BMI Special Report Global Telecare Healthcare For The Digital Age 2012-04-01

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2012
GLoBaL teLecaRe: HeaLtHcaRe FoR tHe DIGItaL aGe

sPecIaL RePoRt BMIs oPPoRtUNItY MatRIX IDeNtIFIes MaRKets FoR INVestMeNt
Published by Business Monitor International Ltd.
GLOBAL TELECARE
Contents
Summary ................................................................................................................ 7 Opportunities In The Developed And Emerging World .......................................... 7 Introduction ............................................................................................................ 9
CHART: InCReAsIngly MobIle ......................................................................................................................................................9 Global Mobile Subscriptions Self Care .................................................................................................................................................................. 9 Outpatient Care ..................................................................................................................................................... 10 Health Monitoring ................................................................................................................................................ 10 Disease Surveillance ............................................................................................................................................ 10 Drug Monitoring ................................................................................................................................................... 10
Methodology ......................................................................................................... 13 Opportunity Matrix ................................................................................................ 13
1. Health Monitoring ....................................................................... 15

Telecare Matrix Findings ......................................................................................................................................... 15
Health Monitoring: Case Studies .......................................................................... 17 Tanzania: MHealth Project To Improve Maternal Care ........................................ 17
charT: ZanTel carvinG OuT iTS niche ........................................................................................................ 17 Tanzania Mobile Market Shares, June 2011 CHART: low HeAlTHCARe expendITuRe And low CusToMeR spendIng ...................................................................... 17 arPu vs health care expenditure Per capita (uS$) CHART: sTIll FAR To gRow .........................................................................................................................................................18 rwanda internet use Growth
Rwanda: Mobile And Wireless Technology Improving Healthcare Provision ....... 18

TAble: InsTITuTIons suppoRTIng ARV TReATMenTs In RwAndA: CuRRenT ICT sTRuCTuRe ..................................... 19 CHART: on TARgeT..........................................................................................................................................................................20 Rwanda Specific Goals CHART: posITIVe gRowTH ...........................................................................................................................................................20 rwanda Pharmaceuticals & healthcare expenditure (uS$bn)
Canada: Ontario Expands Telehealth Services ..................................................... 20 Middle East: Mobile Baby - A Growing Trend In MENA........................................ 21 New Zealand & Australia: Cisco Eyeing Australia, New Zealand IT Healthcare . 22
2. Drug Monitoring .......................................................................... 25

Drug Monitoring: Case Studies ............................................................................. 27
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Ghana: HP To Work With mPedigree To Combat Counterfeits ............................. 27

CHART: A HIgH buRden ................................................................................................................................................................. 27 Ghana: DalYs lost To Malaria
3. Outpatient Care........................................................................... 29
Outpatient Care: Case Studies .............................................................................. 31 Netherlands: Philips Electronics To Implement Telemedicine System .................. 31 USA: Telecare Finds Its Algorithm ......................................................................... 31
CHART: gRowTH In HeAlTHCARe CosTs .................................................................................................................................. 31 netherlands healthcare expenditure Trends CHART: TeleCARe wIll need sCAlAbIlITy To bRIng beneFITs To IndusTRy ................................................................ 32 uS Burden Of Disease
4. Self Care ...................................................................................... 32

Self Care: Case Studies .......................................................................................... 35 Iraq: AsiaCell Launches mhealth Services As Value-Added Strategy Improves Its Competitiveness ............................................................................................... 35
CHART: FlAT MARkeT sHARes IndICATe lACk oF seRVICe dIFFeRenTIATIon .................................................................. 35 iraq Mobile Operators By Market Share, (%) AsIACell VAlue-Added sTRATegy key To ..............................................................................................................................36 CHART: ouTpeRFoRMAnCe ..........................................................................................................................................................36 asiacell vs Zain revenue (uS$mn) CHART: AsIACell pulls AHeAd ..................................................................................................................................................36 asiacell vs Zain arPu (uS$)
5. Disease Surveillance ................................................................... 37

Disease Surveillance: Case Studies ....................................................................... 39 Kenya: Government And HP Launch Mobile Project To Improve Disease Management ......................................................................................................... 39
CHART: HIgH InFeCTIous dIseAse buRden ............................................................................................................................. 39 DalYs lost in Kenya CHART: lARge RuRAl populATIon ...........................................................................................................................................40 Kenya Population Forecast CHART: on THe RIse ......................................................................................................................................................................40 Kenya Mobile Subscribers and Mobile penetration
Company Focus ................................................................................ 41

Europe & Latin America: Telefnica Launches eHealth Initiative ......................... 41 Malaysia: Mobile Healthcare Growth Potential Attracts REDtone ........................ 41
A gRowIng deMAnd FoR pHARMACeuTICAls & HeAlTHCARe .......................................................................................... 42 new Zealand Pharmaceuticals & healthcare Market Forecast (uS$bn)
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New Zealand: Bupa Adopts Telecare.................................................................... 42

CHART: AgeIng populATIon MeAns... .......................................................................................................................................43 new Zealand Population Data CHART: ...InCReAsed pRessuRe on THe goVeRnMenT......................................................................................................... 43 New Zealand Ageing Profile Ratio *
Country Focus: BRICs ....................................................................... 45

China: Telecare Market Has Plenty Of Potential ................................................... 45
CHART: gRowTH wIll ConTInue sTRong ...............................................................................................................................45 Mobile Market Subscriber Forecasts CHART: bAsIC seRVICes need To CATeR To subsCRIbeRs................................................................................................... 45 Forecasts By Technology CHART: RegIonAl dIspARITIes CReATe CHAllenges FoR TeleCARe gRowTH ............................................................. 45 regional Mobile Penetration rates (%), June 2011 CHART: gRowTH In ConneCTIons To pRoVIde beTTeR CARe ........................................................................................... 46 china internet and Broadband Forecasts (000) CHART: TeleCARe pRoVIdes oppoRTunITIes FoR CHInAs HeAlTHCARe FuTuRe ........................................................ 47 china healthcare expenditure and Pharmaceuticals Sales
Russia: Telecare Creates Opportunities ................................................................ 48

CHART: CITIes leAd ......................................................................................................................................................................48 russia Mobile Penetration (%), Q311 CHART: FIndIng new AVenues oF gRowTH .......................................................................................................................... 48 russia Mobile Market CHART: ConsIdeRAble gRowTH poTenTIAl ......................................................................................................................... 49 russia healthcare Market
Brazil: Mobile And Wireless Technology Improving Healthcare Provision .......... 50

CHART: dIgITAl dIVIde ReMAIns ............................................................................................................................................... 51 regional Mobile Penetration rate (%) CHART: TeleCARe CAn boosT gRowTH In bRAzIls pHARMACeuTICAls HeAlTHCARe MARkeT .............................. 52 Brazil Pharmaceuticals & healthcare expenditure CHART: posITIVe gRowTH ..........................................................................................................................................................52 Brazil Mobile Market historical Data and Forecasts
India: Public And Private Sector Investment Boosting Telecare Growth .............. 53
CHART: dIspRopoRTIonATe .......................................................................................................................................................53 india Teledensity urban/rural Split (%), 2011 CHART: IndIA populATIon ...........................................................................................................................................................53 urban/ rural Split, 2011 CHART: oppoRTunITIes FoR opeRAToRs ...............................................................................................................................55 india 3G Mobile network CHART: bAsIC seRVICe wIll dRIVe THe MARkeT ................................................................................................................... 55 india Mobile Subscriber Forecasts CHART: gRowIng MIddle ClAss boosTIng gRowTH ......................................................................................................... 55 india Broadband internet Subscribers CHART: HIgH gRowTH MARkeT .................................................................................................................................................56 india Pharmaceuticals and healthcare Market Forecast
Risks ................................................................................................ 57
Telecare risks......................................................................................................... 57
Reliability of Infrastructure ................................................................................................................................. 57 Technical Understanding .................................................................................................................................... 57 Network Capacity ................................................................................................................................................. 57
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Regulatory Environment ..................................................................................................................................... 57 CHART: A-ppoRTunTIes FoR dRugMAkeRs .......................................................................................................................... 58 uS healthcare expenditure (uS$mn)
FDA To Regulate Medical Apps.............................................................................. 58 Telemedicine Demand Exists, But Does It Work? .................................................. 60
Key Study Findings: ............................................................................................................................................. 60
Appendix: Results of BMIs Telecare Matrix .................................... 61

TAble: HeAlTH MonIToRIng ....................................................................................................................................................... 61 TAble: dRug MonIToRIng ...........................................................................................................................................................62 TAble: ouTpATIenT CARe .............................................................................................................................................................63 TAble: selF CARe ..........................................................................................................................................................................64 TAble: dIseAse suRVeIllAnCe ..................................................................................................................................................65
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Summary
Opportunities In The Developed And Emerging World

