive mobile phones and simple text messaging, Josh and his team are helping healthcare communities vastly improve communication and, consequently, the efficiency and efficacy of locally-based healthcare workers. Now, CHWs are able to use SMS to collect, convey, and receive important medical and logistical information without the need to travel back and forth between the point-of-care and the base hospital or clinic. In this way, decentralized, locally-led healthcare in remote regions is achieving its high potential. In short, Josh’s solution is building the infrastructure for the model of community health workers to function.
One of the most significant barriers to rural public health is isolation. In rural health systems, a single hospital or clinic serves as the only medical hub for a quarter of a million rural dwelling citizens widely dispersed throughout a catchment area 100 miles or more in radius. Only limited infrastructure connects these citizens with their nearest medical facility and the overburdened doctors and nurses who work there. This scenario is not uncommon in much of the world. In fact, more than one billion people—the large majority of them living in the most remote and underserved regions of the world—will go their entire lives without ever seeing a doctor.
The widespread community health worker model adopted by many health networks across the globe combats such issues by training local volunteers within communities to perform many basic but essential health services such as medication adherence monitoring and drug distribution. CHW models vary from country to country and community to community. In different places, CHWs are offered different incentives, have obtained different educational requirements, and engage in different relationships with centralized medical facilities. No matter the model, however, all CHW systems have a similar purpose: To decentralize rural medical care by training locals to serve as community-based liaisons between health facilities and the patients they serve in the periphery.
Yet the efficacy of these CHWs is also severely limited by distance—the distance from one patient home to the next, the distance between a patient’s home and the CHW’s home, the distance between the point-of-care and the hospital or clinic that serves as the CHW’s medical hub. Consequently, CHWs across the globe travel hours upon hours back and forth between patient homes and medical facilities to, for example, deliver reports on the patients they are monitoring, to announce that a drug is out of stock, or to request emergency home-based care for an immobilized patient. This time spent in transit of course translates into funds wasted on fuel or other transportation costs. But, more critically, the time wasted in transit translates into health costs as well. In a greatly overburdened health system where there is an estimated shortfall of 4.3 million healthcare workers, time a health worker spends in transit is time a health worker does not spend delivering much-needed care. It represents a huge inefficiency in decentralized medical care that prevents local health workers—a powerful but underutilized existing resource—from achieving maximum impact.
This highly uncoordinated health system hinders not just the quantity but also the quality of care. When CHWs are hours if not days away from the nearest health facility, point-of-care issues—if a healthcare worker runs out of one medication, for instance, or has questions about dosage and use of another—cannot be simply resolved. What is more, CHWs record point-of-care questions and comments on paper, and when these paper-based medical records finally do reach clinicians at a hospital or clinic, they are often outdated, impossible to read, or incomplete. Care suffers accordingly. Thus, the consequence of inefficiencies in the global rural health system is not merely a waste of time and money but also greatly reduced health outcomes for the communities that health workers serve.
Medic Mobile, the organization Josh co-founded, promotes decentralized medical care for the rural poor by maximizing the efficiency and efficacy of community-based healthcare workers using mobile phone-based communication systems. Instantaneous communication among community health workers and between CHWs and physicians and nurses at clinical hubs means that citizen health workers can provide care to their communities with much less dependence on a centralized medical facility.
At the core of the coordinated and connected rural health systems, Medic Mobile helps shape SMS. As Josh first began to brainstorm how to solve the inefficiencies he witnessed in the healthcare system in rural Malawi, SMS—also known as text messaging—immediately made sense to Josh for a number of reasons. First of all, SMS operates on the most basic of mobile phones, a technology that has already penetrated the rural communities that are the focus of Josh’s work. Relatedly, an SMS-based solution faces low barriers of adoption because of the fact that SMS is familiar to those with mobile phones and simple to those learning how to use mobile phones. SMS is affordable—for a mere $1 credit, a CHW can send ten messages. SMS requires minimal infrastructure, it operates independently of Internet and is thus an ideal answer in the types of communities Medic Mobile works with, where Internet connectivity is unreliable at best and, more often, non-existent.
