Mobile Health for Development

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mHealth for DevelopmentThe Opportunity of Mobile Technology for Healthcare in the Developing World


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A u t h o rVital Wave C onsu lting

A b o u t T h e U n i t e d N a t io n s F o u n d a t i o n a n d Vo d a f o n e F o u n d a t io nTe c h n o lo g y P a r t n e r s h i pThe United Nations Foundation and Vodafone Foundation Techno logy Partnership is a leading pub lic-

private all iance using strategic techno logy pro gram s to strength en the UNs hum anitarian efforts

w orldwide. The Partnership has three core com mitm ents: (1) to suppo rt the use of rapid response m obile

telecom m unications to aid disaster relief; (2) to develop health data system s that improve ac cess to he alth

data there by helping to c om bat disease; and (3) to p rom ote rese arch and innovative init iatives using

techno logy as an agent and to ol for international developm ent. Further inform ation can be found at :

www.unfoundat ion.org/vodafone.

C o n t a c t

United Nations Foundation The Vodafone Foundation

1800 M assachusetts Ave., NW Vodafone House

Suite 400 The Connec tion

Washington, D.C. 2003 6 New bury, Berkshire, RG14 2FN

USA UK

Registered Charity No : 10896 25

R e c o m m e n d e d C it a t io nVital Wave Consulting. m Health for Developm ent: The Oppo rtunity of Mo bile Technology for He althcare

in the Developing W orld. Washington, D.C. and Berkshire, UK: UN Foundation-Voda fone Foundat ion

Partnership, 2009 .

C o v e r P h o t o C r e d i t sUN M ark Garten and UN Foundat ion.


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The United Nations Foundation and The Vodafone Foundation are working

together to harness the pow er of m obi le technology in support of United

Nations prog rams ac ross the globe. Since 200 5 our 15 million Techno logy

Partnership has funded the use of w ire less co mm unicat ions to advance g lobal

health and disaster relief work, and to further public discourse about how

wire less technology can address so me of the wo rld s toughest c hallenges.

This fourth publication, mHealth for Development: The Opportunity of

Mobile Technology for Healthcare in the Developing World, in our Access

to Com municat ions ser ies evidences, through i ts research and select ion of

case studies, the potent ia l of m Healththe use of m obi le c om municat ions

(m obile phones and PDAs) for health services and inform ation. This f ield has

the potential to transform the approach to a variety of healthcare challenges

in the developing world by accelerating the collection and storage of patientdata, training rural professionals with health updates and g uidance, and

personalizing to new levels the process of patients receiving and engaging in

available medical treatment.

As the case studies in the report dem onstrate, governments, com panies, and

non-profit groups are already developing mHealth applications to improve

healthcare and conseq uently save lives. These new mo bile applications,

bypassing the f ixed-line solutions, are creating new pathways for sharing

health-re lated informat ion, even in the most remote and resource- poor e nvironments.

We invite you to review the po tential of this area of activity and join the discussion of m Health for

development. We would welcome your comm ents and ideas at ww w.unfoundat ion.org/mH ealth-report .

Vittorio Colao , CEO Ted Turne r, Chairm an

Vodafone United Nations Foundation

1

Foreword

Foreword

Foreword


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Acknowledgements

The United Nations Foundation and The Vodafone Foundation are thankful to the numerous

individuals who have shared their ideas and experiences to inform this report and to contribute to

the advanc em ent of the m Health f ield. In particular, we w ould like to thank K en Banks , Found er of

kiwanja.net; Greg Elphinston, Director Co m m unity Involveme nt at No kia; Dr. Adesina I luyem i of the

University of Portsm outh; Vuyani Jarana, Regional Operations Director at Vod aco m A frica; Eduardo

Jezierski, Vice President o f Engineering at InSTEDD; Jrn Klungsyr, Research er / Developer,

Centre for International Health at the University of Berg en; Dr. Jennifer Leaning, Professor of

International Health at Harvard School of Public He alth and Assoc iate Professor of M edicine at the

Harvard M edical Scho ol; Dr. Balcha M asresha, Wo rld Health Organization; Dr. Patricia N. M echae l,

m Health and Teleme dicine Advisor to the M illennium Villages Project at the Earth Institute at

Columb ia University; Lauri M edeiros, Director, Corpo rate and Foundation Relations at the University

of California, San Francisco; Jess e M oore of the GSM Assoc iation; Dr. Joel Selanikio, Co-fo under

and Director of DataDyne; John Stephenson from Dalberg Global Developm ent Advisors; Dr. Boris

Nikolic, Senior Program Officer, Global Health Disco very at the Bill & M elinda Ga tes Found ation;

and Dr. Pamm la Petruck a, Assoc iate Professor, University of Saskatchew an, College o f Nursing.

We are also appreciative of the support of the organizations that shared their experiences with

us in the case stud ies. Thank you to H ajo van Beijm a, Co-found er of Text to Chang e; Robin Miller

and Sheetal Gordhan o f the Praekelt Foundation (Project M asiluleke); Andre Erthal, Head of the

Com mu nity Group at Nokia M obile Solutions and Services (No kia Data Gathering); and Ne al Lesh,

Chief Techno logy Officer at D- Tree International (OpenRosa).

This report wo uld not have been as com pelling w ithout the r ich p ictures contr ibuted by DataDyne,

ENACQKT: Enhancing Nurses Access for Care Quality and Knowledge through Technology, the

Praekelt Foundation (Project M asiluleke), RAMP: Recycled AIDS M edication Program , Text to

Change, UN ICEF, and the United Nations.

Lastly, we would like to thank the team that worked on creating and producing this report. This

includes Vital Wave Consult ing, cop yeditor Lelani Arris, and Hal Kow enski and And re Tem oney at

Linemark Printing.

Acknowledgements2


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Contents

Contents

Foreword __________________________________________________________________________ 1

Acknowledgements _______________________________________________________________ 2

Contents __________________________________________________________________________ 3

Introduction _______________________________________________________________________ 4

Potential of Mobile Phones to Improve Health in the Developing World ___________ 6

The Promise of Mobile Technologies for Health 7

Defining mHealth Within the Context of eHealth __________________________________ 8

Meeting Health Needs Through a Broad Array of Applications ____________________ 9

Education and Awareness 10

Remote Data Collection 11

Remote Monitoring 12

Communication and Training for Healthcare Workers 13Disease and Epidemic Outbreak Tracking 13

Diagnostics and Treatment Support 14

Examining the Impact of mHealth Projects _______________________________________ 15

Assessing mHealth and Future Health Needs in Developing Countries ___________ 18

Evolution of Mobile Technologies 20

Identifying the Building Blocks for Sustainable and Scalable mHealth Programs 21

Key Building Blocks for Success 21

Project Masiluleke 22Multiple Health Issues Addressed by SMS Campaigns 24

Text to Change (TTC) 25

Data Gathering 28

Open Source Movement: A Building Block for mHealth Success 30

Understanding the Incentives for Multiple Players: mHealth Value Chain ________ 31

Value Chain Models for mHealth: One-way Data Applications 31

Value Chain Models for mHealth: Two-Way Data Applications 33

A Call for Action _________________________________________________________________ 34

Operators 34NGOs 35

Policymakers 36

Funders 36

Conclusion: Looking Forward ____________________________________________________ 37

Compendium of mHealth Projects________________________________________________39

Education and Awareness 41

Remote Data Collection 43

Remote Monitoring 50

Communication and Training for Healthcare Workers 55

Disease and Epidemic Outbreak Tracking 58

Diagnostic and Treatment Support 62

Contents


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Credit: DataDyne

M ounting interest in the field of m Healththe pro vision of health-related se rvices via mobile com m unica-

tionscan be traced to the evolution of several interrelated trends. In many parts of the world, epidemicsand a shortage of healthcare w orkers cont inue to present grave c hallenges for go vernments and health

providers. Yet in these same places, the explosive grow th of m obi le co mm unicat ions over the past dec ade

offers a new ho pe for the p romo t ion of qual ity healthcare. Among those w ho had p reviously been lef t behind

by the digital divide, b ill ions no w have acc ess to reliable techno logy.

There is a g rowing bo dy of e vidence that dem onstrates the po tent ia l of mob i le c om municat ions to radical ly

imp rove healthcare serviceseven in some o f the mo st remo te and resource- poor e nvironments. This report

exam ines issues at the he art of the rapidly evolving intersec tion of mo bile pho nes and hea lthcare. It helps the

reader to understand m Health s scop e and implementat ion across developing regions, the health needs to

which m Health can be app lied, and the m Health applicat ions that prom ise the g reatest imp act on heath care

init iatives. It also ex amines b uilding block s required to m ake m Health m ore w idely available throug h sustain-

able implem entations. Finally, it calls for con certe d ac tion to help realize m Healths full potential.

