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    At the Intersection of Health, Health Care and Policy

    doi: 10.1377/hlthaff.2009.0965

    , 29, no.2 (2010):252-258Health Affairs'Mobile' Health Needs And Opportunities In Developing Countries

    James G. Kahn, Joshua S. Yang and James S. KahnCite this article as:

    http://content.healthaffairs.org/content/29/2/252.full.html

    available at:The online version of this article, along with updated information and services, is

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    written permission from the Publisher. All rights reserved.mechanical, including photocopying or by information storage or retrieval systems, without prior

    may be reproduced, displayed, or transmitted in any form or by any means, electronic orAffairsHealthFoundation. As provided by United States copyright law (Title 17, U.S. Code), no part of

    by Project HOPE - The People-to-People Health2010Bethesda, MD 20814-6133. Copyright is published monthly by Project HOPE at 7500 Old Georgetown Road, Suite 600,Health Affairs

    Not for commercial use or unauthorized distribution

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    By James G. Kahn, Joshua S. Yang, and James S. Kahn

    Mobile Health Needs AndOpportunities In Developing

    Countries

    ABSTRACT Developing countries face steady growth in the prevalence of

    chronic diseases, along with a continued burden from communicable

    diseases. Mobile health, or m-healththe use of mobile technologies

    such as cellular phones to support public health and clinical careoffers

    promise in responding to both types of disease burdens. Mobile

    technologies are widely available and can play an important role inhealth care at the regional, community, and individual levels. We examine

    various m-health applications and define the risks and benefits of each.

    We find positive examples but little solid evaluation of clinical or

    economic performance, which highlights the need for such evaluation.

    E

    conomic development improveshealth. It increases life expectancyand well-being and decreases childmortality and birth rates.13 This re-

    lationship reflects the effect of ris-ing incomes on access to health-enhancinggoods and services,4 such as improved diet, san-itation, and health care. Further, economicdevelopment drives an epidemiological transi-tion, from a predominance of infectious dis-eases to chronic, noncommunicable ones.1,5 Atthe same time, improved health spurs economicgrowth. Better physical and mental health in-creases labor productivity; reduces days lost toillness; decreases medical spending; and fostersinvestment in education and capital as a result oflonger expected life spans.68 Thus, a virtuous

    cycle exists, with mutual reinforcement of eco-nomic and health progress.

    Mobile health, or m-healththe use of wire-less communication devices to support publichealth and clinical practicehas great potentialto enhance this virtuous cycle. More than anyother modern technology, mobile phones areused throughout the developing world.9 Innova-tive applications of mobile technology to exist-ing health care delivery and monitoring systemsoffer great promise for improving the quality oflife. They makecommunication among research-

    ers, clinicians, and patients easier, and aschronic disease becomes more prevalent, mobiletechnologies offer care strategies that are parti-cularly suited to combating these conditions.

    In this paper we propose a conceptual model toconsider the potential contributions of m-healthto help address the huge health care challengesin developing countries. We examine the rela-tionship between wealth and health, and wedocumentthe growing burden of chronic diseasein developing countries. We describe ways inwhich mobile health technologiescan contributeto a nations health care response, at the regio-nal, community, and individual levels.

    Health And Health Systems In The

    Developing WorldDeveloping countries face an increasing inci-dence of noncommunicable chronic disease,even as communicable disease remains a persis-tent threat. Diseases formerly concentrated indeveloped countries, such as hypertension, obe-sity, heart disease, and diabetes, are on the rise(see Online Appendix).10 The combined effect ofcommunicable disease and chronic or noncom-municable disease is described as a dual bur-den for developing countries.11 Successful ef-forts to reduce the dual burden of disease will

    doi: 10.1377/hlthaff 2009.0965HEALTH AFFAIRS 29,NO. 2 (2010): 2542612010 Project HOPEThe People-to-People HealthFoundation, Inc.

