mHealth New horizons for health through mobile technologies
Based on the findings of the second global survey on eHealth
Global Observatory for eHealth series - Volume 3
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2011
Global Observatory for for Observatory Global 3 - Volume series eHealth Based on the findings the of on eHealth global survey second mHealth for horizons New throughhealth mobile technologies iv
eHealth: MishaKay, Jonathan Santos, andMarina Takane. The global survey and this report were prepared and managed by the WHO Global Observatory for Special thanksto Jillian Reichenbach Ott forthedesignandlayout,KaiLashley forediting. Union, intheglobaldeploymentofmHealth. We acknowledge the important roleofourpartner organization, theInternational Telecommunication United NationsFoundation,andmHealth Alliance. Foundation, Rockefeller the partners: our of collaboration and support financial the for grateful are We Garrett Mehl,Robin Miller, NeilPakenham-Walsh, Getachew Sahlu, Chaitali Sinha, andDiana Zandi. Sharing at WHO. The reportwasreviewed by David Aylward, Bailey,Chris Peter Benjamin, Bloch, Alison Guidance for thisreportwas provided by Najeeb Al-Shorbaji, DirectorofKnowledge Management and Nations Foundation. Switchboard; Sodzi Sodzi-Tettey,– Adele and Senegal Medical Association; Ghana Waugaman, United Inter-TribalNorthern Health Authority; – Ghana Samuel Quarshie, Health Ghana Service; Eric Woods, Kupchanko,InuitNations Health, First Saskatchewan; Labaty,Christine Health Canada; Shirley Woods, of Health Cambodia; Canada – Kim Fraser,Inuit Nations Health, First Saskatchewan; Deborah – Abul Kalam of Health&Family Azad, Ministry Welfare of Bangladesh; Cambodia – Ly Sovann, Ministry We wouldlike tothankthefollowingprofessionalswhocontributedcasestudies.InBangladesh Perez-Chavolla forwritingthecasestudies. security issuesinmHealthDeployment; Joan Dzenowagisforservingasaprimary reviewer; and Lilia the International Eskandar of report; Hani this to Telecommunication contributions detailed for hisadvice on Union significant their for University Columbia Institute, Earth the at Development Economic including: PatriciaMechael, Nadi Kaonga, andHimaBataviafromthe Center for Global Healthand Special tothemanyauthorsandreviewersthanks who contributedtheirexpertisepublication to this in114countries experts 800eHealth over to worldwide whoassistedwiththedesign,implementation,andcompletionofsecondglobalsurvey. due are thanks Sincere offices. country and regional, eHealth expertsandthesupportofnumerouscolleagues at the World Health headquarters, Organization of network extensive Observatory’s the of input the without possible been have not would report This Acknowledgments v Photo credits: Front cover - Top, Centre, Bottom: ©Dreamstime , PAGE vii - Top, Bottom: , Bottom: ©Dreamstime Top, vii - , PAGE Bottom: Centre, ©Dreamstime Top, Photo Front credits: cover - WHO/Nadia Bettega 5 - Left: , PAGE 4 - ©Dreamstime , PAGE Centre, Right: ©Dreamstime 1 - Left, PAGE Centre, Right: 9 - Left, WHO/Girish PAGE Babu Bommankanti, 8 - , PAGE Right: ©Dreamstime Centre, - Centre, Right: Otieno - WHO/Jessica 19 - Left: PAGE WHO/Nadia Bettega, 18 - , PAGE ©Dreamstime Ministry 32 - of Health PAGE , ©Dreamstime 30 - PAGE WHO/Nadia Bettega, 29 - PAGE , ©Dreamstime of (Courtesy 2009 Levine, Brian 37 - , PAGE ©Dreamstime 36 - PAGE Bangladesh, Welfare, and Family 44 45 - UN - ©Dreamstime Foundation/ , PAGE PAGE Walmsley, WHO/Damien 41 - Switchboard), PAGE WHO/WPRO Holmes, Jim 49 - PAGE , ©Dreamstime - 48 PAGE WHO/Nadia Bettega, - 47 PAGE Dalberg, WHO/Girish 55 - PAGE , ©Dreamstime 51 - PAGE Cambodia, Ministry - of Health, 50 PAGE Bank, Image Nations, First Council, Tribal Qu’Appelle Hills File - 56 PAGE , ©Dreamstime - 56 PAGE Bommankanti, Babu Saskatchewan, Council, First Nations, Tribal Agency Touchwood 58 - Canada, PAGE Saskatchewan, 71 - Left, PAGE Aguayo, Alberto WHO/ 70 Centre, Right: , PAGE ©Dreamstime 63 - Left, Canada, PAGE , Right: ©Dreamstime Centre, Left, - 75 , PAGE ©Dreamstime - 74 , PAGE Centre, Right: ©Dreamstime Bottom: ©Dreamstime. Centre, Top, 98 - ©Dreamstime , Back cover - - ©Dreamstime , PAGE 78 PAGE vi
3. 2 1. . Overview Global results Global Results analysis category mHealth and by 3 3 3 3 3 3 3 3 3 3 3 3 3 Acronyms and abbreviations and Acronyms Acknowledgments 2 2 2 2 1 1 1 Executive summary ...... 1 2 3 9 7 5 8 6 . . . . 10 1 13 12 11 4 2 3 1 4 2 3
Patient monitoring Information initiatives Patient records Patient Overview ofOverview findings eHealth on survey global Second mHealth Defining Health surveys and surveillance surveillance and surveys Health emergencies health Public awareness Raising Treatment compliance line help care call centres/Health telephone Health Mobile telemedicine Community mobilization & health promotion Appointment reminders services toll-free telephone Emergency Decision support systems support Decision Adoption of mHealth initiatives by World Bank World Bank initiatives by of mHealth Adoption region WHO initiatives by of mHealth Adoption initiatives globally mHealth Categories of mHealth initiatives, globally initiatives, Categories of mHealth income group
T able of contents Table of
7 6 6 1 viii iv 61 60 54 52 42 40 34 27 26 25 23 22 19 16 14 12 9 5 19 9
vii 75 79 83 93 99 63 71 92 83 66 68 71 73 84 92
a
. .
responding Member States survey on eHealth survey Member States by region and WHO Member States mobileGlobal phone of subscriptions Methodology of theMethodology global second of World Bank group income World
. .
Barriers by Bank World income group Relevant literature Relevant Barriers by WHO region Survey results
1 2 1 .2 . . . 5 5 Literature review review Literature References Purpose 4 4 Survey implementation References mHealth Implementation to Barriers mHealth initiatives of Evaluation Conclusion . . . 5 6 4 Appendix 3 Appendix 2 Appendix 1. 7 Acronyms and abbreviations
3G Third generation mobile telecommunications AIDS Acquired immunodeficiency syndrome DataCol Data Collector eHealth Electronic health EHR Electronic health record EMR Electronic medical record EMRS Emergency medical response systems H1N1 Influenza A (H1N1) HIV Human immunodeficiency virus ICT Information and communication technologies IMCI Integrated Management of Childhood Illness ITU International Telecommunications Union mHealth Mobile health MDGs Millennium Development Goals MMS Multimedia messaging service GMA Ghana Medical Association GDP Gross domestic product GNI Gross national income GOe Global Observatory for eHealth GPRS General packet radio service GPS Global positioning system OECD Organisation for Economic Co-Operation and Development PDA Personal digital assistant RFID Radio frequency identification SIM Subscriber identity module SMS Short message service SQL Structured Query Language TB Tuberculosis UN United Nations WAP Wireless application protocol WHO World Health Organization
viii Executive summary 1 Executive summaryExecutive For the first time the World Health Organization’s (WHO) Global Observatory for eHealth contained section a survey global its States; 2009 sought to the status determine of mHealth in Member (GOe) has specifically devoted to Completed by mHealth. 114 States, Member the survey documented for analysis to and barriers status of evaluation, four aspects of mHealth: adoption of initiatives, types of initiatives, health call centres, emergency surveyed: services were Fourteen categories of mHealth implementation. appointment telemedicine, and disasters, mobile telephone services, managing emergencies toll-free patient compliance, mobile mobilization and health promotion, treatment community reminders, and data collection, surveillance, health patient monitoring, health surveys records, information access, awareness raising, and decision support systems. The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has (mHealth) objectives health of achievement the support to technologies wireless and mobile of use The combination A powerful of across the potential to the globe. transform the face of health service delivery technologies a rise advances in mobile and applications, rapid These include factors is driving this change. and the continued into existing eHealth services, health for the integration of mobile in new opportunities Union Telecommunication to the International According networks. growth in cellular of mobile coverage (ITU), there are now over 5 billion wireless world’s the of subscribers; 85% over cover over signals wireless commercial 70% reports Association of GSM The them countries. reside income in low- and middle- the reach of the electrical grid. population, extending far beyond 2 Executive summary that large-scalethat andcomplexprogrammes will becomeasmHealth matures, more commonstrategies anticipated is it While partnerships). public-private by supported (primarily implementations mHealth address that singleissuesininformation sharingandaccess.pilot projects There werelimited only larger The surveycharacterized bysmall-scale the dominantformofmHealth todayis results highlightthat directions inthe short- andlong-term. and initiatives mHealth and eHealth harmonizing in efforts to vital be also will Policies implemented. of securityissuesinthemHealth domainsoappropriatepoliciesandstrategiescan bedeveloped and necessary precautionsare nottaken. Policy-makers andprogramme managers need tobe made aware message transmissionsecurity anddatastoragesecuritycanputcitizeninformation atriskifthe the securityprogrammes using ofcitizeninformationby mobile healthtechnologies. Inparticular, policy.of area the addresswithin to issue particularlyimportant legitimateconcernsaboutThereare a is security Data matures. mHealth of field the as important increasingly become will policy Effective the importanceofevaluation andthesharingofresultswithallMember States. promote to made be to needs effort concerted services. A mHealth evaluating reported States Member found that results-based evaluation of mHealth implementations is not routinely conducted. Only 12% of important barriersmHealthadoptionbyMember to States. Despite the need for evaluation, the survey the benefits of mHealth, and leads to government policy – all of which were reported as among the most Evaluation is part of a process that can determine cost-effectiveness, involves educating the public about which policy-makers, administrators,andotheractorscanbasetheirdecisions. evaluation. This is the foundation from which mHealth (and eHealth) can be measured: solid evidence on require programmes mHealth priorities, other among considered be to order In difficult. interventions choosing makes which of all budgets, limited and shortages, staff chronic challenges, health multiple worldwide pressureperform systems areunderincreasingto Health responding countries. by rated as thegreatest Competing healthsystemprioritieswasconsistentlybarrier to mHealthadoption to implement,andthereforemaynotbeahealthpriorityinMember public awareness, anddecisionsupportsystems. These require enhanced capabilities and infrastructure using mobile communications. surveillance, mHealth inraising the useof The leastfrequentlyseenis the majority of countries are already offering health call centres, toll-free numbers and emergency services telephone networks. conventional through use voicecommunication historically would explainwhy This RegionAfrican processes andserviceswhich theleastactive.mHealthismosteasilyincorporatedinto lower-income countries. European Regionthe in Countries the in active andthose the most arecurrently with eHealthtrendsingeneral, Consistent higher-incomemore thando countriesshowmHealthactivity disasters, approximatelytwothirdsofmHealthprogrammesareinthepilotorinformalstage. the With (49%). emergenciesand centres,emergencymanaging call toll-freetelephoneservices,and health exceptionof telemedicine mobile and (54%), disasters and emergencies managing (55%), services most frequently reported mHealth initiatives were: health call centres (59%), emergency toll-free telephone four programmes. The six to four offered countries many However, service. mHealth of type one least at The survey shows there is a groundswell of activity. The majority of Member States (83%) reported offering States withfinancialconstraints. Executive summary 3 It will support the use of mHealth in Member States to maximize its impact. This will be achieved achieved This will be its impact. to maximize States of mHealth in Member the use It will support by providing information on mHealth best practices and the kinds of mHealth approaches best suited to specific public health scenarios. A series of databases need to be developed which and lessons evaluations learnt, national and local initiatives, on selected information include cost-effectiveness. recommendations, best practices, and WHO creating a National and ITU are In support of eHealth policy and strategy development, of States with the development to support Member Toolkit Development Roadmap eHealth their own comprehensive eHealth strategies. The Global Observatory for eHealth (GOe) and of mHealth programmes, for the evaluation a framework its partners will work to develop of selected evaluation A database global indicators. and measurable including meaningful research findings will be built formHealth with a particular emphasis on developing country projects when planning and database to the access States will have ready initiatives. Member preparing project proposals. on States the content and WHO in to collaboration guidance Member with the ITU will provide for mobile telecommunications in health. scope of data privacy and security policy • • • Mobile health will advance through creating country-based eHealth strategies that incorporate it into through creating country-based eHealth strategies health will advance Mobile by to and solid need be complemented standards, architectures, the existing eHealth domain. Policies their full potential – and utilizing mobile partnerships to and realize help pilot mHealth initiatives mature wireless technologies to improve health and well-being. Moving towards a more strategic approach to planning, development, and evaluation of mHealth of mHealth evaluation and to planning, development, strategic approach more Moving towards a to needed and information are guidance Increased of mHealth. enhance the impact greatly activities will help align mHealth with broader health priorities in countries and integrate mHealth into overall efforts actions. several WHO will undertake this end, To systems. to strengthen health and policies that integrate eHealth and mHealth interoperability into health services would be wise. be into health services would and mHealth interoperability eHealth that integrate and policies mHealth is no different from other areas ofeHealth in its need to adopt and information The use of standardized globally architecture. using open ideally technologies, and interoperable accepted standards will countries this, accomplish To cost. reduce and efficiency enhance would technologies communication need to collaborate in developing global best practices so that data can move more effectively between systems and applications.
Overview 5
Overview 1 This interest has into manifested a series of mHealth deployments that worldwide are 1 /. http://www.who.int/topics/millennium_development_goals/accountability_commission/en providing early evidence of the potential for mobile and wireless technologies. applied and wireless is being of the potential for mobile mHealth providing early evidence with poverty, of the diseases linked in and child reducing the burden maternal health, and programmes including HIV/AIDS, malaria, and tuberculosis (TB). mHealth health services and information, and general to emergency timely access scenarios as improving diverse applications are being tested in such shortages managing patient care, reducing drug at health clinics, enhancing clinical diagnosis and treatment adherence, among others. 1 Governments are expressing interest in mHealth as a complementary strategy for strengthening Governments are expressing interest in mHealth as a complementary strategy health systems and achieving the health-related Millennium Development Goals (MDGs) in low and middle- income countries. The unprecedented spread of mobile technologies as well as advancements in their innovative application technologies as advancements of mobile as well spread The unprecedented to address health priorities has evolved into a new field ofeHealth, According to known the as mHealth. Union there are now close to phone subscriptions 5 billion mobile in Telecommunication International the world, with over 85% of the world’s population now covered by a commercial phone networks in countries The penetration of mobile surpasses other many low- and middle-income wireless signal (1). infrastructure such as paved roads and electricity, and dwarfs fixed Internet deployment. The growing sophistication of these networks – offering higher and higher speeds oftransforming the way health services and information handsets – are powerful and more cheaper data transmission alongside comes the possibility of greater With increased accessibility and managed. delivered, are accessed, personalization and citizen-focused public health and medical care. 6 Overview the barrierstoitsadoption. This included,specifically, identifyinganddocumenting: The goalsofthemHealthmoduleMember in were documentmHealthactivity to States aswellidentify designed andpresented moredetailedquestionsinaseries ofsurvey modules, includingmHealth. general andprimarilyasked high-level questionsatthenationallevel, the 2009 survey wasthematically was them. survey for first subscriptions the phone While mobile of level the and shows group, 3 Appendix survey. the respondingcountriesby of Appendix 2containsalist WHO region and World Bankincome and analysisisincluded in Appendix 1. One hundred andtwelve Member States responded tothe2009 knowledge base generated by the first survey conducted in 2005. A detailed description of the methodology The secondglobalsurvey oneHealth wasconducted inlate2009 andwasdesigned tobuilduponthe 1 positioning system(GPS), andBluetoothtechnology. global systems), 4G and (3G telecommunications mobile generation fourth and third (GPRS), service radio packet general including applications and functionalities complex more as well as (SMS) service mHealth involves the use and capitalization on a mobile phone’s core utility of voice and short messaging monitoring devices, personaldigitalassistants(PDAs),andotherwirelessdevices. medicalsupported mobile health asandpublicpracticebydevices,mobile patient as phones, such mobile or mHealth defined (GOe) eHealth for Observatory Global the survey, the of purposes the For mHealth is a component of eHealth. To date, no standardized definition of mHealth has been established. 1 is complementedbyfivecountrycasestudiesandareview ofthecurrentliteraturerelatedtomHealth. of thedata It combinestheresultsandanalysisgathered mHealth projects.fromthesurveyand to make policy-makers aware of themHealthlandscape and themainbarriers to implement or scale across Worldnext step toadvancingmHealthglobally. Bankincomegroupsisacritical report aims This understandingnew environmentfromtheperspective An ofthis Member WHO States andanalysis module onmHealthinthe2009 Global eHealthsurvey. a included latter 2010.The September 22 New on Yorkin launched Health Children’s and Women’sfor former included mHealth asakeyto achieveinnovation the goalsoutlined in thenew Global Strategy The field’s potential is recognized by the United Nations (UN) and World Health Organization (WHO). The during 2010 and2011. to create to aseriesofeightpublications– The thematicdesign of thesurvey hasprovided the GOe witha rich source ofdata that are being used .2 . 1 • • • • Second global surveySecond global eHealth on Defining mHealth Defining barriers toimplementation. status ofmonitoringandevaluation ofmHealthinitiatives;and types ofmHealthinitiativesbeingconducted; the existenceandmaturityofmHealthactivitieswithin Member States; The Global Observatory for eHealth Series eHealth for Observatory Global The – due –forpublication Overview 7 Rather than strategic implementation, the emergence of mHealth is occurring in many Member of the Rather than mHealth is strategic implementation, emergence occurring with technologies in States through experimentation many health settings. Policy-makers the transition from pilot to to need have the necessary and administrators knowledge make large-scale deployments. programmes to strategic per country. up to six mHealth programmes Many countries reported call centres Health from initiatives ranging adoption of the top mHealth the ranked The survey (number 1) to decision support systems (number 14); patterns WHO region. Bank income group and World of to according adoption were described for further need to the related to mHealth implementation Many of the top six barriers mHealth of cost-effectiveness and effectiveness assessing as such information, and knowledge applications. Other key barriers included conflicting issues. and legal supporting policy, health system priorities, the lack of of those activities activity mHealth is growing in countries, evaluation of Although the level by Member States is very low (12%). Evaluation will need to be incorporated into the project quality results. management life-cycle to ensure better Data security policy and citizen and privacy areas that legal attention require to are ensure that mHealth users’ data are properly protected. share global ICT standards States will progress further in mHealth if they implementing Member of best practices architecture will enterprise Cooperation in the development and architecture. between systems and applications. ensure that data can move more effectively Overview of findings of Overview • • • • • • • 3 . 1 will show that: This report
Global results 9
. Each mHealth initiative is initiative Each mHealth 2
Global results 2 majority (83%) reported at least one mHealth initiative in their country initiatives. Responding Responding low-income countries (77%; n=22) reported at least one mHealth initiative compared to 87% (n=29) of high-income countries. (n=29) compared to 87% One hundred and twelve Member States completed the mHealth module of the survey. A vast of the survey. module the mHealth completed States Member twelve and One hundred Of this 83%, most Member States reported implementing four or more types of mHealth mHealth globally initiatives -classifications. http://data.worldbank.org/about/country
1 Key findings Key . presented independently. Evidence from the literature is presented along with the results to provide a to provide along with the results is presented the literature Evidence from independently. presented more complete picture. 2 2 The 2009 survey results and analysis are presented from a global, regional, and economic perspective, regional, from a global, results and analysis presented are survey The 2009 Bank income groups. World WHO regions and of the through the lens 10 Global results Figure 1.Member States reportingatleastonemHealthinitiative,by WHO region but doesnotrepresentthedepthofactivitywithineachcategory. category. Thus, thenumber of initiativesreported depicts thebreadthinacountry of mHealthactivity the survey waslimited provide by thefactthatrespondentscouldonlyoneexample for eachmHealth and theexpert known informantscompletingthesurveyhave maynotbeen aware of them.Inaddition, widely be not may (NGOs) organizations nongovernmental or organizations small by executed being the country.mHealth initiativesarebeingconductedin indicate thatno initiatives doesnot Local projects the presenceofanmHealth initiative. It is important to notethata Member State reporting zero mHealth quarters reported four or more typesofmHealth initiatives. 19 responding Only countriesdid not report three 1). these, Figure Of (See country in initiative mHealth one least at of presence the reported States The survey found that most Member States use mHealth initiatives: 83% of the 112 participating Member Percent of countries 100 60 40 80 20 0 South-East Asia Americas Europe WHO regions Mediterranean Eastern Western Pacific Africa Global Global results 11 Low incomeLow Lower-middle World Bank income groups World Upper-middle High income 0
20 80 40 60
100 Percent of countries of Percent Figure 2. Member States reporting at least one mHealth initiative, by World Bank income group Bank income World initiative, by States reporting at least one mHealth Figure 2. Member Analysis of the survey results by World Bank income group is shown in Figure 2. The low-income The low-income 2. is shown in Figure Bank income group World by results survey Analysis of the group reported the fewest participating Member States with at least one mHealth initiative however, this (77%); was not significantly lower than that for the high-income group (87%). Based that it appears and economically, mHealth activity both geographically of reported wide distribution on the with global appeal. mHealth is an approach At least 75% of participating Member States from each WHO region reported the presence of one mHealth one of presence the reported region WHO each from States Member participating of 75% least At initiative in the country (Figure 1). Countries in the African Region reported the fewest initiatives, while reported the most. Asia Region South-East those in the 12 Global results Table 1.mHealthcategoriesusedinthe2009 survey country, provideanexample,anditsstageofdevelopment according tothefollowing definitions: Countries were asked to report whether a certain typeofmHealth initiative was taking place in their public andwithinthehealthsystemitself. the and system health the between interactions mHealth well-established most the reflect to created a healthcaresystem,eightcategorieswere in the useofmobile In orderhelpclassifytechnology to 2 Table 1liststhetypesofmHealthinitiativescoveredinsurvey. Access toinformation forhealthcareprofessionalsatpointof care Consultation betweenhealthcareprofessionals Communication betweenhealthservicesandindividuals Communication betweenindividualsandhealthservices Health monitoringandsurveillance Intersectoral communicationinemergencies .2 Key findings • • • • • • • • • • • • • • • • Treatment compliance Awareness raisingoverhealthissues Appointment reminders Community mobilization Surveillance Mobile surveys (surveys bymobilephone) Health callcentres/Healthcaretelephonehelpline Information anddecisionsupport systems Patient monitoring Emergencies Mobile telemedicine Emergency toll-freetelephoneservices Patient records Categories of mHealth initiatives, globally h lat rqety eotd ntaie wr hat sres 2%, uvilne (26%), surveillance (26%), surveys health were initiatives reported frequently least The The mostfrequently reported typesofmHealth initiatives globally were health call centres/ awareness raising(23%), anddecisionsupportsystems(19%). emergencies (54%),andmobiletelemedicine(49%). elh ae eehn hl lns 5%, mrec tl-re eehn srie (55%), services telephone toll-free emergency (59%), lines help telephone care health Established: anongoinghealth-relatedprogrammeusingmHealth Pilot: testingandevaluating theuseofmHealthinagivensituation to communicateforhealth-relatedreasons Informal: not part of anorganized health programme but involves theuse ofmobile technology
Global results 13 Established Pilot Informal None given
Decision support systems y. y.