The report is organized into the follow ing sections:

Identifying the potent ial of m obile phones to im prove he alth in the deve loping wo rld1

Defining mH ealth within the co ntext of eH ealth2

Meet ing health needs through a broad array of m Health appl icat ions3

Examining the imp acts o f mH ealth projects4

Assessing mHealth and future health needs in developing countries5

Identifying the building blocks for sus tainable and scalable mHe alth program s6

Understand ing the incentives for m ult iple players: mH ealth value cha ins7

A call for action8Looking forward9

Comp endium of mHealth projects10

44 Introduction

Introduction


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Though the mH ealth f ield is still in its early stages, it has already b egun t o transform health delivery. Proj-

ects throughout the developing wo rld are dem onstrat ing c oncrete b enef its, including:

Increased access to healthcare and health-related information, particularly for hard-to-reach popula-

t ions

Improved ability to diagnose and track diseases

Timelier, more actionable p ublic h ealth inform ation

Expanded acc ess to ongoing m edical educat ion and tra in ing for health wo rkers

Due in large p art to the succ esses of pioneering m Health prog rams , activity in the f ield is rapidly gaining

mo mentum . In 2008 alone, over a dozen new mH ealth appl icat ions have been implemented or are in the

trial stage . These include:

InSTEDD, a US-based non-governmental organization (NGO) that provides technology solutions for

humanitar ian and disease support , opened a de velopm ent center in Cambodia where m Health-based

disease and surve illance solutions are b eing designed fo r the Southeast Asian region.

The Canadian development agency, IRDC, expanded support for a project providing nurses in the Ca-

r ibbean with portable d ig i ta l assistants (PDAs) to em pow er improved diagnosis and decision m aking.

The United Nations Foundation and Vodafone Foundation Technology Partnership, together with the

World Health Organization (WHO), a specialized agency of the United Nations (UN), announced plans

to expand their m obi le data- gathering prog ram to mo re than 20 c ountr ies in sub-Saharan Afr ica.

This report prof iles m ore than 50 mH ealth projects taking place in the developing w orld. The long-term goal

is that such programs will make healthcare more effective, and have a demonstrable and signif icant posi-

t ive impact on clinical outcomes such as reduced infant mortality, longer life spans, and decreased con-

traction of disease.

Experts acro ss the f ield, and interviewed as p art of this report, assert that there is an unpreced ented

opp ortunity at hand to fulf il l m Healths prom ise.To a c c e l e r a t e t h is m o m e n t u m a n d f u lly u n le a s h t h e

p o t e n t i a l o f m H e a l th a p p lic a t i o n s , d y n a m i c m u lt i- s e c t o r c o l la b o r a t i o n b e t w e e n g r o u p s a s

d i v e r s e a s g o v e r n m e n t s , m u l t ila t e r a l o r g a n i za t io n s , a n d t h e p r i v a t e s e c t o r i s n e e d e d . Jointact ion should be directed tow ard the creat ion of a g lobal mHealth infrastructure that lays out co mm on

standards and guidelines, and serves as a repository for shared resources and best practices. This is the

best approach for scaling mHealth solutions and maximizing the f ields capacity to serve a vital develop-

ment imp erat ive.

Right now, we are at an inflection point in t erms of acceptance.

Whether it t urns out t o be the peak of inflated expectation or t he

trough of disi l lusionment wil l depend on whether governm entsmake the l ink betw een telecommunic ation policy and health, and

the extent t o whic h donors encourage transparency in sourcing

and the part icipation of local entrepreneurs. Ult i mately, the t ake-

up of mobile comm unications in the health sector isnt really

about technology at all.

Greg Elphin ston,Director Communit y Involvement, Nokia

55Introduction


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Potential of Mobile Phones to Improve Health in

the Developing World

As the f irst dec ade of the 21st century draw s to a close, leade rs in many de veloping countries can po int w ith

pride to trem endo us strides in their efforts to impro ve the lives of their cit izens. In many parts o f the wo rld,

ci t izens in emerging econom ies have beg un to taste the f ru its of h igher incom es and g reater access to tools

that pro mise to increase their quality of l ife and that o f their children. Yet formidab le obstac les remain. Health

challenges present arguably the most signif icant barrier to sustainable global development. Disease and the

lack of adequat e prevent ative care take a significant toll on bo th developing po pulations, m easurable in dis-

ability-adjusted life years (DALYs), and economies. Despite the broad economic advances of this decade, the

2008 UN report on progress to ward mee t ing the Millennium Developm ent Goals (MDGs) indicates c ont inuingdire cond it ions in cruc ial public health areas. For exam ple:1

A child born in a developing c ountry is over 33 t imes m ore likely to die w ithin the f irst f ive years o f life

than a child bo rn in an industrialized co untry, even thoug h the leading causes o f deaths (pne um onia,

diarrhea, malaria, and measles) are preventable through basic services and vaccinations.

Every m inute, at least one w om an dies f rom com plicat ions re lated to pregnancy or chi ldbir th. And for

every w om an w ho d ies in childbirth, appro ximately 20 m ore s uffer injury, infection, or d iseasenearly 10

million each year.

An estimate d 2.5 m ill ion pe ople w ere new ly infecte d w ith HIV in 2007.

Com m unicable, and entirely avoidable, diseases s uch as tub erculosis (TB) and malaria continue to claim

l ives due to preventable factors such as lack of access to prop er drugs and med ical t reatment. By cur-

rent estim ates, m eeting the targ et M DG of halving the TB prevalence rate by 2015 is unlikely.

1 United Nations, The Millennium Development Goals Report 2008(New York: United Nations, 2008).

66 Potential of Mobile Phones to Improve Health in the Developing World

Potential

Credit: DataDyne


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The ability of developing countries to ove rco me these se rious health challenges is hindered by several core

obstacles, among them a global shortage of healthcare wo rkers. Acco rding to the WH O, among 57 coun-

tries, mos tly in the de veloping wo rld, there is a crit ical shortfall in healthcare w orkers, rep resenting a to tal

deficit of 2.4 mill ion healthcare workers worldwide. 2 This hum an resourc es co nstraint intensif ies the already

increasing pressure o n developing-w orld health systems. No t only must they c ope w ith the burden of con-

ta in ing the sp read of co mm unicable d iseases associated w ith extreme poverty, they must a lso co ntend w ith

the grow ing incidence of c hronic d iseases, such as d iabetes and heart d isease, an ef fect of new -found (re la-

t ive) affluence. Governm ents, businesse s, NGOs, found ations, and m ult ilateral organizations all reco gnize the

importance of leveraging new tools and solutions to address these distinct but interrelated health challenges.

The Promise of Mobile Technologies for Health

Mo bile c om municat ion o f fers an ef fect ive m eans of br inging healthcare services to developing-c ountry

cit izens. With low-cost handsets and the penetration of mobile phone networks globally, tens of mill ions of

ci t izens that never had regular access to a f ixed-l ine te lephone or com puter now use m obile de vices as dai ly

tools for communication and data transfer. A full 64% of all mobile phone users can now be found in the de-

veloping world.3 Furthermo re, estimate s show that by 2 012, half of all individuals in remote areas of the w orld

w ill have mob ile pho nes. This grow ing ubiquity of mo bile pho nes is a central elem ent in the prom ise of mob ile

technologies for health.

Figure 1 illustrates that deve loping wo rld cit izens have plentiful access to m obile phones, eve n w hile othe r

technologies and health infrastructure are scarce. This explosion of mobile phone usage has the potential to

improve health service delivery on a massive scale. For example, mobile technology can support increasingly

inclusive health system s by enab ling health wo rkers to p rovide real-t ime health inform ation and diagnose s in

rural and marginalized areas where health services are often scarce or absent altogether.

77Potential of Mobile Phones to Improve Health in the Developing World

Figure 1. Technology and health-related statistics for developing countries (millions).4

2 World Health Organization, The World Health Report 2006 - Working Together for Health(Geneva: WHO, 2006).3 United Nations Department of Economic and Social Affairs, Division for Public Administration and Development Management, Compendium of ICT Applications on Electronic Government - Volume 1. Mobile Applications on

Health and Learning(New York: United Nations, 2007).4 Vital Wave Consulting, Business Monitor International (BMI), International Telecommunications Union, World Banks World Development Indicators, and the United Nations.

11305

2,293

5,300

0

1,000

2,000

3,000

4,000

5,000

Hospital Beds Computers Mobile Phones Population

Reduce child mortality: Reduce by two-thirds, between 1990 and 2015,

the unde r-f ive m ortality rate.

Imp rove m aternal health: Reduce b y three-quarters, betw een 1990

and 20 15, the m aternal mo rtality ratio.

Com bat H IV/AIDS, malaria, and o ther diseases : Have halted by 2 015and be gun to reve rse the sp read o f HIV/AIDS; have halted by 2015 and

begun to reverse the incidence of m alar ia and other m ajor d iseases.

MDG 4.

MDG 5.

MDG 6.

Mobile phones reach

furt her into developing

countr ies than other

t echnology and health

infrastructures.

Health-Related Millennium Development Goals


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Defining mHealth Within theContext of eHealth

In recent years, mHealth has emerged as an imp ortant sub-

segm ent of the f ield of electron ic health (eHealth). While there

is no widely agreed -to definit ion for these f ields, the p ublic

health co mm unity has co alesced around these w orking d ef in i-

t ions:

eHealth: Using information and communication technol-

ogy (ICT)such as computers, mobile phones, and satel-

l ite co mm unicationsfor health services and inform ation.

mHealth: Using mobile communicationssuch as PDAs

and mobile phonesfor health services and information.

mH ealth and eHealth are inextricab ly linkedboth are used to

imp rove health outcomes and their technologies wo rk in con-

junction. For exam ple, m any e Health init iatives involve digit iz-

ing pat ient records and creat ing an electronic backbo ne that

ideally w ill standardize acc ess to patient data w ithin a national

system. mH ealth programs c an serve as the access point for

entering patient data into national health inform ation system s,

and as remote information tools that provide information to

healthcare clinics, home providers, and health workers in the

f ie ld. While there are m any stand-alone m Health programs,

it is important to note the oppo rtunity m Health presents for

strength ening broad er eHe alth init iatives.