What is more, because SMS is simple, affordable, and widespread, it represents a healthcare solution that can be championed at the most grassroots level. This factor was integral to Josh’s early idea, and continues to be a core foundation of Medic Mobile’s ongoing strategy. While many other mHealth pioneers are enamored with the potential of PDAs and the advanced functionality such devices offer, Josh wants to create a system that is optimized for the lowest-end phones with the most limited functionality. In Medic Mobile’s eyes, the simplicity of their technology—both the SMS software and the mobile phone hardware—is exactly the point. The simpler the solution, the lower the barriers-to-entry, and Josh wants a solution that can be championed by literally anyone. Indeed, in the rapidly growing field of mobile health, Medic Mobile wants to position itself as the organization most committed to serving the “lowest common denominator”—not the physician at a nearby hospital but the volunteer, citizen CHW embedded within his or her community. After all, enhancing the capacity of these citizen paraprofessionals is core to a functional decentralized rural health system. While other leading mHealth initiatives have focused their attention on developing data tools that can lead to better policy decisions, Josh is creating a platform where a series of communication tools can be rolled out easily to the health workers’ whose impact can be most leveraged: Community health workers.
Simplicity is also core to Medic Mobile’s spread strategy. They even have a term for this approach—“grassroots scalability.” It is the type of scale a solution is able to achieve because the solution is so easily adopted and because the citizen is its agent. While ministries of health, USAID representatives, and state department officials alike have lauded Medic Mobile’s software solutions, the true champions and implementers of Medic Mobile’s tools are the CHWs. Core to Josh’s approach is also this focus: Medic Mobile does not see itself as a technology company, but rather as a global health equity organization.
CHWs not only will define how widely Medic Mobile tools are used, they also define, at a more fundamental level, how Medic Mobile tools are used. The simplicity of Medic Mobile’s solutions leaves room for flexibility, and user-driven functionality has been core to Medic Mobile since day one. The technology is simple and flexible enough that CHWs themselves are shaping the way the technology is used. Rather than the technology prescribing the solution, solutions instead emerge between an organic interaction between problem, technology, and user.
That organic, problem-driven process is precisely how Medic Mobile came into existence. Medic Mobile’s system was built out from existing software that was flexible enough to be adapted to a context very different from the one in which it was originally developed. Medic Mobile originally grew out of FrontlineSMS, a simple, open source mass text message platform developed by Ashoka Fellow Ken Banks. While the platform was originally designed so that organizations could send SMS messages to large groups of people at one time, Medic Mobile adapted the SMS software—in the early days of FrontlineSMS’ development—to the needs of the rural health sector, allowing clinic staff to communicate with a large network of CHWs in the field. Hospital staff can now, for instance, text the CHWs in their network about upcoming vaccination outreach. CHWs, in turn, can text hospital staff for urgent matters, such as important point-of-care questions about medication dosage. In emergency situations when a physician or nurse practitioner is needed, CHWs no longer have to travel back to a distant clinic to seek support but rather can text for urgent care.
Communication between CHWs and medical hubs isn’t limited to urgent SMS, however. Medic Mobile offers OpenMRS, an existing open source, mobile medical record system, a simple mobile Electronic Medical Record, and text-based forms for structured data collecting. These tools allow CHWs to send organized and immediate medical information from the field to the centralized medical facility for analysis or archiving. The team is also working to empower CHWs with the ability to diagnose certain conditions. Medic Mobile is excited to be working with UCLA to develop a revolutionary mobile diagnostic tool that will be able to perform basic diagnostics such as complete blood count, and diagnosis of malaria and TB on the back of a simple camera phone. All of these tools enhance the capacity and elevate the role of CHWs, transforming the crucial position—which is often under or uncompensated—into a more desirable position.
