1. T
he epidemiologic profile of the population in Latin
America has been continuously changing for the last
30 years. Noncommunicable diseases have emerged
as the main burden of national health systems, shifting the
pattern from the youngest population to the eldest e.g.
diabetes, cardiovascular diseases and obesity. The average
mortality 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 that
in 2007 there were 20.7 million people with DM and
impaired glucose tolerance whereas in 2025 there will be
41.2 miliion people; this is a 99.2% growth rate. In fact,
WHO estimates that in 2030 nine out of the ten main causes
of death will be attributable to noncommunicable diseases4
.
Research into causes of this increase does not point a linear
cause. A sedentary lifestyle and bad diet have been pointed
to as the main driving forces5
. On the other hand, cognitive
and 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 people
living with HIV/AIDS in Latin America has grown from 1.3
million in 2000 to 1.6 million in 2007; a 20.9% growth
rate7
. Thus, the analysis is now between acute and chronic
diseases8
. The centre of the analysis in public health is now
on morbidity rather than on mortality9
. At the Carso Health
Institute, an initiative of the Carlos Slim Foundation, we argue
that chronic diseases are conditions of life and an effective
strategy must integrate health services through multiple
bidirectional 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 health
system-level and at the patient-level. First, there must be a
change 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 interaction
between the physician and the patient. Patients are still
passive 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 necessary
to shift from acute discrete interventions to preventive
continuous care, integrating hospital-based interventions with
community participation.
The second major turnaround refers to the degree of
involvement of patients with respect to their own disease. It
is estimated that only 50% of patients comply with their
physicians’ prescription irrespective of the disease or their
age10
. Treatment of chronic diseases requires an intake of
several doses of medication on a daily basis, and there is an
inverse linear relation between the number of doses and the
levels of compliance11
. Additionally, people discontinue their
medicine intake within a period of time; patients suffering
from hypertension generally discontinue their medication
intake in 90 days12
. On the other hand, the ageing of the
population plays a key role. In Latin America life expectancy
at birth has increased from an average 61.1 years for the
1970–1975 period to 73.8 in 2005–2010, and it will
increase to 77.3 years in 2025–2030, as Figure 1 shows13
.
This scenario is immersed in a context of globalization and
immigration, which limits the capacity of national health
systems to provide continuous and sustained health
treatment. 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 Health
Institute – Carlos Slim Foundation, Mexico, and Rodrigo Saucedo, Researcher,
Carso Health Institute – Carlos Slim Foundation, Mexico
Last mile delivery in health care
and patient empowerment through
technology: the case of
“Telecommunication for Health”
80
78
76
74
72
70
68
66
64
62
60
1970-1975
1975-1980
1980-1985
1985-1990
1990-1995
1995-2000
2000-2005
2005-2010
2010-2015
2015-2020
2020-2025
2025-2030
Figure 1: Life expectancy at birth in Latin America, 1970–2030
Source: UN Population Division

2. health care, either with mobile health units or through
patients’ remote management.
As a consequence, complications related to disease arise,
increasing the direct and indirect costs associated to it and
driving national health costs in both developed and
developing countries. In the US, for diabetes alone, the total
cost of treatment and complications was 132 billion in
2002, and it will grow at an annual rate of 3.3% to 192
billion in 202014
. In the UK, National Health Service
expenditure will grow at an average real rate of 4.2 to 5.1%
by 202215
. Turning to Latin America, the cost of treatment for
diabetes was US$ 7 667 million in 2007 and it will grow at
an 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 is
the agent of change for the current paradigm in the delivery
of health services. In Latin America the use of technology is
increasingly becoming a part of people’s everyday lives. In
1999 there were 62.7 million fixed phone lines in Latin
America, increasing to 99.4 in 2008. With respect to mobile
phone users, there were 19 million in 1999, and it
dramatically increased up to 374.9 million in 2008 for an
average of 80 mobile phone users per 100 inhabitants
(Figure 2). Some factors explain this. Firstly, mobile phones
require wireless infrastructure only. Secondly, mobile phones
can 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 almost
87 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, increasing
to 183.5 million in 2008, 17.4 times the number of users
in 1999. Two possible factors explain this. Firstly, a single PC
may be used by more than one person in a household;
secondly, the number of public Internet kiosks has risen
dramatically 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 even
created some terms to define them: eHealth, telemedicine,
telehealth or mHealthi
. Furthermore, there has been a large
movement about the benefits of it; yet only a few studies
provide solid evidence to support this argument.
Some systematic reviews have been performed but
unfortunately some methodological limitations in the projects
evaluated impede their replication and escalation18,19,20
.
Furthermore, almost all mHealth projects are designed to
improve health system efficiency, or to improve efficiency in
the way physicians allocate their time. Finally, none of the
studies found in the literature refer to projects implemented
in Latin America. To our knowledge, those projects are only
found 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 insights
worth a deeper analysis. Within all the technologies the most
studied is the mobile phone. In a recent study, Fjeldsoe
found out that 93% of SMS-based interventions delivered
positive behaviour changes22
. He found that dialogue
initiation, continuous interactivity and customization of SMS
were highly effective; this is consistent with a 2003 WHO
study in which motivation and behavioural skills were
described as the main drivers of compliance23
. Furthermore,
mobile phones were not used for information sharing only.
Some studies have demonstrated a decline of between 33
and 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 uses
the phone a lot less frequently compared to younger groups,
especially in developing countries, where the use of mobile
phones is mainly by adolescents and young adults.
Therefore, an integral strategy must consider the use of the
Internet, the fixed phone line and community-based
participation. As some studies have proved, phone-based
interventions have demonstrated positive results among
persons 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 unique
technological platform created to provide strategic integral
bottom-up services to the individual and achieve last mile
delivery. If users have access to multiple communication
platforms, we expect an increase in the extent to which users
are 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
400
350
300
250
200
150
100
50
0
1990 2000 2001 2002 2003 2004 2005 2006 2007 2008
Millions
Fixed phone lines Mobile phone users
Figure 2: Number of fixed lines and mobile phone users in Latin
America, 1999–2008
Source: ITU 2008
200
180
160
140
120
100
80
60
40
20
0
1990 2000 2001 2002 2003 2004 2005 2006 2007 2008
Millions
Number of PCs Internet users
Figure 3: Number of PCs and Internet users in Latin America,
1999–2008
Source: ITU 2008
i
Hereafter we will refer to this movement as mHealth.

