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The epidemiologic profile of the population in LatinAmerica has been continuously changing for the last30 years. Noncommunicable diseases have emergedas the main burden of national health systems, shifting thepattern from the youngest population to the eldest e.g.diabetes, cardiovascular diseases and obesity. The averagemortality rate from diabetes mellitus (DM) in Latin America1

is 35 with the extreme cases of Mexico (83.1) and Uruguay(14) 2,3 . The International Diabetes Federation estimated thatin 2007 there were 20.7 million people with DM andimpaired glucose tolerance whereas in 2025 there will be41.2 miliion people; this is a 99.2% growth rate. In fact,WHO estimates that in 2030 nine out of the ten main causesof death will be attributable to noncommunicable diseases 4.Research into causes of this increase does not point a linearcause. A sedentary lifestyle and bad diet have been pointedto as the main driving forces 5. On the other hand, cognitiveand motivation factors play a key role too6.

Nevertheless, some communicable diseases are present inpeoples entire lives such as HIV/AIDS. The number of peopleliving with HIV/AIDS in Latin America has grown from 1.3million in 2000 to 1.6 million in 2007; a 20.9% growthrate7. Thus, the analysis is now between acute and chronicdiseases 8. The centre of the analysis in public health is nowon morbidity rather than on mortality 9. At the Carso HealthInstitute, an initiative of the Carlos Slim Foundation, we arguethat chronic diseases are conditions of life and an effectivestrategy must integrate health services through multiplebidirectional channels of communication so that the patient,the physician and the health system can continuously interact.

For the strategy to be effective, we believe that a majorturnaround is required at two different levels: at the healthsystem-level and at the patient-level. First, there must be achange in the way traditional health services are provided.

The current system is hospital-centric, it works on a one-to-one interaction and it is limited in the time of interactionbetween the physician and the patient. Patients are stillpassive recipients of vertical and reparative interventions.This limits follow-up of the patients health conditions and

therefore limits the success of any treatment. It is necessaryto shift from acute discrete interventions to preventivecontinuous care, integrating hospital-based interventions withcommunity participation.

The second major turnaround refers to the degree of involvement of patients with respect to their own disease. Itis estimated that only 50% of patients comply with theirphysicians prescription irrespective of the disease or theirage 10 . Treatment of chronic diseases requires an intake of several doses of medication on a daily basis, and there is aninverse linear relation between the number of doses and thelevels of compliance 11 . Additionally, people discontinue theirmedicine intake within a period of time; patients sufferingfrom hypertension generally discontinue their medicationintake in 90 days 12 . On the other hand, the ageing of thepopulation plays a key role. In Latin America life expectancyat birth has increased from an average 61.1 years for the19701975 period to 73.8 in 20052010, and it willincrease to 77.3 years in 20252030, as Figure 1 shows 13 .This scenario is immersed in a context of globalization andimmigration, which limits the capacity of national healthsystems to provide continuous and sustained healthtreatment. Health systems must be able to provide mobile

10 Global Forum Update on Research for Health Volume 6

Social innovation: incentives from push to people

Article by Roberto Tapia-Conye (pictured), Director-General, Carso HealthInstitute Carlos Slim Foundation, Mexico, and Rodrigo Saucedo, Researcher,Carso Health Institute Carlos Slim Foundation, Mexico

Last mile delivery in health care

and patient empowerment throughtechnology: the case of Telecommunication for Health

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Figure 1: Life expectancy at birth in Latin America, 19702030

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health care, either with mobile health units or throughpatients remote management.

As a consequence, complications related to disease arise,increasing the direct and indirect costs associated to it anddriving national health costs in both developed anddeveloping countries. In the US, for diabetes alone, the totalcost of treatment and complications was 132 billion in2002, and it will grow at an annual rate of 3.3% to 192billion in 2020 14 . In the UK, National Health Serviceexpenditure will grow at an average real rate of 4.2 to 5.1%by 2022 15 . Turning to Latin America, the cost of treatment fordiabetes was US$ 7 667 million in 2007 and it will grow atan annual rate of 3.8% to US$ 28 080 million in 2025 16 .