88 Defining mHealth Within the Context of eHealth

Definit ion

mHealth involves using

w ireless t echnologies

such as Bluetoot h, GSM/

GPRS/3G, WiFi, WiMAX,

and so on to t ransmit

and enable various

eHealth data cont ents andservices. Usually these are

accessed by the health

w orker through devices

such as mobile phones,

smart phones, PDAs,

laptops and t ablet PCs.

Dr. Adesina Iluyemi,

PhD Candidat e,University of Portsmouth, UK

With eHealth

and mHealth, an

ecosystem approach is

recommended. Many of

the basic appl ications and

devices exist and are in

use, but now w e need to

make them t alk to each

other in a w ay that yields

strategic benefi ts.

Dr. Patri cia Mech ael,mHealth and Telemedicine Advisor t othe Mil l ennium Vil lages Project at t heEarth Institut e at Columbia University

Credit: Praekelt Foundation


11/7099Defining mHealth Within the Context of eHealth

Applications

99Defining mHealth Within the Context of eHealth

Education andAwareness, 6

Remote DataCollection, 14

Remote monitoring,10

Communication andTraining for HealthCare Workers, 5

Disease andEpidemic Outbreak

Tracking, 7

Diagnostic and

Treatment Support, 9

South Africa, 6

Uganda, 6

Worldwide, 1

Eastern Europe, 1Asia (excluding

India), 7

India, 11

Latin America, 10

Africa (excludingSouth Africa and

Uganda), 9

Figure 2. Distribution of mHealth programs by location and application area.

Credit: DataDyne

Meeting Health Needs Through a Broad Array of Applications 9

Meeting Health Needs

Through a Broad Array ofApplications

A grow ing num ber of developing countr ies are using mob ile

technology to address health needs. The mHealth f ield is

remarkably dynamic, and the range of applications being

designed is constantly expand ing. The key app lications for

mHealth in developing countries are:

Educat ion and aw areness

Remote data c ol lect ion

Remote mo nitor ing

Comm unicat ion and tra in ing for healthcare w orkers

Disease and epidemic outbreak t racking

Diagnost ic and t reatment sup port

This repo rt details 51 mH ealth program s, either currently

operating or slated for implementation in the near future,

that are taking place in 26 different de veloping countries.

mH ealth programs are mo re prevalent in some co untr ies

than others for reasons that have not yet b een assessed

by the acad em ic literature. In particular, India, South Af-

rica, Uganda, Peru, and Rwanda stan d out for their level

of m Health activity. As the c ase studies exam ined in this

report reveal, mH ealth program s are gain ing strong support

across regions, as we ll as sectors as d iverse as govern-

ments, technology providers and acade mia. Figure 2 sho wsthe geog raphic and appl icat ion area breakdow n of these

mH ealth projects.


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Figure 3 provides another view of the distribution of mHealth programs both geographically and

by app lication area.

The following section describes the major mHealth applications in developing countries and pro-

vides e xamples of p ro jects where the appl icat ion has been put into act ion.

Education and Awareness

Popular ized by teenagers in western countr ies and Japan who w anted a low -co st means of

com municat ing w ith f r iends, short m essage service (SMS) messag es now of fer a cost-ef fect ive,

eff icient, and scalable me thod o f providing outreach se rvices for a wide array of health issues.

In educ at ion and awareness ap pl icat ions, SMS m essages are sent d irect ly to users phones to

offer inform ation about test ing and treatm ent m ethod s, availability of health services, and d isease

management . Fo r m a l s t u d ie s a n d a n e c d o t a l e v id e n c e d e m o n s t r a t e t h a t S M S

a le r t s h a v e a m e a s u r a b le i m p a c t o n a n d a g r e a t e r a b i l i t y t o i n f lu e n c e b e h a v io rt h a n r a d io a n d t e l e v is i o n c a m p a i g n s . SMS alerts pro vide the further advantage of being

relatively unobtrusive, offering recipients co nfidentiality in environments w here d isease (espe cially

HIV/AIDS) is often tabo o. In the deve loping wo rld, SM S alerts have proven particularly effective

in targeting hard-to-reach populations and rural areas, where the absence of clinics, lack of

healthcare workers, and limited access to health-related information all too often prevent people

from making informed decisions about their health.

SMS m essage c ampaigns can b e set up either as one- way alerts or interact ive tools used for

health-related education and communication. For example, a cit izen may sign up to take a survey,

delivered via SMS messag e, quizzing them on their know ledge abo ut HIV/AIDS and the loca tion

of the nearest test ing center. Depending up on their responses, informat ion regarding w here and

how to receive a free test will be transmitted. This interactive model has been deployed in several

co untries (e.g., India, South Africa, and Uganda) to prom ote AIDS educ ation and testing and p ro-

vide informat ion about other com municable d iseases (such as TB), as w el l as to p romo te m ater-

nal health and educate youth about reproductive health.

Figure 3. Distribution of mHealth programs by location and application area.

Worldwide:

FrontlineSMS

Education & Awareness

Remote Data Collection

Remote monitoring

Communication & Training for Health Care Workers

Disease & Epidemic Outbreak Tracking

Diagnostic & Treatment Support

Meeting Health Needs Through a Broad Array of Applications


13/70111111Meeting Health Needs Through a Broad Array of Applications

While other communication mediums, such as radio, television, voice-based information hotlines,

and even interact ive w ebsites can be emp loyed in the service of ed ucat ion abo ut publ ic health

issues, SMS stands out as having several advantages over each of these: cost-effectiveness,

scalability, convenience, broad reach, and widespread popularity in the developing world.

By prom ot ing health-conscious behavior, the mH ealth educat ion and aw areness program s cur-

rently in place have already had po sit ive impac ts. The ubiquity and low c ost of SMS mes sages

hold the potential to shift the paradigm for health education by communicating with people in an

accessib le, engaging manner that bo th respects their pr ivacy and gives them the tools to m ake

informed choices.


Data collection is another crucial component of public health programs. Policymakers and health

providers at the national, district, and community level need accurate data in order to gauge the

effect iveness of exist ing po lic ies and prog rams and to shape new ones. In the developing w orld,

co llecting f ield information is particularly impo rtant since m any segm ents of the p opulation are

rarely able to visit a ho spital, even in the c ase o f severe il lness. Gathe ring data w here p atients live

is vital, and inform ation should ideally be up dated and ac cess ible on a re al-t ime bas is. The data

collection process is more eff icient and reliable if conducted via smartphones, PDAs, or mobile

phones rather than paper-based surveys that must be submit ted in person and m anually entered

into the central health database.

Data collection programs have been deployed in mult iple developing world countries, mainly

as p i lot pro jects. The most successful programs are sc aling up and beg inning to be de ployed

in mult iple count ries or regions. T h e s e i n it ia t i v e s a r e c l o s i n g t h e i n f o r m a t i o n g a p

t h a t c u r r e n t ly e x i s t s f o r p a t ie n t d a t a i n t h e d e v e l o p in g w o r l d , e n a b l in g

p u b l ic o f f ic i a ls t o g a u g e t h e e f f e c t i v e n e s s o f h e a l t h c a r e p r o g r a m s , a l lo c a t e

r e s o u r c e s m o r e e f f i c i e n t ly , a n d a d j u s t p r o g r a m s a n d p o l ic i e s a c c o r d in g l y .

Education and Awareness

Project M asiluleke an d Text to Change use SMS message cam paigns to

provide H IV/AIDS educ ation in South Africa and Uganda, re spec tively.

Project M asiluleke takes advantag e of the 120 sp are charac ters on free

please call me SMS messages to provide HIV/AIDS education andawareness, w hile Text to Change em ploys an SMS-based quiz to test

users HIV/AIDS knowledge and encourage testing and counseling.


Hundreds of health workers have used PDAs provided by the Ugandan

Health Information Network to c ollect health data in the f ield. Not o nly

has this so lution re sulted in significant co st savings25% in the f irst six

mo nthsbut health workers report increased job sat isfact ion due to

the gre ater eff iciency and flexibility provided by the techno logy.


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Remote Monitoring

TB patients in Thailand w ere given m obile phones so that healthcare

wo rkers ( themselves former TB p at ients) could cal l these pat ients on

a daily basis to remind them to take their medication. Medicine compli-

ance rates reached 90% due to the introduct ion of th is remo te mo ni-

toring app lication.

Remote Monitoring

One of the areas m ost uniquely suited to grow in tandem with mo bile technology is the remo te m onitor ing of p a-

tients. Rem ote m onitoring ope ns new pos sibil it ies for treating patients in an outpatient sett ing, a cruc ial cap ability

in developing countries w here acc ess to ho spital bed s and c linics is l im ited. This group of app lications co nsists

of one- or tw o-w ay com municat ions to mo nitor health cond it ions, mainta in caregiver appointments, or ensure

medication regimen adherence. Some applications may also include inpatient and out-patient sensors for moni-

toring m ult iple con dit ions.