Awareness raising
Surveillance
Health surveys
Patient monitoring
Information
Patient records
Treatment compliance mHeath initiatives mHeath Community mobilization
Appointment reminders
Mobile telemedicine
Emergencies
Toll-free emergency
Health call centres
0
10 30 50 20 40 60 Percent of countries of Percent Figure 3. Adoption of mHealth initiatives and phases, globally Adoption Figure 3. Further, it is important to note that the definition of ‘awareness raising’ used in the Second Global eHealth Global Second the in used raising’ ‘awareness of definition the that note to important is it Further, web require Since this would device”. “downloading health information onto the mobile included Survey – browsing and data storage capabilities functionalities not necessarily on devices available mobile readily is and of health issues the awareness reports of initiatives to raise in fewer to result this is likely – globally as mobile however, future, to increase in the near expected are Such initiatives for HIV/AIDS. often used Internet capabilities and enhanced data storage. increasingly have devices The least frequently reported mHealth initiatives were health surveys (26%), surveillance (26%), awareness (26%), surveillance (26%), surveys health were initiatives mHealth reported frequently least The These and results raising decision differ(23%), support fromsystems the reports(19%). in the literature, most for data collection surveillance. However, and disease use of devices which the mobile supported studies focused on observing the differences, effectiveness, and feasibility between traditional methods of data collection and disease surveillance (e.g. paper and pen) to mHealth solutions, with Thus, such projects may not be health information systems. limited no with government-supported integration to and/or informants completing the surve widely known among government officials Globally, the types of mHealth initiatives most frequently reported were health call centres/health- were the types reported most frequently of mHealth initiatives Globally, care telephone help lines (59%), emergency toll-free telephone services (55%), emergencies (54%), and core the using of characteristic common the share initiatives mHealth These (49%). telemedicine mobile of mHealth initiatives globally. Figure 3 shows the adoption of a mobile device. voice functionality 14 Global results into thisparticularprocess. This ismostlikely due tothe fact thatmobiletechnologieshave notyetbeen accepted orintegrated 20%. only of uptake an with exception, the is variation Region Pacific figure. The Western this little below or above show regions five and 40% almost of uptake global a shows compliance Treatment the African and EasternMediterraneanRegions arelower(approximately40%). and 70%) (around adoption average than the higher and South-East Regionsof show Americas The Asia 50%). (approximately globally reported frequently also is situations emergency for mHealth of use The level ofacceptance oftheseservices itislikely thatthey willexpandinthe African Region. increasing and infrastructure of development ongoing the With 60%. approximately are which other regions all to compared 40% over just is it where Region African the except regions all across adoption levelshigh consistently frequently reportedinitiative,showof centres, globallythemost call Health ambulances tohospitals). connecting systems dispatch roads, paved of lack (e.g. countries some in calls emergency to effectively (28%) Region African the in compared to other regions (42–75%) reported could be due to insufficient infrastructure to respond efficiently and services telephone toll-free emergency of frequency low The 48% ofMember States acrossallregions exceptthe African andEasternMediterranean Regions. of the African Region. The use ofmobile devices foremergency anddisaster situations wasreported byover initiatives acrossall WHO regions; the other isemergency toll-free telephone services–withthe exception Figure 4showshealthcallcentres/health caretelephone help lines areone ofthetwomostcommonmHealth attempts toidentifyregionalfindingswherepossible. applies and thistodata commonalities incountriesgatheredmHealthadoption.However,on thereport Due to the diversity within WHO regions it is often difficult to identify common trends between based on 2 . Key findings 3 Adoption of mHealth initiatives WHO region by The use ofmobileinhealthcallcentres/healthcaretelephone phones help lineswasrelatively emergency anddisastersituations. Forty-eight per cent ofrespondingMember States reported the use of mobile devices for Except for the for Except Region,African mobile inemergenciesrelatively theuseofphoneswasalso high. high acrossallregions. Figure 4. Adoption of mHealth initiatives and their phases, by WHO region
mHealth initiatives
Global results
1514 16 Global results country incomecorrespondstotechnologicaladvances. related to thelevel medical/healthof maturityelectronic records inhigh-incomecountries,where compared to approximately 20% among countries in the other groups. This significant difference is likely adoption 60% over just reported countries high-income instance For others. the and group high-income The use of mobile technologies forpatienta records showslargebetween contrast countries inthe this challenge ishigh.mHealthcould wellprovideacost-effective andsimpleanswertothisproblem. Britain and Northern Ireland an estimated £790 million per year (2), the demand for solutions to overcome non-attendance forhospitaloutpatientappointmentscostcountriessuchasthe United Kingdomof Great initiatives. these of existence the reported that 71% reports well; With as group high-income the in States The useofmobiledevices tosend appointment reminders isbecoming morecommonamongMember have someexistingsurveillancecapacityandsowillnotbelimitedtosuchinitiatives. them. very fewof groups higher income the in countries that is probable this The mostexplanationfor Member the highand upper-middleStates inthelow-incomegroup.Incontrast, income groupsreported Health surveys andsurveillance initiatives were among the mostfrequentlyreported by participating the entirepopulationofacountry, andthushavethepotentialforscalesustainability. for mobile telemedicine and emergencies. of mHealthinitiativesinparticulartarget These threetypes telephone help lines werereportedinallincomegroups, commonly bycountriesinaddition toinitiatives care centres/health call Health categories. all for less or 50% was initiatives mHealth reporting group more ofMember conducting establishedtheproportion initiatives. Incontrast, States inthelow-income of mHealthinitiatives,andwere the high-incomegroupreported proportion in thehighest Countries Figure 5 provides anoverview oftheadoptionmHealthinitiativesby World Bankincomegroup. 2 . Key findings 4 income group Adoption of mHealth initiatives World by Bank Appointment reminderinitiativeswerefrequentlyreportedbyhigh-incomecountries. Countries inthehigh-incomegroup reported a greater range of initiativescompared to those Health surveys and surveillance initiatives were reported by a relatively high proportionof Health call centres/Health care telephone help lines were among the most frequently reported were amongthemost call centres/Healthcaretelephonehelplines Health by countriesinthehighandupper-middle incomegroup. in thelow-incomegroup. responding Member the low-incomegroup. States in These initiativeswere the leastreported types ofinitiativesacrossallincomegroups. Figure 5. Adoption of mHealth initiatives and their phases, by World Bank income group
mHealth initiatives
Global results
17
Results and analysis by mHealth category 19
Results and by analysis category mHealth 3 for health call centre/health care telephone help line initiatives. regions. reproductive health/family planning, pandemics, and drug abuse. health care telephone help lines that address specific health issues such as HIV/AIDS, H1N1, centres (61%). Countries in the high-income group reported the highest number of established health call of established the highest number reported Countries in the high-income group The European Region reported more general-purpose health call centres (64%) than other The African (17%) and South-East Asia (38%) Regions reported a low level of pilot-stage activity pilot-stage of level low a reported Regions (38%) Asia South-East and (17%) African The The African, Americas and Eastern Mediterranean Regions health call centres/ reported Americas and Eastern Regions Mediterranean African, The Health call centres/Health care telephone help telephone line care centres/Health call Health 1 Key findings Key . Health call centres/Health care telephone help lines are a service created to deliver health care advice triage to deliver created help lines are a service care telephone call centres/Health Health to is established This method of communication professionals on the telephone. by trained health services 2009. in outbreak influenza H1N1 the during available made routinely was and emergencies, national manage 3 The survey results indicate a more mature view of mHealth than had been predicted. Member States States Member predicted. been than had of mHealth view mature more results indicate a The survey in The literature, to the national level. scaled categories mHealth many initiatives of several reported from higher-income predominantly pilot studies, comparison, was found to focus mostly on small-scale by literature results and comparison the survey between This section a detailed provides countries. queried in the survey. considering each of the mHealth initiatives 20 Results and analysis by mHealth category frequently reportedmHealth initiative. Member States in each World Bank incomegroup reported activity inthiscategory, making it themost in the upper income group reported more established initiatives (61%). Overall, over 40% of participating States Member participating while (68%), activity centre call health of percentage highest the reported With respectto World Bankcategories, Member States inthelowand lower-middle income groups such as Our Village andBRAC havealsolaunched healthcallcentres(4). organizations non-profit-making and hospitals, private operators, telecommunication Other (3). calls mobile phones bydialling“789”. Since November 2006,million received 3.5 theservice hasmorethan been designedbeaccessibleand hasto managed licensedphysicians hotline isby The from directly operator.telecommunications a local called partnershipwith launched ahealthcallcentreHealthLinein provide and patientstomedical from citizensadvice. calls incoming 2006,Second, in anentrepreneur remains and sub-districthospital,onedoctoravailable 24 hours per day seven daysper week to receive promote free to access.community the local numbers websitefor are advertisedacentral on In eachdistrict phone mobile The hospitals. (421) sub-district and (64) district all to phones mobile provided Welfare Family & Health of the Ministry public andprivatemodels.First, implementations includingbothsector Bangladesh deservesItreported initiative inmention.thepresenceofadvanced An healthcallcentre address theH1N1influenzapandemicof 2009. and emergencies. syndromes Six Member to States reportedestablishedinformalhealthcallcentre an or AIDS, drug abuse, addictionandsuicide,cholera,dengue family planning,smokingcessation, and febrile call health offering centres and reported help lines that addressed specific health frequently issues. This included public Regions health issues such as HIV/ Mediterranean Eastern and Americas, African, The many healthcallcentreswerelinked toelectronicmedicalrecords. team of freelance, specialized reported medical Finlandasimilarmodel, that professionals. indicating Greece, operatesafee-for-servicewhich 24-hour health helplineandin-homemedicala service with telephone help lines withestablished business models. example An is of this reported SOS Doctors,by private contrast, companiesinFinland, Germany, and Greece operate paid health callcentres/healthcare triage 24-hour nurseswhopatients.In a no-costhealthcallcentre/healthcaretelephonehelplinewith operates and Scotland England in (NHS)Health Service National the that reported Kingdom The United triage servicesandhealthinformation. These operationsareeitherpubliclyorprivatelyowned. help lines that operated 24 hours per day seven days per week, staffed by health professionals to provide Member States suchasEstonia,Finland,France, Germany, and Greece described health callcentresand indicated that theEuropean Region has more all-purpose health callcentresthananyotherregion. (n=22) information additional provided that countries those from responses qualitative the of Analysis countries intheseregionsareincreasinglyinvestigatingthistypeofmHealthactivity. individual that indicate however, respectively), 38%, and (17% regions these in projects Pilot Regions. health call centre/health care telephone help lines, with theexceptionof African and South-East Asia The survey results show that over 40% of participating Member States in each WHO region had established 3.1 1 Survey results Survey .1 Results and analysis by mHealth category 21 health call centres in developing countries are more often for-profit operations than non- profit-making; customers are directly charged for services; and extensive with firms telecom other or operators, network mobile with partner companies many and as billing channels, as well retail and distribution recognition, established networks, brand collection systems. revenue • • • 2 Relevant literature . These characteristics constitute a model often used by the programmes taken from the survey results from the survey taken These characteristics by the programmes constituteoften used a model While this model offers many advantages, it These also canVerte). has include its limitations. Ligne (e.g. the lack of affordability of services for the poorest segments of the population, inconsistent availability to access who less often own or have for women access limited is poor, coverage mobile where in regions other sources of information. a mobile phone, and lack of integration of health call centre systems with Similarly, Mexico’s Similarly, MedicallHome service offers its one million subscribers access to professional health invoice, phone mobile consumer’s the to directly billed is which month, per 5 US$ of fee fixed a for advice found were The health call centres studied a physician price for consultation. and is far below the market (5): to share three common characteristics For example, in the Democratic Republic of the Congo Population Services International (PSI), in partnership in (PSI), International Services Population Congo the of Republic Democratic the in example, For Hotline to Toll-Free Verte called the Ligne launched an initiative operator, with a telecommunications complement its family planning initiatives in the region and other commodities. Each contraceptives clinics to access to nearby information, and refers patients (6). It provides confidential family planning telecommunications users partnered of the for US$ 0.36, and was exclusively mobile device call cost PSI from sales generated was funded by revenue programme The Calls were limited to two minutes. operator. Men calls in 2008. 036 and had a total of 20 at family planning clinics, and commodities of contraceptives planning programme (6). by the family unanticipated made 84% of these calls – a result 3.1 capitalizing on interest in a growing the been there has income countries, lower-middle In low and health call centres that can technology ubiquity of increase accessibility mobile to infrastructure develop found to This overcome approach has been to and information patients and the public. of health advice and/or on untrained shortages, reliance professional such as health health system barriers widespread While information. cost of service and transportation, informal providers, and lack of sources of reliable United Kingdom, the Canada, the indicates that literature health call centres have been operating in Bloch Moore and documented America, for a study conducted by decades, Ivatury, States of United and (5). India, Mexico, and Pakistan countries such as Bangladesh, examples from developing 22 Results and analysis by mHealth category established initiatives(around55%). States in thehigh-incomeand lower-middle income groups both reported the highestpercentage of in the low-income group to approximately 60% for the other three income groups. Participating Member Across the World Bank income groups, activity of emergency toll-free telephone services ranged from 37% the Philippinesthatprovidesanemergencytoll-freetelephone serviceforpoison-relatedqueries. National Management and Poison Control Center atthePhilippines General Hospital at the University of and parentsstrugglingwitheatingdisorders. The Philippinesreported a programme implemented by the of Health in Austria setup an emergencytoll-free telephone supportwomen, service togirls,teachers, Similar reports were seen inMember States from other regions.Forinstance,the Styrian regional Ministry up forcitizenstoobtaininformationonH1N1and TB. victims ofdomesticviolence; and Togo gave an accountof anemergency toll-free telephone service set cases; Madagascarsupport report cholera had aserviceto to citizens a telephonelinefor launching telephone toll-free services. emergency For example, Benin established a service specifically for HIV/AIDS patients; Zimbabwe reported disease-specific however, report, did Region African the in countries category.this in (31%) activity The of percentage lowest Regionparticipating the African few reported A emergency callcentreservicesupportingvoice,e-mail,web,andfax. a mobile or fixed line phone, with the exception of Portugal, which documented a multi-channel toll-free dispatch supportduring an emergency. All implementations reported of relied thevoicefunctionality on from thesurveyresponses did useemergencytoll-free numbers fortransportation citizens showed that with theexceptionofthosein African andEasternMediterranean Regions. of thequalitative Analysis toll-free Emergency telephoneserviceswere reported overhalfofallrespondingMember by States, 3. engage withahealthcallcentreand/oremergencytoll-freenumber( trained to provide direction during a medical emergency. Access totelephonyservicesisrequired to staffor professionals health to access quick for used often are services telephone toll-free Emergency 3 .2 2 Key findings 1 Survey results Survey .1 Emergency toll-freeEmergency telephone services The African Region reportedtheleastactivityinthiscategory(31%). The South-East RegionAsia reportedpercentageemergencytoll-free thehighestoftelephone Countries from the lower-middle income (63%) and high-income (58%) groups reported the reported groups (58%) high-income and (63%) income lower-middle the from Countries services (88%). highest level ofservice. e.g. 911inthe United States). Results and analysis by mHealth category 23 income groups are in the informal stage. conducting treatment compliance initiatives. compared to approximately 30% in other income groups. compared to approximately 30% in other Approximately one third of responding Member States across all WHO regions reported States across all Approximately one third of responding Member Almost 60% of countries in the high-income group have treatment compliance initiatives, A large number of treatment compliance initiatives in Member States in the high- and low- A of large number treatment compliance initiatives in Member Treatment compliance Treatment 2 Relevant literature Relevant .2 3 Key findings Key 3.1 Surveyresults . .2 In the European Region, reported treatment compliance initiatives targeted chronic compliance initiatives targeted illnesses such treatment as reported Region, In the European diabetes, asthma, obesity, chronic obstructive pulmonary disease (COPD), and chronic heart disease. has SMS their contraceptive pills via women to take to remind a programme Czech Republic, In the Approximately 35% of Member States WHO across regions reported conducting treatment compliance initiatives, with the Asia South-East Region highest (50%) and PacificWestern Regionthe lowest (23%). that as an example has undergone Txt2Quit smoking cessation programme Zealand reported New a clinical trial, achieved scale in the country, and has been replicated by other countries (10). Txt2Quit On to quit smoking. to consumers attempting to send support text messages designed has been local by a Canada in month, and was recently adopted per clients new attracts 317 the service average telecommunications operator (11). 3. Treatment compliance is described as the sending reminder messages, by voice or SMS, to patients with SMS, by voice or messages, sending reminder as the compliance is described Treatment and overcoming treatment compliance, disease eradiation, such challenges as the drug aim of achieving TB. patients with conditions such as diabetes, HIV/AIDS, and resistance. It has been applied to support 3 3 Yang and colleagues found infrastructure costs required to establish an emergency toll-free telephone service in low and lower-middle income countries to be prohibitive (7). Costs incurred may include the costs. In management as personnel and data as well number, of the toll-free package set up and service adoption has established been found telephone services are emergency toll-free some countries where phones in Egypt of mobile found that, uses health-related study of a qualitative For to be weak. example, to call participants preferred service, telephone toll-free of a national emergency the presence despite by the fact that This was explained emergency. a medical transportation services during local private emergency calls were being routed to a call centre in Cairo and resulting in a slow response time (8). In services telephone toll-free emergency established organizations have contrast, sector private in India for transportation dispatch during an emergency. For example, Dial 1298 for Ambulance was the first the company which to with the subsequently led engage attacks in 2008, the Mumbai during responder contracts (9). public sector through state government 24 Results and analysis by mHealth category the impactoftreatmentcomplianceinitiativesforchronicdiseasepatientsinKenya andPeru. study design have been reported by Lester control et al. randomized (24) a and employing Curioso et by al. (25).studies rigorous These studies more are conduct investigating to plans Recently, (21–23). TB and studies fromlowandlower-middledrug focusedonadherenceforHIV/AIDS,malaria, countries income noncommunicable diseases, or whereas chronic on Studies tendedfocus from high-incomecountries to Treatment compliance programmesincomegroups. theliteraturecountry in were varyacross found to 3. reporting informalinitiatives(around20%). States Member of proportion large a had groups low-income the and high- the Both (12–20). obesity diabetes, as asthma,and diseases such mobile applications,webande-mailchronic phone browsingfor Canada, the United Kingdom, and United treatment compliance programmes States withusing SMS, with theliterature review,of studies foundfrom which aconcentrationhigh-incomecountriessuchas compliance consistent treatment are results These groups. reported income other group the for 30% high-income approximately to the compared initiatives, in countries participating of 60% to Close voice functionalityratherthan SMS. Bhutan, Colombia, the and Congo, Sierra-Leone reported treatment compliance programmes using record of messages sent and received. This aligns with the findings from the literature review. In contrast, inexpensive or without cost, is a succinct way of sending a message without the need to talk, and offers a enormous popularityof The It is surprising. not mobile is communicating byphone a methodof SMS as A preference forusing SMS for treatment compliance programmes was observedtheglobe. across providers in Ghana andEthiopia,anHIV/AIDStreatmentcomplianceprogrammeinthe Congo. Informal programmes reported include general medication reminders being instituted byhealthservice (7%). programmes compliance treatment established of percentage lowest the but (21%) programmes Participating Member States inthe RegionAfrican reported thehighestpercentage of informal hospital; Germany and Switzerland highlightedlocalcorporatesolutions. operated or based out ofa single hospital. Forinstance, Greece reported a system deployed in a private been initiated. Treatmentinitiatives reported compliancefromtheEuropeanRegion werelocally often 3. 2 Relevant literature Relevant 2 Results and analysis by mHealth category 25 functionalities including voice, SMS, and the Internet. SMS, and the Internet. functionalities including voice, initiatives (71%). The majority of these initiatives were established (42%) using various States with appointment reminder initiatives. SMS was the most common mobile phone feature used for appointment reminder initiatives. SMS was the most common mobile Countries in the high-income group reported the largest proportion Countries of appointment reminder in the high-income group reported The Americas (58%) and European (53%) Regions have the highest percentage of Member Appointmentreminders