Growth in the number of mobile phone users and wireless subscribers, and advances in the innovative application of communication technology to address health priorities, has the potential to transform the delivery of healthcare across the world. This will provide significant opportunities to companies looking to invest in the telecare sector.
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Introduction
BMI defines telecare as the use of mobile and internet technology to provide clinical care and non-clinical services such as health education, disease surveillance and drug monitoring. It is our view that a combination of factors - including the continued growth in demand for and delivery of healthcare, the continued growth in mobile and broadband subscribers and penetration rates and the growing sophistication of the infrastructure of the communication networks - is driving new opportunities in telecare across the globe. We expect this to create significant revenue-earning opportunities for companies operating in both the developed and emerging world. The Platform For Telecare Is Growing - As Highlighted By BMI's Forecasts According to BMI's Pharmaceuticals and Healthcare team, global healthcare spending in 2011 reached and by 2016, experiencing a compound annual growth rate (CAGR) of 4.43%, we forecast healthcare spending reaching US$7,692bn. According to BMIs Pharmaceuticals and Healthcare team, global healthcare spending in 2011 reached US$6.517trn and by 2016, experiencing a compound annual growth rate (CAGR) of 4.26%, we forecast healthcare spending reaching US$8.026trn. According to BMIs Telecommunications team, there were 6.1bn mobile subscribers in the world in 2011 (global penetration rate: 156%) and by 2016, this is forecast to increase to 7.9bn mobile subscribers (global penetration rate: 194%). Additionally, in 2011, there were 743mn broadband subscribers globally (global penetration rate: 19.2%) and by 2016, this is forecast to increase to 1.2bn broadband subscribers (global penetration rate: 29.1%). According to the GSM Association, commercial wireless signals cover over 85% of the worlds population, extending far beyond the reach of the electrical grid. A Global Application Governments of emerging markets are adopting telecare as a complementary strategy for strengthening healthcare systems, increasing populations' access to healthcare, which continues to be a major issue. In developed markets, governments are choosing to utilise telecare to improve healthcare delivery efficiency, aiming to reduce the burden on overstretched national health services and public finances.
Global Mobile Subscriptions
9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0
2011e 2005 2006 2007 2008 2009 2010 2012f 2013f 2014f 2015f 2016f
Increasingly Mobile
140 120 100 80 60 40 20 0
Subscribers ('000) (LHS)
Average Penetration Rate (%) (RHS)
e/f = BMI estimate/forecast. Source: BMI, Regulators, World Bank (ITU)
Attractive To Public And Private Players Various stakeholders - including governments, drug companies, insurance companies, mobile operators and software vendors - have invested funds in numerous telecare initiatives across the globe, illustrating the recognition of field's potential. Here BMI identifies the types of initiatives that are in place: Self Care This involves patients' use of technologies such as smartphone applications and smart medical devices to enable adherence to medication and access to disease diagnoses and treatment information. Multinationals Pfizer, Merck & Co, GlaxoSmithKline (GSK), AstraZeneca, Sanofi-Aventis, Roche, Novartis, Johnson & Johnson (J&J), Bayer and Abbott Laboratories have all produced apps for use by patients
GLOBAL TELECARE
and healthcare professionals. The apps include disease calculators, educational packages, patient diaries and even information about drugs. In addition to improving compliance to prescriptions, drug companies can use apps to differentiate their products from those offered by the competition. Outpatient Care This entails the use of technology to provide medical care remotely, enabling doctors to monitor patients' health and equip them with devices to better manage conditions such as respiratory diseases at home. Moreover, chronically ill and older patients can be treated for longer at home rather than in hospitals or care homes. This also includes communication between health services and individuals in order to ensure treatment compliance and provide appointment reminders. Multinational company Philips Electronics signed a deal with the largest health insurer in the Netherlands, Achmea, to focus on a home healthcare project that will help doctors monitor patients' health remotely. Inpatient costs account for a large proportion of healthcare expenditure and therefore a reduction in the number of patients that receive on-site hospital care can lead to savings that would be welcomed by insurance companies as well as the country's national health service, the Verplicht Ziekenfonds Verzekerd . The country's population aged over 70 years is expected to increase from 6.4% of the total in 2008 to 11.4% by 2030 (see case study, page 29). Health Monitoring This entails the use of communication technology to enable intersectoral communication in emergencies, mobilise community healthcare, provide access to information for healthcare professionals at the point of care (including patient records and decision support systems) and enable the transmission of information and communication between healthcare professionals. In 2010, in California, the service provider AT&T was awarded a US$27mn contract to build an 860-site statewide network to connect smaller hospitals and clinics to larger hospitals, their specialists and experts. Funded by the FCC's Rural Health Care Pilot Programme, with the
goal of significantly increasing access to acute, primary and preventive health care in rural America, this is a coalition of healthcare, technology, government and other stakeholders. Disease Surveillance This entails the use of mobile technology to detect and manage disease outbreaks. Health workers collect and transmit real-time information regarding disease occurrence at a local level (including context-rich data through pictures, video, audio, GPS coordinates and qualitative and quantitative information regarding the case) and share the data with healthcare organisations focused on controlling infections and diseases, allowing health officials to promptly analyse data and identify trends, as well as launching prevention and cure schemes. The Kenyan government launched an Integrated Disease Surveillance and Response (IDSR) system in partnership with Hewlett-Packard (HP) East Africa and the Clinton Health Access Initiative (CHAI), enabling health workers to detect and manage disease outbreaks through smartphones. HP has donated 250 Palm Pre smartphones and the CHAI has provided US$1mn in funding for the design and purchase of the hardware and mobile handsets to run the system (see case study, page 37). Drug Monitoring This entails the connection of mobile networks to a central registry which stores information on medicine brands belonging to participant manufacturers, providing consumers with a service that verifies the authenticity of a medicine. The phone-based interception strategy does not allow the same drug code to be sent twice, which is a novel tactic in pre-empting the production of forged consignments.Initiatives in this area also involve the use of SMS technology to track and manage the supply of medicines. The system works by sending an automated SMS to healthcare staff at local healthcare facilities, reminding them to check stock levels of drugs. The staff then reply via SMS to a central database system, detailing stock levels. Deliveries can then be managed centrally to more efficiently manage drug supplies.
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Multinational technology provider Hewlett-Packard and Airtel are working with Ghana based mPedigree - a company that connects GSM mobile networks in Ghana to a central registry which stores information on medicine brands belonging to participant manufacturers. Under initial HP-mPedigree efforts, 125,000 packets of malaria drugs displayed a scratch-off panel hiding 10 digits. Consumers were to send the code to a widely-advertised number and received a reply confirming or disputing the product's authenticity (see case study, page 25).
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Methodology
Opportunity Matrix
BMI's approach in assessing markets for telecare industry investors globally is twofold. First, we identify the demand for the particular telecare service (in terms of the burden of disease, healthcare spending) which represents opportunities to would-be investors, assigning each market a 'high, medium or low' - which indicates the level opportunity for investors . Second, we identify the level of infrastructure (in terms of Average Revenue Per User (ARPU) levels, ICT Development Index (IDI)) in place to deliver the particular telecare service which pose or could pose operational risks to would-be investors, assigning each market an 'excellent, average or poor' - which indicates the level of opportunity for investors. We note that only the aspects that are most relevant to the type of telecare system being examined are incorporated into the assessment and each variable is weighted according to its importance in the provision of the service. Overall, the system offers an industryleading, comparative insight into the opportunities/risks for companies across the globe.
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Health Monitoring
Health monitoring is perhaps the largest section of the telecare industry, covering a wealth of services that can improve healthcare provision while also lowering costs. The applications of health monitoring services may differ depending on the service needed and the state of the local healthcare system. There are applications in both developed and emerging markets, hence the mix of countries featuring at the top of our health monitoring matrix. The cost of medical devices means that expensive equipment and specialists cannot be available in every hospital or healthcare centre. Health monitoring services enable more remote or smaller communities to have access to the latest technology or medical experts at a much lower cost. The key to health monitoring is the connectivity between two entities making broadband availability a major barrier to rolling out such services. Health monitoring relies on sending data easily, ensuring the quality of information or images do not deteriorate. While the majority of developed markets have established broadband infrastructure, this is more of a restriction in emerging markets where the fixed broadband infrastructure is weak. The devices to capture images and data are also important to the expansion of health monitoring projects and services. In communities where devices will not be replaced often, the durability and maintenance of these devices will play a key role in making health monitoring services financially viable. Health monitoring is an area that brings in all stakeholders in the telecare industry as operators need to ensure network availability and reliability while device manufacturers need to build the products to meet the needs of health monitoring projects. Governments can be important drivers of health monitoring services through national or local projects tying together the different areas of healthcare. Telecare Matrix Findings BMIs analysis of the opportunities for Health Monitoring show that it is not a particularly emerging market or developed market phenomenon. The majority of countries that score high for opportunities was the size of the land that needs to be covered. This explains the presence of Australia and the US among the top rated markets. Although access to healthcare is largely good across these markets, health monitoring services that would allow costs to be reduced would likely be very appealing to insurance companies and governments. One of health monitorings greatest benefits is the ability to reach more remote communities. This makes it a key telecare service for emerging markets with larger rural communities. Uganda, Sri Lanka and Kenya stand out from our list of markets with the highest rural populations; a key factor in the potential success of health monitoring services. However, large countries such as Australia and Canada have low population density, offering similar opportunities, albeit for different reasons. BMI highlighted countries that have particularly low health spending per capita as markets that offer considerable opportunities for Health Monitoring along with a higher rural population. This will, of course, depend on the kind of service offered as the need for connectivity and technology understanding will depend on different products. Those that use the most basic devices such as mobile handsets will particularly stand out in emerging markets. For full results of BMIs Telecare Matrix, please see Appendix.
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Markets with greatest opportunities for Health Monitoring
For full results of BMIs Telecare Matrix, please see Appendix.
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Health Monitoring: Case Studies

Tanzania: MHealth Project To Improve Maternal Care
In September 2011, it was announced that technology hardware manufacturer Qualcomm, telecoms operator Zantel and its parent company Etisalat and telecare organisation D-tree International was launching a mobile health (m-health) program in Tanzania. The program will focus on healthcare provision for women and children and will specifically target pregnant women using a combination of technologies to support extended care as well as tackle chronic diseases. BMI believes there is great potential for such projects to drive improvements in healthcare across the country. Tanzania has a maternal mortality rate of 790 per 100,000 live births, higher than the regional average of 620, which highlights the need for projects to aid pregnant women. Medical professionals will have access to mobile devices, with specific software provided by the telecoms companies, which will enable them to identify obstetric emergencies, arrange transportation for emergencies and maintain patient records.
Tanzania Mobile Market Shares, June 2011
Tigo 22.2% Zantel 6.4% TTCL 0.3% Benson & Sesatel 0.1%
a positive effect on Tanzania's health service, where healthcare spending per capita is low, but growing. Efficient mhealth services can help lower the costs of medical services.
Low Healthcare Expenditure And Low Customer Spending
ARPU Vs Health Care Expenditure Per Capita (US$)

35 Health expenditure per capita ARPU 30 25 20 15 10 5 0
2007
2008
2009
2010
2011f
2012f
2013f
2014f
2015f
e/f = BMI estimate/forecast. Source: World Health Organization (WHO), BMI
Zantel Carving Out Its Niche
Vodacom 42.9% Airtel 28.2%
As mobile penetration reaches 50% in Tanzania, it is clear there is still considerable scope for expansion of services. Although the market is highly competitive, with seven operators, BMI believes that rural areas have limited coverage. Zantel has already said it will increase its subscriber base by two-thirds by rolling out infrastructure in mainland Tanzania, and BMI believes this as an important factor in the success of the m-health project as healthcare will be more limited in rural areas, as well as connectivity. While the press release from the partners does not suggest that the project will be principally in rural areas, this is where BMI believes there will be most demand for the service. However, while we believe there is a real need for health monitoring services in Tanzania, the telecoms infrastructure is not yet sufficiently developed for these services to be widely deployed and customers are not used to spending heavily on their services. We welcome the drive to improve maternal care and offer solutions for malnutrition in children. Nevertheless, with spending on mobile services low in Tanzania, it seems clear that
Source: BMI, Operaotrs, TCRA
Data from BMI's Burden of Disease Database (BoDD) show that over 3mn DALYs (disability-adjusted life years) were lost to maternal conditions; perinatal conditions; birth asphyxia and birth trauma; and nutritional deficiencies in 2011 or 15% of total DALYs for Tanzania. Reducing the incidence of these conditions will have
2016f
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this project will be funded by the companies involved and government healthcare budgets, rather than offering great opportunities for Zantel to boost revenues from subscribers. Although BMI believes the company will generate greater revenues from its mobile payment services, we welcome the launch of new services taking advantage of mobile technologies to improve healthcare.
emergency; Submit patient reports - In the past, community health workers would travel long distances and make several trips to the health centers to submit reports, but with M-health, communication is instant. Currently all community health workers are able to send and access vital health information using mobile phones; Report cases of negligence at health centres and district hospitals - This is especially for cases involving expectant mothers. Increased Internet Connectivity In December 2009, it was reported by The New Times that the Kigali WiBro Network and the Kigali Metropolitan Network had gone live. Both were deployed by South Koreas KT Corp and are part of the Rwandan government's plan to have high-speed internet access available to and used by at least 4mn Rwandans within two to three years.
Still Far To Grow
Rwanda: Mobile And Wireless Technology Improving Healthcare Provision