3. Furthermore, users can test themselves at home, and then
send the results through the channel that is most convenient
to them, either at home through the 01-800 telephone
number, at their personalized website or through their mobile
phones. For us, mHealth does not refer to the use of mobile
devices to provide a health service; it refers to mobilizing the
health resources to wherever the user goes, literally following
him and enhancing the probability of a treatment succeeding.
With Telecommunication for Health it is the user that
demands results from the health system, setting a new
bidirectional channel of communication and empowering him
to take further action. These innovations are available even in
the poorest communities.
To our knowledge, this is the first scalable project that uses
a bottom-up approach that places the person in the centre of
the strategy. Some studies have demonstrated that remote
management of chronic diseases decreases the number of
hospitalizations by up to 32%, the number of emergency
room visits by 40%, the number of hospital admissions by
63% 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 services
that place prevention as the main approach, considering the
community 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 implies
shifting the balance of responsibility, transforming the
traditional view in which patients are passive recipients of
care towards a full partnership in their management of
health. It is when patients are aware and empowered to act
that the strategy may succeed. J
Roberto Tapia-Conyer is the Director-General of the Carso Health
Institute. Prior to that, he served as the Vice-Minister of Prevention
and Health Promotion for 12 years. He also chaired the Strategic
Technical Advisory Group of WHO’s TB Programme and has been
appointed a member of the Influenza Global Action Plan Advisory
Group. He is an active member of the Mexican Academy of
Sciences, the Mexican Academy of Medicine, the Mexican
Academy of Surgery and the Mexican Public Health Society, which
he chaired in 1997. Roberto Tapia-Conyer holds a Master of Public
Health degree from Harvard University and a Doctorate in Sciences
conferred 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 health
projects, as well as the strategic positioning of the various health
projects. He has been a consultant for the Mexican Ministry of
Health, the Mexican Ministry of Social Development and the
Centre for Research and Development in Economics in Public
Finance, Financial Protection in Health and sustained public
policies. Rodrigo Saucedo holds a Bachelor in Economics from
CIDE in Mexico, specializing in Public Finance and has taken
courses in Management and Corporate Finance.
Social innovation: incentives from “push” to people
12 Global Forum Update on Research for Health Volume 6
Key messages
Chronic diseases are conditions of life and an
effective strategy must integrate health services
through multiple bidirectional channels of
communications, setting the patient at the centre
of the analysis.
It is necessary to change the current paradigm of
provision of health services, from acute discrete
interventions to continuous preventive care,
integrating hospital-based interventions into a
nonspatial environment.
The current view of patients as passive recipients of
care must be shifted to a full partnership in health
care, where patients are informed, are aware of their
diseases, and are empowered to take further action
to 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 the
majority. Washington, Inter-American Development Bank, 2009.
6.
Tackling obesities: future choices – project report. Scotland, UK
Government, 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 effects
during 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 1
diabetes in young people: economic evaluation. In: The role of mobile
phones in increasing accessibility and efficiency in healthcare. Vodafone
Policy Paper Series 4, 2006.
15.
Chauhan D et al. The upward trend in healthcare spend. In: The role of
mobile 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/ (last
accessed 3 August 2009).
18.
Whitten P. Systematic review of cost-effectiveness studies of telemedicine
interventions. 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 in
Peru (www.perupreven.org).
References

4. Social innovation: incentives from “push” to people
Global Forum Update on Research for Health Volume 6 13
22.
Fjeldsoe et al. Behavior change interventions delivered by mobile
telephone Short Message Service. American Journal of Preventive
Medicine, 2009, 36(2):165–175.
23.
Adherence to long term therapies: Evidence for action. Geneva, World
Health Organization, 2003. http://www.who.int/chp/knowledge/
publications/adherence_report/en/index.html (last accessed 3 August
2009).
24.
Rifat A. A review of the characteristics and benefits of SMS in delivering
healthcare. In: Vodafone Policy Paper, The role of mobile phones in
increasing 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