2 Relevant literature Relevant .2 .1 Survey results 4 Key findings Key 4 4 . . 3 Studies show that missed appointments have a financial and operational cost,especially in health systems in studies from reminders appointment of effectiveness the on results However, (26). capacity strained with China, Brazil, and the United Kingdom were mixed (27–30). Fairhurst and Sheikh’s randomized controlled trial in Scotland yielded insignificant results theon evaluationof using reminders SMS attendance to improve rates non- (31). In contrast, a study in Sao Paulo, Brazil system to patients at four medical clinics found that non- software clinic manager and clinic web through the that sent 7890 SMS reminder messages attendance rates were lower among patients SMS who messages received (28). For appointment reminder widespread. be must capability SMS with penetration phone mobile implemented, effectively be to systems Over 70% of participating Member States in the high-income group reported established appointment by SMS to complemented send appointment reminders, initiatives with for using reminder a preference offered were reported options. Most implementations online scheduling and reminders e-mail and voice by health service providers and These hospitals. findings are in contrast to the other groups, where less than 40% of Member States reported appointment reminder initiatives. Zimbabwe was one exception, reporting established mHealth follow-up programmes for HIV/AIDS, TB, cholera, and influenza home- Arab Syrian and the Egypt, Lebanon, Region, In the Eastern Mediterranean areas. care patients in rural reported established appointment reminder programmes. Republic The Americas and European Regions had the highest percentage of Member States reporting States reporting of Member had the highest percentage Regions Americas and European The African the in States Member Responding respectively). 53%, and (58% initiatives reminder appointment percentage lowest the reported Regions (38%) Asia South-East and (36%), Mediterranean Eastern (31%), of appointment reminder initiatives. 3. 3 sent to SMS messages or attend an appointment. patients to schedule are voice or reminders Appointment include to definition this expanded GOe the responses, survey the from reports qualitative receiving After calls. In low and lower- follow-up results, and post-appointment treatment immunization reminders, middle income countries, where access to fixed-line telephony is minimal and in high-income countries where fixed line telephony is being replaced with mobile phones, the mobile phone is rapidly becoming of receiving appointment reminders. the primary means 26 Results and analysis by mHealth category to the to SMS shortcode States reported an SMS-based initiative to promote HIV/AIDS testing aswell.sendingtheirzipcode By messages to pregnantwomen toencourage prenatal care, HIV/AIDS testing, and vaccination. The United Colombia reported a programme being implementedsends the Department that by ofHealth SMS this in activity contrast, In category amongparticipatingMember States intheupper-middle incomegroupwaslow(19%). initiatives. established were 32% which of (55%), initiatives mobilization community most the reported group high-income the from Countries (50%). category this in adoption with the Americas, Eastern Mediterranean, and South-East Asia Regions reporting the highestrate of moderate, was initiatives leveland healthpromotion Overall, themobilization community for activity of 3. campaigns ortopromotevoluntarycounsellingandHIVscreening. groups ofhealthcampaigns. be can used, This forexample, increase participationinimmunization to target alert to or promotion health for messaging text of use the as defined is mobilization Community Mobile phones provide a new communicationchannelforhealthpromotionand community mobilization. 3 3 and direct referrals to web sites and help lines by texting the name of a substance to the shortcode DRUG. and directreferrals towebsitesandhelp lines bytextingthename ofasubstance totheshortcode DRUG. information service. The service offers free health and safety information about common legal and illegal drugs collaboration withalocaltelecommunicationsprovider, Get theMsg!hasnowbecomeanestablished reportedan established programmecalled Get theMsg!Launched in August 2006 asapilotproject in Zealand New (31%), area this in adoption of level low relatively a had Region Pacific Westernthe Although Bangladesh, the Congo, Ethiopia,the Syrian Arab Republic, and Yemen. testing centre.Programmes to remind parents tohavetheirchildrenvaccinated are running in Albania, . 5 Key findings 5 1 Survey results Survey .1
(multimedia messagingservice) fromamobilephone A shortcodeisaspecialtelephone number, oftenshorter thanconventional numbers, used toaddress SMS orMMS Community mobilization & health promotion The Americas, Eastern Mediterranean, and South-East Asia Regions reported the highest Community mobilization and health promotion initiatives addressed mobilization andhealthpromotiongeneral Community health (55%), ofwhich32%wereestablishedinitiatives. SMS wastheprimarymethodofcommunicationusedininitiatives. vaccination, reproductivehealth,chronicillness,andblooddonation. adoption forcommunitymobilizationandhealthpromotion. High-income countries had the highest percentage mobilizationinitiatives had thehighestofcommunity High-income countries information or specific public health issues such as H1N1, HIV/AIDS, immunization and immunization H1N1,HIV/AIDS, as such issues health public specific or information 3 KNOWIT, usersreceive the nearestHIV/AIDS a textmessagetheaddressto with Results and analysis by mHealth category 27 though the Eastern Mediterranean (28%), European reported using this initiative the most. (28%) and Americas (25%) Regions initiatives (42%). High-income countries had the highest proportion of countries with awareness raising Main health topics for these initiatives were women’s health, drug and alcohol abuse, smoking abuse, alcohol and drug health, women’s were initiatives these for topics health Main cessation, and HIV/AIDS. Awareness raising initiatives showed relatively low levels of uptake across WHO regions, across of uptake low levels raising initiatives showed relatively Awareness Raising awareness
2 Relevant literature . 6 Key findings Key 5 3. of health information products, it includes the use in the survey; was queried awareness Raising public are These programmes on health topics people such as HIV/AIDS. to educate or quiz programmes games, phone or that for download onto messages tell a story often the mobile as a series of text available with embedded health messages. Barriers to using mobile technology for health promotion campaigns have been identified in the literature the in identified been have campaigns promotion health for technology mobile using to Barriers and include the following: SMS length restrictions (maximum of 160 especially critical and privacy issues are Security and lack of technical areas. support in rural illiteracy, characters), language barriers, and family among often shared phones are mobile income countries, where in low and lower-middle community members, leading to potential challenges with protecting confidential health information, HIV/AIDS, which remain highly stigmatized (34). like particularly in the case of conditions Many studies were described as donor-funded and short-term. In contrast mDhil is a health promotion In contrast is a health promotion mDhil short-term. and as donor-funded described were Many studies organization launched in India with a businessfor-profit model. For 1rupee a consumers day, receive to physicians nurses and by registered on created topics phone three health messages such their mobile as subscribers, paid 000 mDhil had 150 At the end of 2009, health, and H1N1. sexual weight management, and closed a A ‘series financing round’ with a venture capital firm. mDhil sent out 1 millionpublic health (33). SMS messages by the end of 2010 3. Health challenges such public health promotion as nutrition, addressing studies cessation, smoking such outbreaks as H1N1, transmitted infections, health, sexually disease have and maternal HIV/AIDS, Project Africa called South in project executed collaborative A in the literature. documented well been telecommunications operator of a local day to subscribers per messages SMS sent out 1 million Masiluleke and project partner to encourage HIV/AIDS testing While (32). these types of interventions have proven evidence of the impact of such studies that provide few there are in disseminating information, effective change. programmes on behaviour 28 Results and analysis by mHealth category operators toeducate consumers about HIV/AIDS and other health-related issues. non-profit-making organization Text the to Change setup SMS in quizzes Uganda inpartnershipwithtelecommunications instance, For countries. middle-income and low than rather countries income awareness havebeen projects documented in theliterature, with mostexamples coming fromhigh- stigmatized. However,are highly which sexually transmittedinfections, fewmobile phone-based health Health informationvia mobile phones isespeciallyuseful for diseases such asHIV/AIDS and other 3. in comparison,adoptionotherincomegroupswas20% orbelow. (42%); initiatives raising awareness with countries of percentage highest the had countries High-income sober be again, inadditiontotheassociatedrisks. will user the when time the provides phone, mobile a on browsers web and (WAP) protocol started drinking, and typeofbeverage. works with The application,which SMS, wireless application prevent drunkdriving. to Users provideassex,age, personal informationsuchweight, time when they behaviour alcohol person’s a monitoring supports that application mobile a Czech documented the Republic example, For HIV/AIDS. and cessation, smoking abuse, alcohol and drug health, women’s Examples reportedthesurvey in had diverse healthobjectives,includingraisingawarenessregarding used onlineinterfaces.Bangladeshwasoneofthese. The programmeisdetailedbelow. which of many topics, health of awareness raise to programmes mHealth of examples specific reported of Member had thehighestproportion typeofmHealthinitiative. States reportingthis 15 countries Only Regions (25%) Americas and (28%), European (28%), Mediterranean Eastern The queried. categories levelThe globalactivity of initiativeswasonethelowestcomparedothermHealth forthesetypesto 3. 4 are usedtoeducatethepopulationonvarioushealthtopics (case study1). example aprogramme thelow-incomegroup,how An offromBangladesh,in highlights SMS messages with evaluation assessmentsshowingpromisingresults(35). a sexual health SMS service. The pilotprogramme be found usageoftheservicetogreaterexpected than developed Health, SEXINFO,Public of Department the Francisco with San partnership (ISIS),in Services gonorrhoea ratesamong African in American youth Internet San Francisco, Sexuality Information 6 6 . results Survey .1 2 Relevant literature literature Relevant 2 http://www.texttochange.org. 4 Inresponsetorising
30 Raising health awareness in Bangladesh via SMS campaigns case study Bangladesh messages on diverseHealthworkershealth topics. incommunities can advise throughout thecountry allows mobile telephone users to subscribe, at a reduced rate, to an SMS service that broadcaststext epidemic. The secondservice, initiatedandthepublic by theMinistry mobile operator in March2010, their roleafter providing themon a naturaldisasterorcommunicable withinformation disease situations, health emergency during members staff health among coordination improve and awareness increase to aims 2009, in launched one, promotion. first health The for SMS use that services additional service delivery as expressedtheDigitalBangladesh in Vision 2021has introducedtwo plan,theMinistry health in ICT of use the expanding of goal the fulfil help and plan eHealth Bangladesh’s implement To Safe Motherhood Day. nationwide healthcampaigns,suchasits Vitamin A Week, NationalBreastfeeding Week, andNational now usesthe SMS service foritsNationalImmunizationDaycampaign, aswellotherlarge-scale the event’s date were sent via SMS. Heartened by the positive response of the population, the Ministry Immunization Day. Messages encouraging parentstobringtheirchildrenget vaccinated, alongwith numbers inthecountry, irrespectiveoftheirservice providers, initiallytomobilizecitizens forNational awareness ofitshealth campaigns bybroadcasting SMS text messagestoallmobiletelephone and overcome existingcommunication barriers.In2007, theMinistrystarted aproject toincrease increasing numberofmobiletelephone subscribersinthecountrytoimprove the health ofitscitizens The MinistryofHealth and Family Welfare ofBangladesh hastaken advantage oftherapidly Project overview SMS campaigns Bangladesh via awareness in Raising health Case study
Raising health awareness in Bangladesh via SMS campaigns 31 Second trimester Second 3 months. If you did not st Mrs.
Case study Raising health awareness in Bangladesh via SMS campaigns 33
From the users’ perspective, the English language messages and cost of the Health SMS subscription service subscription SMS Health the of cost and messages language English the perspective, users’ the From sent can only be messages text The portions of the population. for some to access barriers still represent into Bangla. messages text the to translate the intervention of a third person in English, which can require competing Similarly, health priorities limit the financial ability of the Ministry to subsidize the distribution local possibility of using the and the SMS services for cost rates Lower service. costs of the subscription Bangladesh. care promotion in tool for health effective more an even this service would make language The development and improvement of the SMS health services, Attracting and retaining technical shortage of skilled personnel at the Ministry to promote innovation. however, have been affected by a technically trained personnel requires an salary adequate structure and continuous training to the update voice incorporate Ministry the help would IT skills with personnel sufficient Having staff. the of capacity IT SMS capabilities into the current health awareness services. and multimedia Lessonslearnt commitment the of result the largely is services SMS Health Ministry’s the by far so achieved success The network and the enabling telephone use of the growing mobile good of the Bangladeshi Ministry to make regulatory and strategic environment – as expressed in the BTRC’s rules, the Digital Vision Bangladesh of health awareness among the population. and its own increase the level eHealth plan – to 2021, The effective implementation of the services has also been drivenand the mobile the telecommunications regulator, the Ministry, coordination of activities between the by sustained cooperation and as part of their corporate responsibility efforts. operators that contribute to this project
The operational costs of the Ministry for providing these services have been minimal, as the regular staff staff The operational costs as the regular of the Ministry minimal, these services have been for providing workers, field numerous its utilize to plans also Ministry The duties. their of part as work the do members The to promote the subscription service at almost no operating at the operational cost. community level, Ministry’s budget and the political support of the Digital Bangladesh Vision 2021 also help ensure the SMS project. long-term sustainability of the health Costs reach. cost their low and broad are for health campaigns messages SMS of using advantages The main conducted at no are cost health campaigns for both SMS the nationwide In the case of Bangladesh, the mobile telephone users and the Ministry due to the country’s telecom regulatory framework that the Ministry only Therefore, has to the bear of charge. the service free operators to provide mandates cent one than less operators mobile the paying members, staff health its for service SMS bulk the of cost is service subscription SMS Health the of cost the Finally, message. SMS per (BDT) Taka Bangladeshi a of users who telephone the operators only subscribe to borne by the mobile half of the regular it, but charge SMS message. per rate (1 cent BDT) 34 Results and analysis by mHealth category other areas of central Asia. Cameroon reported a mobile telemedicine programme in thepilotstagefor education, in addition to experimentation with low-bandwidth technologies thatcanbe replicated in areasnorthern ofPakistan andurban centres. medical includes tele-consultation andcontinuing This the by between the increase collaboration community-based in foundation to health centres Aga Khan free reportedsupported each otherofcharge.Pakistanaproject mobile communicatewith services to specialists. with reported operator provided Ghana aprogrammemobile phonephysicians where alocal urban andrural in areas, betweenand between physiciansgeneralistsand for consultation opinions, between initiatives involvingcommunications health professionalsusingvoice and SMS for second groups. Developing inthe countries and EasternMediterranean African Regions reported informal A large proportion ofinitiativesreported were informal or in thepilotphaseregionsand across income great interestinadaptingthemtoageingpopulations. diseases for themanagementwithapplicationsinelderly ofchronic health andhomecare,indicated European Region suchas Austria, Belgium, Finland, and Germany reported mobile telemedicine initiatives regulate that mobile guidelinestelemedicine. policy fortelephoneconsultationsMember the States in electrocardiogram ofa transmission patient during travel to abyambulance. health clinic Belize reported and SMS communication between health professionalstomore advanced applications suchaswireless initiatives foundarange of mobile telemedicine examples reported asvoice from theseregionssuch reported of analysis Qualitative Regions. (62%) Asia South-East and (64%) European (75%), Americas A highlevel of mobile telemedicine was reported activity among participating Member States in the 3. the pointofcareandreduceunnecessaryreferrals. patients, community healthworkers inurban and physicians rural areas to improve quality ofcare at specialized care. Mobilepresentanopportunitytocircumventthischallenge technologies by connecting and/or treatment to access patient’s a to barrier major a pose sector health the in shortages resource is oneexample. In developing countries, aswell as underserved areas of developed countries, human But itcanbe applied to othersituations;themanagementdiseases of patientslivingathome of chronic professionals about patients usingthevoice,text,data, imaging, or videoofamobile functions device. health between consultation or communication the as survey the in defined was telemedicine Mobile 3 . 7 Key findings 7 1 Survey results Survey .1 Mobile telemedicineMobile The Americas (75%), European (64%) and South-East Asia (62%) Regions reported high rates of Countries inthehigh-incomegroup reported the highestpercentage of mobile initiatives (64%) followedbylower-middle incomecountries(53%). adoption ofmobile telemedicine initiatives,thoughalargeoftheseinitiativeswere proportion Mobile telemedicinebetweenincluded health-care initiativesconsultationsproviders and informal orinthepilotphase. transmission ofapatient’s health-relateddata usingmobiledevices. Results and analysis by mHealth category 35 2 Relevant literature Relevant .2 7 .