Evidence shows that strict adherence to a medication regime is essential for effective treatment of a variety

of health co ndit ions, from AIDS to d iabetes. In addit ion, m o n it o r i n g p a t ie n t s a t h o m e f o r c h r o n ic

c o n d i t io n s d r a m a t i c a l ly im p r o v e s s u r v i v a l r a t e s . Remote monitoring applications are being

implem ented on a relatively limited b asis in deve loping countries, but the y are gaining traction in the develope dworld, particularly for chronic diseases. As the benefits of these applications are documented in the developed

wo rld and funding m odels evolve in developing co untr ies, remote mo nitor ing is expected to bec om e w idespread

and signif icant ly imp rove health outcom es for a wide range of com municable and chronic d iseases.

Credit: DataDyne

1212 Meeting Health Needs Through a Broad Array of Applications


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Communication and Training for Healthcare Workers

An acute shortage of healthcare workers is a major challenge facing developing country health sectors.

Train ing new cadres o f health professionals and emp ow ering c urrent wo rkers in order to increase job

satisfaction and reduce attrit ion are essential to meeting human capital needs. C o n n e c t in g h e a l t hw o r k e r s w i t h s o u r c e s o f i n f o r m a t io n v ia m o b i le t e c h n o lo g y i s a s t r o n g b a s i s f o r

e m p o w e r m e n t , a s i t p r o v id e s t h e s u p p o r t t h e y ne e d t o p e r f o r m t h e i r f u n c t i o n s

e f f e c t i v e ly a n d s e l f - s u f f ic i e n t ly .5

There is also a pressing need to improve communication among different health units to facilitate more ef-

f icient patient care. Due to the dearth of landline phones and Internet-enabled computers, it is not uncom-

mo n, for exam ple, for a patient to be sent to the reg ional hosp ital by the loc al clinic, only to f ind that there is

no bed available. Mobi le phones can help br idge these co mm unicat ions gaps that in the health context c an

often mean the difference between lives lost and lives saved.

Disease and Epidemic Outbreak Tracking

Outbreaks of com municable d iseases of ten begin in pockets, and, when left undetected , can develop

into epidemics. Recent instances of suc h devastat ing outbreaks ab ound, f rom c holera and TB to dengue

fever and Severe Ac ute Respiratory Syndrom e (SARS). D e p lo y m e n t o f m o b i le d e v i c e s , w i t h t h e i r

a b i li t y t o q u ic k l y c a p t u r e a n d t r a n s m it d a t a o n d is e a s e i n c id e n c e , c a n b e d e c i s iv e in t h e

p r e v e n t i o n a n d c o n t a in m e n t o f o u t b r e a k s .

Disease and epidemic outbreak tracking mHealth applications are being used in Peru, Rwanda, and India as

an early warning system , allowing pub lic hea lth off icials to mo nitor the spread of infectious diseases. Prior to

the ado ption of m obile netwo rks, public health officials relied upon w ritten, satellite, and radio co mm unica-

tion for such emergency tracking. The migration of this function to mobile systems is simultaneously improv-

ing data quality and lowering costs.

1313Meeting Health Needs Through a Broad Array of Applications

Disease and Epidemic Outbreak Tracking

Incidents of Japanese Encephalit is were tracked real-t ime in Andhra

Pradesh, India, via a c om bination of mo bi le pho nes and web -based

technologies. The government used the information to better priorit ize

vaccinat ions based on evidence o f clusters of o utbreaks.

Communication and Training for HealthcareWorkers

In the Primary Healthcare Nursing Promotion Program, the National

School for Nurses in Coban, Guatemala used an innovative combina-

tion of mob ile phon es, landline phones, and te le-w riters to train nurses

in this rainforest com m unity.

5 Iluyemi, A. and J.S. Briggs.Access and Connectivity for Community Based Health Workers in Developing Countries: Employing Wireless Technologies, Med-e-Tel 2008 Conference, Luxembourg.


16/70141414 Meeting Health Needs Through a Broad Array of Applications

Diagnostics and Treatment Support

Diagnostics and tre atm ent sup port are vitally im portant in healthcare m isdiagno sis or the inability to diagnose

a co ndit ion c ould have serious, even fatal, ramifications. m Health app lications in this area are designed to

provide diagnosis and treatment advice to remote healthcare wo rkers through wire less access to m edical

information databases or medical staff. W it h m H e a l t h -e n a b l e d d i a g n o s t ic s a n d t r e a t m e n t

s u p p o r t , p a t ie n t s a r e a b l e t o r e c e i v e t r e a t m e n t in t h e i r v i l la g e s a n d h o m e s , a v e r t in g t h e

n e e d f o r e x p e n s i v e h o s p i t a l v is i t s , w h ic h a r e b e y o n d r e a c h f o r m a n y .

Diagnost ic and t reatment ap pl icat ions use the phone as a point-of-care d evice. Health workers phones are

typically equipped with specialized tools, such as built- in software that leads the worker through a step-by-

step diagnost ic proc ess. Once data are entered into the system (e.g. , symptom s and an image of a pat ient s

injury captured on the mobile phone), remote medical professionals can diagnose the il lness and prescribe

treatm ent. By eliminating the need for patient travel, these app lications have th e po tential to d ramat ically in-

crease access to care.

Credit: UN Tim Mc Kulka

Diagnostic and Treatment Support

Researchers from the University of Melbourne are creating diagnostic

and analytical tools specif ically for m obile phones fo r health wo rkers in

Mozambique. These tools include a built- in calculator for determining

drug do sage and reference m ater ia ls stored in the phones m emo ry.


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Impact

1515Examining the Impact of mHealth Projects

Examining the Impact of mHealth ProjectsFormal studies and prel iminary project assessme ntsin bo th the developed and developing w orlddem on-

strate that m obile technology imp roves the e ff iciency of healthcare d elivery, and ult im ately makes he althcare

mo re ef fect ive. The long-term goal, and expectat ion, is that m Health programs will have a dem onstrable and

significant posit ive imp act on c linical outc om es suc h as reduc ed infant mortality, longe r life spans, and d e-

creased contract ion of d isease. Figure 4 i llustrates som e early results f rom other m Health programs across

the developing wo rld.

Muc h of the excitement over the po tent ia l of mHealth centers on the developing w orld, where m Health

programs put in place since the early part of the decade are now yielding actionable data that indicates that

som e of the ho ped- for benef its are m ater ia liz ing. These studies are c om plemented by those co nducted in

the developed w orldwhere mo bile phones achieved a h igh level of penetrat ion m ore than a de cade ag othat have begun to establish a signif icant body of evidence pointing to the health outcomes and eff iciency

gains that can result f rom the thoughtfu l design and implementat ion of m obi le-based program s and appl ica-

t ions. A br ief review of samp le m Health programs around the w orld de mo nstrates the palpable benef i ts of

using mobile phones in healthcare and prevention.

Improved Patient Health

Published clinical studies of mHealth programs point to an increasingly strong case for expanded mHealth

implementation. Patient health has been improved in three ways:

Im p r o v e d c o m p l ia n c e w i t h t r e a t m e n t r e g im e s : A 2007 Thai study showed that TB patients

who received daily text m essage m edicat ion rem inders jumped to over 90% adherence. A device cal led

SIMpill that uses mobile technology to monitor and direct medication adherence 6 also show s promise.

South AfricaProject Masilulekes SMS

message campaign promotingHIV/AIDS awareness resulted innearly a tripling of call volume to

a local HIV/AIDS helpline.

PeruCell-Preven. Health workersuse mobile phones to send

SMS messages with real-timedata on symptoms experienced

by clinical trial participants.Enables immediate response

to adverse symptoms.

UgandaText to Changes SMS-based

HIV/AIDS awareness quiz led toan increase of nearly 40% in thenumber of people coming in for

free HIV/AIDS testing.

PhilippinesPhoned Pill Reminders for TBTreatment. TB patients were

given mobile phones and calleddaily with reminder to take their

TB medication90% d id.

Figure 4. Impact of mHealth applications across the developing world.

6 Phoned pill reminders make inroads against TB. The Nation(Bangkok), January 28, 2007.


18/70161616 Meeting Health Needs Through a Broad Array of Applications

A 200 7 pilot in South Africa sho w ed that w ith SIMpill, 90% o f patients co m plied w ith their me di-

cat ion regime, co mp ared w ith the typical 22 to 60% c om pliance rate w ithout the system. The

solution is now available worldwide. In the United States, a study found improved drug adherence

rates amo ng HIV-po sit ive pat ients who received SMS

reminders to take dai ly med icat ion com pared to p a-

t ients w ho d id no t . The major ity of studies conduc ted

in Spain, Australia, Finland, and K orea on the bene fits

of using mobile technology in areas such as vaccina-

t ion fo l low -up and asthma or d iabetes self-care c on-

clude that mo bi le technology dem onstrably improves

pat ient outcomes.

Im p r o v e d p u b lic a w a r e n e s s o u t c o m e s : In

South Africa, Project Masiluleke, which promotes an

AIDS hotline throug h SMS mess ages, resulted in a

350% increase in phone c alls to the ho tline.