Thus, governments are now struggling to find a new wayto approach chronic diseases. We believe that technology isthe agent of change for the current paradigm in the delivery

of health services. In Latin America the use of technology isincreasingly becoming a part of peoples everyday lives. In1999 there were 62.7 million fixed phone lines in LatinAmerica, increasing to 99.4 in 2008. With respect to mobilephone users, there were 19 million in 1999, and itdramatically increased up to 374.9 million in 2008 for anaverage of 80 mobile phone users per 100 inhabitants(Figure 2). Some factors explain this. Firstly, mobile phonesrequire wireless infrastructure only. Secondly, mobile phonescan be purchased without any credit conditions.

With respect to personal computers (PCs), in 1999 therewere 18.6 million PCs in Latin America, increasing to almost87 million in 2008, a growth rate of 368% in only 9 years.Nevertheless, the trend is much steeper for Internet users.There were 9.97 million Internet users in 1999, increasingto 183.5 million in 2008, 17.4 times the number of usersin 1999. Two possible factors explain this. Firstly, a single PCmay be used by more than one person in a household;secondly, the number of public Internet kiosks has risendramatically since 2000, as is the case in Mexico 17 .

The use of technology to deliver health services is now acurrent practice. Scholars and project designers have evencreated some terms to define them: eHealth, telemedicine,telehealth or mHealth i. Furthermore, there has been a largemovement about the benefits of it; yet only a few studiesprovide solid evidence to support this argument.

Some systematic reviews have been performed butunfortunately some methodological limitations in the projectsevaluated impede their replication and escalation 18,19,20 .Furthermore, almost all mHealth projects are designed toimprove health system efficiency, or to improve efficiency inthe way physicians allocate their time. Finally, none of thestudies found in the literature refer to projects implementedin Latin America. To our knowledge, those projects are onlyfound in grey literature, i.e. research and technical papers,government reports, surveys, etc 21 .

Nevertheless, the very few studies that performed

controlled studies or clinical trials provide interesting insightsworth a deeper analysis. Within all the technologies the moststudied is the mobile phone. In a recent study, Fjeldsoe

found out that 93% of SMS-based interventions deliveredpositive behaviour changes 22 . He found that dialogueinitiation, continuous interactivity and customization of SMSwere highly effective; this is consistent with a 2003 WHOstudy in which motivation and behavioural skills weredescribed as the main drivers of compliance 23 . Furthermore,mobile phones were not used for information sharing only.Some studies have demonstrated a decline of between 33and 50% in missed appointments given the SMS reminders 24 .

Nevertheless, SMS may not be the most effective way toaddress chronic diseases given that the elderly group usesthe phone a lot less frequently compared to younger groups,especially in developing countries, where the use of mobilephones is mainly by adolescents and young adults.Therefore, an integral strategy must consider the use of theInternet, the fixed phone line and community-basedparticipation. As some studies have proved, phone-basedinterventions have demonstrated positive results amongpersons with low socioeconomic status 19 .

With this scenario, at the Carso Health Institute we createdTelecommunication for Health in which the mobile phone,the Internet and the fixed phone converge in a unique

technological platform created to provide strategic integralbottom-up services to the individual and achieve last miledelivery. If users have access to multiple communicationplatforms, we expect an increase in the extent to which usersare informed and willing to treat and control their disease.


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Figure 2: Number of fixed lines and mobile phone users in LatinAmerica, 19992008

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Figure 3: Number of PCs and Internet users in Latin America,19992008

Source: ITU 2008

i Hereafter we will refer to this movement as mHealth.


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22. Fjeldsoe et al. Behavior change interventions delivered by mobiletelephone Short Message Service. American Journal of PreventiveMedicine , 2009, 36(2):165175.

23.

Adherence to long term therapies: Evidence for action. Geneva, WorldHealth Organization, 2003. http://www.who.int/chp/knowledge/ publications/adherence_report/en/index.html (last accessed 3 August2009).

24. Rifat A. A review of the characteristics and benefits of SMS in deliveringhealthcare. In: Vodafone Policy Paper, The role of mobile phones inincreasing accessibility and efficiency in healthcare . Vodafone Policy

Paper Series 4, 2006.25. Technology trends: how technology will shape future care delivery. San

Francisco, Health Tech Report, 2008.

References continued

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