Case study 2 contains the details from a programme in Ghana, where telemedicine is being used to to Ghana, where telemedicine is being used in a programme Case study 2 contains the details from to improved health leading doctors, barriers between costs and geographical high referral overcome for patients. outcomes Feasibility studies were often found in the literature from parts of Asia, including China and its province, its province, China and Asia, including parts of from in the literature often found were Feasibility studies for tele- phone camera mobile of using a the feasibility al. studied Hsieh et For example, Taiwan. consultation and diagnosis of soft tissue injuries in Taiwan, China. They found an in 85% the accuracy diagnosis, rate and noted that the system would benefit if accompanied withcommunication on-line (36). Limitations or telephony to mobile telemedicine systems include mobile phone to transmit data (36). image quality and network connection screen size, 3 The high-income group had the largest percentage of participating Member States reporting mobile of participating Member percentage the largest had group The high-income telemedicine income The initiatives group lower-middle (64%). had the next highest rate of adoption at initiatives (34%). of which were informal and pilot 53%, a large proportion managing patients with hypertension. More advanced mobile telemedicine initiatives require significant significant initiatives require telemedicine mobile advanced with hypertension. patients More managing established infrastructure, fast telecommunication networks (i.e. general packet radio services (GPRS), adoption and growth to challenges pose can that factors all are which technology, advanced and 4G), 3G, countries. income for low and lower-middle 36 Mobile communications between doctors in Ghana improve medical practice case study Ghana in Ghana, and Switchboard and Ghana, in provider telephony mobile a with collaboration New in from Yorkand support University patients. With in Ghana needand referring tohave a reliableconsultations systemforconducting communication serving apopulationofnearly24 With anestimatedmillioninhabitants,doctors two thousand physicians Project overview 5 a moreefficientandculturallyresponsivemeanstoprovide theservice. of Internetservices,particularlyinrural areas of thecountry, made it evident thatcellular telephony was yet, thelackofaccessfor physicians; tool online communication computers andthelowpenetration to and urban areas already of thecountry use in theirdaily practice. was todevelopThe initialconcept an in between physicians rural in doctors most communication means of the mobile – using phones Ghana MDNet is the first service of its kind implemented in Africa and aims to promote the transfer of knowledge contact doctorswithinaparticularspecialty. allowing about GMA tosendinformationdoctorsnational emergencies and meetings, as well as to currently registered with the More recently,Association. aone-waybulk SMS service wasalsoenabled, in 2008.Ghana in Itprovidesfree in mobile-to-mobile all thephysicians voice andtextservicesto Ghana forward) here (MDNet programme (MDNet)/Medicareline Network Doctors Mobile (GMA)the launched Switchboard waspreviously knownas Africa Aid andchanged itsname inearly 2011 (http://www.africaaid.org/). 5 (a US-based non-profit-making organization) the Ghana Medical Association medical practice Ghanain improve between doctors communications Mobile Case study Mobile communications between doctors in Ghana improve medical practice 37 Photo: Brian Levine, 2009. Courtesy of Switchboard. of Courtesy 2009. Photo: Brian Levine, has removed MDNet service, mobile telephone to free By facilitating access among doctors, advancingan important cost barrier for clinical consultations the provision of medical advice and the of referral patients needing GMA process referral the ease To Ghana. medical attention across specialized and Switchboard will soon launch the first Ghana doctordirectory, using Sodzi Sodzi-Tettey, General Secretary of GMA, on the left, and Brian Levine, Secretary of General Sodzi-Tettey, Sodzi Switchboard, led the deployment of MDNet Officer of Chief Medical NYU and in Ghana.
Using information collected for the directory, Switchboard and GMA are planning, in collaboration planning, in collaboration GMA are Switchboard and Using information collected for the directory, Council, the Ghana Medical and Dental and the Service, Ghana Health with the Ministry of Health, the development of a dynamic software database of physicians that will integrate data collected by the five the The Ministry is also discussing with its service provider organizations in a central data repository. operator’s mobile the of part as charge, of free Ministry, the to services MDNet the extending of feasibility social responsibility programme. information collected through GMA. The directory will include a physician’s MDNet telephone number, specialty. and medical by both last name organized hospital, and region where s/he practises,
Benefits Switchboard, doctors consider that MDNet of MDNet users conducted by survey to a 2009 According health Ghana’s has improved communication about patient management among physicians throughout delivery system (see Figures 7 and 8). Similarly, district and rural medical practitioners report that they are increasingly reaching out to colleagues for advice on of more experienced the management complex and clinic availability, MDNet to solicit specialists, bed regarding cases and use information medical care. of times, facilitating the referral of patients to higher levels Tech nologysubscriber with over 1600 free physicians provided were GMA-registered to MDNet, gain access To work cards SIM The network. mobile the within numbers telephone to linked cards, (SIM) module identity are voice calls of charge, as long free as they with phone and allow doctors any of mobile to brand make are still GMA and provider discussing the The contacting within other colleagues the MDNet programme. by the three partners. best way to operationalize the free text messaging service originally agreed MDNet also facilitates emergency response communications between doctors on a cellular network. This MDNet also doctors communications emergency response facilitates network. on between a cellular phone, letting practitioners advice over the to use peer access unlimited doctors service provides rapid, of concerns without situations, continuously phone the number emergency their mobile about during account. on the phone’s minutes still available 38 Mobile communications between doctors in Ghana improve medical practice case study GHANA implementation inKenya. Liberian Medical andDental of Healthitspossible with theMinistry discussing and iscurrently Council, the LiberianofHealth,Dental with Ministry cooperation MTN mobile provider,Association, andthe Based on thesuccessprogramme of this in Ghana, Switchboard extended the servicetoLiberia in 2009, in in services care Ghana haveobtainedfromtheimplementationofMDNet. health benefits the of some indicates physicians GMA of survey 2009 Switchboard’s Source: Africa Aid, 2009 MDNet Ghana survey. N=77doctors Figure 8.MDNetsuccess indicators Source: Africa Aid, 2009 MDNet Ghana survey. N=77 doctors Figure 7. Top MDNetusesin Ghana Scale: 1 (not) - 10 (very successful) Scale: 1 (least) - 10 (most important) 10 10 6 6 4 4 8 8 2 2 0 0 connectivity Enhanced Giving physician advice emergency During Frequency of consultation Seeking advice quality ofcare to enhance MDNet success MDNet uses diagnosis and Success of treatment more effective To be Referral time speed doctor's practice specialists in Incorporate patient recovery Impact on Impact Referrals
Case study Mobile communications between doctors in Ghana improve medical practice 39
An essential factor in MDNet’s success has been partnering the project on the ground. to act as local champions and lead to the programme committed that are with health institutions in the country The GMA, for example, has facilitated MDNet’s deployment in Ghana the provision of economic incentives to Similarly, faced during its of the problems implementation. and actively addressed some the long- promote and participation their to ensure fundamental the telecommunication partners is go through MDNet should a process of initiatives like Finally, term sustainability of the programme. processes involved evaluation logistics, training and institutionalization, documenting the management, This institutionalization would facilitate the transfer of to knowledge local in running the programme. partners in the country (that could step in and run the programme, that will make and support model the right revenue to create will be challenge The ultimate countries. if necessary) as well as to other With the support of other national health institutions and mobile in the long-term. the project sustainable operators, MDNet has the potential to become a scalable pan-African initiative. Lessonslearnt
Costs was conceived MDNet as a scalable minimal. Ghana were costs of launching in MDNet The start-up that on model provides incentives based a business for the participation programme of telecom gaining MDNet members, the all cards for SIM the donated for example, One service provider, providers. access to a group of active telephone users that could generate profits from personal calls made with GMA, on its has the part, absorbed to outside the MDNET the network cards programme. numbers and maintains ongoing contact among its members, cards the service with SIM costs the of distributing Switchboard has contributed technical skills new MDNet users. the activation of to facilitate provider to The directory all will be distributed Ghana Doctor Directory. the services and tools like and designed doctors registered with GMA for an estimated cost of US$ 6000, which will be partially offset through of more advanced tools, including the development GMA. Finally, sponsorships advertisement sourced by a database, which is expected to cost around US$ 40 000, will require additional fundraising efforts to is still in its model early The business the MDNet programme. and expand implemented successfully be The costs need to stages be of better development. understood as well as the ramifications of the direct that will be received by the professionals using the service. marketing 40 Results and analysis by mHealth category systems aregenerallyestablished in high-income countries compared to simple solutions (37). Whatever the reason, it has been found that solution. found advanced systems may be theresultofpreferringimplement This to more technologically is oftengiven low priorityinand lower-middle income countries,despite being a low-cost and viable The literature suggests that implementing comprehensive emergency medical response systems (EMRS) 3. the lower-middle incomegroupdescribedtheirinitiativesasestablished. in countries of 30% only contrast In programme. established an reporting emergency,these of 55% with Countries inthehigh-incomegroup most frequentlyreported using mobileduring technologies an northern partoftheisland. coordinate healthcareservicesanddeliverydisplacedthe voice telephonytoforinternallypopulationsin were reported by Eritrea,Ethiopia,and Guinea-Bissau. Sri Lanka documented used an initiativethat Additional examples of informal initiatives usingmobiletoalertduring technology citizensanemergency Bhutan, Colombia, Malta,and Viet Namreportedtheuseoftwo-wayradiosaswell. as Belgium, such Belize, reported countries were commonlymethodsofcommunication, the most alertsystems, communication, citizen coordination, dispatch, andreporting. transportation and telephony While voice mobile on phones SMS functionality internal between varied conflict or pandemic Globally, thereportedmobile uses ofdevicesemergency,during anational naturaldisaster, disease Regions of South-East Asia (75%) andthe Americas (67%) alsoreportedhighlevels ofactivity. the in Region(48%). initiative African mHealth adopted highly The most the was across It regions. WHO The use ofmobile devicesreported foremergenciescommonlymHealthinitiatives was oneofthemost 3. outbreaks, andconflict. to respondandmanage emergencyanddisastersituationssuchasnaturaldisasters,disease devices mobile of use the as defined is mHealth of context the in response emergency health public A 3 . 8. results Survey 8.1 Key findings 8 2 Relevant literature Relevant 2 Public health emergencies health Public The useofmobile deviceswas oneofthemostfrequently foremergencycommunications during emergencies. Many respondingMember Many States usedincludingtwo-way multiple channels communication High-income (64%)andlow-income(50%) groupsreportedhighuptake. Regions, havethehighestlevels ofadoptionat48%,75%, and67% respectively. radios as a back up to manage duetheunreliabilityofmobile a backuptoemergencysituationsnetworks radios as reported all initiatives across WHO regions. The African, South-East Asia, and Americas after after a countryexperiencesdisaster. Results and analysis by mHealth category Descriptive studies of emergency response systems were found, but few documented sufficient evidence sufficient documented few but found, were systems response emergency of studies Descriptive of Overall, impact the (39–43). use of mobile phones in emergency contexts has been shown to improve very little is to however, transportation coordination of a formal EMRS, and emergency outside access known the impact of such access about systems delayed on complications to case fatality rates, related to health services, and health outcomes. Documentation of mHealth initiatives during an emergency in low and lower-middle income countries income countries was and lower-middle in low an emergency initiatives during of mHealth Documentation Ocean tsunami found to focus on the of impact mHealth to using respond to such disasters as the Indian in South-East Asia, versus the potential economic impact (38). In 2010, during to partnered create a citizen reporting SamaSource and Ushahidi, FrontlineSMS organizations the Haiti Earthquake, to shortcode to SMS a standardized to send an Citizens asked were phones. system mobile mapping via then translated SamaSource by coordinated Volunteers a missing person. or report communicate needs and plotted then uploaded were SMS messages Translated from Haitian messages to English. SMS the This system initially was used by agencies for aid rescue Ushahidi platform. on of a map Haiti using the (39). to identify needs and provide services operations and later 42 Results and analysis by mHealth category small pilotprojecttocollectchildhealthdata. a started it exception; an is Mali, by cited organization non-profit-making Pesinet,a data. health collect mHealth initiative.FewMember this States provided detailed examples of usingmobileto technology with States Member of proportion highest the reported (31%) Regions African the and (42%) Americas The surveythe usemobile found thatofdevices health surveysfor all across was low regions. WHO The 3. the twotypesofmHealthinitiatives,they havebeenpresentedtogether. diseases forsurveillanceprogrammes. track will beusedto data that transmit Given theoverlapbetween and input to devices mobile of use the as defined is reporting. Similarly,surveillance and collection data health-related for devices mobile of use the as defined are mHealth, of context the in surveys, Health 3 6 Communicable Disease utilizes early warningdiseasesurveillance initiative that pilot an to Control communicable of incidents record to diseases in communities. Similarly, Cambodia reported that InSTEDDisalsoworkingwiththe Disasters) Cambodian and Diseases Emergencies to Support (Innovative health workerswith community usingmobile phone datasoftwaredevelopedcollection by InSTEDD instance, Thailand reported that theMukdahan Provincial Health Department is piloting a programme mobile general phones tocollectepidemiological data to prepare for potentialdisease outbreaks. For of use the illustrating examples provided regions These (38%). Asia South-East and (41%) African the When aggregated by region, forsurveillance WHO the highestactivityinitiativeswasfoundtobe in in Bangladesh isexpectedtouseamobilephoneinterface tocollect individualandhouseholddata. developed being currently is that registry health electronic citizen’s the Further, access. continuous as beingusedtoexecutethenationalhealthsurvey, withresults being uploaded toacentralserver for Tobacco tobaccoof Surveystatus current the assess to In adults. useamong reported were PDAs Colombia, using PDAstocollect survey data.InPoland, PDAsarebeingusedtocollect dataforthe Global Adult is that (NIPSOM) Medicine Social and Preventive of Institute National the and (ICDDR)Research Disease theInternational by led Otherexamplesin Bangladesh project reportedpilot includea Centre forDiarrhoeal 9 . 9 Key findings 1 Survey results Survey .1 http://www.pesinet.org/wp/. Health surveyssurveillance and The African and South-East Asia Regions hadthe highest percentages forsurveillance The use of mobile devices forhealth surveysall waslowacross WHO regions, with theexception of theRegion ofthe Americas (42%). Responding countriesinthelow-income group reported ofhealthsurveythe highestactivity initiatives (41%and38%,respectively). initiatives (37%). Hat srelac atvt i mr peaet n onre i te o-noe 4% and (40%) low-income the in countries in prevalent more is activity surveillance mHealth lower-middle incomegroups(27%) thanthoseinthehigher-income groups. 6
Results and analysis by mHealth category 43 Currently, 12 diseases and syndromes are under surveillance using SMS using surveillance under syndromes are and 12 diseases Currently, 7 / information: http://instedd.org/technologies/geochat for more See 2 Relevant literature Relevant .2 9 . 7 Two Two programmes show the benefit to health outcomes that mHealth can provide. The one in Senegal in outbreaks tracks disease Cambodia, in The other, collection. data highlights how mHealth expedites studies 3 and 4). real-time (case Increasingly sophisticated health information systems (enabled through mobile and computer-based and computer-based through mobile systems Increasingly sophisticated health information (enabled data collection, aggregation, and reporting) are expanding the capacity for real-time monitoring and to monitor altogether health health surveys for paper the need removing prospective surveillance, outcomes and tracking utilization of health services (46). Advances in mobile technology have resulted or monitoring diseases. collection in support for data solutions, such health surveys as administering with surveillance methods of disease and paper traditional pen compared most studies have date, To mobile technologies. Benefits reductions of in the time latter and included cost, improved and accuracy, improved data quality (47). A study conducted by Patnaik, Brunskill, Thies and compared which mobile device functionality (i.e. voice, SMS, electronic form) produced the least errors during data collection. SMS by electronic forms and followed rate, the lowest error had that the voice method The study found (48). More comparative research is required to better understand the most effective methods for data generate. and the health benefits they collection using mobile devices 3 SMS, e-mail, and Geochat. and e-mail, SMS, When mHealth surveillance activities are aggregated by World Bank income group the results show that the Bank income group World by aggregated activities are When mHealth surveillance there are more initiatives taking place in countries in the low-income (40%) and lower-middle income income groups. than those in high- and upper-middle groups (27%) The Eastern Mediterranean (14%) and European (17%) Regions reported the lowest activity in the use countries in these regions Explanations that be surveillance. for this could technologies for of mobile to not the of and may have established methods feel need to disease surveillance, are more likely technologies the European at this initiatives using mobile transition stage. For surveillance example, flexible “highly a as described is which (TESSy), System Surveillance European The established has Union metadata-driven system for collection, validation, cleaning, analysis and dissemination of data” (45), An that does use mobile example but is not on technologies mobile for dependent its implementation. coalition a of partners – Indus Region; the Eastern Mediterranean technologies Pakistan, in comesfrom a pneumonia – enables Lab in Pakistan, and MIT Media phone provider a mobile Center, Hospital Research surveillance programme in Karachi. technology to send data from district levels to provincial levels, and from provincial levels to the national from provincial levels and to provincial levels, technology to data from district send levels Automatic analysis of trends to into has abnormal events detect the programme been integrated level. The country will save time, anticipates the implementation outbreaks. for potential disease and prepare for other things (44). staff of its monitoring and evaluation freeing the capacity 44 Senegal’s use of EpiSurveyor for maternal health data collection case study SENEGAL to respondtheshortagesandspecificneedsdata revealed. order in budgets their reallocate to data processed the used officials Health districts. other from reports to theleveldistrict with for analysis,andsubsequentlytransferredofHealthsynthesis to theMinistry real-time supervisorydata in 82-questionbasic usingan survey. The datacollectedwereelectronically sent the health workers made monthly field visits to 90 health posts collecting information using EpiSurveyor – devices (PDAs) loaded with EpiSurveyorwith loaded devices(PDAs) of mobiletechnology. Twentyhealth workerscommunity were intendistrictsequippedhandheld with In Senegal, ofHealthteamed the Ministry up with to improve WHO health datathroughtheuse collection which often facethe compound challenges ofheavy disease burdenandweakhealth infrastructure. makers, andelicitingactionsto improvehealthoutcomes. This isparticularly the case indeveloping countries, High-quality andup-to-date healthdataare essential foridentifyinghealth needs, informingdecision- Project overview 8 * sponsored bythe United NationsFoundationandthe Vodafone Foundation Technology Partnership Free datacollectionsoftware developed by DataDyne.org. The project anddevelopment ofthesoftwarewere Based onanevaluation byDalberg Development Advisors data collection* maternal health EpiSurveyor for Senegal's use of 8 , and trained in its use. Duringasix-monthits , andtrainedin 2008in pilot project Case study Senegal’s use of EpiSurveyor for maternal health data collection 45 A midwife in Senegal’s district Pikine holds a partogram, a Senegal’s A midwife in fundamental tool enabling healthy deliveries. Source: UN Foundation/Dalberg
Based on these data, Senegal’s Ministry of Health increased the distribution of partograms and asked field officers to encourage midwives to use the tool during everyhealth delivery. During workers surveys, follow-up using EpiSurveyor verified use of partograms,the training was required to and, ensure the when necessary, tool’s effective use. Subsequent noted that data collection using EpiSurveyor on average to assist increased labour of partograms use 2008, August March and that, between revealed partograms of use the in increase 1% a to compared project, the in involved regions ten all among 28% by pilot study. in areas outside the EpiSurveyor In areas where maternal mortality is a prevailing challenge, the partogram has shown to the partogram been challenge, improve mortality is a prevailing maternal In areas where the chance of survival for both mother and child. tool, the However, EpiSurveyor-collected despite data in the Senegal revealed recognized that only benefits55% of ofthe the districts surveyed were the partogram. systematically monitoring labour using Benefits Gaps in the Senegal. within the six months of in Faster the programme data processing time was achieved across multiple data collected by EpiSurveyor For example, more quickly. health system revealed were is The partogram a graphical tool districts showed a shortage of a basic tool birthing called a partogram. used by midwives to monitor the process of labour and ensure The safe effective,delivery. inexpensive from the expected identify deviations and midwives systemhelps community health workers and simple additional interventions. trajectory of labour that might require
Tech nologyto and collect health it simple public tool that phone-based makes and mobile is a web- EpiSurveyor as as well country, in every phones available on common mobile Usable phones. on mobile other data no-cost tool only is a simple, basic word that requires PDAs a variety of smartphones, EpiSurveyor and processing and cell phone skills to use. Survey forms can be downloaded and modified, dataand in charts graphs analysis entered and automated include of EpiSurveyor releases synchronized. and Recent SMS. and upload of data via reporting by e-mail 46 Senegal’s use of EpiSurveyor for maternal health data collection case study SENEGAL health personnelin Senegal identifiedstrongprogressinthetestphase,including: An evaluation of thepilotprogramme based on interviews with WHO, ofHealth,and the Ministrydistrict learnt Lessons and over US$ 1millioninfundingto WHO tosupportmHealthprogrammesacrosssub-Saharan Africa. support thedevelopmentmillion to liketools and analysis mobile ofhealthdatacollection EpiSurveyor, Vodafone Foundation TechnologyPartnership. 2006,Since have investedover thefoundations US$ 1 The Senegal pilot waspartofalarger mobile health programme funded the by and Foundation UN Costs analysis arecriticaltoeffectivedecision-making. and data timely where surveillance, disease in use its considered also officials regions, Senegalese other information fromhealthfacilitiesaround the country. Inaddition toexpanding the use of EpiSurveyorto workersEpiSurveyor with mobile on devicesrunning ofup-to-date increase thecollectionhealth to success,this Based on and Health of the Ministry equip morehealth plan to designed expansion WHO an additional hardwareneededforscale-up. national-levelwith integration afterthorough continues pilotfundingconcludes; programmes; and for significant training to roll out the programme to all 65 health districts; incentives to ensure supervision need the included expansion pilot Successful identified. were expansion programme to challenges Still, from, Senegal’s MinistryofHealthwasstrong;andthe pilotprogramme waswellplannedandexecuted. EpiSurveyor; health districtswere empowered touse thedatacollected;ownership by, andpoliticalsupport The evaluation alsoindicatedthatthe Senegal healthsystem waswell-equippedsupport theexpansion toof • • • current needs. data madeavailable fordecision-makers could be usedtoreallocate funds toaddress collect onpaperwasbeingcollectedinonehour);and (oneand analysis faster datacollection reported districtthatdata requiring uptwoweeks to (every 3–6months); areas non-pilot versus months) 1–2 every (visits areas pilot the in supervision frequent more