Im p r o v e d d is e a s e m a n a g e m e n t : A recent US

study on the use of wireless-enabled PDAs by Type 2

diabetes pat ients found g reater imp rovements in b lood

sugar indicators am ong regular users than among less

frequent users.7

Improved Health Systems Outcomes

Efficiency g ains enable im prove d quality of care. With ef-

f ic iency gains, more resources can be f reed up and distributed to a broader populat ion, and service

programs can be strengthened. Examp les of docum ented ef f ic iency gains include:

In Uganda, an AED SATELLIFE program that uses w ireless- enabled PDAs for disease surveillance,

col lect ion, and report ing produc ed a 24% cost saving o ver the t radit ional paper app roach. Eighty-

seven percent o f healthcare w orkers involved in the program said i t a llowed them to m ake faster

and mo re accurate d iagnoses.8

A Chinese study co nducted by Zhej iang University researchers found that send ing text message s

as appointment rem inders improved at tendance at a health prom ot ion center as ef fect ively as

phone reminders, whi le c ost ing o ver one- th ird less.9

In the United Kingdom, researchers at the Imperial College, London, examined the health out-

comes and eff iciency gains that mobile device usage might bring to their national system. They

found that the annual d irect c ost o f missed hosp ita l appointments in England each year amounts

to 575 m ill ion. These co sts are in addit ion to higher exp enditures incurred by the health system

for pat ients w hose health or t reatment are negat ively af fected by m issed app ointments and w ho

then req uire addit ional med ical attention.10

7 Forjuoh, Samuel N., Michael D. Reis, Glen R. Couchman, and Marcia G. Ory. Improving Diabetes Self-Care with a PDA in Ambulatory Care. Telemedicine and e-Health. 14(3), April 2008. See http://www.liebertonline.com/toc/

tmj/14/3 for the article and author listing.8 Gebru, Berhane. Disease Surveillance with Mobile Phones in Uganda. Retrieved 16 November 2008 from http://mobileactive.org/berhane-gebru-disease-surveillance-mobile-phones-uganda.9 Chen, Zhou-wen, Li-zheng Fang, Li-ying Chen, and Hong-lei Dai. Comparison of an SMS text messaging and phone reminder to improve attendance at a health promotion center: A randomized controlled trial. Journal of

Zhejiang University Science. 9(1), January 2008.10 The Role of Mobile Phones in Increasing Accessibility and Efficiency in Healthcare. Moving the debate forward. The Vodafone Policy Paper Series, Number 4 (Newbury: Vodafone Group Plc, March 2006).

A 2007 pi lot in South

Afr ica showed t hat

wit h SIMpi l l , 90% of

patients compl ied

wi th thei r m edicat ion

regime, compared wit h

the typical 22 to 60%

compl iance rate w ithoutthe system.

When talking about effici ency versus healt h

impact, i t shouldnt be about ei ther/ or.

Improving efficiencies can ensure that more

people receive l i fe-saving int erventions.

John Steph enson,Dalberg Global Development Advisors


19/70171717Meeting Health Needs Through a Broad Array of Applications

While developed countries present different economic and cultural condit ions from those found in

developing nations, the results of the studies m ay contain app licable lessons, esp ecially as rich wo rld

diseases become increasingly prevalent in the developing world. The World Diabetes Foundation

pred icts that by 202 5, 80% of all new diabetes c ases w ill originate in developing co untries, which w ill

require new approaches for deal ing w ith th is and other c hronic d iseases. Studies conducted in the de-

veloped w orld may also pro vide useful lessons in monitoring and evaluation, as well as study d esign.

There remains a need for large-scale evidence of m Health ef fect iveness, as m easured by long-term ,repeatable imp roved outco mes in e ither health or ec onom ic terms. Such studies w ould be part icu-

larly valuable in developing country contexts, and sponsors should continue to evaluate progress in

order to establ ish clear-cut proof of concep t and strengthen the c ase for scal ing p rograms nat ional ly,

regionally, and beyond .

Creating a Framework for Impact Measurement

mH ealth program s that def ine r igorous impact assessment m ethods w il l be m ore l ike ly to secure c on-

tinuing funding and become sustainable over the long term. A Dalberg Global Development Advisors

study, commissioned by the UN Foundation and Vodafone Foundation Technology Partnership on the

use of PDAs for health inform ation, offers a potential tem plate for determ ining the effect iveness of cur-

rent and future m Health programs. Dalberg w orked w ith the Partnership, the W HO, M inistry of Healthoff icials in pilot count ries, and DataDynea non-p rofit provider of m obile health data so lutionsto

develop a theory of change and to c onduct a basel ine assessm ent of the test p rograms funct ional ity.

The study lays out a proc ess for m onitoring the collection and analysis of health data at the local and

regional levels. This app roach identified unforesee n tech nical, logistical, and d ecision-m aking prob -

lems in the pilot case. For example, it was discovered that the high cost of fuel prevented Ministry of

Health off icials from g oing out to c ollect d ata and the sho rt battery life of som e PDAs caused a loss

of data. Bot h of these issues significantly reduc ed the am ount and q uality of data available for dec i-

sion making. Dalberg also monitored the use of data once it was collected, particularly in the context

of health ministry meetings. The study identif ied instances where the data was not properly integrated

into dec ision making and d escr ibed how processes c ould be improved to ensure that resource alloca-

tion decisions are more data-driven. Overall, the study helped to determine both the cost effective-

ness of d ata col lect ion and the outputs that f low d irect ly f rom the data.

Dalberg notes th at mo nitoring and e valuation efforts can fac e crit ical challenges in the short term , par-

t icularly with lim ited budg ets to fund suc h activit ies. To overc om e som e of these c hallenge s, it is im -

portant to focus f irst on managing toward short- term outputs, such as how many PDAs are deployed.

The next step is to correlate short-term outputs with actual long-term health impact. This is quite diff i-

cult , because the object ive is of ten to m easure outcom es that d id not oc cur, such as d ecreased infant

mo rta lity and disease incidence, or outcom es that oc cur over the long term . As m Health applicat ions

improve the process of data collection and the incorporation of data into decision making, this will

provide a foundat ion upon which to c onduct long-term imp act evaluations.

It s import ant t o have an ROI [return on

investm ent] m odel that art ic ulates the cost

savings of m Health, and also to t ake into acc ount

th e economic burden of h ealth. You are tr ying

to prevent negative health out comes, and i f you

prevent t hem you cant easi ly measure that .

Eduardo Jeziersk i,

Vice Presid ent of Engineer ing, InSTEDD


20/7018

Credit: Vital Wave Consulting

Assessing mHealth and Future Health Needs in Developing Countries

Fut ure Healt h Needs

Assessing mHealth and Future Health Needs in

Developing CountriesEqually impo rtant to the cos t-e ffectiveness and s calability of mHe alth is its ability to provide an effec tive tool for ad-

dress ing emerg ing health needs. Hea lth expe rts note that w ithin the next 15 years, policym akers and health provid-

ers in the developing world will be forced to turn their focus to prevention and early detection rather than late-stage

treatment of non- com municable d iseases, such as d iabetes and c ancer, as w el l as to the health needs of an ag ing

population. 11 These changes are being caused by t rends such as m igrat ion f rom rural to urban areas, econom ic

growth, and changing dietary habits. As developing countries tackle and make signif icant improvements in the

spread of communicable disease, average income levels increase along with average life expectancy. Even a slight

increase in incom e contr ibutes to changing dietary habits, and consum pt ion of meat produc ts and proc essed foods

is linked to the contraction of diabetes and cancer. Late detection of these diseases leads to lower survival rates

and reduc ed l ife expectancy, and has neg at ive co nsequences for socia l and ec onom ic development. Developing

countr ies are therefore being co nfronted with a double burden o f t reat ing and c ontain ing the sp read of co mm unica-ble diseases w hile c om bating a w ide range of unfam iliar health cha llenge s. Table 1 illustrates these evolving trends.

11 Gutirrez-Robledo, L.M. Looking at the Future of Geriatric Care in Developing Countries.Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 57:M162-M167, 2002.

Current Healthcare Picture

Communicable diseases.

Lack of immunizations.

Lack of safe water sources.

Global & Demographic Changes

GDP growth increases spending on healthcare.

Traditional diseases controlled (TB, smallpox)and new diseases appear (SARS, avian flu).

Aging populations mean increase in death fromnon-communicable causes.

Declining birth rate and climbing life expectancy.

Adop tion of developed country behaviors.

Tomorrows Healthcare Picture

Current health care picture issuescontinued.

Shift from late stage treatments toprevention and early detection.

Increased focus on health issues of elderly.

Continued health worker shortages anddistribution inequities.

Table 1. Looking ahead: Evolving mHealth services for evolving health needs.

18 Assessing mHealth and Future Health Needs in Developing Countries18


21/7019Assessing mHealth and Future Health Needs in Developing Countries

m Health is well-p osit ioned to add ress these c hallenge s using tools currently available. For examp le, just as

SMS alerts are useful in raising public health awareness of communicable diseases, these same types of

a lerts can be used to ensure pat ient adherence with t reatment of c hronic d iseases such as d iabetes. SMS

alerts can be sent out to address c hronic d iseases and m ental health issues in urban areas such as sm oking

cessation and nutrit ion reminders.