Increased Mobile Phone Usage The Rwanda Utilities Regulatory Authority (RURA) published market data for the mobile segment relating to the end of September 2011. According to the regulator's data, the mobile market grew by 10.1% y-o-y to reach 4.305mn subscribers by the end of Q311. This represented a penetration rate of 40.2%, up from 36% at the end of the previous quarter. BMI expects the regulator to be pleased by the strong growth of Rwanda's mobile subscriber base considering its ambitious target of 60% penetration rate by the end of 2012. Providing The Infrastructure For Mobile Health Benefiting from the growth in the mobile market, in 2010, community health workers in Rwanda were provided with mobile phones, enabling them to coordinate their sector's activities in a more centralised manner, promoting quality care - an issue that has always challenged the delivery of health services. An example of this is ensuring that expectant mothers in rural areas are provided with a way of accessing skilled care during pregnancy and child birth, including access to emergency obstetric and newborn care, postnatal care, preventing HIV and malaria during pregnancy. BMI notes that the focus on providing improved care to expectant mothers is in line with our BoDD forecasts for declining DALYs lost to maternal conditions. Health workers have access to toll-free numbers, enabling them to: Report emergency cases - The Ministry of Health has standby ambulances that are ready to respond to any
Rwanda Internet Use Growth

3,500 Number of Internet Users ('000) 3,000 2,500 2,000 15 1,500 1,000 500 0 2007 2008 2009 2010 2011e2012f 2013f 2014f 2015f 2016f
e/f = BMI estimate/forecast. Source: ITU, BMI
30 Internet Users RHS
25
20
10
WiBro was developed in South Korea to provide mobile broadband and is effectively the same as mobile WiMAX solutions devised elsewhere. It offers high data rates and a high degree of mobility. It will offer broadband access to users in Kigali, and will likely be available to individuals and businesses, although BMI expects that take-up will be slow initially. There were suggestions that, while the network was approaching
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completion, there was a rush to get WiBro compatible end-user equipment imported, as there were not many units available. The Kigali Metropolitan Network is a fibre-optic network providing connectivity for local area networks. It will increase broadband availability to over 700 institutions such as schools, universities and government offices, according to reports. KT Corp is also assisting the construction of a national fibre-optic ring, which will provide connectivity to submarine cables, landed this year along the east coast of Africa. Connecting to these should also help Rwanda's new broadband services run more efficiently, reliably and cheaply. In October 2010, it was reported by the East African Business Week that the launch of a 2,300km national fibre-optic backbone in Rwanda is about 80% complete. About 50 public institutions have already been connected to the network and 300 people in the capital Kigali are testing it. These projects are among many aimed at increasing
Rwanda's connectivity as part of a wider and highly ambitious plan for the country's development into a regional ICT hub. However, fulfilling the dream of rapidly transforming a traditionally agricultural economy, which is still recovering from the genocide in the 1990s, into a knowledge-based economy will require many other initiatives to come to fruition to be successful. ICT equipment is untaxed, and the government is cooperating with other agencies to bring more low-cost computers to the country. Reports suggest that PC ownership in Kigali at least has increased, and the One Laptop per Child (OLPC) programme has seen many schools gain access to at least some computers. A World Bank-funded project has internet buses traversing the country, giving rural communities their first taste of ICT. Enabling The Creation Of Healthcare Information Systems Working with the Rwandan Treatment and Research AIDS Centre (TRAC), the US Center for Disease Control is currently funding a pilot project to build an HIV/ AIDS information System for Rwanda. The system will support the increasing delivery of treatment to HIV/
TABLE: InsTITuTIons supporTIng ArV TrEATmEnTs In rwAndA: CurrEnT ICT sTruCTurE

Number
Kigali Minsitries Labs Pharmacies Research Hospitals Regional Centers Adminstrative Offices Las Pharmacies Reference Hospitals District District Hospitals Local Health Centers
Source: BMI
Broad-band
Possible Possible Possible Possible
Dial-up
Yes Yes Yes Yes Yes Yes Yes Yes Some
Has PC
Yes Yes Yes Yes Yes Yes Yesw Some Some
Landline/fax
Yes Yes Yes Yes Yes Yes Yes Some Some Some
Mobile
Yes Yes Yes Yes Yes Yes Yes Yes Yes Most
10 1 1 1 13 2 2 3 39 117
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AIDS patients in the country (the government aims to move from 1,000 people on treatment to 50,000 within five years), alleviating the strain on the health system and on the information system currently supporting it. According to our BoDD 705,693 DALYs were lost to HIV/AIDS in Rwanda in 2009 and by 2030 this figure is expected to increase to 1,151,720, highlighting the need to build systems that can cope with the required increase in treatment regimes. The system aims to replace the paper system currently in place. At the moment, if a patient moves from one village to another, the doctors and caregivers in the new village have no access to his or her previous tests, prescribed drugs, or diagnoses and if blood work is ordered, the sample is be sent slowly to one central lab and then returns, just as slowly and in paper form, to the rural clinic. The system under development aims to tie together the labs, pharmacies, ministries, and most importantly, the local and rural health clinics providing HIV treatment, in order to provide timely and accurate information. This will include the number of patients enrolled at each treatment location and the current and projected supply of drugs and other critical consumables.
Rwanda Specific Goals
Positive For Pharmaceuticals And Healthcare Companies As Will Boost Healthcare Provision And Access To Drugs Healthcare Expenditure Forecast In 2011, healthcare expenditure in Rwanda reached RWF376.31bn (US$636mn) and over the 2011-2016 period, we forecast the sector will experience a compound annual growth rate (CAGR) of 11.20% in local currency terms and 10.11% in US dollar terms, reaching a value of RWF639bn.98bn (US$1.03bn).
Rwanda Pharmaceuticals & Healthcare Expenditure (US$bn)
1.6 Pharmaceutical sales (US$bn) Health expenditure (US$bn) 1.2 1.0 0.8 0.6 0.4 0.2 0.0 1.4
Positive Growth
2006
2007
2008
2009
2010
2011
2012f
2013f
2014f
2015f
2016f
2017f
2018f
2019f
2020f
f = forecast. Source: World Health Organization (WHO), BMI
On Target
Rwanda Millennium Development Goals
Eradicate extreme poverty and hunger Achieve universal primary education Promote gender equality and empower women Reduce child mortality Improve maternal health Combat HIV/AIDS, malaria and other diseases Ensure environmental sustainability
Source: United Nations Development Programme
Pharmaceuticals Expenditure Forecast In 2011, Rwanda's pharmaceutical market was valued at RWF56.39bn (US$95mn) and by 2016, BMI calculates that spending on medicines will reach a value of RWF105.90bn (US$170mn) - experiencing a CAGR of 13.44% in local currency terms and 12.33% in US dollar terms. By 2021, we calculate spending on medicines will reach a value of RWF181.11bn (US$282mn), experiencing a growth of 12.37% in local currency terms and 11.47% in US dollar terms.
Canada: Ontario Expands Telehealth Services

In September 2011, the Ontario Telemedicine Network (OTN), a provincial non-profit organisation, announced that it will use technology from US-based Vidyo to expand clinical care and distance education services. One of the world's largest telehealth networks, the OTN operates some 2,200 video conferencing sites across 1,200 hospitals and clinics. At present, approximately 3,000 healthcare professionals across the province use
The Use Of Technology Positive For Patients Mobile technology has the ability to support Rwanda's Millennium Development Goals (MDGs), specifically MDGs 4 and 5, which call for reduced child and maternal mortality by improving information and communication between mothers, providers and administrators.
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telehealth services to deliver 135,000 'patient events' and 11,000 webcasts. Dr Ed Brown, OTN's chief operating officer, says the decision to expand is driven by year-on-year usage growth of 20-25%. According to the deal, the network expects to implement its video conferencing system to 200-300 new sites and bring thousands more patients and providers online over the next three years. Ontario currently provides residents with telephone access to registered nurses, but the recent emphasis on videoconferencing has shifted to delivering tele-presence to rural homecare patients. As such, BMI believes it is important for videoconferencing systems to accommodate patients that might have limited computer knowhow and sub-standard internet connectivity. BMI notes Ontario's previous telephone initiative cut hospital stays by 65% and emergency ward visits by 70%. Despite curbing its healthcare expenditure slightly, the Canadian government has consistently accounted for close to 70% of the country's overall healthcare expenditure. In 2011, public health expenditure reached a value of CAD122.95bn (US$124.30bn) and BMI forecasts government healthcare expenditure will increase to CAD135.82bn (US$118.10bn) by 2016. We believe the spike in telehealth announcements comes from a willingness to fund upfront investment costs aimed at reducing future operational costs. One such way to do this is encourage provincial health ministries to invest in innovative health initiatives. As Ontario's investment demonstrates, electronic health records and telehealth can play a key role in improving healthcare, particularly for Canadians that live in regions without access to medical care. While Ontario stands out as a leader in the field, the federal government released a 10-year health vision in 2004 that encouraged provinces to accelerate their own telehealth initiatives.
a wider m-health initiative in the Middle East and North Africa (MENA). In February 2011, the firm announced the launch of Mobile Baby services with three operators in the region, two in Egypt and one in Saudi Arabia. The initiative, which BMI welcomes, is a significant telecoms-healthcare crossover and a potentially profitable value-added service (VAS) for mobile operators in the region. Great Connection stated that it would be providing the Mobile Baby service in Egypt in collaboration with mobile operators Orascom Telecom and Mobinil. The announcement was contained in a press release at Mobile World Congress (MWC) 2011 in Barcelona, Spain. This followed the launched of a similar service in February 2011 in Saudi Arabia by Great Connection in collaboration with mobile operator Mobily. Mobile Baby, the first application in a portfolio of image conversion m-health services from Great Connection, is facilitated by wireless technology company Qualcomm, which is working with a wide network of companies worldwide to promote health monitoring and diagnosis services over wireless networks and using smartphone applications. According to Great Connection, Mobile Baby enables medical practitioners to send ultrasound images, video clips and 3D scans to and from referring physicians for remote diagnostics. The application is compatible with any ultrasound machines and delivers images to specified mobile phones via SMS, MMS and email. The main aim of the service is to enhance pre-natal healthcare through immediate availability and low-cost transmission of images and video clips from the womb. The Mobile Baby application was first introduced by Great Connection in May 2009 with Mama Mia, Scandinavia's largest private women's and child health service provider. BMI believes Great Connection's venture into MENA with the service is strategic considering the wide gap in healthcare delivery in the region. In Egypt, the patient-to-doctor ratio is put at one to 1,900, making it hard for patients particularly in rural areas to receive sufficient attention. Mobile Baby aims to plug this gap by making it possible to send sonograms to anywhere in
Middle East: Mobile Baby - A Growing Trend In MENA