48 Results and analysis by mHealth category case study CAMBODIA an outbreak(Table 2). ensuring promptincaseof action the population, withthepurpose of affecting syndromes and diseases data apredeterminedon set of analysis, and interpretation of collection, the ongoingsystematic Cam e-WARN, intendstoexpedite using indicators. The system,called abnormal events oroutbreaks, system fortheearlydetectionof introduce amoreadvancedto in collaborationwith WHO, conductedaneeds assessment andrevised its disease surveillance programme disease – topromptlyrespond to major outbreaks. To address thisgap,ofHealth the Ministry Cambodia, existing country’s the of limitations surveillance system – an event-based the telephone hotline used by the population to report apparent specific cases of made 2003 in Cambodia in SARS of outbreak The Project overview Cambodia via SMS Cambodia outbreaks in monitoring disease Cam e-WARN: Table 2. Cam E-WARN diseasemonitoringin Cambodia Acute lowerrespiratory Suspected measles Suspected Acute Flaccid Suspected Acute Cam E-WARN monitorsthe outbreak of12majordiseases in Cambodia. Rabies Dysentery Dengue Paralysis (Polio paralysis) infection Diseases monitoredthrough Cam e-WARN Acute jaundice(malaria, Acute waterydiarrhoea/cholera Cluster ofunknownetiology Neonatal tetanus Meningoencephalitis Diphtheria hepatitis A, Band C) Case study Results and analysis by mHealth category 49
predetermined threshold, it triggers a signal in predetermined the corresponding computer database, indicating the specific province and district where the abnormal event has occurred. Once the staff members at the provincial and district offices confirm that the abnormal event is not the result of a mistaken data of the event is sent to the site team response a rapid entry or statistical error, action. to investigate and take Cambodia’s Improving the health of its population is priority top for Ministry of Health. Photo: Jim Holmes. Courtesy of WHO/WPRO image bank. Courtesy of Holmes. Jim Photo: When the number of cases When the number on a any of the monitored diseases exceeds
Cellular technology provides a fast, simple, Surveillance still unavailable. services are Internet where Cambodia in district areas in rural particularly and affordable platform for operating e-WARN, officers Cam use the technology to communicate and transmit data SMS via on the monitored diseases from the district and provincial offices to the national office. The mobile phones employ SIM cards owned by private mobile network operators with national or regional coverage. Tech nology
Cam e-WARN has a staff of 1200 employees distributed throughout the collection and acute watery including hepatitis and analysis diseases, on monitored of data twelve country, the who participate in structure. health the of levels different at data aggregates and collects system surveillance The diarrhoea. Local health centres and hospitals information report of cases to on related these the number and deaths officers Surveillance person. in even and calls, phone SMS, using office district e-WARN Cam a to diseases in districts then the 78 phones onto sum up the local send their mobile and data using software downloaded the information SMS via to the provincial Staffoffice. at the province level enter the district information database and analyse Cam it into e-WARN’s for trends at the health centre, district, and province levels. Finally, to obtain national trends, the 24 provincial offices send their database information viaSMS to the national office, where it is analysed for trends and incidence of diseases by province, creating also diseases at the provincial level. matrices and tables of the monitored 50 Results and analysis by mHealth category case study CAMBODIA of abnormalevents. reporting the encourage to usage phone for of 5.0 stipend US$ monthly a staff surveillance its gives also training. surveillance and phone’smobile maintenance for as well as fee, monthly Health of Ministry The computers, mobile phones, and SIM cards; meanwhile, government funds havebeen used to coverthe developmentthe equipment, purchase of including software andthe automatic dataanalysis the of donors, andcomplemented with regular public budget resources. supported The externaldonors Costs also beusedforcross-bordercollaboration,supportingtheexchangeofinformationaboutoutbreaks. Papua New Guinea, and Viet Nam are preparing to implement versionsaswell. The e-WARN toolcould likecountries and other already operating a similarsystem the region.Laosis throughout Indonesia, Moreover, Cambodia is collaboratingwithitsneighbouringtouse thee-WARNcountries system expects toexpedite Cam e-WARN’s analysisandresponserates. Ministry the steps, intermediate current bypassing By office. national the at database computer the to officers that would allow them to use their mobile phones to report primary disease data via SMS directly becomes available, ofHealthalsointendstoprovidesurveillance the Ministrysoftwaretoitsdistrict data error.abnormalities for risk whenaredetected verifyandcheck assess andto capability to If funding The updating Cambodian governmentwillcontinue Cam e-WARNimprove, aspects,its to amongother policy-makers welcometherapidavailabilityofdatafromsystemwhenoutbreaksoccur. and officials government Similarly,Cambodia. in e-WARNsystem the of implementation the eased has method,which reporting ofthe and cost-effectiveness the simplicity appreciate officers Surveillance the recentH1N1globalpandemic. during illnesses influenza-like monitor to also used was system SMS level. The district the at diarrhoea 2008,fully operationalin helped it hasdetectmultiple outbreaks, ofacutewatery including incidents became e-WARN Cam Since public. the from calls prank and reports unconfirmed of number higher a particularly whencompared to thead-hoctelephone hotline surveillancestillreceives system, which million inhabitants. Cam e-WARNaccuracyincreased the has country,disease outbreakthe of reports in of health the protect and diseases Cambodia’sof spread Ministry’sthe the improved control 14 to ability The implementationof Cam e-WARNfor therapid detectionofearlystagedisease outbreaks has Benefits with fundsfrom WHO, the Asian Development Bank and other financed 000 100 US$ approximately of investment an required 2003,in inception Since its the operationof Cam e-WARNhas Courtesy ofMinistryHealth Cambodia. Remote healthpostin Cambodia. Case study
Results and analysis by mHealth category 51
Beyond of technical the availability Beyond tools, a fully sustainable surveillance ownership, system leadership, requires and knowledgeable staff to continuous to provide monitoring be able This is most likely and data follow-up. to happen if there are incentives to the work into health integrate the these Achieving information system. to goals also securing access requires long-term funding. Cam e-WARN faces technical barriers Cam e-WARN as well, due to the lack of IT staff at the facilitate To provincial level. district and and analysis data at the district level data entry, quality of event the improve the Ministry of Health is planning to install more computersin its district offices and provide low-costphones to local health centres to ease mobile the reporting process at the field level. The Ministry is also training its staff to and the integrity of the database secure protect it from viruses. Since most of the funds supporting Cam supporting Since most of the funds sources, external come from e-WARN a major concern is the long-term address To sustainability of the system. this issue, the Ministry is planning to funding strategy a long-term develop and an ICT policy to support the continuity of the system. Lessons learnt As part of its with the best national phone operator social mobile responsibility the private activities, phone a discounted fee (less users Cam e-WARN has with coverage to the government partnered provide Other mobile operators SMS SMS, per for US$ offer service. but month) .50 the free theirthan networks This system. for the surveillance their usefulness limiting the full country, for do not coverage provide into the programme. if more operators could be brought could be overcome 52 Results and analysis by mHealth category services tosupport hypertensive,cardiac, andasthmapatients. manage portal todiabeticpatients. online successthe With expand programme to this there areplans of programme uses mobile that technology, Bluetooth-enabled glucometers, telephone helplines,andan In the South-East Region,Asia established integrated has an Bangladeshdescribedthat a privatecompany administration, specimencollection,andphysicallocation ofthepatient. system that can monitor among other things: patient identification, admission, transfer, discharge, drug RFID tags. with wristbandscontaining be The tagscanusedofahospitalinformation asonecomponent a hospital. track patientswithin to supply patients is to technology application ofthis common The most Singapore also reported that some hospitals were using radio frequency identification (RFID) technology devices that trackvital signs and transmit data through themobile network toa secure online database. and sensors remote of use the included all Region the WesternPacific in Singapore and Philippines, the programmes initiatives. Pilotreported reported ofpatientmonitoringbyNew the lowestactivity Zealand, Member States from the Eastern Mediterranean (14%), African (20%), and Western Pacific (23%) Regions the provinceofNova Scotia toincreaseaccess toclinical careforcommunitiesinruralareas. example, Canada described the Congestive HeartFailure Home Telehealth being Project implemented in For region. Americas the in reported were implementations specific few a Only Estonia. and Bulgaria, countries intheEuropean Region are also pilotingsimilar patient monitoringsystems,including Austria, wearable and transmitted biosensors over the mobile wireless network toacentralserver. Several other using measured are (ECG) electrocardiography and sugar, blood weight, pressure, blood as such signs management of patients with chronic diseases such as diabetes, heart insufficiency, and hypertonia. Vital instance, For patients. using telebiometrythe is for that Switzerland reportedcompany a local The survey indicated that private companies are beginning todevelopdisease for chronic solutions Americas and Regions (33%). (47%) European the in reported frequently most were initiatives monitoring Patient 3.10 the healthserviceprovider. This canreducetheneedforvisitstoahealthcentrecheck-ups. households orimaging devices linked mobile to phonesare often used facilitatedatato to transmission in installed sensors Remote patients). cardiac and diabetes (e.g. distance a from illness patient’s a treat and monitor, manage, to technology using as defined is monitoring patient mHealth, of context the In 3 . Key findings Patient10 monitoring 1 Survey results Survey .1 Countries inthehigh-incomegroupreportedhighestlevels ofactivityinthisarea(58%). (23%) Regions reported the lowest activity of patient monitoring initiatives; none reported none initiatives; monitoring patient of activity lowest the reported Regions (23%) established programmes. ebrSae fo te atr Mdtraen 1%,Arcn 2%, n etr Pacific Western and (20%), African (14%), Mediterranean Eastern the from States Member Patient monitoring initiatives were most prevalentwere most initiatives monitoring EuropeanRegionPatient the in (47%), followedby the Region ofthe Americas (33%). Results and analysis by mHealth category 53 2 Relevant literature . 3.10 which is not yet at the low available Mobile patient monitoring requires diagnostic sensor technology, Since transmitted via the health data are countries. in developing it accessible costs make that would phone and/or wireless mobile to a access to have required patients are telecommunication network, device, to which diagnostic sensors can easily connect (50). In regions where mobile patient monitoring reported primarily The literature resolved. be may in care delays implemented, been initiatives have and in high-incomecountries throughout the European individuals for elderly studies monitoring patient Caregivers are Asia increasingly (51–53). Regions able to South-East monitor the real-time status of vital using a mobile phone, PDA, and/or computer. signs of patients remotely, One of the more recent drivers within the European Union is that of personal health or implantable systems with care through wearable, portable, personalized These systems promote systems (49). managing of method efficient an is It management. disease remote and diagnosis early of objective the chronic diseases and often allows patients to remain at home – both of which can health care costs. significantly cut When reviewed by World Bank income group, Member States from the high-income group reported the reported group States from the high-income Member income group, Bank World by When reviewed highest percentage of patient monitoring activity (58%). In comparison, the level of adoption for other Overall, the income survey found groups patient was monitoring approximately as 20%. one of the least established mHealth initiatives. However, a significant amount of pilot activity was reported across all remotely. to monitor patients for growth of programming strong potential indicating the income groups, 54 Results and analysis by mHealth category developed countries,wheremedicalprofessionalsareoftenequipped withadvancedmobiledevices. health information. While relativelydevelopingnew to countries,theseservicesareestablished in health informationtoregisterednursesworkingwith Aboriginal communitiesinremotelocations. tohealth 55). (54, education and in information programme recent a highlights 5 study access Case provides that Canada mobile allow that for services however, need, identified an was There technologies. Few studieswere retrieved from theliterature with evidence reporting accessto informationusingmobile 3 included responses whichtheuse of PDAs,smartphones,mobile websites, survey their in and Thailand India, Bhutan, Bangladesh, by provided were examples Specific initiatives. information mobile of level highest the show Regions (58%) Americas and (62%) Asia South-East The 3.11 or databasesatpointofcareusingmobiledevices. mHealth information initiatives are defined as services that provide access to health science publications 3 9 . . 11 Key findings 11 .2 Relevant literature results Survey .1
http://www.pcmag.com/encyclopedia_term/0,2542,t=mobile+Web+site&i=60020,00.asp. This refers toweb sitesdesigned for use onthesmallscreensofhandhelddevices. Formore information see: Information initiatives The African Region (7%)hadthelowestrateofadoption. The South-East Asia (62%) and Americas (58%) Regions had the highest proportion of Member Countries in the high-income group reported the most activity (42%); those in the low-income States withinformationinitiatives. Bandwidth andhandsets arenotaprerequisite foraccess asdatacanbedownloaded ontoPDAs. group reportedtheleast(17%). Most initiativesused PDAs, smartphones,mobile web sites, andweb browsing toaccess health information. 9 andweb browsing toaccess
56 PDA enhances nursing care in Aboriginal communities of Saskatchewan case study CANADA technology, specifically, PDAs. access totoolsanddetailed health informationatthe pointofcare throughhandheldcomputer communities intheprovince of Saskatchewan. The aimistoprovide nurses serving these communities Nations) (First Aboriginal on-reserve with collaborating is Canada Health challenges, these address need quick access to effective tools and health information resources to support their practice. To help acute andcomplexnursingcare isrequiredinthehome. Under these circumstances, registered nurses (outside their usual scope of practice) and second, in the case of home-care services where increasingly support isscarce andprimary care nurses needtoperformdiagnosticandprescribing functions nursing. This isparticularlytrue inremote andless populated regions of Canada. First,wheremedical Nurses playanessentialroleinhealth service delivery bothatnursingstationsandthrough home care Project overview Canada of Saskatchewan, Aboriginal communities nursing care in enhances technology Personal digital assistant on herPDA. Registered nursereferringtorelevanthealthinformation Digital and Nursing Assistant which Software EvaluationProject, Saskatchewan. InMay2007, Health Canada launched the Personal Health Canada is currentlysupporting twoPDA-relatedin projects Saskatchewan, Canada. Nations, First Photo: NadineMorris,2010. Courtesy ofFileHills Qu’Appelle Tribal Council,
Case study PDA enhances nursing care in Aboriginal communities of Saskatchewan 57
10 12 representing over 30 communities in Northern Saskatchewan. representing over 30 communities in Northern 11 First Nations and Inuit Health Branch. 2007. to December June Saskatchewan. in Communities in First Nations Nurses Care Personal Community and Home Digital Assistant (PDA) and Nursing Software Evaluation Project: “Homecare nurses embrace technology”. FNIH Saskatchewan, p.8. FNIH nurses embrace technology”. “Homecare Tribal Council, and the Meadow Lake Grand Albert Indian Band, Prince Nation, Cree Lac La Ronge Ballantyne The Peter First Nations populationCouncil are partners of NITHA and their comprise almost half of the on-reserve communities in Saskatchewan. [Unpublished Nursing innovation investments. Project Proposal 2008-2013. Authority. Health Northern Inter-Tribal document]. 10 NITHA’s objective is for the nurses participating in this project to use the PDAs not only for education and education for only not PDAs the use to project this in participating nurses the for is objective NITHA’s care material to primary access The PDAs will provide also for clinical decision-making. but reference, to digital on such subjects clinical and assessment, as well as ready access as medication, guidelines tools, other and calculators drug references, pharmacy interactions, and side-effects drug on information including immunization charts. 11 12 NITHA nursing stations function 24 hours per day seven days per week and are distributed over the over distributed are and week days per day seven NITHA nursing stations function hours per 24 northern Saskatchewan region, which covers an area of 11 000 Some Km2. nurses have to be flown into nurses working by road. Registered nursing stationszones, located in remote which not are accessible for chronic to care trauma emergency from ranging services, at the nursing stations various provide illnesses and immunization. aims to evaluate the technology’s potential for improving the quality of health care in the province. The second project supported by Health Canada, PDAs for Primary Care Nurses in Northern Saskatchewan Saskatchewan Care Nurses in Northern Canada, PDAs for Primary The second project by Health supported (NITHA), Authority Health Inter-Tribal Northern the by 2009 in launched and proposed was Nations, First a partnership of four tribal councils/bands While the project was originally intended to last only six months, Health Canada has extended it to meet has extended Canada to last only months, project was originally intended six Health the While a factor for the future, will be Although the evaluation nurses in the province. home-care requests of more to the positive results of this project project led plans to to improve have already introduce a telehealth by nurses and will link used devices camera audio/video This mobile feature will care. wound and diabetes medical and specialized health professionals in urban areas. clients living with chronic diseases to To help evaluate their experiences, nurses were asked to at the beginning of complete a questionnaire asked nurses were their experiences, evaluate help To of their PDA at intervals logs the frequency and purpose usage as weekly detailing the project, as well throughout the evaluation period. Early findings show the nurses frequently used the devices to support Reference and their families. clients and to educate to questions diseases care planning, respond about for home visits and to support typically to prepare are used such handbook, materials, as the drug medication reconciliation for client safety. Health Canada provided PDAs, loaded with nursing software, to a group of home and community care community care of home and to a group software, with nursing PDAs, loaded Canada provided Health to join the project and received Thirty nurses volunteered with First nurses working Nations communities. on including a manual materials, with reference loaded were received The PDAs they technical training. a handbook on diseases and disorders, laboratory – and diagnostic tests, guide all frequently and a drug used in nursing practice. This four-year project (2009–2013) aims to use PDAs to support primary project care (2009–2013) nursing practice and better This four-year nursing stations. 13 meet the needs of clients at NITHA’s 58 PDA enhances nursing care in Aboriginal communities of Saskatchewan case study CANADA even morenecessary, givenpersistentnursingshortagesandtheneedforgreaterefficiency. health recordsintheprovince.Furthermore,isbecoming activities andelectronic use oftechnologies sense, aretowardstheadoptionofnewtelehealth Inthis theprojectssteppingstones these technologies. with comfort of care, graduallytheirsense of increasing at point ICT use of the with and nurses clients in dailynursingpractice of PDAs The introduction Saskatchewan isexpected to helpfamiliarize both twenty thousandFirstNationscommunitymembersmay benefitfromtheNITHAproject. estimated an Meanwhile, home. client’s the in right information health current to access increasing by services provided to approximately 2500 clients inatleast 40 communities First Nationsin Saskatchewan all Canadians. for efficiency and quality,accessibility, system care health in improvements in result to expected is ICT of use expanded where agenda, eHealth Canada’s with fits also technology PDA of adoption areas. The rural andremote of servicesprovided,communitiesin the quality particularly in enhance health careto Both PDA-related projects are in-line with the overall national effort to promote the use of technology in Benefits aid. medication errors, ease nursing workload, and facilitatepatienteducationthroughapracticalvisual reduce nurses, for access information improve can that tool low-cost efficient, an considered are PDAs nology Tech 14 13 personal dataprotection. and nurseswere an importantconsiderationrequiredtakeupdates. wasalsoto Data safety acourseon ease of use, compatibility withdiverse PDA devices, andtheavailability of asimple process forautomatic on thenursingPDAsoftware took intoaccount thequalityand source ofinformationprovided including decisions Similarly, life. battery and capacity, storage size, display use, of ease affordability, including
13 of thePDAmodels The selectionused for the Saskatchewanwas basedvariouscriteria, projectson deployment andinvestment ofthese services.” See: http://www.hc-sc.gc.ca/hcs-sss/ehealth-esante/index-eng.php. the in progress measuring in and system care health Canada’swithin services eHealth mainstreaming in challenges and According to Health Canada’s eHealth site, “Health Canada’s priorities and efforts have focused on addressing policy issues prepared fortoday, poised fortomorrow. Online Journal ofNursingInformatics, 2005, 9(2). education: nursing in PDA LJ. Davidson & LE. and, Home George 2003,21(12):797–800; Care andHospice Professional, care. home in PDAs for uses 10 (2003). M. Smith-Stoner example for See 14 evaluationThe PDA improve ofhomehealthcare the potentialtoquality has project Saskatchewan, Canada. of Courtesy Touchwood Agency Tribal Nations, First Council, Photo: Mary Skolney, registerednurse,Home-careprogramme,2010. Sasketchewan, Canada. in programs home-care delivery of the in PDAs of use The Home HealthcareNurse: The Journal forthe
Case study PDA enhances nursing care in Aboriginal communities of Saskatchewan 59
The projects clearly demonstrate that PDAs communities can isolated support nursing practice in rural, Canadian PDA projects The at the point of care. tools information to better and by facilitating access anticipate that with effective resources in the hands of health professionals to support care provision where people live and work, residents of rural communities will receive better care. Since the benefits similar projects could be of Internet access, on not of PDA in health care are dependent the level usage conducted in other countries. Health Canada also contributed to also contributed the PDA Evaluation project Canada by supporting the initial research on, Health from the First health leaders Nations communities While and investment in, the PDAs and software. not to search on their did have they in the decision-making process, the collaboration meant participated to start their projects. own to determine the best products Lessonslearnt The two projects have overcome different barriers, yet they share some common issues. For example, the lack of dedicated funding for project coordination involved had to temporarily delay both projects, to focus on more critical health priorities, such as the meant the Health Canada and NITHA staff technology Both of new projects highlight the fact that promoting the adoption in 2009. H1N1 epidemic requires a dedicated leader and available technical staff to encourage participation, support technology usage, and educate practitioners.