M any midd le-incom e co untries in the deve loping wo rld (i.e., Brazil, Argentina, Thailand, Mexico, and Turkey)

are a lready seeing a shift away from c om municable d iseases tow ard chronic d iseases (such as heart d is-

ease and diabetes). In these co untries, there is already evidenc e that mHealth program s are expe rimenting

with addressing a w ider range of c hronic non- com municable d iseases, with a focus on early t reatment.

12 World Diabetes Foundation. Diabetes Facts. Retrieved on 16 November 2008 from http://www.worlddiabetesfoundation.org/composite-35.htm.

Credit: WFP Susan Schulman

Shift from Communicable to Chronic Disease

Over the next 10 years the co st of diabetes, heart disease, and stroke w ill take a trem endo us

toll on the national incomes of developing world countries. According to estimates by the

WH O, diabetes, heart disease, and st roke to gethe r will co st abo ut $555.7 bill ion in lost

national inco me in China, $303.2 bill ion in the Russian Federation; $ 336.6 bill ion in India; and$49.2 b ill ion in Brazil. Even beyond these c ountries the c ost w ill be signif icant. The co st of

these d iseases for Tanzania in the sam e period is estimated to be $ 2.5 bill ion. 12

19Assessing mHealth and Future Health Needs in Developing Countries 19


22/70202020

Evolution of Mobile Technologies

Addressing future health needs will be facilitated by the development of mobile technologies and network

expansion. The key technology t rends in mobile technology co nt inue to be the same trends that have char-

acter ized technological progress for the p ast 40 years: miniatur izat ion, greater sp eed, and cost reduct ion.

These advances are ref lected in mob ile te lephony by som e of the advancem ent issues shown in Table 2. A

greater range of services b ecom es po ssib le with more uniform, faster, and m ore af fordable broadb and ac-

cess; greater acc ess and coverage expands the subscr iber base, bui ld ing volume, creat ing incent ives for

players, and helping push sustainable mHealth applications beyond simple one-way data services.

Table 2. Evolving mobile technology capabilities.

The MediNet Healthc are Management System is beingdeveloped by researcher s at t he Universit y of the

West Indies and Mic rosoft for m onitor ing and treatingdiabetes and cardiovascular d isease. The system w il l

provide treatment suggestions to patients via mobile

phone text or pre-recorded voice m essages.

Assessing mHealth and Future Health Needs in Developing Countries

Current Technology PictureKey Technology

Advancement IssuesTomorrows Technology Picture

Hardware

Mobile phones carry range of featuressuitable for basic mHealth services andcountry varations.

Most new handsets acc ess web (GPRS,other), download pictures and images.

Speed limits applications andcountry variations.

Most laptops, handhelds, PDAs easilyaccess wireless networks where available.

WiMAX-type chipset standardfor PCs (Intel, others) becomes

standard.

Increased intelligence blurs distinctionbetween cell phones and mobile c omputers.

Solar chargers, larger displays.

Software/Applications

Widely available for laptop and handhelds.

Only recent availability for handsets asvendors open architecture.

Java Virtual Machine (JVM),Open Systems.

Acceptance of OSS accelerates applicationdevelopment, reduces cost.

NetworkAccess

Cellular common in urban, less so in rural.

Broadband, Internet access limitedgeographically, costly.

Greater bandwidth for newapplications.

NGN, IMT-2000.

Network transparency.

Wireless networks create near universalInternet access.

Standards Broadband, Standards may require policy

decisions.

Spreading IP access forstandards, licensingdecisions.

Greater range of servic es, providerpartnerships permitted.

Services

Education/awareness programs.

Medication monitoring.

Data collection services.

Disease tracking.

Remote monitoring.

More sophisticated diagnoses/consultation,e.g., teleradiology, teleopthamology.

More effective use of healthcare workers.

More personal mHealth services.

Services for travel-restricted.


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Sustainable and Scalable

2121Identifying the Building Blocks for Sustainable and Scalable mHealth Programs

Identifying the Building Blocks for Sustainable

and Scalable mHealth Programs

Success can beget success in the f ield of mHealth if organizations enhance their opportunity to drive

successful outcom es b y learning f rom similar pro jects taking place w ith in the mH ealth ec osystem. This

section identif ies mHealth projects that embody practices of highly scalable and sustainable mHealth

program s. The case studies reveal som e of the key benef its of m Health, and provide examp les of how

to struc ture succ essful mHe alth init iatives. These c ase stud ies also reflect the f ields dynam ism, as each

w as implem ented w ithin the 12 m onths prior to the pub lication of this repo rt.

Key Building Blocks for Success

As a young field, mHealth is well posit ioned to b enefit from best p ractices and available techno logy

docum ented in ear ly project reports. The case studies of mH ealth projects and input f rom industry

experts reveal com mo n pract ices that c ol lect ively form the bui ld ing b locks for succ ess in th is young,

dynam ic f ield.

Forge strong partnershipsPartners from multiple sectors bring diverse strengths to the project. Ensuring that each part-

ner advances its organizational goals through the project paves the way for successful future

collaborations.

Be accessibleCommunication is more effective when tailored to specif ic social, ethnic, and demographicgroups. Colloquial language and references to pop culture may be effective in reaching teen-

agers, whi le o lder populat ions m ay prefer a mo re formal approach.

Design with the end user in mind and maintain a focus on usabilityApplicat ions and devices must take the users w ork environm ent into acc ount in the design

phase . In the m Health environmen t, ease of use is essential.

Build a long-term funding planContinuing the project be yond the init ial seed funding can be a cc om plished b y aligning w ith

long-term national health goals. Integration with the national health care program of the coun-

try of o peration is essen tial.

Set measurable goalsBy set t ing inter im goals and benchm arks, mHealth projects c an provide proof of succ ess, a l-

lowing them to secure support and funding for expansion. Sett ing measurable goals also helps

project p rincipals to identify the need t o quickly correc t a particular course of ac tion in the

event that inter im targets are not m et.

Collaborate with other mHealth organizationsWith dozens of projects currently operating, the mHealth f ield is now in a strong posit ion to

move forward by sharing techniques and applications. Organizations such as the Open Mobile

Conso rtium are facilitating the ab ility of the field to m ove forw ard by sharing be st prac tices.


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Credit: DataDyne

Project Masiluleke

C o u n t r y : South Africa

S p o n s o r i n g O r g a n iz a t io n a n d P a r t n e r s :

Praekelt Foundation, iTeach, N ational Geographic, No kia Siemens N etw orks, M TN, Ghetto Ruff, Children of

South African Legac ies, Aricent , frog d esign and National AIDS Helpline

The Project

Project M asiluleke sent three hundred and sixty f ive m ill ion tex t m essag esone m ill ion pe r dayin 2008 to

encourage people to be tested and treated for HIV/AIDS and TB. According to sponsor Pop !Tech, Project

M asiluleke represe nts the largest us e of m obile devices for the d elivery of HIV/AIDS and TB information and

treatm ent in South Africa, with the pot ential for future expansion to o ther co untries.

Project M asiluleke takes advantag e of the po pularity of Please Call M e (PCM ) services, which are w idely

used in South Africa and throughout Africa. These free text messages are used by individuals without phone

credit to prom pt recip ients to cal l them. PCM m essages co ntain the w ords Please Call Me, and the phone

number of the sender. The remaining 120-character spaces can be f i l led with advertising, but Project Masi-

luleke sponsor MTN is donating the space in one mill ion messages each day to be used for HIV/AIDS and TB-related information. The message content is provided by outreach and service organization iTeach.

M essag es are w ritten in local languag es, and are used to direct rec ipients to the National AIDS Helpline. Once

patients have ca lled, repre sentatives of the hotline provide inform ation about tes ting services and locations.

Be Accessible

With many countries having mult iple local and regional languages, communicating with

peo ple in the language th ey kno w best is crit ical. Similarly, it is esse ntial to und erstand the

target dem ographic. Col loquia l language and references to pop culture m ay be ef fect ive inreaching teenagers, w hile o lder po pulat ions m ay prefer a m ore formal approac h.

2222 Identifying the Building Blocks for Sustainable and Scalable mHealth Programs


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Objectives and Results

Project Masiluleke is designed to make more people aware of their HIV status because in South Africa, one-

quarter of the population is estimated to be infected with HIV, but less than 3% know their status. The broader

goal of the program is to have those infected receive treatment and to halt the spread of the disease. Init ial

results from a beta te st of the p roject indicated that it helped to nearly triple call volum e to the helpline in the

three w eeks d uring which it ran. The project partn ers are building in rigoro us m onitoring and evaluation of the

project b y, for exam ple, linking calls to the helpline to PCM text m essag es throug h the use of distinct phon e

numbers that a llow organizers to ver ify the number of cal ls generated b y the program . Once the p roject is

operat ing successfully, the system will be expanded to p rovide informat ion abo ut TB resources and treatme nt.

Future Plans and Scaling Challenges

The next phases of the project will be the use and extension of the Praekelt Foundations TxtAlert program to

remind HIV-posit ive patients to take their medication and keep medical appointments; the creation of virtual

call centers staffed by highly adherent patients; and the deployment of easy-to-use home HIV test kits, as the

social st igma attached to HIV often prevents people from going to public clinics for testing.