Healthcare technology firm Great Connection is keen to expand its trademark product Mobile Baby as part of
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the world within seconds, including to specialists whose opinion might be required in case of complications. BMI is encouraged by the seeming willingness of leading operators in MENA to collaborate with Great Connection in the delivery of Mobile Baby. With slower customer and revenue growth in the region due to intense competition and fast-saturating markets, we believe m-health services such as Mobile Baby are likely to offer sustainable revenue streams in the future. Approximately 153bn ultrasound images are taken annually around the world. With Mobile Baby, mobile operators are well placed to cut out a piece of that market. Mobinil had highlighted m-health as a key focus in 2011 and beyond to drive future revenue growth amid declining revenue from basic voice and SMS services. Mobile Baby is certainly a step in that direction and we expect other operators to pursue a similar strategy. BMI has a positive outlook for Mobile Baby even as Great Connection plans to extend the service to other countries. We expect the service to attract substantial interest from users, not least because images and videos can be sent to family and friends as well. Meanwhile, Great Connection's collaboration with major operators in target markets should be a key growth driver as the service would be promoted alongside other offerings on the operators' wide advertising network.
2012, which allows them to control which healthcare providers are able to see their information. Through separate web portals, patients and medical professionals from both the private and public sectors can access information when permitted by patients. Recent Developments In Health-IT Implementations In August 2011, the New South Wales state government created the eHealth NSW agency, which aims to develop a strong governance framework for information and communication technology (ICT) by the end of 2011. The state was previously criticised for having a series of problems in its previous e-health system, such as patient details assigned to the wrong patient. In the same month, management consultants Accenture secured a national infrastructure partner contract for Australia's PCEHR project. The firm is responsible for the testing and integration of PCEHR with existing eHealth infrastructure around Australia. Also in August 2011, the Health Minister granted AUD$70mn (US$72mn) to nine state IT health projects, such as NSW Health, and private projects such as online personal health diary for insurers by Medibank Private. Is E-Health The Way Forward? BMI believes countries will increasingly implement e-health solutions to facilitate medical professionals' access to patients' medical records and to provide better medical care, as patients will not be required to remember many details prior to first consultations with a new doctor. E-health projects are already being implemented or trialled in several countries. For example in Canada, eHealth Ontario must create electronic health records for all patients in the province by 2015. In Europe, there are two organisations that promote the usage of eHealth across several countries: 1. The European Health Telematics Association (EHTEL) provides an information exchange platform
New Zealand & Australia: Cisco Eyeing Australia, New Zealand IT Healthcare
In a bid to introduce digital technology to hospitals in Australia and New Zealand, US-based, Cisco has published a health-dedicated blog that focuses on the role of technology in managing healthcare issues. This is in line with the firm's aim to promote its Connected Health solutions. Australia's E-Health Plan Unveiled Cisco's announcement was unsurprising, as Australia's Health Minister, Nicola Roxon, unveiled an AUD$467mn (US$480mn) e-health plan in September 2011. Under the programme, Australians will be able to opt for a Personally Controlled E-Health Record (PCEHR) from July
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for all European eHealth stakeholders. Currently there are 60 member organisations under the EHTEL. 2. The European Institute for Health Records, founded in 2002, is involved in the promotion of EHR systems in the European Union through its role as Europe's authorised EHR certification body. In Asia, the Philippines announced its plans to deliver rural e-health services in August 2011. Together with Smart Communications, the Philippines Department of Health (DOH) will implement a Secured Health Information Network and Exchange (SHINE) to boosts healthcare delivery by cutting the time spent documenting patients' data. Under the programme, health workers will be able to access patient data through mobile phones equipped with the SHINE system. In 2009, Singapore invested US$140mn to implement EHR in the country. The Ministry of Health Holdings (HOHH) partnered with more than 300 clinicians across the island to define the requirements for e-health records system architecture. The first phase of Singapore EHR went live in April 2011, when a copy of the summary information from different hospitals was held at a central repository. The contract was awarded to Accenture, Oracle and Orion Health and the first phase implementation is expected to last until June 2012. Challenges To Nationwide Implementation BMI believes the implementation of a nationwide EHR is a challenging task due to the sheer size of the populations. Singapore has failed to reach its aim of rolling out an EHR system by November 2010 despite its relatively smaller population size. Therefore, we believe Australia will have difficulty in meeting its July 2012 target. Moreover, despite the government awarding a contract to Accenture to create the nationwide infrastructure for Australia's e-health, individual states are using different IT e-health solutions providers. Each platform's integration with the others will also need to be addressed. For example, in September 2011, Hewlett-Packard (HP) was awarded the contract to supply and maintain ICT to a portion of South Australia's yet-to-be-built Royal
Adelaide Hospital. The company stated that its system will integrate with the state government's health patient admission and medical records. Patients were also concerned about the security of their medical data. According to Newspoll research for Inquirer, 41% of respondents were not confident that their details would remain confidential under the new system, while 15% were not confident privacy would be maintained. In order to protect the identities of celebrities, politicians and victims of domestic violence, the ministry stated that they will be allowed to use pseudonyms when signing up for the system. However, the Australian Medical Association pointed out that such usage would 'undermine public confidence in security and privacy of e-health records'. The voluntary basis of the system, coupled with citizens' distrust, would potentially mean that a large group of the population will not be covered under the system, diminishing the purpose and utility of the scheme.
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Drug Monitoring
For many patients in emerging markets, ensuring the validity of the medication purchased can be a major concern. The advantage to a simple solution such as drug monitoring is that it uses the most basic mobile technology to provide a vital service. The relative low cost of sending an SMS message with the code for a particular medication in order to verify its validity makes drug monitoring a cheap means of getting genuine medication to customers. Adherence to such programs is likely to be increased if the SMS service is free of charge to the end user as, in many cases, cost is a considerable challenge. Such services are likely to be offered over mobile handsets and the wireless network as SMS use little bandwidth and the service is available on even the most basic of handsets. SMS-based services prove particularly popular in markets where mobile is still a relatively new service and incomes are low. Drug manufacturers or government health services can provide services allowing the population to verify their drugs and helping to boost brand loyalty and awareness. Telecare Matrix Findings In our assessment of markets for investment, we believe that markets such as Pakistan, Bangladesh, India, Tanzania, Iraq and Honduras characterised by low affordability levels for pharmaceuticals, low per-capita spending on healthcare and whose markets are plagued by counterfeit medicines demonstrate a demand of for drug monitoring systems. The question to ask once the demand for a telecare system has been identified is that is there a technological base present to support the system? Assessing the technological base present in these markets we believe that high mobile penetration figures and low ARPU levels will facilitate the roll out and success of the mobile-based initiative. On the contrary, we note that markets such as the US, Canada, Germany and the UK developed nations with secure medicine supply chain systems do not demonstrate a demand for drug monitoring systems. For full results of BMIs Telecare Matrix, please see Appendix.
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Countries with greatest opportunities for Drug Monitoring
Countries with good opportunities for Drug Monitoring
special report
Drug Monitoring: Case Studies

Ghana: HP To Work With mPedigree To Combat Counterfeits
In early 2010, it was announced that multinational technology provider Hewlett-Packard and Airtel (previously known as Zain) was partnering with Ghana based mPedigree - a company that connects GSM mobile networks in the West African Republic of Ghana to a central registry which stores information on medicine brands belonging to participant manufacturers, providing consumers with a service that verifies the authenticity of a medicine. BMI welcomes this new partnership as we believe that both HP and Airtel will provide mPedigree with the muscle to run a successful nationwide anticounterfeit effort. mPedigree So Far mPedigree was established in 2007 in response to the relatively weak performances of anti-counterfeit strategies adopted by the Ghanaian government. BMI notes this is a global problem that has been particularly difficult to address in Africa. Core reasons for this include poor infrastructure, unregulated customs and imports, the proliferation of illegal pharmacies and road-side medicine vendors, a lack of communication between health authorities, unclear allocation of responsibilities and resources among authorities and poor law enforcement where clear violations have been noted. Previous anti-counterfeiting efforts in Ghana comprised holographic or ultraviolet tags on existing medicine packaging and were being increasingly forged by illegal drug manufacturers. With no clear way for people to verify medicine safety in the country and a distinct lack of public awareness, mPedigree designed a cell-phone based interception strategy that involves a patient texting a code found on the medicine packaging to mPedigree, which will verify whether it is genuine or fake and send a reply within a few minutes. The same drug code cannot be sent twice, which we believe is a novel tactic in pre-empting the production of forged consignments. In 2007, mPedigree acquired a shortcode reverse-bill on all cell-phone networks in the country. The Ghanaian population is accustomed to texting shortcodes during television competition voting, reaching up to 250,000 texts per month. Following this, a pilot system involving bottles of acetaminophen, a painkilling syrup for children made by Ghana's Amponsah Efah Pharmaceutical, was tested in 2008. According to mPedigree, all 3,000 customers who bought the syrup sent in the code, highlighting the viability of the system. mPedigree, HP And Airtel BMI welcomes the focus on drugs used to treat malaria. According to our BoDD, 813,057 DALYs were lost to malaria in Ghana in 2009, accounting for 20% of the communicable disease DALYs lost that year. By 2030, the number of DALYs lost to malaria will decline to 570,742 and account for 15% of the non-communicable disease burden. However, we believe that efforts such as ensuring the country's citizens consume genuine drugs will help decrease the disease burden even more quickly.
Ghana: DALYs Lost To Malaria
4,500,000 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000
2005e 2007e 2009e 2011e 2013f 2015f 2017f 2019f 2021f 2023f 2025f 2027f 2029f
A High Burden
25 20 15 10 5 0
Malaria, DALYs Communicable, maternal, perinatal and nutritional conditions, DALYs Malaria DALYs As A % Of NC Disease DALYs RHS
e/f = estimate/forecast. DALYs = disability-adjusted life years. Source: BMIs Burden of Disease Database (BoDD)
Airtel and mPedigree plan to market the programme through posters in pharmacies, text messages and radio advertisements and drugmakers' own ads. Drugmakers will pay for the system through a subscription fee, which mPedigree will share with Airtel and HP.
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How Will Drugmakers Benefit? According to Bloomberg, multinational drugmaker GlaxoSmithKline (GSK) is in discussions with mPedigree regarding the feasibility of the technology. BMI believes that once set up, both local and multinational drugmakers will benefit from the mPedigree network as it will reduce the need for companies to invest in expensive in-house technologies to ensure their drugs can compete with counterfeits. Furthermore, HP plans to use the system to generate supply-chain information so drugmakers can locate their products - information that will prove useful to companies located in international markets. Ghana's leading import partners include the UK, India, Switzerland, Belgium and Denmark. Is The Service Viable? BMI believes that in a low-tech, resource-limited environment such as Ghana, mPedigree will work well as it uses a technology that millions of people have access to. Ghana's National Communications Authority (NCA) published mobile and fixed-line market data for Q411 that ostensibly show that the mobile market grew faster than BMI had expected. While the new data have been factored into our five-year forecasts, which have been raised slightly as a result, we again caution that operators' different subscriber accounting practices could mask significantly different market share information than the NCA's data would imply.
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Outpatient Care
The cost of managing long term conditions is often very high. Diseases such as diabetes require regular monitoring of the patient's condition while long term hospitalisation for chronic conditions puts a burden on already over-stretched healthcare systems. Many outpatient care solutions use the combination of small devices and data connectivity to ensure that monitoring a patient's status does not require constant personal attention. New devices can provide regular testing for key medical indicators such as blood pressure, automatically sending data to a central computer that will assess the patient's condition with limited input from the patient. Any changes can read against the patient's norms to alert the patient's doctors if help is needed. Connectivity and tech awareness will be two key drivers of outpatient care and two key hurdles to overcome for the proliferation of services. Many of the potential users of outpatient care may well be elderly with healthcare providers making use of new technology in order to keep patients in their homes, which is more cost effective. It is also preferable to most patients but full training to use the devices effectively would need to be undertaken for it to be fully effective. The challenge for companies in the outpatient care arena will be to design devices and software that can be used by patients that are less accustomed to new technology and also ensure that technology acts as an enhancement to their healthcare. Telecare Matrix Findings In our assessment of markets for investment, we believe that markets that are characterised by ageing populations, a high chronic disease burden and high government spending on healthcare demonstrate a demand for outpatient telecare services. This includes the ageing nations of the US, Japan, the UK, Germany, France and the Netherlands. Assessing the technological base present in these markets we believe that factors such as adequate access to power and populations access to and use of broadband will facilitate the roll out and success of the home healthcare initiative. On the contrary, we note that markets such as the emerging Latin American and African economies lack the infrastructure to support such high tech services. For full results of BMIs Telecare Matrix, please see Appendix.
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Countries with greatest opportunities for Outpatient Care
Countries with good opportunities for Outpatient Care
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Outpatient Care: Case Studies