    James G. Kahn ([email protected]) is a professor ofhealth policy andepidemiology at the Universityof California, San Francisco.

    Joshua S. Yang is an assistantprofessor in the Department

    of Health Science atCalifornia State University,Fullerton

    James S. Kahn is a professorin the Positive HealthProgram at the University ofCalifornia, San Francisco.

    254 H E A LT H A F F A I R S FEBRUARY 2010 29:2

    CELL PHONES & M-HEALTH

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    improve quality of life for millions. M-healthoffers some hope on both fronts.

    The leading preventable causes of noncommu-nicable diseases globally are tobacco, poor diet,and low physical activity. They contribute toheart disease, diabetes, lung disease, andcancerconditions that account for half of alldeaths worldwide.12,13 All are projected to in-

    crease in the developing world as incomesrise.1418 Chronic, noncommunicable diseases re-quire unique care strategies that may be difficultto deliver in developing countries19 and that maybenefit from mobile technology. This is the casefor several reasons.

    (1) The long latency period for chronic dis-eases often requires early, broad based commu-nity health interventions. (2) Reducing chronicdisease often requires rejecting behaviors asso-ciated withgreater wealth (for example, tobacco,diets high in fat and sugar, and low physicalactivity) and thus relinquishing perceived status

    value. (3) Treatmentof chronic diseases typicallyuses complex interventions involving ongoinginteractions with multiple components of thehealth system. This requires skilled health pro-fessionals and coordinated and continuous care.(4) Chronic diseases often require chronic med-ication, introducing issues of access, cost, andquality of pharmaceuticals and adherence totreatment regimens. Self-care is often requiredby people with chronic diseases. Health systemsmust equip patients to deliver self-care.

    Many factors constrain health system perfor-mance in developing countries. Infrastructure is

    limited, and hospital resources are concentratedin urban areas (see Online Appendix).10 Diseaseburdenthat is, incidence of disease and its im-pact on peoples livelihoods and economic pro-ductivityis great.20,21 There are not enoughhealth care workers (shortages are estimatedat 800,000 for Africa),22 and such workers aredifficult to recruit and retain, especially in ruralareas.23,24 Supervisory and management systemsare often lacking or weak. One review of theseconstraints25 identified several areas where mo-bile health might help by removing physical bar-riers to care and service delivery and by improv-

    ing weak health system management, unreliablesupply systems, and poor communication.

    The Promise And Pitfalls OfM-Health In Developing Countries

    We define m-health as the use of portable elec-tronic devices for mobile voice or data commu-nication over a cellular or other wireless networkof base stations to provide health information.Mobile phones are the most ubiquitous type ofequipment in the world: 3.3 billion peopleone

    of every two of earths inhabitantshas at leastone.9 The growth of this technology has beentransformative worldwide. The penetration ismore than 90 percent in the developed worldand more than 33 percent in the developingworld,including close to90 percent among somehigh-risk urban populations.26

    Exhibit 1 lists some of the ways in which the

    growing presence of mobile technology may beadvantageous and how these technical applica-tions may greatly influence developing coun-tries health systems. Mobile communicationcan foster solutions at different organizationallevels: large geographic areas, local commu-nities, and individual patients and providers.

    As we review this range of m-health opportu-nities, we include a few illustrative examples.Weidentified these examples through professionalnetworks (m-health meetings and colleagues in-

    volved in innovative health service delivery), on-line searches in the journal database PubMed

