The epidemiologic profile of the population in LatinAmerica has been continuously changing for the last30 years. Noncommunicable diseases have emerged

as 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 diseases4.Research into causes of this increase does not point a linearcause. A sedentary lifestyle and bad diet have been pointedto as the main driving forces5. On the other hand, cognitiveand motivation factors play a key role too6.Nevertheless, some communicable diseases are present in

people’s 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 chronicdiseases8. The centre of the analysis in public health is nowon morbidity rather than on mortality9. 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 major

turnaround 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 patient’s 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 theirage10. Treatment of chronic diseases requires an intake ofseveral doses of medication on a daily basis, and there is aninverse linear relation between the number of doses and thelevels of compliance11. Additionally, people discontinue theirmedicine intake within a period of time; patients sufferingfrom hypertension generally discontinue their medicationintake in 90 days12. 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 the1970–1975 period to 73.8 in 2005–2010, and it willincrease to 77.3 years in 2025–2030, as Figure 1 shows13.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 careand patient empowerment throughtechnology: the case of“Telecommunication for Health”

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Figure 1: Life expectancy at birth in Latin America, 1970–2030

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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 202014. In the UK, National Health Serviceexpenditure will grow at an average real rate of 4.2 to 5.1%by 202215. 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 202516.Thus, governments are now struggling to find a new way

to approach chronic diseases. We believe that technology isthe agent of change for the current paradigm in the deliveryof health services. In Latin America the use of technology isincreasingly becoming a part of people’s 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 there

were 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 Mexico17.The use of technology to deliver health services is now a

current practice. Scholars and project designers have evencreated some terms to define them: eHealth, telemedicine,telehealth or mHealthi. 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 but

unfortunately some methodological limitations in the projectsevaluated impede their replication and escalation18,19,20.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, etc21.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 changes22. 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 compliance23. 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 reminders24.Nevertheless, SMS may not be the most effective way to

address 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 status19.With this scenario, at the Carso Health Institute we created

Telecommunication for Health in which the mobile phone,the Internet and the fixed phone converge in a uniquetechnological 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.

Social innovation: incentives from “push” to people

Global Forum Update on Research for Health Volume 6 � 11

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Figure 3: Number of PCs and Internet users in Latin America,1999–2008

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i Hereafter we will refer to this movement as mHealth.

Furthermore, users can test themselves at home, and thensend the results through the channel that is most convenientto them, either at home through the 01-800 telephonenumber, at their personalized website or through their mobilephones. For us, mHealth does not refer to the use of mobiledevices to provide a health service; it refers to mobilizing thehealth resources to wherever the user goes, literally followinghim and enhancing the probability of a treatment succeeding.With Telecommunication for Health it is the user thatdemands results from the health system, setting a newbidirectional channel of communication and empowering himto take further action. These innovations are available even inthe poorest communities.To our knowledge, this is the first scalable project that uses

a bottom-up approach that places the person in the centre ofthe strategy. Some studies have demonstrated that remotemanagement of chronic diseases decreases the number ofhospitalizations by up to 32%, the number of emergencyroom visits by 40%, the number of hospital admissions by63% and the number of hospital bed days of care by 60%25.Shifting the current paradigm means changing the focus of

care, from discrete services to integral continuous servicesthat place prevention as the main approach, considering thecommunity as a strategic player in addressing health needs.It also means setting a turnaround in the location of care,from hospital-based interventions to nonspatial interventions,where health care is present everywhere. Finally, it impliesshifting the balance of responsibility, transforming thetraditional view in which patients are passive recipients ofcare towards a full partnership in their management ofhealth. It is when patients are aware and empowered to actthat the strategy may succeed. �

Roberto Tapia-Conyer is the Director-General of the Carso Health

Institute. Prior to that, he served as the Vice-Minister of Preventionand Health Promotion for 12 years. He also chaired the StrategicTechnical Advisory Group of WHO’s TB Programme and has been

appointed a member of the Influenza Global Action Plan AdvisoryGroup. He is an active member of the Mexican Academy ofSciences, the Mexican Academy of Medicine, the MexicanAcademy of Surgery and the Mexican Public Health Society, whichhe chaired in 1997. Roberto Tapia-Conyer holds a Master of PublicHealth degree from Harvard University and a Doctorate in Sciencesconferred by the University of Mexico.

