Mobile Applications for the Health Sector Christine Zhenwei Qiang, Masatake Yamamichi*, Vicky Hausman and Daniel Altman ICT Sector Unit World Bank December 2011 This report is the product of the staff and consultants of the World Bank. The findings, interpretations, and conclusions do not necessarily reflect the views of the Executive Directors of the World Bank or the governments they represent. The World Bank does not guarantee the accuracy of the data included in this work. * Corresponding author: 1818 H Street NW, MSN MC6-616, Washington DC 20433, USA. [email protected] Contents Abbreviations ................................................................................................................... 3 Acknowledgements ........................................................................................................... 4 Executive Summary ........................................................................................................... 5 1 Introduction ........................................................................................................... 11 1.1 What is mobile health? 11 1.2 Technological context for mobile health 12 1.3 Perceived potential of mobile health 13 1.4 The mobile health ecosystem 16 1.5 Social goals of investments in mobile health 17 1.6 How does mobile health relate to other intersections of health and technology? 19 2 Health Needs in Developing Countries ...................................................................... 21 2.1 Common health burdens 21 2.2 Challenges of strengthening health systems 22 3 Developing New Mobile Health Interventions............................................................ 24 3.1 Inputs 25 3.2 Outputs 33 3.3 Multipliers 35 3.4 Outcomes 36 4 Country Case Studies: Early Patterns and Results ....................................................... 38 4.1 Broad observations 38 4.2 Evidence of mobile health‘s Impact 43 5 Business Model Analysis......................................................................................... 49 5.2 For-profit models 53 5.3 Hybrid models 54 6 How Mobile Health May Evolve .............................................................................. 55 6.1 Basic guidance for new mobile health applications 55 6.2 Emerging risks 56 6.3 Mobile health‘s long-term future 58 7 Conclusion: Realizing the Potential of Mobile Health ................................................. 61 2 Abbreviations 2G second generation mobile telephony 3G third generation mobile telephony 4G fourth generation mobile telephony 4G-LTE fourth generation mobile telephony long-term evolution ART antiretroviral therapy CHAI Clinton Health Access Initiative GPRS general packet radio service GPS global positioning system GSM global system for mobile communications HP Hewlett Packard ICT Information and communication technology PEPFAR [U.S.] President‘s Emergency Plan for HIV/AIDS Relief SIM subscriber identity module SMS short message service WHO World Health Organization WiMAX worldwide interoperability for microwave access 3 Acknowledgements This report is based on inputs from consultants, policy experts, and industry leaders, including work conducted by a team of consultants from Dalberg, lead by Vicky Hausman, under the supervision of Christine Zhen-Wei Qiang. Valuable input, guidance, and support at various stages of the preparation of the manuscript were received from Jose Luis Irigoyen (director, TWI), Philippe Dongier (manager, TWI ICT sector unit), Valerie D‘Costa (manager, Information for Development Program (infoDev)), Edward Anderson, Elizabeth J. Ashbourne, Paolo Belli, Deepak Bhatia, Eduard R. Bos, Mukesh Chawla, Carol Hullin, Eva Jarawan, Tim Kelly, Siou Chew Kuek, Samia Melhem, Kate Otto, Krishna Pidatala, and Feng Zhao. External reviewers and experts who offered valuable advice at various stages of the study include, J.P. Auffret, Director of George Mason University Center for Advanced Technology Strategy and Heather Thorne, Director of Grameen Foundation. This report would not have been possible without generous funding the Korea Trust Fund for ICT for Development, which is managed by infoDev. The authors would also like to thank Paul Holtz for his editorial support and Marta Lucila Priftis for administrative support. 4 Executive Summary M-health—the use of mobile applications for healthcare—is a young and dynamic field that could improve the well-being of people around the world. Mobile applications can lower costs and improve the quality of healthcare as well as shift behavior to strengthen prevention, all of which can improve health outcomes over the long term. As an intersection of health, technology, and finance, m-health is also a complex industry where it can be difficult to develop sustainable business models. A paucity of data on the impact of m-health services, combined with a lack of interoperability between them and other mobile applications, has presented challenges for governments and other large-scale funders of global healthcare. Flexibility is critical because designing policies and regulations to steer or enhance m-health‘s growth. The industry would be best served with regulatory strategies that focus on the most urgent needs of health systems. This report assesses the current state of m-health in the developing world, including extensive case studies of three countries—Haiti, India, and Kenya—with very different health sectors, financing options, and technological bases. It examines interventions serving entirely new functions in the health system, less costly substitutes for existing interventions, and interactive functions that multiply the power of existing interventions. In addition, the report identifies emerging trends, risks, and opportunities in the industry‘s immediate future. This report is intended to be a tool for donors and governments to understand the growing m-health industry and anticipate the policy issues that will affect its development. The use of mobile technology creates more than 5 billion points of contact between consumers, healthcare workers, health system administrators, and firms in supply chains for health commodities. Goals and uses of mobile health One of the main goals of using mobile technology in the health sector is to improve the quality of and access to care. Because so many different factors can contribute to these aspects of healthcare, a wide variety of m-health interventions have arisen to address them. For example, m-health applications can help patients manage their treatments when attention from health workers is costly, unavailable, or difficult to obtain regularly. For example, WelTel provides SMS-based messaging to monitor and support antiretroviral (ARV) therapy in Kenya. WelTel‘s SMS communications are estimated to have raised ARV patients‘ adherence to their treatment regimens by a quarter (Lester 2010). This increased adherence and associated viral load suppression lowered health system costs by 1-7 percent (WelTel 2011). Patient tracking using m-health applications can also support the coordination and quality of care, especially in rural and underserved communities including the urban poor, women, the elderly, and the disabled. Kenya‘s ChildCount+ registers pregnant women and children 5 under 5 and collects basic information about their health to prioritize visits by community health workers. M-health applications can also be used for supply chain management, reducing delays in medicine shipments and providing point-of-use technologies for consumers to verify the authenticity of products they buy. The Stop Stock-Outs campaign encouraged consumers and pharmacists in six Sub-Saharan countries to report shortages of medicines and other products using SMS, resulting in hundreds of reports in a six-month period. And a system developed by mPedigree and Hewlett Packard assigns codes to consumer drugs that are scratched off by consumers and authenticated by SMS; the system is being launched in Kenya. Finally, access to care can benefit from health financing applications based on mobile devices, which can reduce the overall cost of care, including health system costs associated with treating and managing chronic conditions such as HIV/AIDS, often in conjunction with other mobile applications. For instance, Kenya‘s Changamka allows users to deposits funds into health savings accounts using mobile money (m-money) services such as M-PESA and then use the accounts to pay for health services. Another major category of m-health services focus on making human resources more efficient in the health sector, both at the point of care and in administration. Scores of applications exist for clinical decision support, enabling consumers and health workers to receive medical advice using technology rather than have to rely on face-to-face interactions. India‘s Health Management and Research Institute (HMRI) delivers 104 Advice, an integrated medical center in the state of Andhra Pradesh that has served more than 10 million callers. In rural areas, where seeking treatment at a medical facility tends to be costly and more than half of unmet requests for outpatient care could be treated by phone, 104 Advice provides a hotline for medical consultations. Better recordkeeping is another widespread outcome of m-health technologies. Replacing dated processes with electronic systems lowers costs and saves health workers‘ time. Workers often have to keep several sets of books and medical records to comply with funding requirements. Automating these processes with