Josh is also elevating the status of rural public health in the public eye. In 2009 he launched Hope Phones, a mobile phone recycling initiative. Hope Phones is a fundraising campaign that taps into the half a million phones that are discarded daily in the U.S. as a source of revenue for Medic Mobile’s innovative mobile work. For every phone recycled through Hope Phones, Medic Mobile receives between $5 and $80 from a recycling partner. But Hope Phones is more than a recycling program or fundraising mechanism. It is also an engagement campaign that provides an accessible and tangible way for ordinary Americans to contribute and connect to the global health work that Josh’s team is advancing across the globe.
Medic Mobile is a non-profit company (501c3) and consists of a small but growing team of eleven full-time staff and a handful of part-time employees and volunteers. Josh recently moved Medic Mobile’s U.S. headquarters from Washington, DC—where he has been based for the past two years to build relationships in the government and international aid communities—to San Francisco. His co-founder Isaac remains based in East Africa, where he has guided their field employees since the organization’s founding. A project manager based in Canada coordinates communication between the field staff and software developers, who are mostly based in a hub in Nairobi, Kenya.
Medic Mobile is at an important inflection point. Having demonstrated a variety of different use cases in thirteen countries with more than thirty partners, the organization is now on the verge of a project with Malawi’s Ministry of Health to bring their system to nationwide scale in that country. This adoption will increase the number of Malawian CHWs using Medic Mobile from 2,000 to 20,000. Close relationships with USAID and the UN hold promise for large-scale public health contracts. Medic Mobile is also in early conversations with Twitter about a potential collaboration to carry messaging on Twitter servers for free, a move that would eradicate cost-of-airtime as a barrier to wider spread adoption.
Josh’s passion for health is life-long. The son of two parents working in the field of medicine, Josh grew up exposed to the way in which healthcare professionals improve peoples’ lives. He entered his freshman year at Stanford as a pre-med student with the intention of becoming a physician.
In college, Josh was also a varsity athlete, serving as his university soccer team’s goalie. It is a role that Josh believes taught him extreme discipline—in season, Josh spent on average four hours a day in training—as well as management skills—as the only player who can see the entirety of the field, the goalie is responsible for coordinating his teammates. Merging his athleticism and his interest in health, Josh co-founded Play4Health, a student organization that addresses health disparities by coordinating community health events for under-resourced communities in East Palo Alto.
Josh spent the summer of his junior year of college researching access to malaria treatment in Malawi. For eight weeks, he lived and worked at St. Gabriel’s, a rural hospital first introduced to Josh by his mother, who is spearheading Malawi’s first physical therapy program at the facility. It was there that he witnessed firsthand the inefficiencies that limited the impact of community healthcare workers delivering care in remote regions. Josh returned the next summer with 100 recycled cell phones, a donated computer, and a plan to coordinate communication between St. Gabriel’s and the expansive region under the hospital’s care using existing open source text message software, FrontlineSMS. During that six month pilot project, which Josh dubbed Mobiles in Malawi, texting saved hospital staff 1,200 hours of follow-up time, allowed the hospital to double the size of its tuberculosis program, brought home-based care to 130 patients who otherwise would not have received care, and saved antiretroviral therapy monitors 900 hours in travel time. The success of the project moved Josh to shelve his medical school plans and to devote his efforts full-time to transforming the CHW system. With close collaborator Isaac Holeman, he soon founded the organization that is today called Medic Mobile.
When the historically devastating earthquake hit Port-au-Prince in 2010, Josh called upon lessons he had learned in Malawi to spearhead the coordination of an SMS-based relief communication system. The result was 4636, a groundbreaking emergency response project named after the short-code to which relief workers and victims could text requests for aid and report on ground conditions. SMS messages texted to the number were gathered, translated, categorized, and mapped, allowing relief agencies to respond to requests for aid with unprecedented efficiency and cross-sector coordination.