    (using terms such asmobile and cellphones)and Google (for example, mobile health); andscrutiny of bibliographies. A useful resource, in-cluding capsule summaries of fifty projects, is areport titled The Opportunity of Mobile Technology

    for Healthcare in the Developing World.27

    Using the strategies noted above, we foundminimal formal evaluation of m-health. Two sys-tematic reviews indicated little formal outcomeevaluation of m-health in developing coun-tries.28,29 Santosh Krishna examined use of mo-bile calls and short message service (SMS), ortext messaging, in twelve clinical areas and

    found significant improvements in compliancewith medicine taking, asthma symptoms,HbA1C, stress levels, smoking quit rates, andself-efficacy. Process improvements were re-ported in lower failed appointments, quicker di-agnosis and treatment, and improved teachingand training. However, this research was con-ducted in wealthier countries, except for onestudy in China.28 A 2006 review reported thatthere is almost no literature on using mobiletelephones as a healthcare intervention for HIV,tuberculosis, malaria, and chronic conditions indeveloping countries. Clinical outcomes are

    rarely measured.29LARGE GEOGRAPHIC AREAS The integrated nature

    of mobile communication systems providesunique opportunities for m-health in large geo-graphic areas.We discuss some specific applica-tions of m-health below.S O C I AL NE T W O RKI NG: Social networking

    models (that is, techniques to electronically linklarge numbers of individuals) include varioustools,of which mobiletext messagingis themostubiquitous. At the large geographic level, thismass communication capacity can be used to

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    EXHIBIT 1

    Emerging M-Health Applications

    Level of application M-health tools Health system functions Benefits RisksLarge geographic

    areasSocial networking:

    users connectedvia short messageservice (SMS),

    instant messaging,or third-partyapplication

    Disaster aversion andmitigation

    Rapidly lower exposure toecological or epidemicthreats; obtain fieldreports; provide advice;

    coordinate response;efficiently direct scarceresources

    Incorrect information(through error ormalfeasance) maycreate alarm or

    havoc

    Health promotion Promote healthier behaviors(for example, reduce riskysex or smoking, improvediet)

    Poorly designedcampaigns couldhave unintendedeffects

    Web surfing: usersbrowse Web sites

    Information on healthcondition diagnosisand care

    Patient self-education canspeed diagnosis; providersin remote areas can obtainlatest information

    Inaccurate/confusinginformation can leadto delay or error incare

    Commodity pricing andpurchasing

    Health care providers andindividuals pay less forsupplies and equipment, viaprice shopping and buyer power

    Loss of coordinatedsupply chain

    E-mail lists forcommunication Provide information onhealth topics ofspecial interest

    Shared resources, informationexchange Misinformation;misunderstandingor not appropriateliteracy

    Web-based dataentry

    Disease surveillance casereporting

    Improved disease surveillance;increased communityawareness and participation

    Incorrect or misleadinginformation; lackinggranularity of data

    Web-based learning Online courses that allownovel and independentlearning

    Health care workers maintainand improve knowledge andskills

    Loss of humaninteraction forteaching andeducation

    Community Social networking Share experiences regardinglocal health care system

    Efficiently navigate health caresystem to best/mostappropriate provider

    Incorrect or partialinformation; lossof confidentiality(disclosure of

    personal healthinformation)Peer-to-peer education:

    providers and patientsLocally tailored mutual assistance

    and support on health care andbehaviors

    Loss of confidentiality

    Web surfing Supply pricing andpurchasing (local)

    Health care providersand individualspay less for supplies

    Loss of coordinatedsupply chain

    Individual Data transmission:Send and receivedata

    Medical imaging: rawdata sent to processingcenter, image returned

    Medical imaging services providedin remote areas, improveddiagnosis

    Loss of confidentiality

    E-mail/textmessaging

    Provider-to-providercommunication

    Share information about care forpecific patients; exchangebest practices; raise quality

    Loss of confidentiality;incorrect ormisunderstoodinformation

    Provider-to-patientcommunication Answer questions, provide dataand guidance, encouragemedication and visit adherence

    Burden providers withnew channel ofpatient interaction;loss of humaninteraction, forempathy/support

    SOURCE Authors analysis.

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    although these risks may be no higher than withcurrent systems. Patient privacy must also beaddressed in Web-based data entry systems.