Netherlands: Philips Electronics To Implement Telemedicine System
In November 2009, multinational company Philips Electronics signed a deal with the largest health insurer in the Netherlands, Achmea (which has approximately a 30% share of the Dutch health insurance market), to focus on a home healthcare project that will help doctors monitor patients health remotely and equip them with devices to better manage conditions such as respiratory diseases at home. Home monitoring is at the heart of Philipss home healthcare unit.
Netherlands Healthcare Expenditure Trends
100 90 80 70 60 50 40 30 20 10 0
2011e 2009 2010 2012f 2013f 2014f 2015f 2016f
The countrys population over the age of 70 years old is expected to increase from 6.4% of the total population in 2008 to 11.4% by 2030. In 2011, health expenditure reached EUR56.8bn (US$83.6bn), demonstrating 6.3% growth on the previous year. In 2011, it is forecast to decline to EUR56.1bn (US$79.0bn) as a result of the economic downturn, before rising again to EUR58.4bn (US$80.0bn) by 2010. BMI calculates a 2011-2016 compound annual growth rate (CAGR) of 5.3% in local currency terms and 2.82% in US dollar terms. Health expenditure as a percentage of GDP was 10.2% in 2011 and is expected to be 9.7% by 2016. Public sector health expenditure reached EUR50.4bn (US$70.5bn) in 2011, accounting for over 80% of total health expenditure. BMI calculates that in 2012, government spending on health will reach EUR51.5bn (US$69bn). By 2016, it is expected that the governments contribution to healthcare will decline to 74.7%, reaching EUR57.3bn (US$71.6bn) - a 2012-2016 CAGR of 2.6% in local currency terms. BMI believes the decline in public sector health expenditure as a percentage of total health expenditure is a trend that mirrors other countries in the region and comes as a result of government efforts to contain costs. We therefore believe that the implementation of cost-saving technologies to ease the burden placed on the public healthcare budget will be welcomed by the government.
Growth In Healthcare Costs
14 12 10 8 6 4 2 0
Health expenditure, (US$bn) (LHS) Health expenditure, (EURbn) (LHS) Health expenditure, % of GDP (RHS) Population, 60-69 yrs, % total (RHS) Population, 70+, % total (RHS)
e/f = BMI estimate/forecast. Source: World Health Organization (WHO), European Federation of Pharmaceutical Industries and Associations (EFPIA), Organisation for Economic Cooperation and Development (OECD), BMI research
BMI believes that use of technology to provide medical care remotely is an important tool that can facilitate the improved and more efficient provision of health services. In-patient costs account for a large proportion of healthcare expenditure, therefore a reduction in the number of patients that receive on-site hospital care can lead to savings that would be welcomed by insurance companies as well as the countrys national health service, the Verplicht Ziekenfonds Verzekerd. Furthermore, we believe such tools can help chronically ill and older people to be treated for longer at home rather than in hospitals or care homes, a benefit that will be welcomed by countrys rapidly ageing population.
USA: Telecare Finds Its Algorithm

Using electronic devices and software to monitor patients will bring tangible benefits to patients and healthcare providers. A pilot scheme in St Louis aims to regularly measure vital signs from at-risk patients and inform nurses if there is any deterioration in the patients condition. Telecare projects such as these are encouraging in BMIs opinion, and we expect the use of IT and telecoms services to become increasingly integral to healthcare. The new network will create a clinical warning system,
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which monitors a patients vital signs and calls nurses on a mobile phone if there is deterioration in the patients condition. One of the major benefits is cutting time needed for nurses to check heart rate or blood oxygenation freeing up time to be spent on other areas. Furthermore, the rate of checking patients can be dramatically increased, improving the chances of seeing deterioration in the patients condition before it becomes life threatening and updating the clients electronic medical records automatically. With an ageing population, the burden on US healthcare increases each year. Lowering costs is vital to enable healthcare systems to provide care to the growing number of elderly patients. According to BMIs BoDD, disability-adjusted life years data show that, in 2010, people over the age of 60 accounted for 31% of the countrys healthcare burden; by 2030 this will be more than 40%. In the trial in St Louis, patients wore a pulse oximeter to monitor their condition. This has the advantage of allowing patients that are able to move around not to be hooked up to monitors and machines. The pilot could, in theory, be expanded to in-home care, further reducing the burden on hospitals and available hospital beds. The burgeoning telecare industry is full of trials of this type that could provide considerable benefits if scaled up to provide data for all patients. Scalability is key to
Telecare Will Need Scalability To Bring Benefits To Industry
US Burden Of Disease
42,000,000 41,000,000 40,000,000 39,000,000 38,000,000 37,000,000 36,000,000 35,000,000
2005e 2010e 2015f 2020f 2025f 2030f
making these projects viable for major rollouts. The software receiving the data uses an algorithm to highlight changes in received data that could indicate a problem with a patient. The data received could be integrated with patients electronic medical records, creating an individual measure for all patients and improving the reliability of the system, although this is part of the next generation pilot. The service could be taken further, with apps on smartphones able to monitor patients with long-term health problems outside of hospitals. Network reliability is also extremely important for telecare projects to work. Using its own network avoids the issue of possible failures in the hospitals Wi-Fi network or a spike in data usage that could prevent patient data being delivered. The St Louis project built its own mesh network - rather than relying on the hospitals Wi-Fi - which can be deployed on demand and requires less power and no cabling. Sensors were programmed to only switch on the radio connection when data were to be transmitted, conserving power. BMI believes a project such as this provides potential for software companies and medical device manufacturers to create new methods of monitoring patients. The trial in St Louis was run by a computer scientist at Washington University in the city, but could have commercial potential for companies already involved in medical software provision or those hoping to get into these markets. Further, network infrastructure providers that can create small low-power networks could also benefit from the success of such projects becoming standard practice in the healthcare industry.
30 25 20 15 10 5 0
34,000,000
All Causes, DALYs LHS All diseases and injuries, 60-69 yrs, total, DALYs, % of total RHS All diseases and injuries, 70+ yrs, total, DALYs, % of total RHS
e/f = estimate/forecast. DALYs = disability-adjusted life years. Source: BMIs Burden of Disease Database (BoDD)
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Self Care
In the world of apps and value-added services (VAS) on mobiles, developed markets clearly stand above their emerging market rivals. Customers willing and accustomed to spending on their communications services, as well as being, for the most part, regular users of technology are the most likely to adopt self care technologies. Among the stand out countries for self care are markets in the G7, developed Asian markets such as South Korea and Australia and Western European markets like the Netherlands and Spain. While BMIs analysis shows that self care is a largely developed market phenomenon, the growing consumer story in emerging markets cannot be ignored. Brazil, Russia, Turkey and Poland all ranked highly in our self care matrix as the markets report relatively strong spending on mobile services as well as a high ICT Development Index score. However, BMI cautions that self care services in these latter markets are likely to have most success on a smaller scale, concentrating on major cities where the potential consumer will be wealthier and more tech-savvy; mobile and broadband networks in these locations will also be strongest. Nevertheless, there will be selected demand in these countries and other markets with similar profiles. The burden of non-communicable diseases is also higher in developed markets, making self care a product of greater potential in these markets. Patient diaries saved on smartphones or tablets alongside drug information and consistent access to services will become more common in these markets, helping reduce healthcare costs and providing opportunities for app developers and telecoms companies to capture the demand for these services. Telecare Matrix Findings Developed markets such as Japan, Western Europe and North America offer the greatest opportunities for companies looking to benefit from the expected growth in self care services. Largely these services will be consumer driven, and so BMI expects take-up to be highest in markets where subscribers are used to spending on their mobiles for a variety of services. For many consumers, medical apps will simply be another function of using their smartphones. Emerging markets Russia and Brazil score well in our matrix as both show high private final consumption as well as high drug spending. Nevertheless, BMI believes there are only select areas within these markets that will see self care really take off. Major cities such as Moscow and St Petersburg in Russia as well as Brazils So Paulo, Rio de Janiero and Curitiba have large affluent populations whose spending and telecoms usage habits reflect those seen in more developed markets. However, we expect widespread use of self care services in these markets to take much longer to proliferate. For full results of BMIs Telecare Matrix, please see Appendix.
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Countries with greatest opportunities for Self Care
Countries with good opportunities for Self Care
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Self Care: Case Studies

