Marco’s presentation will shift the focus from health workers to the potential recipients of mobile-phone-based health services. Focusing on upstream elements of mHealth, Marco will explore patterns of mobile phone use and healthcare-seeking behaviour, drawing on fieldwork insights from rural India (Rajasthan) and China (Gansu). The evidence suggests that common assumptions of mHealth proponents are easily violated; that is, mobile phone ownership is not ubiquitous and does not necessarily reflect mobile phone use, people do not necessarily share mobile phones freely amongst each other, they are not necessarily keen and excited technological learners, and they do develop mobile phone-aided coping strategies that may compete with mhealth. While both contexts offer, at least in theory, the potential for mobile technology to break boundaries, the presentation will emphasise the importance of understanding upstream factors of mHealth before deploying technological solutions in order to provide effective solutions and to avoid the potential exacerbation of healthcare inequities.

1. OXFORD DEPARTMENT OF
INTERNATIONAL DEVELOPMENT
Persistent Boundaries
(Or why we should
be aware of our
assumptions in ICT4D)
Breaking Boundaries: ICT for Development
Department of Education
Marco Haenssgen
Oxford Department of Int„l Development
13 March 2014

2. BACKGROUND
3 February 2014Phone use and
rural health in
India and China
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3. Background
Common Assumptions About End-User Oriented mHealth
Academics and professionals hope to revolutionise healthcare access
through mobile health technology.
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rural health in
India and China
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“Text messaging demonstrates
strong potential as a tool for health
care improvement.” (Cole-Lewis &
Kershaw, 2010:3)

4. Background
Common Assumptions About End-User Oriented mHealth
mHelath proponents’ narratives often (over-)emphasises the potential
of technology to revolutionise healthcare.
 Technology excites (as it excites us)
 (Almost) universal phone ownership
 Sharing and lending where there are no phones
 The underlying technological platform is neutral
 People have a demand for mobile health services
 They will have a positive effect on people‟s access to healthcare
 Inequities between urban and rural areas will decrease
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rural health in
India and China
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Euromonitor International
(2012, 2013)

5. EVIDENCE
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rural health in
India and China
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6. Evidence
Sample characteristics
Qualitative data has been gathered from a high-
variance sample in rural Rajasthan and Gansu.
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rural health in
India and China
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Adapted from Google Inc.
(2014)

7. Evidence
Ownership
Phone ownership is widespread, but penetration is larger in
China, especially among older population. Smartphones are rare.
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rural health in
India and China
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50
40
30
20
10
0
10
20
30
40
50
18-24 25-39 40-54 55+ Male Female
No.ofRespondents(VillageResidents)
Phone Ownership Among Respondents, by Age Group and Gender
Phone No Phone Age Group Gender
India(n=89)China(n=89)