Rodrigo Saucedo is a researcher at the Carso Health Institute.He is actively involved in the design of technology-intensive healthprojects, as well as the strategic positioning of the various healthprojects. He has been a consultant for the Mexican Ministry ofHealth, the Mexican Ministry of Social Development and theCentre for Research and Development in Economics in PublicFinance, Financial Protection in Health and sustained public

policies. Rodrigo Saucedo holds a Bachelor in Economics fromCIDE in Mexico, specializing in Public Finance and has takencourses in Management and Corporate Finance.

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12 � Global Forum Update on Research for Health Volume 6

Key messages

� Chronic diseases are conditions of life and aneffective strategy must integrate health servicesthrough multiple bidirectional channels ofcommunications, setting the patient at the centreof the analysis.

� It is necessary to change the current paradigm ofprovision of health services, from acute discreteinterventions to continuous preventive care,integrating hospital-based interventions into anonspatial environment.

� The current view of patients as passive recipients ofcare must be shifted to a full partnership in healthcare, where patients are informed, are aware of theirdiseases, and are empowered to take further actionto control and manage their health.

1. Latin America refers to Argentina, Belize, Bolivia, Brazil, Chile, Colombia,Costa Rica, Ecuador, El Salvador, Guatemala, Honduras, Mexico,Nicaragua, Panama, Paraguay, Peru, Uruguay and Venezuela.

2. There was no information for Belize, Bolivia and Honduras.3. Basic Health Indicators 2008. Geneva, World Health Organization, 2009.4. World Health Statistics 2008. France, World Health Organization, 2008.5.Mobile health: the potential of mobile telephony to bring health care to themajority. Washington, Inter-American Development Bank, 2009.

6. Tackling obesities: future choices – project report. Scotland, UKGovernment, 2007.

7. Report on the global AIDS epidemic. Geneva, UNAIDS/WHO, 2008.8. Frenk J. Reinventing primary health care: the need for systems integration.

Lancet, 2009, 374: 170–173.9. Frenk J et al. La transición epidemiológica en América Latina. Bol. of

Sanit Panam 1991, 111(6):485–496.10.Bloom B. Daily regimen and compliance with treatment. British Medical

Journal 2001, 323:647.11.Bloom B. Direct medical costs of disease and gastrointestinal side effectsduring treatment for arthritis. American Journal of Medicine, 1988,84(2a):20-24.

12.Bloom B. 2001, ídem.

13.2008 World Population Prospects. Geneva, UN Population Division,2009. http://esa.un.org/unpp/index.asp (last accessed 3 August 2009).

14.Rifat A et al. Use of mobile technologies to enhance control of type 1diabetes in young people: economic evaluation. In: The role of mobilephones in increasing accessibility and efficiency in healthcare. VodafonePolicy Paper Series 4, 2006.

15. Chauhan D et al. The upward trend in healthcare spend. In: The role ofmobile phones in increasing accessibility and efficiency in healthcare.Vodafone Policy Paper Series 4, 2006.

16.Diabetes Atlas, 3rd ed. Brussels, International Diabetes Federation, 2008.17.World Telecommunication/ICT Indicators Database online. Geneva,International Telecommunications Union. http://www.itu.int/ITU-D/ict/ (lastaccessed 3 August 2009).

18.Whitten P. Systematic review of cost-effectiveness studies of telemedicineinterventions. British Medical Journal, 2002, 324:1434–1437.

19.Krishna S et al. Healthcare via cell phones: a systematic review.Telemedicine and e-Health, 2009, 15(3):231–240.

20.Guide to regional good practice: eHealth. Brussels, IANIS, 2007.21.Two projects are the Andean e-Health Initiative(www.andeanehealthhomestead.com) and the Cell PREVEN project inPeru (www.perupreven.org).

References

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Global Forum Update on Research for Health Volume 6 � 13

22.Fjeldsoe et al. Behavior change interventions delivered by mobiletelephone Short Message Service. American Journal of PreventiveMedicine, 2009, 36(2):165–175.

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 PolicyPaper Series 4, 2006.

25.Technology trends: how technology will shape future care delivery. SanFrancisco, Health Tech Report, 2008.

References continued