The initial investment for the NITHA project was $166 000. The cost for the entire project, including the The cost project, for the entire NITHA investment for the project was $166 The initial 000. over the four 000, addition of a pharmacy system, electronic to management is estimated be about $300 years of the pilot project. Costs Health Canada is financing these two nursing total This project software. including PDA device, Canadian dollars per of 400 to 500 investment projects. The PDA evaluation project an required PDA The costs for future 000. is under $25 upcoming evaluation, the years, including cost over three and regular updates replacements of clinical and medical reference software are built into the operating services. costs for home-care 60 Results and analysis by mHealth category established initiatives. activity of level highest (42%), in comparison the to other groups. Overall, pilot and informal initiatives were more common than reported group high-income Bank’s World the from States Member phone applicationcanbeusedtoverifyprognosisandcheckformedicationinteractionsinreal-time. In the for drug check allergies, and costs. to interactions, support systems United States, apopular mobile mobile phones (56). Clinicians at the National Healthcare Group in Singapore use PDAs to access decision and middle-income countries, theprogramcomputer-basedwas initially being and isnowextended to low in professionals health by use For strategy.(IMCI) Illness Childhood of Management Integrated the Foundation for Sustainable Development and WHO todevelop a decision support program as part of Further,support tools. in aprivatecompany Novartis Switzerland detailedthe a partnership with establish withinambulances an Internet to enable connection access topatient information and decision example,reportedbeingimplementedto medication. For apilotprojectprivatecompany Estonia by for prescribingandordering as drugandsystems such databases,protocols, treatment andinteraction by Member the EuropeanRegionStates in includedsupportsystems deployment ofpilotdecision reported applications of Typesboth). for (25% Regions Americas and European the by reported being Globally theuptakewas low,mobile supportsystems ofdecision levelthe highest with activity of 3.12 drugs. Mobiledevices areusedtoinputpatientdataandreceivetargetedhealthinformation. onclinical prescribed patient dataas of andmedicalsuch patientsbased theinteractioninformation, diagnoses ofon health providers that advise algorithms software as defined are systems support Decision 3 . Key findings 12 1 Survey results Survey .1 Decision support systemsDecision support There is low global uptakeThere islow within support systems ofmobiledecision region regions; no WHO Countries inthehigh-incomegroupreportedhighestpercentageofuptak drug databases, and treatment protocols,systemsforprescribing and interaction ordering Pilot and informalinitiativeswereestablished Pilot morethaninitiatives;theseincluded common medication. reported adoptionofover25%. e (42%). Results and analysis by mHealth category 61 and the Harvard School of Public Health. The programme School Health. of Public and the Harvard 15 reporting a patient record initiative. World Bank income groups. World Countries in the high-income group had the highest level of uptake, with 65% of countries The European (47%) and Americas (42%) Regions reported the highest levels of activity. reported the highest levels Americas (42%) Regions The European (47%) and The level of adoption of mobile patient records was moderate across all WHO regions and of adoption across of patient records mobile was moderate all The level Patient records Patient /. http://www.d-tree.org 2 Relevant literature . 13 Key findings Key . develops clinical algorithms for HIV/AIDS, diabetes, reproductive health, and child health – including and health, reproductive diabetes, algorithms for HIV/AIDS, clinical develops of patients and treatment in the diagnosis and community health workers – that support nurses IMCI control A in pilot study conducted care initiatives. through home-based facilities or at government South Africa to treat HIV/AIDS patients validated the software (57). Future plans include integration of collection. support and data health records to combine point-of-care algorithms into electronic 15 Countries in the high-income group had the highest level of uptake for this category (65%). This indicates This (65%). category this for uptake of level highest the had group high-income the in Countries in developed are primarily being implemented to at point-of-care EMRs that enabling access programmes countries, possibly due to the availability of services such as mobile Internet. The level of adoption of this initiative was moderate across WHO regions and World Bank income groups. World WHO regions and across was moderate of adoption of this initiative The level In the European reported the of highest activity. levels Americas (42%) Regions The European (47%) and to EMR at point of care, either in a primary health care implementations included access reported Region, Switzerland reported Germany and clinic, hospital, or in the home during a visit by a nurse or midwife. rather use patient at aimed generally are which programmes, record health personal of examples specific that combines an of an implementation is an example Canada, than use. MyChart, by provider reported reminders. EMR with other mHealth applications such as appointment and medication The survey enquired about patient record initiatives that specifically use mobile devices to create and/or access EMRs and/or electronic health records (EHRs) of patients at the point Although of EMR care. and were used interchangeably (58). they EHR are not strictly the same, for the purposes of this survey 3.13.1 Survey results The use of mobile devices to support the treatment of patients (including collecting displaying of patients and the treatment to support devices mobile of The use medical electronic to access enables mHealth of aspect This prevalent. more becoming is records) patient through mobile technologies. records (EMRs) at point-of-care 3 3.12 systems of decision support was low across the implementation documenting all of studies The number regions, indicating that this may still be an emerging field within mHealth. A noteworthy initiative has International launched jointly by D-Tree been 62 Results and analysis by mHealth category is essentialthatmHealthsolutionsareinteroperablewitheHealthsolutions. systems (60). An effective EMR programme must be a part of the overall health system. For this reason it technology and communication information existing into speed adoptionwilldependintegration of on makecan assert thatwhilemobile technology accesspatient data to andhealthinformationeasier, the concerns regarding the security, confidentiality, and privacy of patient health data (59). Martins and Jones Internet andmobileresistance,increased barriers adoptingEMRsonplatformsincludeclinician to However,these settings. increase thequalityofpatientcarein the potentialto for mobilehas phones software EMR countries, developing in computers personal exceeds significantly devices mobile of use that advanced mobileismaking technology it possible to accessEMRs directlyandinputdata. Since devices.were MostEMRsystemsdesigned for use on apersonalcomputer. Itshouldbe noted, however, No literature was found that supported the use and development ofEMR software exclusively for mobile . 3.13 2 Relevant literature Relevant 2
Barriers to mHealth implementation 63
Barriers to to Barriers mHealth implementation 4 priorities as their top barrier. their most important barriers. groups; they all reported competing priorities, cost-effectiveness and lack of knowledge as Similar trends were found in countries in the high, upper-middle, and lower-middle income and lower-middle found in trends were countries Similar in the high, upper-middle, Globally, infrastructure was cited as the least important barrier (26%). infrastructure was cited as Globally, Approximately half of responding Member States (53%) reported competing health system Key findings Key Figure 9 illustrates the cited barriers to mHealth implementation globally. The highest is conflicting health conflicting is highest The globally. implementation mHealth to barriers cited the illustrates 9 Figure system priorities (52%) and the lowest is underdeveloped infrastructure (26%). All identified barriers, can impede mHealth adoption. when considering the many factors that should be reviewed however, The The results, which were supported by the literature, explain the differences in the adoption of adoption and to mHealth Understanding the barriers groups. regions and income initiatives found between mHealth be – can technical and human, financial, – resources that so vital is contexts country in utilization effective its populations. of health the better to practice into initiatives these put optimally to re-allocated) (or allocated One of the aims of the 2009 survey was to to identify the most important barriers mHealth implementation survey One of the aims of the 2009 that barriers to select the four most important asked States were and the scaling of projects. Member Additional barriers could also be listed. a list of nine options. applied to their country situation from 64 Barriers to mHealth implementation communications, andtechnology). of mHealth–wheretechnology evolves soquicklyandthere are multiple sectors involved (e.g. health, field the of true especially is this demand; public’s or development technological with up keeps rarely process policy-making The policy). of and their (part use for guidelines trials and effectiveness, (innovation), prove to evaluation development and research solution/benefit), potential and need the This isamulti-step process, of course, whichincludespublic awareness campaigns(highlighting promote andvalidatemHealth,systematizingit. will health mobile and electronic includes that policy health a within points such Addressing (61). occur as wereidentified challenges toovercomebeforeofmHealthasastrategicinitiativecan pertinent policy theconsideration systems and interoperable metrics, standardized confidentiality, patient security, in a relatively early stage of adoption and development. Recent studies indicate that healthinformation still is mHealth that given surprising not issues. is health-related finding to This approach an as mHealth The third most important barrier identified was that of country or regional eHealth policy not recognizing disseminated by WHO orotherpartnerinternationalagencies. mHealth of studies and targetgroups. settings a rangeof across applications evaluation evaluated,Once be resultswillneedto the for need the highlights This (47%). barrier rated highest next the was The lack of knowledge thepossible concerning applications ofmHealth and public health outcomes of generalinterestorunderstandingthefield. generally indicates that funding is allocated to other programmes ahead of mHealth, or can reflect a lack barrier.main priorities their Conflicting as priorities competing reported Member States responding the understandable abouthalfof is that it and healthsystems, health outcomes impact on verify its base to evidence- a strong lacks currently mHealth Since priorities. competing about decisions difficult make to are severelyhealth systems Most overburdened. means theyThis challenged bytheneed are constantly Figure 9.BarrierstomHealthimplementation,globally Percent of countries 50 30 10 60 40 20 0 Priorities Knowledge Policy effectiveness Cost Legal Barriers Operating costs Demand Technical expertise structure Infra- Other Barriers to mHealth implementation 65 Once such programmes began evaluation would follow, either conducted by industry itself, itself, by industry conducted either follow, would began evaluation programmes Once such 16 The case study from Ghana in this report is a good example. Ghana in this report from study The case As there have not been large-scale deployments of integrated systems, however, it is not yet possible to systems, of integrated however, As deployments there have not large-scale been present the business case. Still, as the field matures the costs of implementation and expectations will change, and the environment will become more conducive to evaluation of Allefforts. stakeholders can promote or support sound evaluation and cost-effectiveness studies of mHealth initiatives, particularly industry. donors, academia, governments, and or other organizations. organizations. or other 16 Most mHealth solutions to date are independent, local initiatives. Such solutions are unlikely to be the be the to unlikely Such solutions are date are independent, local initiatives. solutions to Most mHealth be to likely more are systems interoperable Integrated, true. is opposite the indeed cost-effective; most the cheapest to deploy and operate, as well as having the most Thatsignificant is, impact. integrated regional (and even global) solutions are likely to provide the most benefits – there are as yet no data for this. Technology industry leaders could lead this effort, in usage perhaps, subsidized from area motivatedone in gained be by can share market corporate robust – profit as social well as responsibility another. Cost-effectiveness of mHealth solutions was the finalof the top four barriers cited. Most countries at responding the time of the survey did not know the cost-effectiveness ofavailable mHealth solutions. that noted be It should of mHealth programmes. exist on the evaluation data surprising; few This is not cost-effectiveness is justone element of the health system that requires resources alongside operating knowledge, and technical expertise. costs, infrastructure, 66 Barriers to mHealth implementation Figure 10. Top fourbarrierstomHealthimplementation,by WHO region Region; legalissuesfortheEuropeanRegion; andpolicyconcernsforthe South-East Asia Region. The main barriers for theremaining regions were: operating perceived costs as highforthe African the by and barrier Mediterranean, main Eastern the Americas, as identified still PacificWestern Regions. were priorities system health region. Conflicting by WHO mHealth to barriers main the shows 10 Figure 4 Percent of countries Percent of countries Percent of countries . 100% 100% 1 60% 40% 80% 20% 60% 40% 20% 50% 30% 10% 60% 40% 80% 20% 0% 0% 0% Operating costs Barriers WHO region by Priorities Policy Knowledge Knowledge Policy Barriers Barriers Barriers Cost effectiveness Technical expertise Infrastructure Knowledge Operating costs Policy Mediterranean Eastern Global Asia South East Global Africa Global
Percent of countries Percent of countries Percent of countries 60% 60% 40% 40% 80% 20% 20% 50% 50% 30% 30% 10% 10% 70% 60% 40% 20% 50% 30% 10% 0% 0% 0% Priorities Priorities Legal effectiveness Knowledge Legal Cost Cost Barriers Barriers Barriers Cost effectiveness Cost Operating costs Priorities Cost effectiveness Cost Knowledge Policy Americas Global Pacific Western Global Europe Global Barriers to mHealth implementation 67 The The unknown cost-effectiveness of mHealth initiatives was reportedas one almost of the all top four WHO barriers by regions, particularly the Western cost- its evaluate to difficult it make will Pacific,this vacuum; a in considered be cannot mHealth Regions. Americas European, Eastern Mediterranean, and the effectiveness. It needs to be studied in the overall context of eHealth or a larger deployment to recognize studies have the Cost–benefit full been identified value as and one potential offor thecost-savings. largest for national governments as critical to providing evidence and are acknowledged gaps in mHealth research, to summon the policies required to enable mHealth scale-up and sustainability (61). As previously noted, proofs of concept or single problem solutions. technical most mHealth pilot programmes to date have been deployment. large-scale efficient to or analysis, cost–benefit to themselves lend approaches these of Neither The European (56%) and Americas (50%) Regions reported the Regions Americas absence The (50%) of European legal (56%) guidelines and on privacy and confidentiality in the mHealth domain as the two most important barriers tomHealth implementation. have highly regulated health information and patient regions already Many countries in these confidentiality laws. Legal frameworks that govern the integrity of health data transfer and storage, in control and medical liability are critical to enabling eHealth (and therefore addition to identifying access policies eHealth developing of process the in countries Importantly, regions. these in countries in mHealth) and legislation should include mHealth within the framework of their policies, as the field is anextension solutions. and technical almost exactly the same policy and legal considerations and shares of eHealth, The lack of knowledge concerning the possible applications of mHealth was a key barrier reported across reported barrier key was a of mHealth concerningapplications the possible The lack of knowledge all WHO regions except the Western Pacific Region. The results exemplify the ongoing need stakeholders to keep informed of trends and developments in the market, the field, of stage embryonic the and Given eHealth. communicate of context broader the mHealth within evaluations and findings research this of lack and emulated, deployments that integrated can researched be and the absence of model, is knowledge not surprising. In contrast to these results, technical was only expertise as reported a in available be to appear personnel qualified locally that indicating Region, Asia East South the by barrier States in other regions. Member The Americas, Western Pacific, and can of mHealth While elements to systems implementation. priorities as their main barrier mHealth Eastern Mediterranean Regions reportedon their own, many of the applications far and systems implemented now introduced will be be being conflicting health more effective if implemented as a natural extension of eHealth. A stronger understanding of mHealth applications within the context of eHealth will be essential to align the benefits of mobile technologies within broader health and eHealth priorities. The African The Region identified the lack of infrastructure as one of its top barriers. It isevident that although is the infrastructure One indicator of still exist. enormous challenges done in the region has been much work and coverage network on widespread dependent of mHealth is growth The network coverage. of cellular level particular in driven globe, the dramatically across coverage is expanding Network devices. mobile to access infrastructure to stimulate growth in telecommunications as well as policies demand by strong consumer Urban areas and have expand been network covered capacity. first, but services are expanding rapidly into rural areas – which potentially stand to benefit the most from mHealth solutions. Thestill much room to grow. but with market highlight this is a dynamic and subscriber numbers coverage upward trend of 68 Barriers to mHealth implementation Figure 11. Top fourbarrierstomHealthimplementation,by World Bankincomegroup the incomegroups,exceptforthoseinhigh-incomegroup. groups. all important barrierin be anforrespondingcountries was foundto The lackofsupportingpolicy Figure thetopfour 11 showsbarriers to mHealth implementation aggregated by World Bank income 4 Percent of countries Percent of countries .2 60% 40% 20% 50% 30% 10% 60% 40% 80% 20% 50% 30% 10% 70% 0% 0% Barriers World by income group Bank Policy Priorities Cost effectiveness Cost Knowledge Barriers Barriers Priorities Legal Cost effectiveness Cost Knowledge income Lower-middle Global income High Global
Percent of countries Percent of countries 60% 40% 20% 50% 30% 10% 60% 40% 20% 50% 30% 10% 0% 0% Operating costs Priorities Knowledge Knowledge Barriers Barriers Policy Policy Cost effectiveness Cost Infrastructure income Upper-middle Global income Low Global Barriers to mHealth implementation 69 (62). Of particular note were the Telemedicine – opportunities and developments in Member States There are some striking similarities between the survey findings on mHealth and those identifiedin Countries from the low-income group identified operating costs and lack of infrastructure as top barriers, top as infrastructure of lack and costs operating identified group low-income the from Countries countries and text pricing for wireless services in the poorest is still illustrating that handset, voice, data, from ubiquitous. relatively high and infrastructure is far Lower-middle income countries have the following needs with respect to mHealth: policy, knowledge, knowledge, policy, with respect to mHealth: have the following needs income countries Lower-middle and managing conflicting health Cost-effectiveness priorities. of solutions is not considered a barrier, as countries in can this institute group have other critical health they concerns to address before mHealth programmes. Upper-middle Upper-middle income countries have similar concerns as high-income countries: conflicting health the need for more however, cite, countries These funds. to allocate priorities on where systems still not in are policies mHealth a reason be mHealth options, which could available information on the countries. place in many of these High-income countries already have access to many choices in eHealth and are looking for new approaches for new looking are and to many choices in eHealth access have already High-income countries related legislation Some legislation. enhanced is important Equally cost-effective. are and value add that the among are example) for EMRs (of security and privacy strengthening introduced; been has eHealth to to see in future legislation. would like issues these countries When compared across income groups, the results show very similar patterns for the high, upper-middle, for the high, upper-middle, patterns the results show across very similar groups, income When compared and lower-middle income groups, all of which reported conflicting health system priorities, unknown top four barriers. within their and lack of knowledge cost-effectiveness, findings that countries from the low-income group were more likely to report as barriers to telemedicine telemedicine to barriers as report to likely more were group low-income the from countries that findings development resource constraints such as operating costs and insufficient infrastructure; and those in the as barriers report legal and competing priorities to likely more group were from the high-income domain of telemedicine.