Iraq: AsiaCell Launches mhealth Services As ValueAdded Strategy Improves Its Competitiveness
AsiaCell, Iraqs second biggest mobile operator by subscribers, has launched m-health content and SMS services for its prepaid and postpaid customers, according to a statement by the operator. The service offers subscribers useful information on health practices and updates and specific health topics of their choice. The m-health service is the latest in a growing number of value-added services (VAS) introduced by AsiaCell and is indicative of a new strategy that BMI believes could give the operator a significant competitive edge in the Iraqi mobile market. AsiaCells daily SMS service includes topics covering women, men and childrens health; dieting; mental health; and diabetes, while the m-health downloads offers subscribers weekly updates on a wide range of topics from spots and fitness to mental health and emergency medicine. AsiaCell users are able to subscribe to the services by sending messages to toll-free short codes. Subscriptions for the SMS services are priced at IQD2,500 (US$2.1) a month, while the content download service costs IQD2,000 (US$1.7) a month.
Flat Market Shares Indicate Lack Of Service Differentiation
Iraq Mobile Operators By Market Share, (%)
60 50 40 30 Zain AsiaCell Korek 20 10 0
BMI agrees with AsiaCells view of the positive contribution of the m-health services to raising health awareness and promoting a healthy lifestyle among Iraqis. However, we also emphasise its potential impact on the operators performance in the mobile market. AsiaCell competes with Zain Iraq and Korek Telecom, both backed by major international operators, in the Iraqi mobile market. Subscriber figures for the market show the market shares of the three operators remained flat in the three years to 2011. This is indicative of limited differentiation in the services offered by the operators. However, with the market approaching maturity (BMI forecasts mobile penetration to reach 90% by 2016), we believe service differentiation will feature more prominently in competition between the operators. There are few opportunities for service differentiation in Iraq considering the lack of 3G network services because of the governments delay in allocating spectrum and licences. However, while market leader Zain appears to have hinged its value-added offerings on the rollout of 3G services, AsiaCell has demonstrated a strategy to develop attractive offers based on its 2G network infrastructure pending the allocation of licences for advanced data services. Prior to launching the mhealth service, AsiaCell launched the SMS to Facebook service, which allows its prepaid and postpaid subscribers to access Facebook directly from their mobile phones for a monthly subscription of IQD2,500. The operator also introduced a voice chat service, dubbed Allo Chat, which allows subscribers to voice chat with one another on the go for IQD25 a minute. BMI welcomes AsiaCells strategy considering its impact on the operators competitiveness. An analysis of Zain and AsiaCells financial and operational indicators shows an outperformance by AsiaCell, indicating positive results from the operators value-added strategy despite the limitations of its 2G network. AsiaCell continues to report considerably higher ARPUs (US$15.1 in Q111) than Zain (US$11 in Q111) despite having fewer subscribers. AsiaCells impressive subscriber
Jul-09
Jul-10
Jan-10
Nov-09
Sep-09
Sep-10
Nov-10
Jan-11
Jul-11
May-09
May-10
Source: Operators, BMI
May-11
Sep-11
Mar-09
Mar-10
Mar-11
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growth and ARPU, which are reflective of its VAS offerings, have resulted in strong revenue growth during the past two years.
AsiaCell Value-Added Strategy Key To Outperformance
AsiaCell Vs Zain Revenue (US$mn)
420 400 380 360 340 320 300 AsiaCell Zain
Jul-09 Jul-10 Jan-10 Nov-09 Sep-09 Sep-10 Nov-10 Jan-11 Jul-11 May-09 May-10 May-11 Sep-11 Mar-09 Mar-10 Mar-11
280 260
Source: Operators
AsiaCell Vs Zain ARPU (US$)

18 AsiaCell Zain 16 14 12 10 8 6 4 2
Dec-09 Sep-09 Sep-10 Dec-10 Jun-09 Jun-10 Mar-09 Mar-10 Mar-11 Jun-11
AsiaCell Pulls Ahead
Source: Operators
With the introduction of m-health services, which are likely to appeal to a considerable proportion of mobile phone users, BMI believes AsiaCells outperformance in the Iraqi mobile market will continue, at least in the short-to-medium term.
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Disease Surveillance
Tracking the spread of communicable diseases can be vital in ensuring treatment is deployed effectively and stopping an epidemic. Complicated technology does not have to be deployed for disease surveillance to work, with simple SMS-based alternatives easy to use and quick to deploy. Much like drug monitoring, disease surveillance takes advantage of the most basic technology that is available on all handsets. Short codes can be sent via SMS to a central point, allowing quick analysis of patient conditions, spread of the disease and symptoms allowing healthcare providers to distribute the most important care to the areas that need it best. Markets that stand to benefit from these services include those with a high burden of communicable diseases, as well as large rural populations, where reaching the most important patients is more difficult. Providing healthcare workers with devices could potentially be expensive, but older handsets and basic devices should have the capacity to make rudimentary services work. More sophisticated apps could be created if the need arose in developed markets where smartphone usage is higher, but BMI believes emerging markets have the greatest demand for these services. Telecare Matrix Findings Markets that stand to benefit from these services include those with a high burden of communicable diseases, as well as large rural populations, where reaching the most important patients is more difficult. BMI highlights markets such as Russia, the Philippines, Peru, India and Kenya as offering strong opportunities for disease surveillance services. Additionally we note that factors such as high mobile penetration rates (present in the identified markets) are vital for the success of this mobile based telecare initiative. For full results of BMIs Telecare Matrix, please see Appendix.
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Markets with greatest opportunities for Health Monitoring
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Disease Surveillance: Case Studies

Kenya: Government And HP Launch Mobile Project To Improve Disease Management
We welcome the Kenyan government's decision to utilise mobile technology in the detection and management of disease. There is strong potential for rapid take-up of the m-health Integrated Disease Surveillance and Response service in Kenya, considering the growing use of mobile phones in the country and the success of other mobile crossovers such as m-banking. However, poor network coverage to rural areas will limit the reach of the services to urban and semi-urban areas in the short term. The Kenyan government has launched an Integrated Disease Surveillance and Response (IDSR) system in partnership with Hewlett Packard (HP) East Africa and the Clinton Health Access Initiative (CHAI), enabling health workers to detect and manage disease outbreaks through smartphones. HP donated 250 Palm Pre-Smartphones and the CHAI has provided US$1mn in funding for the design and purchase of the hardware and mobile handsets to run the system. BMI welcomes the government's decision to utilise mobile technology in the detection and management of disease. Health workers will be able to collect and transmit real-time information regarding disease occurrence at a local level (including context-rich data through pictures, video, audio, GPS coordinates, qualitative and quantitative information regarding the case) and share the data with organisations like the National Aids and Sexually Transmitted Infections Control Programme (NASCOP), allowing health officials to promptly analyse data and identify trends - launching prevention and cure schemes. Members of the public will also be able to report on health events. Will Improve The Identification And Management Of Disease We believe that the real time transmission of disease data is vital. According to BMI's BoDD, which records the number of DALYs that are lost as a result of having or having had a disease, the number of DALYs lost to all disease in Kenya is to increase from 12,823,021 in 2009 to 16,900,141 in 2030. The number of DALYs lost to non-communicable diseases will rise from 2,550,604 in 2009 to 4,116,757 by 2030. Additionally, according to the BoDD, the number of DALYs lost to communicable diseases will increase from 9,013,730 in 2009 to 10,888,077 by 2030. The country's large and growing infectious disease burden emphasises the requirement for improved communication regarding disease outbreaks in order to launch swift treatment programmes.
High Infectious Disease Burden
DALYs Lost In Kenya
16,000,000 14,000,000 12,000,000 10,000,000 8,000,000 6,000,000 4,000,000 2,000,000
2005 2006 2007 2008 2009 2010 2011f 2012f 2013f 2014f 2015f 2016f 2017f 2018f 2019f 2020f 2021f 2022f 2023f 2024f 2025f 2026f 2027f 2028f 2029f 2030f
DALYs lost to communicable diseases DALYs lost to non-communicable diseases

f = forecast. DALYs = disability-adjusted life years. Source: BMIs Burden of Disease Database (BoDD).
Will Enable Improved Medical Care Provision To Rural Kenya The quality of healthcare infrastructure in Kenya suffers major disparities between regions. Only 30% of the rural population have access to health facilities within 4km of their home, compared with 70% of the urban population. Residents of the capital Nairobi visit hospitals an average of 17.7 times a year, whereas in coastal provinces the average is just 7.8 visits a year. This regional disparity is unsurprising given the uneven distribution of health infrastructure. It is estimated that 25% of households live more than 8km from any form of health facility, while drug allocation favours larger hospitals. District hospitals are allocated 38% of the Ministry of Health's drug procurement budget, provincial hospitals 18% and rural health facilities 18%.
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The Kenyan government is to invest KES25bn (US$324mn) in improving the provision of healthcare to the country's rural population and we believe that the use of IDSR will support the government's plans as it will enable the increased transmission of disease data from rural locations - therefore helping to identify treatment requirements and helping to direct the allocation of relevant resources. Will Overcome Barriers Of Staff Shortages Like many other African countries, Kenya is suffering from inadequate numbers of healthcare workers, especially in less accessible areas. Kenya currently has around 5,000 doctors, which equates to around one doctor per 6,000 people. Highlighting the issue, in October 2009 the National Nurses Association said that Kenya lags behind the recommended ratio of one nurse per thousand patients and requires about 24,000 nurses to tackle the shortage. Furthermore, in June 2011 Chris Rakoum, chief nursing officer at the Kenyan Ministry of Health, stated that the country's public and private hospitals and dispensaries are understaffed by up to 66,000 health workers. Under a stimulus programme, the ministry of health has
Large Rural Population
Kenya Population Forecast
50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000
1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012f 2014f 2016f
in the healthcare sector - allowing the technology to create efficiencies and improve patient outcomes. IDRS allows for real time transmission of alerts by the health workers for reports which previously took up to two days, delays which we believe are escalated by the lack of human resource in the sector.
On The Rise
Kenya Mobile Subscribers and Mobile penetration

30,000 25,000 20,000 15,000 30 10,000 5,000 0 20 10 0 Total Mobile Subscribers LHS Market Penetration (%) RHS 70 60 50 40
Jun-08
Jun-09
Jun-10
Dec-07
Dec-08
Dec-09
Sep-08
Sep-09
Sep-10
Dec-10
Jun-11
Source: BMI, CCK
80 Population ('000) (LHS) Rural Population, % of total (RHS) 70 60 50 40 30 20 10 0
The Benefits Are Clear But Will The IDRS Be Successful In Its Goals? The success of m-banking can be replicated in m-health. Phone users in Kenya have become used to services provided over mobile phones and are likely to be receptive to m-health initiatives. The ongoing price war has made mobile services more affordable. This means that projects such as the IDRS can utilise mobile networks to launch value added services for the healthcare sector. However, There Are Barriers To Success Mobile services are concentrated in urban and semiurban areas. Most rural areas lack adequate network coverage. Additionally, the fierce price war in the mobile market is having a negative impact on operators' profitability and, consequently, ability to finance rural expansion projects. This means that many rural areas are likely to remain underserved for longer than anticipated as network infrastructure build out in those areas is delayed.
f = BMI forecast. Source: BMI
been authorised to recruit 4,200 nurses, 20 for each of the 210 constituencies. 3,000 nurses have been hired as part of a public healthcare reform programme (itself part of the Economic Stimulus Programme) in Kenya, expected to cost KES4bn (US$0.048bn). BMI believes that the IDRS will work to address the lack of human resources
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Company Focus
Europe & Latin America: Telefnica Launches eHealth Initiative
Telefnica has announced the launch of a global ehealth initiative. The Spanish incumbent has a significant presence across Europe through Telefnica O2, and has substantial investments in Latin America. The unit will look into all aspects of e-health, as Telefnica joins such companies as Cisco and Intel in moving to assume a commanding position in what they expect to be a significant industry in future. Telefnica's initiative will look at the systems integration side of the story, as healthcare providers around the world are trying to adapt to growing pressures on services, and will look to find cost- and time-saving efficiencies. The operator is also looking at ways in which telecoms services can be used to decentralise clinical processes and allow existing service to be delivered more efficiently and effectively. The full potential of telemedicine and telecare has yet to be realised, and the research and development that companies like Telefnica do, as well as the relationships they build with healthcare providers, will probably shape the future of this area. E-health and telemedicine initiatives are growing in scope and number around the world, but in general the industry is still in its early stages. However, it is already a well established practice in many developed countries to use phone services and internet sites to help reduce the burden on health services by reducing the number of visits to doctors' offices and hospitals. In many emerging markets mobile checking services for drug box serial numbers are used to help eliminate fake drugs from the market. Other uses of telecoms services in healthcare that are starting to find their way into health service practices include smart pill bottles, which have been shown to increase the rate of compliance among patients who needs to take regular medication for serious and chronic illnesses. Non-compliance on drug regimens costs health service worldwide significant amounts every year, and if smart pill bottles become standard practice the problem could be significantly improved. None of these initiatives is an immediate revenue winner for operators, but Telefnica has the right idea, in that starting early and building relationships will likely be the best way to establish a significant presence in the e-health landscape, with long-term contracts that eventually introduce new revenue streams.
Malaysia: Mobile Healthcare Growth Potential Attracts REDtone