Challenge s rem ain for scaling projects like M asiluleke. Working acros s m ult iple netw orks, deve loping relevant

m essag ing, and catalyzing resourc es to t ake the init iative to scale are all diff icult, acco rding to Rob in Miller ofPraekelt Foundation. Yet the projects early achievements point to some factors that increase the likelihood of

succ ess. M iller says that several ingred ients have been c rit ical for succe ss:

En s u r in g s t r o n g l o c a l p a r t n e r s t o d e v e lo p r e l e v a n t c o n t e n t . Masilulekes partners enable

the organization to tap into an already established customer base and also leverage their knowledge to

build valuable conten t.

M e t h o d o f i n t e r a c t in g w i t h t h e in t e n d e d a u d ie n c e . We have found that mo bi le phone innova-

tions already exist, even without new applications. For example, sending missed calls led to the creation

of the PCM m essage w hich w as the start ing point for the project .

S c a l in g a n d p r o g r e s s a r e o n ly p o s s i b le t h r o u g h r i g o r o u s d a t a c o l le c t io n a n d

a n a l y s i s . Only through measurement c an we know what is working and where redirect ion is needed.

Credit: Vital Wave Consulting

Identifying the Building Blocks for Sustainable and Scalable mHealth Programs


26/7024

Multiple Health Issues Addressed by SMS Campaigns

Netcare Vodacom Smile for You CampaignHundreds of thousands of children in the developing world are af-

f licted w ith the cond it ion kno w n as cleft l ip and palate, a relatively com mo n birth defect that is all but invisible in

rich countries w here surge ry to co rrect it is w idely available and affordable. Children w ho are not ab le to have

this condit ion remedied through surgery often have eating and speech diff icult ies and face social discrimina-

tion. In 2007, the Netcare Group, a private medical hospital group in South Africa, and Vodacom teamed with

the Praekelt Foundation to offer 50 free c left l ip and p alate surgeries to children to o po or to afford the m. A

previous cam paign to raise aware ness of this service had relied o n tradit ional med ia such as print and radio

but yielded disapp ointing results, w ith only abou t 12 cand idates identif ied for the surgery.

For the Smile for You campaign, the sponsors shifted to a mobile technology solution to improve response

levels. In South Africa, Please Call Me (PCM) text messages, which mobile phone users can send for free with

a request to the sender to cal l, have becom e an enorm ously popular service, and o perators subsid ize them

through the sale of advert is ing spac e in the unused character spac e of the text messag e. Over the course o f

f ive days, Vodacom donated sp ace in one m ill ion PCM text m essages for a m essage asking recip ients i f they

knew of children in need of free cleft l ip and palate surgery, using Praekelt s SocialTxt tec hnology (also used in

HIV/AIDS outreach ef forts). During the f irst tw o d ays, recip ients who wanted mo re informat ion w ere prom pted

to phone a call center manned by Netcare staff. Beginning on the third day, recipients were given the option

of sending an SMS with the word SMILE to the Netc are cal l center, whereupon a representat ive w ould phone

them to provide further information about the surgery offer (result ing in a lower cost to the message recipient).

The results of the c ampaign dem onstrated the ef fect iveness of th is concept. C a l ls m a d e t o t h e c a l l

c e n t e r , w h ic h h o v e r e d i n t h e s in g le d i g it s i n t h e w e e k s b e f o r e a n d a f t e r t h e c a m p a i g n ,

a v e r a g e d n e a r l y 3 5 p e r d a y , w h ile s t a f f r e c e iv e d o v e r 3 5 5 t e x t m e s s a g e s d u r i n g t h e

t h r e e d a y s t h a t r e s p o n d i n g v ia t e x t m e s s a g e w a s a n o p t i o n . In a l l , 4 2 c h i ld r e n w e r e

id e n t i f ie d a s s u r g e r y c a n d id a t e s , m o r e t h a n t h r e e t i m e s t h e n u m b e r i d e n t i f ie d d u r in g a

t r a d i t io n a l m e d i a c a m p a i g n la s t in g s i x w e e k s . The sponsors note that 203 people who d id not know

anyone with a cleft l ip or palate responded, indicating that broadening the campaign to include languages

other than English might yield even m ore pro mising results.

According to the Praekelt Foundation, several factors were essential to the campaigns success. All of the

partners involved in the project broug ht streng ths to it , as w ell as a de sire to rigorously track res ults. The w ill-

ingness to c hange tact ics in the middle of the camp aign also a llow ed the spo nsors to co mp are com municat ion

method s in order to determine w hat w as l ike ly to w ork in future c ampaigns. And pe rhaps m ost c r it ica l ly, the

partners leveraged the popular ity of PCM message s and the experience Praekelt had accum ulated in previous

campaigns using SocialTxt software.

Credit: UN Mark Garten

2424 Identifying the Building Blocks for Sustainable and Scalable mHealth Programs


27/70252525Identifying the Building Blocks for Sustainable and Scalable mHealth Programs

Text to Change (TTC)

C o u n t r y : Uganda

S p o n s o r i n g O r g a n i za t i o n a n d P a r t n e r s :

Celtel, AIDs Inform ation Centre (AIC), Merc k, and the Dutc h M inistry of

Foreign Affairs

The Project

Text to Change (TTC) pro vided HIV/AIDS aw areness via an SM S-

based quiz to 15,000 m obile phone subscr ibers dur ing three m onths in

Uganda. TTC was founded with the goal of improving health education

through the use of text m essaging, which holds the advantages of anonymity and strong uptake amo ng

the po pulation. Partnering w ith the mo bile carrier Celtel and the local NGO AIDS Inform ation Centre (AIC),

TTC co nducted a p i lot p rogram from February through Apri l 2008 in the Mb arra region of Uganda, with the

objective of increasing public knowledge of and changing behavior around AIDS. The program aimed to

enco urage c it izens to s eek voluntary testing and c ounseling for HIV/AIDS.

An SMS-based mult iple choice quiz was administered to 15,000 Celtel mobile phone subscribers in the rural

region of Mbarra. Free air t ime was of fered to users to enco urage part ic ipat ion in the prog ram; th is was de -termined to be a pow erfu l incent ive since users c an exchange the air t ime with other subscr ibers as a type

of currency.

The quiz w as interact ive. When p art ic ipants gave a w rong answ er they received an SMS with the correct

answ er from the c ell phone p rovider. The uptake rate of the survey w as 17.4% and focused o n two spec ific

public health areas:

General knowledge about HIV transmission

The benefits of voluntary testing and c ounseling

At the end o f the quiz, a f inal SMS w as sent to m otivate participants to go for voluntary testing and cou n-

seling at the local health center. Those who went to the center were asked a f inal question: Was this wasthe f irst t ime they had an HIV test? After testing, participants were requested to leave their mobile phone

number so that post- test c ounsel ing co uld be arranged. For the peop le w ho cam e to the health centers

through TTC, HIV testing and c ounseling was free o f charge. Init ial grants from M erck, the US pharm aceuti-

cal company, and the Dutch Ministry of Foreign Affairs supported the program launch.

Forge Strong Partnerships

Successful mH ealth projects requ ire the participation of partners w ith expertise in the f ields of techno logy,

healthcare, and academia. Validation and testing are key steps in the conception of mHealth programs and this

phase typ ically occ urs w ithin a university sett ing or a techn ical organization. In order to m ove to the implem enta-

tion stage, how ever, it is essential to bring o ther partne rs into the pro ject. Dr. Patricia Me chael of the Earth Insti-

tute notes that The projects that have b een implemented at signif icant scale have forged strong partnerships,

either with a government or a private corporation. Mechael further aff irms that the mHealth f ield currently f inds

itself in a p lace w here a num ber of pro jects are in the design and test ing phase that have not yet m ade the m ove

to implementat ion. As the diverse sec tors involved in mH ealth cont inue to c ol laborate and the co rporate and

pol it ica l c limate becom e m ore support ive we exp ect to see mo re projects move into the implementat ion phase.

Text to Change (TTC) provided HIV/ AIDS awarenessvia an SMS-based quiz t o 15 ,000 mobile phone

subscrib ers during three months in Uganda


28/70262626 Identifying the Building Blocks for Sustainable and Scalable mHealth Programs


The quiz had tw o g oals:

Collect information. In particular, the program was able to assess the rate of correct or incorrect answers

within certain socio-economic sectors, and pass this information along to UNICEF.

Prom ote te sting and co unseling. The quiz notified participants of the location of the nearest te sting

center. If they stated that they were referred f rom the quiz, test ing w as f ree ( there w as norm ally a small

charge for test ing).

The quiz produc ed a 40 % increase in patients who cam e in for testingfrom 1,000 to 1,400 during a six-w eek

period.

In terms of information gathering, a key f inding of the survey was that although people were quite knowledge-

able about issues such as condom use, they d id not th ink that AIDS test ing w as acc urate or anonym ous. This

was a major f inding, in that the population of Uganda had not been surveyed on this question before. TTC was

able to pass th is along to larger health agencies ope rating in the region, thereby c ontributing to the eff icacy of

existing health programs.

TTC co -found er Hajo van Beijm a notes that there w as init ially an elemen t of risk for the funders since this

type of pro ject had not been conduc ted before, but now that w e have proven results we have the opp ortu-

nity to expand. TTC is planning a follow- up pro gram in Ugand a in January 2009. One o f the goals of this next

campaign is to promote the safety and effectiveness of the testing center, and therefore specif ically encour-

age test ing.