Evaluation of mHealth initiatives 71
Evaluation mHealth of initiatives 5 Member States where mHealth initiatives are relatively mature are most likely to conducting be are most mature likely mHealth initiatives are relatively States where Member evaluations. Only 12% of countries reported having evaluated mHealth initiatives. Only 12% of countries reported having evaluated Survey results
Key findings Key .1 Evaluation is a vital component to any policy or programme, including mHealth. Initiatives like those like including mHealth. Initiatives component to any policy Evaluation is a vital or programme, the potential mHealth has to facilitate health care. highlight discussed in the in the case studies above to the question Responses and success. their development will ensure Evaluation of such programmes income groups most by were frequently reported countries in the high- and upper-middle of evaluation to be a reflection countries being ofThis developed more advanced is likely and 14%, respectively). (23% in the field of mHealth thereforeand having reached the stage where evaluation is within the built The percentage of countries reporting that they had formally evaluated mHealth initiatives was low mHealth evaluated formally had that they of countries reporting The percentage (12%). Figures 12 and 13 show the distribution of evaluation activity by World Bank income group and WHO region, respectively. 5 any of their mHealth initiatives, and evaluated States had formally Member whether enquired The survey had published the results. if so, whether they 72 Evaluation of mHealth initiatives of evaluation maystillnotbeconsideredapriorityatthisstage. process the and growing still is mHealth that reflection a are reported evaluation of levels area. low The and 17%, respectively). The remaining regions display lower levels ranging from 12% to no activity in this (22%evaluations mHealth of percentage highest the reported Regions Americas the and European the Review by region showedsimilar resultsasfoundforincomegroupings:developedWHO from countries Figure 12.EvaluationofmHealthinitiatives,by World Bankincomegroup that evaluation willincreaseacrossallincomegroups anintegral of programme component management as botheHealthandmHealthmature.be In turn,itcanexpected become will analyses, cost–benefit including programmes, of evaluation The evaluation. project management plan. Only 7% of responding developing countries reported conducting an mHealth Percent of countries 20 10 25 15 0 5 High income Upper-middle World Bankincomegroups Lower-middle Low income Evaluation of mHealth initiatives 73 Global Eastern Mediterranean Africa Pacific Western Western WHO regions Asia South-East South-East Americas Europe
0 Relevant literature Relevant 5
20 15 10 25 Percent of countries of Percent .2 Preliminary work has been undertaken in a recent small-scale mHealth monitoring and evaluation survey survey mHealth monitoring and evaluation in a recent small-scale undertaken Preliminary work has been conducted Researchers University. Columbia WHO in collaboration with the Earth Institute, conducted by the current status to understand interventions in 2010 of mHealth evaluation on metrics and survey a and needs of monitoring and evaluation in mHealth (63). The results suggest that there is a degree of and research being conductedthat by mHealth implementers could ongoing monitoring and evaluation of best practices. potentially inform the future of mHealth deployment through the sharing Although the mHealth evidence-base is growing, there are major research gaps that must be addressed. be major research gaps that must are is growing, there Although the mHealth evidence-base The state of mHealth research in the context of developing countries has recently been published (61). mHealth interventions nor provide It concluded that current evaluate research does not adequately sufficient evidence on health impact. To amelioratecontrol using randomized studies approach to a health outcomes-based research investigating usability, this it suggests moving computer-based from indicators standardized and to conduct designs. In order such studies, study replicable and standardized and agreed upon. must be developed metrics for monitoring and evaluating 5 Figure 13. Evaluation of mHealth initiatives, by WHO region WHO initiatives, by of mHealth Evaluation Figure 13.
Conclusion 75
Conclusion 6 Mobile technologies have already changed, and will continue to change, the lives of millions around the the lives of millions around to change, changed, and will continue already have technologies Mobile almost settings. Many are calling this change a revolution: world, though most particularly in high-income 90% of the world’s population could benefit from the opportunities mobile technologies represent, and of mobile incorporating the use already are countries at relatively low cost. Many sectors in low-income ways. Diverse applications in usesophisticated in increasingly business processes into their technologies politicalmonitoring, journalism during election citizen online education, countries include in developing the health sector has been slow Yet unrest, agricultural assistance to farmers, and mobile banking services. patients and providers alike. would benefit which operations, into routine technologies in adopting mobile Alongside benefits to increased business and information access, innovative thinkersopportunity areto seizing the harness the power of mobile technologies for the benefit of public health. The fieldcalled mHealth; it allows patients to connected be to services which include health information on is monitoring of chronic real-time and the remote, conditions health record management, such demand, as diabetes, asthma, and hypertension to name but a few. The world is experiencing an extraordinary phenomenon: the exponential growth of mobile such where world, countries but also in the developing communications not only in developed technology is bypassing conventional telephony to systems communicate across and allowing people The ITU estimates that by the end of distances vast geographical which until now inaccessible. were 2010 77% of the world’s population had a subscription to a mobile phone, and over 85% were covered by a mobile phone network (1). With the rise of mobile broadband through 3G innovation, increasing Africa, to particularly in low-income settings the Internet, such as will have access of people numbers ‘traditional’ cost-prohibitive. to the Internet where inadequate infrastructure makes access 76 Conclusion issues inthemHealth domainso appropriate policies andstrategies canbedeveloped andimplemented. prevent datalossorinfection. Policy-makers andprogrammemanagersneed tobemade awareofsecurity to capabilities firewall and antivirus have to devices for policy.essential security mobilealso the is of It part as defined and evaluated be to need installed applications and recovery and backup and device, the to files surgery survey. Parameters such aspasswordprotection,network logonrequirements, synchronization of entire data life cycle – from the first input of patient data using the mobile device to follow-up through a post- necessary precautions arenottaken. Security policies safeguardhealth identityinformationthroughoutthe particular, message transmissionsecurityanddatastorage canputcitizeninformationatriskifthe concerns aboutthe security ofcitizen informationbyprogrammes using mobile health technologies. In Data securityisaparticularlyimportantissuetoaddress withinthe area ofpolicy. There arelegitimate competing coststhatevery health systemmustface(thenumberonecitedbarriertoimplementation). case forexpenditure on mHealth would most likely be bolstered, putting it intoperspective among the the resolved, were barriers these If barrier). most-cited second (the applications possible its of aware be policy-makers will nor respectively), cited, barrier fifth-highest and third- (the privacy on guidelines Without suchdata,quicklybecome mHealth will notapart of governmentorbe policy protected by legal with aparticularemphasisongatheringdataatthecountrylevel. globe, the across from mHealth in studies evaluation and monitoring selected on findings research of measurable indicators, would be animportantsteptowardsdata collection. would This include adatabase framework theevaluationinternational for An mHealthprogrammes, ofincluding meaningful and unexpected as mHealth is stillrelatively new and therefore unexplored but this practiceneeds to change. entirely not is This programmes). mHealth evaluated have States Member of 12% (only programmes mHealth most for undertaken being not is data, these providing in step first the Evaluation, 9). Figure particularly in low-income settings (whichis thefourth-highest barrier cited byMember States; see There is little published evidence on the effectiveness of mHealth interventions or their cost-effectiveness, uptake which in among Member areas States waslow. two were surveillance disease and systems support Decision Region). African underdeveloped,where theinfrastructureis countries however,low uptake theresultsshow (e.g. the centres, toll-free numbers, and emergency services usingmobile communications. When considering call health offering already are countries of majority the why explain would communication. This voice follow a certain path–itismosteasilyincorporatedintoprocessesand services whichtraditionallyuse Member projects. reported six often upto of which States, many The adoptionofmHealthappears to mHealth across the globe. mHealth activity, or experimentation, was reported by four of five responding The results,reviewed by region and WHO World Bankincomegroup,theclearemergence show of evaluating existingprogrammes. of practice the as well as situation, country their for adoption mHealth to barriers significant most the assess to asked also were States Member 3). (Figure promotion health for mobilization community and the use of mobile technologies forhealthcallcentresandtreatment compliance tomobile telemedicine from ranging areas specific 14 in mHealth of adoption the in trends national about enquired It survey. Toso, is determine this why 2009its about mHealthin included aseriesofquestions WHO globaleHealth Conclusion 77 where governments and governments where 17 /. http://www.ghtf.org
If implemented strategically and systematically, mHealth can revolutionize health outcomes, providing health outcomes, can revolutionize mHealth systematically, strategically and implemented If This is a boon in real-time. and knowledge expertise virtually anyone phone with medical with a mobile to this particularly to those or who marginalized living in areas, would otherwise not remote have access information or care. It is hoped that this report will highlight the possibilities inherent in mHealth and policy- academia, among a broad range of promote a dialogue actors including government, industry, NGOs, and civil society partners that cohesive will help forge a more strategic and direction for makers, this field and its great potential. To this end, WHO and ITU will soon launch an information product called the National eHealth Roadmap WHO and ITU will soon launch an information product called the National eHealth Roadmap this end, To of comprehensive eHealth strategies States in the development to support Member Toolkit Development Observatory and its partners will involve and policies, of which mHealth is action a part. Future of the the lessons evaluations, initiatives, learnt, mHealth information regarding disseminating compiling and country health priorities and the MDGs. to support achieving best practices, and cost-effectiveness industry collaborate to create standards for medical technologies. There is no reason why There such public- technologies. standards for medical industry collaborate to create to bear on eHealth. private partnerships cannot be brought 17 Countries will make far greater and faster progress and will sector in the banking for electronic payment standards developed For instance, standards. global adopt save significant sums moneyof they if to national due their and international adoption and cooperative processing highly have been successful Force, Task Harmonization Global is the example Another such approach. A common pattern for the introduction of ICT and mobile technologies in countries is their entrance to technologies in mobile for the introduction of ICT and A commonpattern a plaster in here pockets, health or markets a bandage there, to fix a particular problem. In this scenario, individual investors with interest in a specific problem find sufficient improvement from use of mobile ICT to invest in a specific The solution. most common result isa profusion of non-interoperable islands of In ICT. fact, many developed countries are now trying to find solutions to this significant problem in prime a These countries provide so. in doing vast sums of money applications and spending their eHealth currently addressing eHealth policy and infrastructure. example of what to avoid for those countries Member Member States indicated their commitment to maximizing the benefits ofeHealth (including mHealth) eHealth comprehensive to develop encouraged to be now need They WHA58.28. resolution 2005 in the technological this to occur, In order for appropriate. of mHealth where the use promote policies that measurably a way that they in such and needs to local realities designed according to be solutions need and administrators country health priorities and contribute the MDGs. to Health policy-makers achieving need to equipped with be the knowledge required to shift emphasis from small pilot programmes to large- silos’. ‘information from away moving goal, the are systems interoperable Standardized, deployments. scale
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Each publication in the series is primarily targeted to ministries of health, ministries of information to ministries of health, targeted is primarily in the series Each publication professionals, eHealth researchers, academics, ministries of telecommunications, technology, sector partners. nongovernmental organizations involved in eHealth, donors, and private The second global survey on eHealth was conducted in late 2009 and was designed to build upon the upon the to build and was designed on eHealth was conducted in late 2009 The second survey global general more was 2005 in conducted survey first the While survey. first the by generated base knowledge was thematically designed survey the 2009 questions at the national level, high-level and primarily asked GOe with a has the provided The thematic design of the survey questions. more detailed and presented Observatory for Global The publications – of eight series a to create used that is being rich source of data and 2011. Series – due for publication during 2010 eHealth The GOe’s first objective was to undertake a global survey on eHealth to determine a series of benchmarks of series a determine to eHealth on survey global a undertake to was objective first GOe’s The in the adoption of the necessary foundation actions to support the levels and global at national, regional as benchmarks for used that could be governments with data was to provide The aim growth of eHealth. States. their own progress with that of other Member as a way to compare as well their own development The survey is part of the mandate defined during the GOe’s inception – to provide Member States with in eHealth. reliable information and guidance on best practices, policies and standards The World Health Organization’s eHealth resolution WHA 58.28 was adopted in 2005 and focused on strengthening health systems in countries through for the and deployment for health; supporting capacity building partnerships in ICT development the use of eHealth (1); building in Success of standards. and adoption and the development States; application of eHealth in Member public-private these areas is predicated on a fifth strategic direction: monitoring, documenting and analysing trends In direct understanding. the results to promote better in eHealth and publishing and developments monitor to established was (GOe) eHealth for Observatory Global the resolution, eHealth the to response of eHealth in countries and analyse the and to support national evolution planning through the provision of strategic information. Purpose 84 Appendix 1. Methodology of the second global survey on eHealth the survey weretoidentifyandanalysetrendsinthe: and outcomesinkeyprocesses issues relatingto The instrumentfocusedon eHealth areas. Objectives for Survey instrument countries, aspecificmodulewasincludedtocapturecountry-specificactivityinthisarea. the results. With theemergence of mHealthasadriver of eHealthinmanylow and middle-income offices and Member States to encourage survey completion, as well as processing the data and analysing survey,creating thesecond digital format,workingwith disseminatingtheinstrumentin regional WHO Based on the experience of the first global survey, the GOe benefited from many of the lessons learned in Survey implementation Table A1 showsthe seven themesofthesurvey. • • • • • • • • Governance andorganizationofeHealthincountries. Internet, andspam Action concerningonline child safety, Internetpharmacies, healthinformationonthe Development oflegalandethicalframeworksforpatientinformationindigitalformat Collection, processingandtransferofpatientinformation Adoption ofeLearningforhealthprofessionalsandstudents Application oftelemedicinesolutions Deployment ofmHealthinitiativesincountries Uptake ofeHealthfoundationpoliciesandstrategies,buildingonthe2005 results Appendix 1. Methodology of the second global survey on eHealth 85 funding approaches, capacity building for eHealth, and multilingual funding approaches, capacity building records. one's own record. Identify and analyse the and control right to access necessary actions to be taken to encourage the global growth and to encourage the global growth and be taken necessary actions to mHealth can overcome the digital divide. mHealth can overcome trends. Systematically review the content and structure of existing the content and structure of existing Systematically review trends. procurement, including: eGovernment, eHealth, ICT the national level identifiable data and health-related data in digital format as well as the identifiable data and health-related data the world and the effectiveness of these approaches. Highlight the most of these approaches. Highlight the world and the effectiveness Consider whether to implementing mHealth solutions. important obstacles by country to act as ready reference of the state of eHealth development by country to act as ready reference of the state of eHealth development Review trends in the uptake of foundation actions to support eHealth at trends in the uptake Review Presentation of all participating Member States eHealth data aggregated Presentation of all participating Member Review the trends in the introduction of legislation to protect personally the trends in the introduction Review Describe the issues relating to the management of patient information relating to the management of patient Describe the issues Identify the uptake of eHealth policies across the globe and analyse by Identify the uptake Identify and review the most frequently used telemedicine approaches most frequently used telemedicine approaches the Identify and review Identify the diverse ways mobile devices are being used for health around are being ways mobile devices Identify the diverse strategies highlighting strengths and weaknesses. Propose model strategies highlighting strengths and weaknesses. scope and of eHealth policies including approaches for the development content. communications. sciences for students and health professionals. to selected indicators. according control of online pharmacies by Member States. Review government States. Review control of online pharmacies by Member Internet. action to provide for child safety on the acceptance of telemedicine, and particularly in developing countries. in developing of telemedicine, and particularly acceptance regional/district, national levels. care facility, – local health at three levels of digital patient the uptake in countries to increase actions to be taken across the globe as well as emerging and innovative solutions. Propose well as emerging and innovative solutions. across the globe as WHO region as well as World Bank income groups to establish possible World WHO region as well as Analyse the extent of use and effectiveness of eLearning for the health Analyse the extent of use and effectiveness Analyse the trends in transition from paper to digital records. Identify Analyse the trends in transition from paper Action
frameworks for eHealth mHealth information Legal and ethical Management of patient eHealth foundation actions eLearning eHealth country profiles eHealth policies – a systematic review Telemedicine Theme
The survey instrument was developed by the GOe with broad consultation and input from eHealth, GOe with broad consultation and input from eHealth, by the instrument was developed The survey started in 2008 global survey and in the case of this experts. module, mHealth for Planning the 2009 countries. from participating and feedback results, instrument survey of the 2005/2006 review with the availability its and data of management the on was survey first the in identified constraints the of One Collector for compilation and analysis. In order to facilitate data collection and Data management, (DataCol) was used to make the survey instrument available online and therefore streamlining the of data. and processing collection Survey development Survey Table A1. Survey themes Table 86 Appendix 1. Methodology of the second global survey on eHealth working relationshipswith regional counterparts,without whomitwould not have been possible to One significant outcome during the survey implementation was the development of strong and productive circulated andwerefollowedbyaseriesofteleconferences. for thesurveythe surveytheir respectiveregion.Instructions in countries with procedures process were included eHealth activities. For this reason many regional offices had responsibilities to whose staff assign have staff offices regional all to assist not regions, WHO across in coordinating priorities differing to Due the regionallevel whocanliaisedirectlywithcountries. One ofthe most importanttasksinexecuting an internationalsurvey istobuild a network ofpartners at Preparation to launch survey the responsible forcompletingtheformsafterobtainingagreementfromexpertinformantgroup. was submitted one entry that onlyperrather country thanmultiple entries. were coordinators Country DataCol bylanguage. In addition, individual loginnamesandpasswordswereensure country assigned to The variouslanguagethesurveyversions of instrument andsupportingdocumentationwere entered into as thevolumeofdataenteredandstoredonline. the systemwasrobustandable to accommodate fromaround the dataprocesstheworld, entry aswell that ensure to required was testing and preparation Significant questions. and text of pages 40 over of This is the first time that DataCol has been used as the primary method of implementing an online survey further analysisusingotherstatisticalsoftware. for file Excel by maintained Microsoft database a as exported be can and administrators, database WHO management and isdesigned, developed and supported by WHO. The collected data are stored ina SQL and collection data for creation form online simplifies that tool web-based a is Collector,Data DataCol, Collector Data Innovation basedatthe University ofHawaiiatManoainthe United States of America. the survey instrument and survey processwasdeveloped and hosted bytheInstitute for Triple Helix (ITU) and Organisation for Economic Co-Operation and Development (OECD). An online forum to discuss programmes as theInternational as wellsuch as internationalorganizations, Telecommunications Union WHO other to extended efforts Collaborative process. the in involved were worldwide experts 50 Over associations. andprofessional centres collaborating offices, country and regional WHO government, through virtualteleconferences. all regions partners in from partners includedthose The rangeof selected to comments for 2009 of quarter first the in circulated and developed was questions of set A 18 procedures weretranslatedintoall WHO officiallanguagesplus Portuguese. testing. Inorder to encourage countries torespond, the surveyand data questions,instructionsentry the surveyreceived and observationsfromthepilot instrument wasenhancedbasedthecomments on in March 2009 in five countries: Canada, Lebanon, Norway, Philippines, and Thailand. The final version of A draftquestionnairewasdeveloped and postedonlineforreview by thepartnersandwaspilottested http://www.triplehelixinstitute.org/. 18