8. Evidence
Use
Mobile phone use is highly variable in rural Rajasthan and Gansu.
 Dominant use of voice communication
 Usability limitations especially from middle-aged upwards
 Active vs. passive use
 Lending restricted to important purposes
 Learning (teaching) restricted to fundamental functions
 Phone use can be beneficial as well as detrimental
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rural health in
India and China
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9. Evidence
Use
Illustrations from the field: Use of phone features
Which mobile phone functions do you use?
I don’t know any. I just press the “OK” button to receive calls, but I can’t dial
numbers. So whenever I want to a make call, my son helps me. Whatever text
messages I receive, they are all invisible for me because I don’t know about them and
I never see them.
(woman aged 45, phone owner, in Rajasthani village)
[Woman] Generally, I take and make calls, and SMS sometimes. The people whom
I contact are relatives and children, to convey holidays greetings or to say hello
sometimes. I can’t use other functions of the phone. I do use the phonebook, but not
the pictures, I can’t use that. I also can’t use the camera.
[Man] I can’t use phones with more functions – the fewer functions, the better.
(married couple, woman aged 42 and man aged 45, phone owners, in Gansu village)
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rural health in
India and China
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10. Evidence
Use
Illustrations from the field: Sharing, but limited use of phone features
Have you ever used the phone of your sons?
[…] We don’t know how to use the mobile, we only know that when someone calls, we
put phone near the ear so the sound comes from other side. We can listen to it and
when we say something, the other side can listen as well to the sound [of our voice].
We all know how to receive phone calls, this has been taught to us by our sons.
They said to receive phone calls, there is a green button on the right side [of the
phone keyboard], so when phone rings, we have to press it.
Do you feel comfortable when using the phone?
[…] I am afraid to use the phone, so I only take it when it’s needed, and
[afterwards] immediately hand it over to my son – if I accidentally press the wrong
button, I will cause money loss.
(focus group, older men aged 55 and 60, non-owners, in Rajasthani village)
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rural health in
India and China
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11. Evidence
Use
Illustrations from the field: Limits to teaching
Have you ever taught your parents how to use the mobile phone?
Yes, we taught them how to make and receive calls, how to send text messages.
Do your parents understand these basic feature at the first attempt?
No, we have to teach them 5-6 times.
Are they were confident after they learned these features, or do they still feel hesitant
to operate their phones?
No, they are usually scared of wasted balance, which is why they don't use the
phone unnecessarily.
(3 young male respondents aged 18, 20, 22 in Rajasthani village, owners)
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rural health in
India and China
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12. Evidence
Healthcare seeking
If people are able to access and use the mobile phone, it can become
part of their strategies to navigate the healthcare system.
 Phones enter healthcare seeking where feasible and deemed necessary
 Access
 Assistance
 Appointments
 Assurance
 Advice
 But facilitation does not follow automatically
 Elderly people
 Restricted social networks
 Savvy vs. basic use
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rural health in
India and China
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13. Evidence
Healthcare seeking
Illustrations from the field: Facilitating healthcare access
Which kind of emergency happened did you encounter and how did you use the
mobile phone?
Recently my father and I had an accident but we couldn’t make a call because our
phone didn’t have reception. So we received help from another person to call the
ambulance and finally we could reach the hospital. There we could call to our home
and inform our family about the accident.
When you go to the hospital, do you call there first?
First I give a call to the doctor and ask whether he is available or not.
(man aged 22, owner, in Rajasthani village close to town)
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rural health in
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14. Evidence
Healthcare seeking
Illustrations from the field: Facilitating healthcare access (non-owner)
How do you make calls in emergencies?
I call from my neighbours’ mobile phone.
[…] Did you get ill recently, and what did you do then?
Last Diwali, I suffered from a very bad fever. I called my mother so that she would
take me to the hospital.
Did the mobile phone play role in this process?
Yes, it made this easy. If I didn’t have the phone, then definitely I would have had to
take help from my neighbours.
How far do your parents live from here?
2-3 hours from here by bus.
(woman aged 28, non-owner, in Rajasthani village)
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rural health in
India and China
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15. Evidence
Healthcare seeking
Illustrations from the field: No facilitating role of the phone
Who takes care of you when you are ill?
Myself. And I wouldn’t go to hospital. I have some common medicines at home
or I get some from the pharmacy in [the district capital of] Huining. We have 2 buses
to Huining in the morning, going back in the afternoon. It takes 1 hour to Huining and
costs 12 yuan [GBP 1.30]. If it’s a common cold, I take some drugs that help, I do not
go to the hospital.
(woman aged 51, phone owner, in Gansu village)
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16. Evidence
Healthcare seeking
Illustrations from the field: Summoning assistance
How long does it normally take you to go to village hospital?
40 minutes if you walk there. Or you can call the village doctor to come here, he can
come here by motorcycle in 20 minutes. […] He comes here almost everyday, and
he comes to whoever calls him […]. Almost all people have the village doctor's
phone number.
Are there people who do not have the number, who would go to the neighbours and
ask for the number or borrow their phones?
Yes, our neighbour who caught by cold came over to borrow mine. They did not have
the number of village doctor, and I dialled the number for them on my phone, and
the doctor came here after calling. These visits generally does not raise the
fees, they wouldn’t ask for the visiting fee, and only charge for the drugs and
diagnosis.
(man aged 50, phone owner, in Gansu village)
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rural health in
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17. CONCLUSION
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rural health in
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18. Conclusion
Revisiting the assumptions
Assumptions of common mHealth narratives are easily violated.
 Ownership not a good proxy for use
 Use not determined by devices – reliance on voice
 People not necessarily keen learners / teachers
 Sharing only for important purposes and within limited networks
 People are creative and active problem solvers
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rural health in
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19. Conclusion
Implications for the design of mhealth applications
The violation of common mHealth assumptions (ubiquity, easy
sharing, enthusiastic and curious users, passive recipients, inevitable
positive impacts) can have implications for design and deployment.
Mhealth may:
 be rendered ineffective by digital exclusion and passive use
 compete with local coping strategies
 potentially aggravate inequitable healthcare access
 suffer from insufficient demand and technological learning
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rural health in
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20. Conclusion
Implications for the design of mhealth applications
But there is a case for mhealth in rural, resource constrained areas.
This can involve, for example,
India
 Snake bite responses
 “Household health activists”
China
 Medication information and order-placement
 Elderly as target recipients
Both
 Real-time information about health staff availability
 One-button emergency call-back
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rural health in
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21. Conclusion
Summary
Need to understand technology users and their coping strategies
before developing mHealth solutions
mHealth can break boundaries, but not every problem should be
solved with ICT first
Under flawed assumptions, mHealth may add little or even increase
inequities
Deployment of services requires (intensive and continuing) training of
users
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22. Conclusion
Emerging questions
Besides the research questions posed here, promising avenues of
future research are emerging.
 Who will be the winners of the upcoming “upscale battle”?
 Who gains most from the mHealth hype?
 How can we integrate new solutions into existing systems while avoiding
patchwork?
 Are similar trends likely for other sectors of mobile service delivery, e.g.
mobile education and mobile money?
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23. Thank you.
Questions?
marco.haenssgen@hertford.ox.ac.uk
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