Malaysian broadband provider REDtone International announced that it expects its mobile health venture with General Electric Malaysia to have a positive effect on the provider's financial performance within the next three years. Telecoms operators are embracing mobile value-added services (VAS), which provide alternative revenue streams and enable companies to differentiate themselves from competitors. The telecoms-healthcare crossover is a budding trend and has growth potential in Asia-Pacific's developed and emerging markets. However, government intervention and coordination may be required to give the nascent industry a push. Under the healthcare component of Malaysian government's national Economic Transformation Programme, General Electric Malaysia will team up with local partners such as REDtone to develop a MYR30mn (US$9.9mn) diagnostic services nexus teleradiology hub. REDtone will provide fixed and mobile broadband connectivity to distribute the workload of radiology and pathology-related diagnostic services between 130 public and 210 private hospitals in the country. Besides lowering healthcare costs, the initiative aims to facilitate workflow and data management, which in turn boosts the quality and accessibility of healthcare services. Meanwhile, mobile operators in the Middle East and North Africa (MENA) region have launched a variety of
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mobile healthcare (m-health) VAS in 2011 such as Mobile Baby by Great Connection, Orascom Telecom and Mobinil amid strong competition and declining revenues. M-health is a potentially lucrative VAS that services an immediate need, especially in underserved areas across the Asia-Pacific region. Bangladesh's Grameenphone has highlighted the importance of m-health in countries such as Bangladesh where doctors and nurses account for only 0.03% and 0.014% of the population of 156mn respectively. The lack of accessibility to traditional forms of medical services is a prevalent theme in Asia-Pacific's emerging markets such as India, China and Sri Lanka. Consequently, telecoms companies play a pivotal role in extending m-health's reach given ongoing rural expansion plans to increase telecoms services' coverage. Companies such as US-based Entra Health Systems partnered with Swedish handset maker Doro in February 2011 to offer Entra Health's MyGlucoHealth (blood glucose monitoring) service on senior-friendly mobile devices. Moreover, a growing number of software developers are creating mhealth mobile applications to capitalise on the increasing smartphone penetration rate. However, a fully-functioning mhealth ecosystem requires the cooperation of stakeholders such as software developers, insurance companies, pharmaceutical firms, healthcare providers and regulators. This is slightly more complex compared to relatively straightforward VAS like telematics or mobile banking and payment services, and therefore hindering m-health's development. We therefore welcome the Malaysian government's initiative to promote the m-health market, which will play a part in generating MYR540mn (US$177.9mn) for the economy by 2020.
give private healthcare providers significant business expansion and revenue-earning opportunities, in addition to creating opportunities for the implementation of non-traditional healthcare delivery systems such as telecare for outpatient care - especially as the government tries to provide healthcare services while containing costs. The proportion of New Zealands pensionable population as a percentage of the total increased from 18.1% in 2005 to 19.6% in 2010, and by 2020 it is forecast that this will increase to 25.4%. According to the Statistics New Zealand, the percentage of the population aged over 65 will account for a quarter of the countrys population by 2030, up from 12% in 2005. The number of people above the age of 65 is projected to increase from 0.5mn in 2005 to 1.33mn by 2051, with the largest increases in the age group occurring in the 2020s and 2030s, when the large birth cohorts of the 1950s and 1960s move into this age range.
New Zealand Pharmaceuticals & Healthcare Market Forecast (US$bn)
1.2 18 16 14 12 10 8 6 4 Pharmaceutical sales LHS Health expendituren RHS
2009 2010 2011e 2012f 2013f 2014f 2015f 2016f
A Growing Demand For Pharmaceuticals & Healthcare
1.0
0.8
0.6
0.4
0.2
2 0
0.0
New Zealand: Bupa Adopts Telecare

The expected growth of New Zealands ageing population over the next 50 years will have an unprecedented impact on the demand for healthcare. The elderly require more medical check-ups and care than young people as a result of the increased prevalence of chronic disease with age, therefore they consume a disproportionately large share of healthcare services. Such robust demand for services over the coming years has the potential to
e/f = BMI estimate/forecast. Source:Pharmaceutical Management Agency (PHARMAC), IMS Health, World Health Organisation (WHO), BMI
Ageing Population = Rise In Chronic Diseases According to BMIs BoDD, chronic diseases will place a greater burden on New Zealands healthcare services as the countrys population ages. Therefore, while the number of DALYs lost to all diseases is forecast to drop, DALYs lost to non-communicable diseases as a percentage of all diseases are expected to increase from 86.74% in 2010 to 89.63% by 2030. The population aged over 70 accounted for 24.61% of the DALYs lost
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to non-communicable diseases in New Zealand in 2010, a figure that is forecast to increase to 36.69% by 2030. According to the Ministry of Health, cardiovascular disease is the leading cause of death, accounting for 40% of all deaths annually. Obesity, diabetes and mental health issues are prevalent in New Zealand, especially among Pacific Islanders and Mori people. Ageing Population = A Growing Demand For Pharmaceuticals And Healthcare Healthcare expenditure in New Zealand is forecast to increase from NZD19.36bn (US$15.31bn) in 2011 to NZD20.23bn (US$14.94bn) in 2012. Annual per capita spending on medical services was US$3,468 in 2011, which is above the Asia Pacific average, and is forecast to rise to US$3,495 by 2016. The government accounts for the majority of healthcare spending (82% in 2011) and expenditure as a percentage of GDP is 9.5%. By 2016, yearly healthcare spending is forecast to rise to NZD23.37bn (US$16.24bn). Ageing Population = Increased Pressure On Public Health Spending As New Zealand population ages, the government will continue to face growing healthcare costs, especially as the increasing number of elderly people among its population means the number of working-age citizens contributing to social service funds will decline. Highlighting this, the ageing profile ratio for New Zealand (the ratio of the population aged under 15 to that aged over 65) is expected to drop from 1.8 in 2005 to 1.3 by 2020. Opportunities In The Private Sector Such robust demand for healthcare services, as well as the need to contain costs and the burden of healthcare on New Zealands healthcare services over the coming years, has the potential to present private healthcare providers with significant revenue-earning opportunities. These can be realised through the direct provision of care devices to the growing elderly population and increased cooperation with the government to provide care, moving patients out of hospitals and back to their homes or to assisted living communities.
Recognising that New Zealands traditional healthcare model will not be economically sustainable and will not be able to meet the increased demand and expectations of the countrys ageing population, multinational insurance provider Bupa has rolled out a telecare system (personal medical alarms) to enable healthcare delivery to the elderly.
Ageing Population Means...
New Zealand Population Data
4.65 4.60 4.55 4.50 4.45 4.40 4.35 4.30 4.25 4.20
2009 2010 2011e 2012f 2013f 2014f 2015f 2016f 2016f
15.5 15.0 14.5 14.0 13.5 13.0 12.5 12.0 11.5
4.15
Population (mn) LHS Pensionable population, % of total RHS

e/f = BMI estimate/forecast. Source: World Bank Data, BMI
...Increased Pressure On The Government

New Zealand Ageing Profile Ratio *
1.65 1.60 1.55 1.50 1.45 1.40 1.35 1.30 1.25
2009 2010 2011e 2012f 2013f 2014f 2015f
1.20
e/f = BMI estimate/forecast. Source: World Bank Data, BMI * Ratio of population under 15 to that over 65
This entails the use of technology to provide medical care remotely, enabling doctors to monitor patients health and equip them with devices to better manage conditions such as respiratory diseases at home. Moreover, chronically ill and older patients can be treated for longer at home rather than in hospitals or care homes. This also includes communication between health services and individuals in order to ensure treatment compliance and provide appointment reminders.
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As a Work and Income-accredited supplier of monitored medical alarm systems, a government allowance may pay for a Bupa Medical Alarm. Telecare, Bupas personal alarm network, is used by 12,000 people in New Zealand and includes: A pressure mat sensor that can be placed in a range of locations, such as unobtrusively under another mat, in order to indicate (for dementia patients) entry into an unsafe area or to indicate when the person has left their chair and is moving about. The pressure on the mat triggers a pager worn by the carer or can be linked to Bupas 24-hour monitoring centre. A bed occupancy sensor that can alert a carer, either by pager or a pillow shaker, when a patient has been absent from the bed for more than a set time. Dementia patients do not perceive time in the usual way so may not sleep all night. A property exit sensor that is triggered by the opening of a door can be used to indicate that a dementia patient is leaving the house, allowing quick action to be taken to locate them and return them safely. An automatic fall alert detector that sends the Bupa monitoring centre a signal if a patient falls, which is useful for a wide range of conditions that predispose people to falling. A movement alert detector that enables the Bupa monitoring centre to send help if there is no movement at a particular time. A medicine reminder programmed into an alarm that provides a verbal medication reminder.
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Country Focus: BRICs

China: Telecare Market Has Plenty Of Potential
The world's largest mobile market by subscribers offers a wealth of opportunities for providers of new services over telecoms networks. It is also one of the world's most attractive emerging pharmaceuticals markets. Nonetheless, becoming a player in China's emerging telecare market can be difficult because international investment in telecoms companies is restricted and the government retains control of the telecoms market's direction. However, operators and network infrastructure vendors have been innovative when catering to the unique demands of the Chinese market.
Growth Will Continue Strong
Mobile Market Subscriber Forecasts
1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000
2009 2010 2011 2012f 2013f 2014f 2015f 2016f
BMI believes telecare services, in combination with growing ownership and awareness of telecoms services, will create opportunities for healthcare providers and telecoms operators. While data suggests there is still ample room for growth in rural areas, the high penetration rates in towns and cities present a different opportunities. Mobile Growth Remains Strong China reported 63% mobile penetration at the end of 2010, with 859mn mobile connections This increased by 61.5mn in H111, beaten only by India's 99.5mn new subscribers. China's growth in the first half of 2011 was 7.2%, slower than the equivalent period of 2010, but the number of new connections in the market continues to grow. Despite differences in technology across the market, operators invested heavily in gaining new subscribers and boosting 3G subscriber numbers.
Regional Disparities Create Challenges For Telecare Growth
Regional Mobile Penetration Rates (%), June 2011
200
120 100 80 60 40 20 0
180 160 140 120 100 80 60 40 20

