Table 3 A Health systems framework: Health system dimensions required for scaling up mHealth for community based health services

Government stewardship: Is there a policy environment supportive of mHealth?

· Strategic leadership: Strategic leadership is present through policy guidelines that promote alignment with strategic health goals, funding sources, common ICT standards and partnerships for collaboration nationally and internationally.

· Learning environment: Government stewardship includes creating a learning environment, where projects are evaluated systematically and where collaboration and sharing of knowledge can contribute to a central repository of evidence on mHealth, which in turn can influence policy and practice.

Organisational: Is there a culture of and capacity for using information technology for management?

· Capacity for implementation: The health system has the capacity, managerially and technologically, to successfully implement mHealth interventions. This includes assessment of eReadiness, a functional ICT environment and effective mechanisms for implementation, support and monitoring and evaluation.

· Culture of information use: There is an organizational culture and tradition of using health information for management - to ensure that the increased access to electronic information is used for quality improvements in health services.

Technological: How useable, integrated and sustainable is the chosen technology?

· Use-ability: The technology has ease of use, flexibility and durability and end users experience the new technology as benefiting their work.

· Interoperability: Interoperability of information systems ensures there is smooth communication across technological and information platforms as well as smooth integration with existing work practices. Common standards (required for interoperable systems) are developed through consensus amongst the multiple stakeholders including health ministries, digital providers, health management, clinical staff, patients, and funders. The relative merits of open source versus proprietary software are addressed as this has implications not only for interoperability, but also for financial sustainability.

· Privacy and security: Privacy and security of data is ensured. Additional regulations for protecting electronic data may be required to secure privacy of data.

Financial: Is adequate financial provision being made for the medium to long term use of mHealth?

· Sustainable funding: Securing sustainable funding for large-scale implementation is a major requirement and requires clear business and funding plans. Plans should be realistic, especially as ICT projects may cost more and take longer than initially planned.

· Cost-effectiveness: The cost-effectiveness of mHealth strategies is evaluated. mHealth interventions are weighed up against other priority and evidence-based interventions (in terms of the costs, resources and capacity requirements), and opportunity costs are routinely considered. Unintended consequences of introducing new technology within a weak health system are monitored to minimize negative effects.