    COMMUNITY At the community level, social net-working can be used to exchange informationabout thelocal health system. People in the com-munity can share experiences about how to ob-tain health system resources they need, identify

    scarce resources, and exchange information (forexample, on price, the experience of care, andquality) for specific providers. The Smile for

    You campaign to provide cleft palate surgeryfor children in South Africa used Please CallMe text messages, which mobile phone userssend at no cost, to identify potential candidatesfor this free care. (Vodacom, the local telecom-munications company, donated spare space in amillion Please Call Me messages to ask recipi-ents if they knew of children needing this spe-cialized surgery.) Phone and text message inqui-ries rose tenfold, and forty-two children were

    identified for surgerymore than three timesthe number identified during a traditional mediacampaign lasting six weeks.27

    Effective messaging can connect people toneeded and available services. Sharing serviceinformation can also encourage providers to im-prove services or lower prices. The risks involvedinclude the exchange of incorrect or partial in-formation that may misdirect patients seekingcare. There is also the potential for a loss ofconfidentiality as users share their own experi-ences and those of others.

    Social networks can also foster peer-to-peer

    interactions among both providers and patients.Discussions can extend beyond a local area toinclude clinician specialists and can provide sup-port for improved health care practices. Simi-larly, patients(or communitymembers)cansup-port each other on specific behaviorswhetherpreventive (such as smoking cessation) or man-agement of a commondisease(suchas diabetes).This model of interaction is, of course, open tomiscommunication as well as to contentious dif-ferences of opinion.

    Social networks created among health care or-ganizations and individuals can be used to share

    information. They potentially create economiesofscaleatthelocalleveltopurchasesuppliesandequipment. The risks involved in this approach,however, are miscommunication among localorganizations, leading to overexpenditures,and, as noted above, an uncoordinated supplychain that can lead to system inefficiency.

    INDIVIDUALS For individuals, m-health offersimproved communication, access to diagnostictools, and ability to store and access personalmedical data in central repositories. Advancesin cellular technology allow for transmission

    of large data files, including medical imagingdata, from remote areas to processing centersor higher-level medical centers. This can leadto more rapid and potentially better diagnosisand care.31 For example, Aravind Eye Systems(Madurai, India) established a regional wirelessnetwork to support nonphysician providers inthirty-one dispersed eye care centers. Each

    patient is examined by a nurse on site, followedby a one-to-two-minute consultation with anophthalmologist at the main hospital, includingtransmission of a slit-lamp photograph ifneeded.32 Use of m-health in this way must en-sure that patient confidentiality is not compro-mised in the transmission of images.

    E-mail can strengthen communication be-tween individuals in the health care system. Bet-ter provider-to-provider communication can im-prove patient care coordination, including teammanagement of chronic disease. It canalso allowexchange of best practices and can raise quality

    standards through professional consultation.PDAs may also serve this purpose.33 Good provi-der-patient communication is essential forchronic disease management. M-health offersthechance to askand respond to questions, sendkey data and guidance, and act as an avenue ofcasemanagement oncepatientsleave the clinicalsetting.

    The complex care required for people livingwith HIV/AIDS has fostered use of m-healthtools. Several groups have reported increasedmobile access among such people, with someevidence of resulting improvements in medica-

    tion adherence and health.26,34 Other applica-tions include automated medication adherencereminders,35 in-the-field consultations for provi-ders,36 and encouraging healthy behaviors.37,38

    Perhaps the most common documented use ofm-health is text-message and phone remindersto encourage follow-up appointments andhealthy behaviors. In the United Kingdom, useof text-message reminders in a sexually trans-mitted infection clinic had two important bene-fits: decreasing time to treatment for chlamydia,and decreasing appointment no-show rates(withincreased revenue of rebooking far exceed-

    ing implementation cost).39,40 In Hangzhou,China, text message and telephone remindersimproved appointment attendance by 7 percent,and messaging cost less than telephone remin-ders.41 A recent randomized controlled trial ofpatients with chronic diseases in Malaysia foundthat nonattendance rates were about 40 percentlower in the text-messaging and phone groupsthan in controls.42

    In Zambia, Population Services Internationaluses m-health for several aspects of male circum-cision services. The circumcision service sends

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    fifteen textmessages as postoperative remindersto patients to encourage appropriate behavior toprotect wound healing, and it conducts servicesatisfaction surveys. New messaging servicesinclude a referral system, appointment schedul-ing, and addressing patients clinical ques-tions.43 The risk for these types of interven-tions is thatthey may complicate clinicalpractice

    with more communication options/burdens,and decrease the important element of directhuman interaction.