Appendix 1. Methodology of the second global survey on eHealth 87 Publication of eHealth series eHealth of Publication GOe data processing and analysis Identification of expert informants
Regional coordination (WHO regional office) Submission of one national survey per country National consensus meeting to complete survey
Global coordination (Global Observatory eHealth) for (Global coordination Global National coordination (WHO Country Office or designee)
Member States were limited to one response per country; thus, the expert informants were required to country; informants required thus, the expert were to one response per limited States were Member with a single response for each question of the country come up that was most representative as a whole. Coming to a consensus could be difficult or in cases where the situation varies widely within the country, where there were significant differences in opinion. The survey does not attempt to measure localized eHealth activity at the sub-national level. Limitations
At the national level, coordinators managed the task. Their responsibilities included finding experts in the survey where and organizing and hosting meeting a full-day by the survey, addressed all of the areas country, informants, per of expert The number group. by the entire collectively completed could be and the globe GOe network of informants around the build process helps The survey 5 to 15. from ranged now consists of over 800 eHealth experts. Survey Survey not of interest, did close until 15 to the high level and due 2009, June was launched on 15 The survey The purpose to participate. States Member to encourage focal points worked Regional 2009. December expert to national coordinators and then to survey conveyed to be of participation have and rewards informants. It is important to build momentum and to maintain enthusiasm. Figure A1. GOe survey and report process GOe survey A1. Figure successfully undertake such a task. The success of the survey implementation can also be attributed to attributed can also be implementation of the survey The success task. a such undertake successfully the assistance of regional and national office colleagues who directly worked with national counterparts the questionnaire. in completing 88 Appendix 1. Methodology of the second global survey on eHealth was performedusingtheRstatisticalprogramminglanguage. format andthedataanalysis reporting ofresults.DatawereExcel exported Microsoft from DataColin were checkedand errors, and countrieswerefor consistencyfollowup contacted to ensure accurate submissionthrough DataColreducederrors,however,Electronic ofentry the possibility survey responses Upon receipt of thecompleted questionnaires, alltextual responseswereEnglish. translated into Data processing no guaranteethatthesewereusedwhenresponding. While the survey was circulated with a set of detailed instructions and terminological definitions, there is eHealth knowledgetackleeachquestion. determine groupshadthecollectiveto to whetherthefocus effort was made to select the best national experts to Every complete in-country. the instrument, however, conducted it being is not initiatives possible eHealth of types specific to frameworks legal and issues The scope ofthesurveywas broad, andsurvey covered diverse questions areas ofeHealth–frompolicy were checkedand accuracy, for consistency possible toverifytheresponsesforevery itwasnot question. detail in theresponses,particularlytofordescriptive, open-ended questions. While survey responses of level and quality the in States Member across variation significant was there consistency, maintain each participatingMember State. surveyAlthough administrators were givendetailedto instructions The survey responseswere fundamentally based on self-reporting bytheexpert informant group for 19 Table A2 showstheadvantagesanddisadvantagesofgroupingsused inthesurvey. countries were different,andthe expert informantsineachiteration ofthesurvey werealsodifferent. level,theregional comparable,particularlyat responding percentagesweredirectly of oftennotthesets as questions were worded somewhat differently, there was little scope for this sort of analysis. In addition, the however,2009coveredthe matter by subject the as survey considerablybroader,was survey the and Results fromthe current survey werecompared tothosefromthe previous survey wherever possible; as mobile phone penetration wereforcomparisonpurposes introduced theanalysiswhere into relevant. the resultsweresuch probed greater indicators in depthaswarranted. External healthandtechnology was performed analysis Cross-question where two ormorewere questions thoughttobe related, and report. this in included not were results these Therefore, p=10-16). ρ=0.93, (Spearman capita per GDP and Index Development ICT between correlation high the to due is This (2). group income Bank World based Preliminary analysisonaggregationICTDevelopmentby Index showedsimilarresultsasfor analysed by region and WHO World Bankincomegroup to see trends byregionandincomelevel. each possibleresponsetoobtaintheglobal level results. Inaddition, the data were aggregated and closed-endedData wereForpercentages analysed bythematic section.questions,were computed for See formoreinformationhttp://www.r-project.org /. 19
Appendix 1. Methodology of the second global survey on eHealth 89 from an economic, health care, or from an economic, population age. institutions wishing to interpret or institutions wishing health of the population, or Limited country commonality Limited country commonality agencies or Less useful for other Does not account for income Does not account ethnic perspective. GOe data. act on disparity, ongoing armed conflicts, ongoing armed disparity, Disadvantages integrated into WHO strategic integrated into analysis and planning, and analysis and planning, operational action. on GNI per capita. on across all countries. WHO regional approach WHO regional approach Simple four-level scale. Simple four-level Clear economic definition based Clear economic definition of criteria Consistent application Advantages
This was particularly encouraging for regions consisting of a large number of Member States African the as such Regions. and European resources being diverted being resources H1N1 the respond prepare and to to other urgent or to pandemic, due public health issues arising from armed conflicts;this was the case withcountriesmany from the region of the Americas. The Western PacificRegion has many smallisland MemberStates a response yielding rate of 48%only respondeda few survey, the ofwhich to region. forThe this response rates for the Eastern Mediterranean, African and European 60%. Regions were over organizational structureorganizational and operational framework of WHO. country in variation considerable participation: 3 shows for example responses ranged Table 73% to of Americas) from the South-East (in Region the 34% (the Numerous Asia Region). participate not to be able would 2009 the in they that indicated Member States survey to due Response rate by WHO rate by Response region WHO up of six made geographical is regions. The heterogeneous: are regions Administratively, MemberStates differ with andrespect health carechallenges. economy, to size, Nevertheless, it is still important to present high-level eHealth analyses at the regional level as this reflects the Figure 3. Responding WHO Member States WHO Member 3. Responding Figure global survey (58%), which is encouraging considering the 2009 the significantlysurveyinstrument considering is encouraging is survey(58%), global which of 2005/2006. that longer than Figure Telemedicine countries the the answered that 3 shows distribution the 4 and 5 show of those countries WHO by region Section Tables of the survey. respectively. group, income Bank and World Response rate sections seven of survey: the all Not completed Member 112 States all it and completed entirely 114 at (59% least completed one section of world’s the 81% population) of Member (the States; The2009 the response Section). to survey roughlysame is the foras previous the Telemedicine Country grouping Country
World Bank income group World WHO region
Figure A2. Responding Member States Member A2. Responding Figure
The Mobile Health section of the survey, which this publication is on, by was completed a total based The Mobile Health section of the survey, of 112 countries (58% of all WHO Member States). Figure A2 shows the responding Member States for A4 show the distribution of the 112 responding A3 and Tables Health section the Mobile of the survey. Bank income group. World WHO region and countries by Response rate Table A2. Advantages and disadvantages of the country groupings of the country and disadvantages Advantages A2. Table
GOE
SECOND
GLOBAL SURVEY GLOBAL
ON
EHEALTH EHEALTH 34 90 Appendix 1. Methodology of the second global survey on eHealth Member States participatinginthesurvey mayreflectacommitmentto moving forwardwitheHealth. have less eHealthincomparisontohighandupper activitymiddle-income brackets. Thus, insomecases, middle income brackets weresurveys high.Past in thesegroups generally countries that have shown a highlevelin eHealth. ofinterestand/oractivity Table response ratesinlowandlower-that A4 shows of the sample often occurs insurveysnature, of thiswhere respondingcountriesare more likely tohave Member 11 of a total of the regionconsists since response ratewasthehighest States. Self-selection the For South-East Region,Asian although thenumber wasthelowest, of respondingcountries Table A3. Response rateby WHO region care asthey maynotberepresentativeoftheentireregion. African andEuropean Regions. Results from regions withlowresponseratesshouldbe interpreted with a large of numberMember of consisting regions was particularlyencouragingfor This the as States such the for region. 48% The response rates for of the Eastern Mediterranean, rate African and European Regions were response over 60%. a yielding survey, the to responded few a only which of States Member situations.conflict as such issues Thehealth public urgent island small many has Western-Pacific Region surveydue other pandemic orto due resourcesbeingdivertedpreparetheH1N1 toandrespond those intheRegion ofthe Americas, indicated that they wouldbe not able to participate in the2009 from 34% for the Americas to 73% for the South-East Asia Region. Numerous Member States, particularly breakdownA by regionalis presented WHO responsesin Table considerable variationranging It shows A3. level, asthisreflectstheorganizationalstructureandoperationalframeworkof WHO. health careproblems. Nevertheless, it isstillimportanttopresenthigh-level analyses attheregional and wealth size, of characteristics differing with countries are States Member Their homogenous. not Administratively, the is made WHO up of sixgeographical regions. However, theregionsthemselves are Response rate WHO region by Total numberof Response rate No. ofresponding countries countries African 63% 46 29 Americas 34% 35 12 East Asia South- 73% 11 WHO region 8 European 68% 36 53 Mediterranean Eastern Eastern 67% 21 14 Western Pacific 48% 27 13 Appendix 1. Methodology of the second global survey on eHealth 91 30 43 70% Low income 53 30 57% income Lower-middle Lower-middle 21 44 48% income
World Bank income group World 20 Upper-middle Upper-middle 31 49 63% High income
http://data.worldbank.org/about/country-classifications
countries Response rate Response No. of responding Total no. Countries Total Table A4 shows the survey response rate by World Bank income group. Low-income countries had the World response rate by A4 shows the survey Table highest response rate (70%), closely followed by high-income countries (63%). In terms of raw numbers, with 30 to 31 countries responding from even, the distribution of responding countries was remarkably of countries and a slightly and low-income groups, lower number income, lower-middle the high-income, income group. from the upper-middle The classification is as follows: low income (US$ 975 or lower-middle less), income (US$ upper-middle 3856–11 905), and high income (US$ 11 income906 or more) based on 2008 country (US$ 976–3,855), of trends a review a convenient for analysis, enabling are and practical basis These income groups data. level to exactly correspond not does income by Classification level. income on based results survey the in of development; however, low and middle-income countries are sometimes referred to as ‘developing’ convenience. for countries as ‘developed’, economies and high-income 20
Table A4. Response rate by World Bank income group Bank income World rate by A4. Response Table
Response rate by World Bank income group Bank income by World rate Response World The Bank classifies all economies with a population greater than 30000 into four income groups per capita. income (GNI) based on gross national 92 Appendix 1. Methodology of the second global survey on eHealth 3. 2. findings from the review have been included in this report to contextualize anddrawcomparisons tocontextualize report this between the surveyresults andmHealthinitiativesreported Member by States, andpublished literature. in beenincluded have review the from findings 4. 1. References Alliance, entitled a recent reviewInstitute withsupportfromthemHealth ofmHealthresearchconductedbytheEarth of themHealthdata, a complementtheanalysisrelevantAs to studies andliterature were drawn from L mHealth toachieve thescaleandsustainabilityneededforitspotentialimpactonhealthtoberealized. in place thepoliciesandstandardsneededfacilitateinvestmentactivity MDG targetsandputintoto States. framework alignmHealthactivitieswithhealthprioritiesincluding Creating thiswillhelpcountries overcome initiatives andpromoteanenablingenvironmenttothechallengesasexpressed by Member development of a policy framework and strategy thataims to identifyand strengthen prioritymHealth generated The informationfromthemHealthmodulesurveyof invaluable the an resourcefor is provide supporttostrainedhealthcaresystemsorcatalyseeconomicgrowthforimprovedlivelihoods. bracketsmobile viewtheubiquityofdevicesovercome publichealthchallenges, to opportunity as an income these of both in countries that notion the reinforces This (3). group high-income the in 106 to that there were 28.5 mobile deviceper subscriptions100 habitants inthelow-incomegroup, in comparison reported was it 2008, In rates. penetration phone mobile different very having despite States, Member that thelow-incomeandhigh-incomegroupshadhighestnumber It isnoteworthyofresponding iterature review review iterature white paper. New York, Columbia University, 2010. The World Bank Group. Bank The World accessed 17 May2011). Telecommunications 2009Union, (http://www.itu.int/ITU-D/ict/publications/idi/2009/index.html, (http://apps.who.int/gb/ebwha/pdf_files/WHA58/WHA58_28-en.pdf 4. 2009 (http://data.worldbank.org/indicator/IT.CEL.SETS.P2 Measuring the information society – the ICT Development Index. Index. Development ICT the – society information the Measuring Resolution 58.28. eHealth.In: WHA Mechael etal. PN Barriers and gaps affecting mHealth in low and middle income countries income middle and low in mHealth affecting gaps and Barriers Barriers and gaps affecting mHealth in low and middle income countries. countries. income middle and low in mHealth affecting gaps and Barriers Mobile Cellular Subscriptions (Per 100 People) 100 (Per Subscriptions Cellular Mobile Fifty-eighth World Health Assembly, Assembly, Health World Fifty-eighth , accessed 17 May2011). 18,accessed 20 May2011). . Washington DC, World Bank, DC, World . Washington Geneva, Switzerland, 2005Geneva, Switzerland, Geneva, International (4). Selected (4). Policy Appendix 2. Member States by WHO region and World Bank income group 93 Fiji Japan China Kiribati Brunei Korea, Korea, Pacific Australia States of Republic Malaysia Federated Western Western Micronesia, Cambodia Cook Islands Republic of Republic Democratic Darussalam Lao People's Lao People's Marshall Islands . Asia India Korea Nepal People’s People’s Bhutan Myanmar Thailand Maldives Sri Lanka Republic of Republic Indonesia Democratic Timor-Leste Bangladesh South-East Chile Aruba Brazil Bolivia Belize Anguilla Barbuda Canada Bermuda Bahamas Barbados Argentina Americas Antigua and Cayman Islands Appendix 2 Appendix Member States by States Member region WHO Bank and World group income Czech Cyprus Andorra Austria Croatia Belarus Albania Belgium Bulgaria Armenia Republic Denmark Bosnia and European Azerbaijan Herzegovina Iraq Egypt Oman Bahrain Jordan Djibouti Kuwait Eastern Morocco Pakistan Lebanon Jamahiriya Republic of Republic Libyan Arab Libyan Iran, Islamic Afghanistan Mediterranean Chad Benin Angola Algeria Congo Republic African Burundi Comoros Botswana Cameroon Cote d'Ivoire Cape Verde Cape Burkina Faso Central African Member States by region WHO Member States (Responding countries in dark green) 94 Appendix 2. Member States by WHO region and World Bank income group Guinea-Bissau Sao Tome and Sao Tome Mozambique Republic ofthe Sierra Leone Madagascar Mauritania Seychelles Democratic Mauritius Equatorial Ethiopia Lesotho Principe Senegal African Gambia Namibia Nigeria Rwanda Liberia Eritrea Ghana Malawi Guinea Guinea Gabon Congo Niger Kenya Mali Mediterranean Saudi Arabia Syrian Arab United Arab Republic Emirates Eastern Eastern Somalia Yemen Sudan Tunisia Qatar Montenegro Kyrgyzstan Republic of Luxembourg Netherlands European Kazakhstan Lithuania Federation Moldova, Germany Hungary Portugal Norway Romania Estonia Finland Iceland Monaco Greece Poland Georgia France Russian Latvia Ireland Malta Israel Italy Saint Kittsand Saint Vincent El Salvador Dominican Netherlands Americas Puerto Rico Grenadines Montserrat Guatemala Saint Lucia Colombia Martinique Paraguay Guadalupe Costa Rica Nicaragua Republic Honduras Dominica Panama Grenada Mexico Ecuador Jamaica Guyana and the Antilles Nevis Peru Cuba Haiti South-East Asia Solomon Islands New Zealand Philippines Singapore Papua New Viet Nam Mongolia Western Vanuatu Pacific Tonga Guinea Samoa Tuvalu Nauru Palau Niue Appendix 2. Member States by WHO region and World Bank income group 95 Pacific Western Western Asia South-East South-East USA Islands Tobago Uruguay Suriname Venezuela Americas Trinidad and Trinidad Turks and Caicos Turks Serbia Spain Turkey Ukraine United Sweden Yugoslav Yugoslav Tajikistan Slovakia Slovenia Kingdom Macedonia Republic of Republic The former San Marino European Uzbekistan Switzerland Turkmenistan Eastern Mediterranean Togo Uganda Zambia African Republic of Republic Swaziland Zimbabwe South Africa Tanzania, United United Tanzania, 96 Appendix 2. Member States by WHO region and World Bank income group (Responding countries in dark green) dark in countries (Responding StatesMember World by income group Bank Brunei Darussalam Antigua andBarbuda Equatorial Guinea Czech Republic High income Cayman Islands Denmark Germany Hungary Belgium Barbados Bahamas Bermuda Australia Estonia Canada Finland Croatia Austria Iceland Andorra Greece Cyprus Bahrain France Ireland Aruba Bosnia andHerzegovina Dominican Republic Upper-middle Montenegro Libyan Arab Jamahiriya Kazakhstan Argentina Botswana Colombia Lithuania Mauritius Costa Rica Malaysia Lebanon Bulgaria Dominica income Belarus Grenada Mexico Jamaica Latvia Algeria Gabon Brazil Cuba Chile Fiji Iran, IslamicRepublic Lower-middle El Salvador Cape Verde Cote d'Ivoire Azerbaijan Cameroon Indonesia Guatemala Armenia Honduras income Albania Bhutan Ecuador Djibouti Georgia Jordan Guyana Congo Kiribati Angola Belize Egypt Bolivia China India Iraq of Central African Republic Central African Democratic Republic Democratic Republic of Democratic People’s Republic ofKorea Guinea-Bissau Low income Burkina Faso Lao People's Afghanistan Madagascar Bangladesh Kyrgyzstan Mauritania Cambodia Comoros the Congo Ethiopia Burundi Gambia Liberia Eritrea Ghana Malawi Guinea Benin Kenya Chad Mali Haiti Appendix 2. Member States by WHO region and World Bank income group 97 Togo Niger Nepal Uganda Yemen Rwanda Somalia Zambia Senegal Tajikistan Myanmar Viet Nam Republic of Republic Zimbabwe Uzbekistan Sierra Leone Mozambique Low income Tanzania, United Tanzania, Samoa Tunisia Tonga Sudan Ukraine Nigeria Vanuatu States of income Principe Lesotho Morocco Pakistan Thailand Maldives Nicaragua Sri Lanka Mongolia Paraguay Swaziland Timor-Leste Philippines Turkmenistan Marshall Islands Sao Tome Tome Sao and Solomon Islands Lower-middle Lower-middle Papua New Guinea Micronesia, Federated Micronesia, Federated Syrian Arab Republic Syrian Moldova, Republic of Moldova, Republic Peru Palau Serbia Turkey Poland Namibia Uruguay Romania income Panama Suriname Venezuela Saint Lucia Grenadines Seychelles South Africa Upper-middle Upper-middle Russian Federation Russian The former Yugoslav Yugoslav The former Saint Kitts and Nevis Saint Vincent and the Saint Republic of Macedonia Republic Italy USA Japan Israel Spain Malta Qatar Oman Sweden Monaco Kuwait Norway Slovakia Portugal Slovenia San Marino Puerto Rico Singapore Netherlands Luxembourg Switzerland Saudi Arabia Saudi New Zealand New High income United Kingdom Netherlands Antilles Trinidad Trinidad and Tobago Korea, Republic of Republic Korea, United Arab Emirates
Appendix 3. Global mobile phone subscriptions of responding Member States 99 a
. 46.9 77.53 37.78 31.07 23.97 87.83 52.74 56.33 37.89 10.10 68.75 89.79 42.63 96.12 20.94 84.98 140.73 131.89 116.65 140.76 100.55 128.84 106.66 (per 100 population) Mobile cellular subscriptions Appendix 3 Appendix Global mobile mobile Global phonesubscriptions ofresponding Member States Albania Argentina Armenia Austria Azerbaijan Bangladesh Belarus Belgium Belize Benin Bhutan Botswana Brazil Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Verde Cape Chad Country Afghanistan 100 Appendix 3. Global mobile phone subscriptions of responding Member States Latvia Lao People’s DemocraticRepublic Kyrgyzstan Kuwait Jordan Israel Iran (IslamicRepublic of) Indonesia India Iceland Hungary Guinea-Bissau Greece Ghana Germany Gambia France Finland Fiji Ethiopia Estonia Eritrea El Salvador Egypt Dominican Republic Denmark Czech Republic Cyprus Croatia Congo Comoros Colombia China Country Mobile cellularsubscriptions (per 100population) 202.99 144.59 136.66 125.84 108.15 119.12 118.01 112.23 135.39 127.79 122.77 137.51 66.69 84.04 58.94 69.25 95.22 99.72 81.85 63.38 92.33 43.83 95.51 85.53 34.79 14.79 70.83 51.18 55.51 75.36 4.89 2.78 ...
Appendix 3. Global mobile phone subscriptions of responding Member States 101
76.2 88.5 84.2 99.2 175.4 79.11 36.13 77.28 17.00 77.94 25.97 110.6 31.98 30.56 47.24 28.76 21.29 84.36 66.32 56.96 26.08 80.98 84.69 117.02 103.27 141.76 164.37 110.16 120.47 139.54 147.94 110.89 150.96 (per 100 population) (per 100 Mobile cellular subscriptions subscriptions Mobile cellular Lebanon Lesotho Liberia Libyan Arab Jamahiriya Lithuania Madagascar Malaysia Maldives Mali Malta Mauritania Mauritius Mexico Mongolia Montenegro Morocco Mozambique Nepal New Zealand Niger Nigeria Norway Oman Pakistan Panama Paraguay Peru Philippines Poland Portugal Qatar of Korea Republic of Moldova Republic Country 102 Appendix 3. Global mobile phone subscriptions of responding Member States (http://www.itu.int/ITU-D/ict/material/FactsFigures2010.pdf Source: Theworldin2010: ICTfactsandfigures a Datafor2009. Zimbabwe Zambia Yemen Viet Nam Uzbekistan USA United Kingdom Turkmenistan Turkey Tonga Togo Thailand Republic Syrian Arab Switzerland Swaziland Sudan Sri Lanka Spain Slovenia Slovakia Singapore Sierra Leone Seychelles Senegal Saudi Arabia Sao Tome andPrincipe Country . Geneva, International Telecommunications Union, 2010 , accessed 13 May2011). Mobile cellularsubscriptions (per 100population) 109.56 100.56 140.43 103.98 130.55 122.57 113.56 174.43 69.65 50.98 36.29 94.83 16.29 55.06 20.36 29.35 23.88 44.27 83.91 39.32 55.36 34.07 33.05 59.73 122.3 101.7
mHealth New horizons for health through mobile technologies
Based on the findings of the second global survey on eHealth
Global Observatory for eHealth series - Volume 3
ISBN 978 92 4 156425 0