In this phase , collaboration with local partners w ill be further strengt hened , with the local HIV/AIDS organiza-

t ions subm itt ing quest ions. Text to Change intends to shorten the durat ion of the p rogram to four w eeks, hop-

ing to minimize participant drop-out rates, and to include non-English speaking subscribers by enabling them

to read SM S messag es in their loc al languag es.

The pilot saw the sponsoring partners benefit as well: Celtel (now rebranded Zain) reaps benefits not only

from a corporate social responsibil ity (CSR) perspective but also through the promotion of its texting service.

The test ing ce nter increased the num ber of tests c onducted, p lacing them in a po sit ion to receive expanded

funding.

Credit: Text to Change

Set Measurable Goals

As w ith any init iative, sett ing m easurable g oals estab lish-

es the barom eter that a llow s mH ealth projects to assess

succ ess o r failure. It builds in the rigor that is required if

course co rrect ions are needed during the project . Once

achieved, these goals, in turn, form the b uilding blocks

for success, a l low ing the project to m ove forward w ith

larger implementat ions and broader partnerships.

The quiz produced a 40% increasein patients who came in for

test ingfrom 1 ,000 to 1,400 dur inga six-w eek period.


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Future Plans and Scaling Challenges

Hajo van Bei jma hopes to bui ld upo n lessons learned from the pi lot . He c om ments, Af ter the p i lot w e

saw that our ini tial program d idnt have a g ood survey running. In the sec ond round we developed a new

survey w ith Ugandans, and used university students . Their IT know ledge is fabulous. They really know how

to prog ram these kinds of sof tw are tools in Uganda.

The new program in January 2009 will target 30,000 people, and ult imately TTC plans to do a nationwide

rol l-out . Van Bei jma notes, I f we are able to p rove that w e can send out a large num ber of quest ions, that

will lay the groundwork for the nationwide program. In the f irst pilot there were some issues with being

able to send out a large number of quest ions at the same t ime.

Van Beijm a cites several crit ical succe ss factors for sc aling Text to Change and similar mH ealth projects.

These include:

D e v e lo p s u r v e y s in t h e n u m e r o u s l o c a l la n g u a g e s . This w ould make their message m ore

acc essible to spec ific ethnic and soc ial group s. Literacy is also an issue. Ho w ever, van Beijma notes ,

I f people do not sp eak or read English and they ge t a text m essage they w i ll ask their neighbor what

it means.S e c u r e o n g o i n g f u n d in g . Though TTC is more cost ef fect ive than many other educ at ion pro-

grams, steady funding will allow for stable operations and growth.

C o l la b o r a t e w i t h o t h e r m H e a l t h o r g a n iz a t io n s . Van Beijma notes that one of the co nsen-

sus f indings of the recent MobileActive conference in South Africa (October, 2008) is the need to

set up a co nsort ium to p romo te co l laborat ion am ong m Health organizat ions in d ifferent developing

countries. The goal is to work with organizations that are doing similar and complementary things in

different countries. This way if we move into other countries we will combine strengths, for example,

by d eveloping sof tware together.

Credit: Text to Change


30/70282828 Identifying the Building Blocks for Sustainable and Scalable mHealth Programs

C o u n t r y : Brazil

S p o n s o r i n g O r g a n i za t i o n a n d P a r t n e r s :

Nokia, Amazonas State Health Ministry

The Project

In the Am azonas s tate of B razil, containing deng ue fever is a con stant ch allenge d ue to he avy rainfall during

mo st of the year, and local methods for stor ing w ater in hom esboth of w hich have been show n to prom ote

mo squito breeding. The state health departm ent must w arn households co nstant ly about the dangers o f be-

haviors that encou rage m osq uito proliferation. Despite these difficult ies, the state is one of the m ost eff icient

at co ntaining the spread of the virus relative to o ther states in Brazil, due pa rtly to its partne rship with No kia

on the Data Gathering m Health init iative.

The Nokia Data Gathering system enables fast and effect ive data collection, w hich is essential to containing

the spread o f the dengue virus. Developm ent of the sof tw are began in the f irst quarter of 2007 and i t was

piloted in different regions of Brazil during that same year. The Amazonas Health Department undertook the

first full im pleme ntation of the solution, which beg an in October 2 008.

Data Gathering allows the creation of customized questionnaires, which are distributed to the mobile phones

of health agents in the f ield. When the f ield w orkers f inish their surveys, they send the d ata bac k to the se rver

via a wireless connection, from which it can be integrated into the organizations existing systems for imme-

diate analysis. Data Gathering also pro vides GPS location inform ation for each rec ord, w hich wo uld otherw ise

require d edicated instruments.

Users repo rt the too l is flexible and easy to us e. As Luzia de Melo M ustafa, an Amazo nas health agent, af-

f irms , It s easier, quicker and m ore p ractical. You type it and send it r ight away, it goes straight to the server.

Then the data is co nsol idated and we can get the result imme diate ly and, consequent ly, we may take ther ight act ions, what w e need to do . The devices are p rovid ing us w ith precision; the informat ion w e need to

develop [effective responses] in the areas where the infection levels are high.


The goals of the p roject are all about saving t ime to save lives. Andre, p roject principal, states The init ial

impetus fo r the project st arted w ith a meeting in Brasilia w ith the federal M inistry of Health w here w e tried to

f ind a w ay to use m obile technology to improve current health data surveys being cond ucted using pen and

paper. There w as a real need to m ake the proc ess m ore agi le and m ore re l iable, provid ing the governme nt

with a tool that could ult imately save lives through the use of smartphones.

Results of Data Gathering implem entation to dat e are highly enco uraging. The project team s preliminary

evaluat ion has show n that the t ime spent in data gathering w as drast ical ly reduced, and end-user ac cept-

ability has been very high so far. Even before the full implem entation, mo re than 400 res ults were g athered

during the tes ts by a te am of 20 f ield pro fessionals in the c ourse o f two days, all w ith GPS inform ation. Luzia

de M elo conf irms, Be fore we used to w ait for one or two m onths before we c ould get a ll the consol idated

inform ation. Now, w e have it on a daily basis. As Greg Elphinston, Com mu nity Involveme nt Directo r for

Nokia, elaborates, If you have to wait two to three months for information in the health context, this can be

the difference between life and death.

In order to stop an outbreak and themeans of disease tr ansfer, w e need

to have the inform ation very fast.Thats the only way to prevent t hevirus of dengue from c irculating.

Luzia de Melo M ustaf a,Health Agent coordinator, Amazonas Brazil

More than 400 r esults were gathered during the tests by a team of 20 f ieldprofessionals in t he course of t w o days, all w it h GPS inform ation. Luzia de

Melo confirms, Before we used to wait for one or t wo m onths before wecould get all the consoli dated inf orm ation. Now, w e have it on a daily basis.


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Future Plans

Plans for expansion w il l be b ased o n a c om prehensive evaluat ion o f current w ork. The imm ediate growth

objective is to broaden the covered areas in the Amazonas state, as well as adding yellow fever and malaria

to the list of diseases to be surveyed.

Project staff cite several crit ical succ ess facto rs for Data Gathering and s imilar projects , including:

W o r k c lo s e l y w i t h lo c a l a n d r e g i o n a l g o v e r n m e n t a g e n c i e s . The service must respond to

the local needs as p erce ived by local officials. Their supp ort for the pro ject will m ake implem entation and

expansion possible.

M a i n t a in a f o c u s o n u s a b i li t y . Acco rding to Andre Erthal, Head o f Comm unity Group at the Nokia

Techno logy Institute, If the f ield agents do no t see the device as part of the ir work o r have diff icult ies in

using it, it may severely dam age the o verall succ ess of the imp lementation. That is one o f the reasons

why the solut ion w as developed since the beg inning w ith the end user in mind, so we could develop the

solution to be a s user-friendly as possible.

Wo rking in partnership w ith Nokia, Pan Am erican Health Organization (PAHO), and N ational Foundation

for Indigeno us Peop les Health (FUNASA), the UNF-VF Techn ology Partnership w ill be launching a pro-

gram called Mobisus in Brazil in 2009, utilizing m obile phones for health data gathering.13

Government Support is Critical for Long-term SuccessThe major ity of m Health projects are imp lemented w ith seed funding f rom phi lanthropic o rga-

nizations suc h as founda tions and m ult ilateral institutions, or as part of a co rporate soc ial re-

spo nsibil ity init iative b y a for-p rofit business. The three case studies highlighted in this rep ort

provide p roof o f conc ept, and init ial pos it ive results. How ever, all too often, onc e the init ial

funding has b een ex hausted the pro jects f ind it diff icult to ac hieve scalability and sustainabil-

ity, result ing in unintended term ination. Ensuring long- term sustainability is a m ajor challenge

for mH ealth projects.

Expert researc hers in the public health and eH ealth arena are currently exam ining the

sourc es o f sustainability for m Health pro jects. In particular, Dr. Adesina I luyem i, a PhD Can-didate at the University of Portsmouth, United Kingdom focusing on sustainable mHealth in

developing countries, has noted that mHealth projects are far more likely to be sustainable in

cases w here buy- in f rom governmental or p ubl ic bodies is

Mobile Health for Development

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