    DiscussionThe positive potential for m-health is huge,although not without risks to be monitoredand minimized. Several broader points bear em-phasis. First, rigorous evaluation is essential.Evidence for the value of m-health remainsscarce, especially for the developing world. On-going evaluation of specific initiatives should

    guide m-health growth. A mixture of random-ized controlled trials,35 natural experiments,and other designs will be needed.

    We believe that the field would benefit greatlyby the establishment of an m-health evaluationregistration, similar to registration of clinicaltrials at http://ClinicalTrials.gov, a service ofthe U.S. NationalInstitutes of Health, whichlistsfederally and privately supported clinical trialsaround the world. Global health coordinatingbodies such as the World Health Organization(WHO) could contribute importantly by foster-ing research using comparable outcome mea-

    sures and disseminating findings.Finally, economic outcomes are important.

    For example, lowered costs, even absent im-proved health outcomes, could justify m-healthstrategies. If m-health is to compete with otherhealth interventions, it will need to be measur-

    able in terms of cost per disability-adjusted life-year (DALY) averted,44 which is increasingly theaccepted measure of health intervention perfor-mance (see Appendix Figure 2).10 An economicevaluation framework for m-health would char-acterize the interventions, their costs, and theirintended clinical outcomes and potential ad-

    verse effects.

    Assessment of m-health should also includeawareness of practical issues, such as sustain-ability. Real-world challenges greatly influencethe ability of programs to survive and grow.45

    Issues include participating organizations, tech-nical capacity, and financing. The WHO andother organizations should develop guidanceon best m-health practices and support coun-tries implementation efforts.

    Vigorous expansion of m-health may also havea nonhealth benefit: fostering local economicdevelopment beyond health care. Although tech-nological advances in hardware often occur in

    developed countries, advances in software aremore widespread. Thus, m-health innovationand implementation are unlikely to be limitedto externalconsultants. M-healthsoftwareappli-cations will be designed and employed in strate-gic partnerships with governments, health sys-tems, individual businesses, professionals, andcommunities in developing countries. M-healthplatforms will be tailored, refined,and expandedby and in consultation with local experts.

    To implement m-health, local technical capa-city and training will be necessary. Thus, m-health should foster local microenterprise, creat-

    ing upgraded platforms and new functionalitiesthat will generate ongoing economic opportu-nities. Ultimately, increased economic opportu-nities in turn would contribute to improvedhealth. The virtuous cycle would continue,with m-health at the very center of it.

    A version of this paper was presentedat the Rockefeller Foundationconference Making the eHealthConnection: mHealth and MobileTelemedicine, Bellagio, Italy, 13 July8 August 2008. Funding was providedby the United Nations Foundation, with

    additional support from the NationalInstitutes of Health (NIH) National

    Center for Research ResourcesUniversity of California, San Francisco,Clinical Translation and Science InstituteGrant no. UL1 RR024131-01;Commonwealth Fund Grant no.P0014838; and NIH Grant no.5K24RR24369-7. The views expressed

    are not necessarily those of the funders.The authors thank Jesse Marseille for

    online searching for reports aboutrecent m-health projects andevaluations. They also thank R.D.Thulasiraj of Aravind Eye Systems(Madurai, India) and Steve Gesuale ofPopulation Services International forinformation about mobile health

    activities in clinical care in theirrespective projects.

    NOTES

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