Zhejiang Shanghai Chongqing Sichuan Beijing Guangdong Hubei
Mobile Phone Subscribers ('000) Mobile Phone Subscribers Per 100 Inhabitants RHS
f = BMI forecast. Source: BMI, Operators, MIIT
Basic Services Need To Cater To Subscribers

Forecasts By Technology
1,600,000 2G Subscribers 3G Subscribers 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000
2009 2010 2011
Source: MIIT
2012f
2013f
2014f
2015f
f = BMI forecast. Source: BMI, Operators, MIIT
2016f
While 3G subscriber growth is expected to be strong, we expect the market will retain more than 1mn 2G subscribers at the end of 2016, accounting for more than 60% of the overall market. This has strong implications for the potential roll-out of telecare, as many services targeted at individual use - such as self care or outpatient care will need to take into account the potential limitations of the networks and handsets owned by these patients. It could also be a key factor when designing services
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for healthcare professionals to use in more remote areas. Data from the Ministry of Communications show the disparity between urban and rural subscribers, with penetration at more than 100% in major cities such as Shanghai and Beijing. Meanwhile, more rural areas of the country report considerably lower rates. East China has the highest rates, while Central and West China has much reduced penetration rates. About 70% of China's population lives in rural areas. While this provides opportunities for mobile operators to grow their subscriber bases, it may prove restrictive when rolling out some telecare services. And M-Health Projects Are Expanding Self Care The growing burden of diabetes on the Chinese medical system has led to a group of researchers from universities and medical centres working with Microsoft to develop a smartphone-based support system for elderly diabetics. The handsets will receive recommendations and guidelines relating to physical activity, glucose and blood pressure monitoring, weigh and diet. The software, designed with the end users in mind, will be available free for users and works on Microsoft's Windows Mobile operating system. Training will be needed for patients who are not used to operating smartphones or PDAs and the data collected will be used to track patient welfare and trends. Disease Surveillance Following the May 2008 earthquake in the Sichuan province, tracking epidemic-prone diseases became crucial to post-disaster care. Prior to the earthquake broadband connections were used to track infectious diseases, but these networks were damaged in the earthquake. The Chinese Center for Disease Control and Prevention created a new system using mobile phones. Using basic SMS services, trained personnel sent data covering 16 categories of information regarding each case using encrypted messages to the national database. It took approximately 2-3 minutes per case to input data, allowing for rapid reporting and a real-time view of the situation facing healthcare professionals.
Broadband Continues To Grow Like the mobile market, broadband services are controlled by just three companies. However, connections are vastly lower than the mobile network and also concentrated in urban areas. However, positive developments are taking place. For example the industry invested CNY4.3trn (US$674bn) on internet infrastructure between 1997 and 2009. Growing interest in mobile broadband services will expand the reach of networks.
Growth In Connections To Provide Better Care
China Internet And Broadband Forecasts (000)
600,000 500,000 400,000 300,000 200,000 100,000 0
300,000 250,000 200,000 150,000 100,000 50,000 0
2009
2010
2011
2012f
2013f
2014f
2015f
Internet Users
Broadband Subscribers RHS
f = BMI forecast. Source: Operator results, MIIT, CNNIC
The ubiquity of internet services and usage allows for a number of new projects to be offered. BMI sees particular potential for transferring images on the internet to central hospitals that have the expertise to diagnose. This reduces the need for specialist equipment and generates vast improvements to healthcare in rural areas. Allowing New Levels Of Healthcare To Reach The Right People New Rural Cooperative Medical System (NRMCS) The NRMCS is available for rural farmers to have access to healthcare professionals. In 2009 China Mobile signed an agreement with the Guizhou Health Bureau to build an information management system. This included the implementation of new payment systems and reduced the need for patients to travel because of minor illnesses. Future developments will include the maintenance of healthcare records, emergency commands and disease control. -
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Health Monitoring Telecoms and medical equipment manufacturer Siemens is working with the Chinese government to create Siemens Rural Centers of Medical Excellence providing the medical devices needed to diagnose conditions. Meanwhile, images and results are sent through broadband connections to larger hospitals in major cities so doctors in the city and countryside can diagnose conditions. Improvements in equipment and the personnel diagnosing the images results in significant benefits to healthcare provision across rural areas. Where will growth come from? IT Innovation China's IT market continues to grow at an exceptional rate and BMI expects developments in healthcare to be one of the driving forces behind the IT industry's growth. Commitments to modernising healthcare is providing many opportunities for IT and consumer electronics providers to expand. The large population allows for local developers to provide products and services specifically for China. Locally-produced handsets and software create new opportunities for telecare provision.
Telecare Provides Opportunities For Chinas Healthcare Future
China Healthcare Expenditure And Pharmaceuticals Sales
medical services was US$215 in 2011, which is above the regional average of US$135 and is expected to rise to US$332 by 2016. The government accounts for just under half the spending and expenditure as a percentage of GDP was 4.1% in 2011. By 2016 yearly healthcare spending will rise to CNY2.919trn (US$456bn). Chinas growing and ageing population is another reason for the rapid increase in healthcare spending and is driving the need for innovation in telecare. Operators And Vendors Telecoms companies will benefit from providing the connections, which will allow new services to flourish. The industry already uses home-grown technology platforms and the potential for China-focused devices and software that specifically cater to local needs is great. Government-owned operators are unlikely to face difficulties in getting involved with telecare projects. International operators will need to work with these providers to reach customers. While foreign equipment manufacturers have already been involved in projects, BMI expects China's ZTE and Huawei to benefit from contracts for network expansion and manufacturing devices.
500 450 400 350 300 250 200 150 100 50

2009 2010 2011 2012f 2013f 2014f 2015f 2016f
35 30 25 20 15 10 5 0
Health expenditure, US$bn LHS Pharmaceutical sales, % of healthcare expenditure

f = BMI forecast. Source: World Health Organization (WHO), BMI
Healthcare Industry Healthcare spending in China is forecast to increase from CNY1.876trn (US$290bn) in 2011 to CNY2.073trn (US$324bn) in 2012. Due to the strengthening yuan, this results in growth of 10.56% in local currency terms and 11.6% in US dollar terms. Annual per capita spending on
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Russia: Telecare Creates Opportunities

Russia's vast size creates a number of opportunities for new technologies to improve the provision of services. With long distances between towns and cities, there is a disparity in care between urban dwellers and rural communities. Telecare offers several opportunities to improve the healthcare of those unable to access services easily. In Russia, telecare is a growing phenomenon, helping to provide better healthcare in more remote areas as well as lower the cost of healthcare in general. Growing availability of mobile phones and communications networks allows a number of services to be offered, including monitoring for heart disease patients and making more data available to those that do not traditionally have access to health information.
Russia Mobile Penetration (%), Q311
250%
Certainly, Russia's main cities offer the latest technologies available in the industry, and customers there have quickly responded to new products as they have launched. This creates a sub-sector within Russia whereby high-end telecare products can be launched within major cities.
Finding New Avenues Of Growth
Russia Mobile Market
300,000 250,000 200,000 150,000 100,000 50,000 0 200 180 160 140 120 100 80 60 40 20
2009 2010 2011e 2012f 2013f 2014f 2015f 2016f
Cities Lead
No of Cellular Mobile Phone Subscribers ('000) No of 3G Phone Subscribers ('000) No of Mobile Phone Subs/100 Inhab (RHS)
e/f = BMI estimate/forecast. Source: BMI, Operators
200%
150%
100%
50%
Moscow
Source: AC&M Consulting
St.Petersburg
Regions
0%
While the mobile penetration rate in Russia suggests that mobile services are widely available, the reality is that there are significant disparities between Moscow and St Petersburg and the rest of the country. Although the regions have a penetration rate of 144%, BMI believes this includes a considerable number of inactive subscribers, and also hides the difference in areas such as Chechnya where mobile penetration is understood to be considerably lower. Nevertheless, the availability of mobile and broadband networks continues to expand, and BMI expects that continued growth offers a wealth of new opportunities for companies looking towards telecare expansion.
Increasing Interest In Telecare Projects Enabling Patients To Self Care Voxiva partnered with Johnson & Johnson in April 2011 to bring Text4Baby to the Russian market. The service sends free SMS to new and expectant mothers with advice on caring for babies as well as self care throughout pregnancy and the first few months. Information is sent in simple text format and is tailored to the stages of pregnancy. The project is based on a US program that launched in 2010. In Russia it is supported by the Kulakov Center for Obstetrics, Gynaecology and Perinatology, part of the Russian Ministry of Health and Social Development (MOHSD). Simple Solutions To Outpatient Care The St Petersburg Cardiac Monitoring Service offers a portable electrocardiogram to patients with heart disease or cardiac risk factors in partnership with Aerotel Medical Systems. Data from the portable monitor are sent via landline or mobile connection to a cardiac monitoring centre that analyses the data and sends back advice on the appropriate course of action. The patient's GP or cardiologist is also notified at the same time, reducing the time for patients to get access
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to the necessary care. As data are sent back to the cardiac monitoring centre at regular intervals, the patient's condition can be monitored constantly. ICT Developments Could Drive Health Monitoring Growth Russia's size makes it a prime candidate for health monitoring services in BMI's opinion, a view that is reflected in the number of health monitoring projects already under way in Russia. Health monitoring enables doctors to provide services to remote areas without travelling there while simple SMS-based services can provide preventative care advice to the most basic mobile device. Although smartphones are increasingly popular, the ability to send and receive larger quantities of data over the mobile network is not necessarily the solution to all problems. The Russian government has plans to roll out a national LTE (4G) network that would enable the rapid transfer of large documents as well as facilitate video conferencing, which would help in the provision of healthcare services to remote hospitals, or connect specialists to community clinics for diagnosis. A switch to electronic health records would make information about individuals more readily available along with patient diagnoses and test results.
Considerable Growth potential
Russia Healthcare Market
250 Health expenditure (US$bn) LHS Health expenditure per capita (US$) 200 1,800 1,600 1,400 1,200 150 1,000 800 600 50 400 200 0 0
to cover large portions of the country, with an emphasis on major towns and cities. However, more remote locations may require the use of more expensive satellite technology, which must be factored into any projects. BMI forecasts continued growth of mobile services and broadband connectivity in Russia with mobile connections increasingly important to the expansion of broadband services. Lightweight notebooks and tablets will make mobility much more user-friendly for healthcare professionals while mobile data services continue to expand. Russia's healthcare market is undergoing a transition from the Soviet-era emphasis on secondary care to a focus on primary care and preventative treatment, as well as the application of modern drug treatments and response to modern lifestyle-related ailments, such as obesity and diabetes. Telecare developments fit well into this shift in outlook and the growth of a number of lifestyle-linked diseases, including cardiovascular disease and cancers, provides an opportunity to supply modern pharmaceutical treatments. Legislation for healthcare provision and reform strategies remain in flux but highlight potential for the pharmaceutical market. Although debates continue over a new medicines law and legislation for healthcare provision, there are positive developments already rolling out in the form of a US$1bn project to increase cancer awareness, screening and treatment and US$3bn announced by President Medvedev in 2010 for children's healthcare over two years. Russia's per capita health spending was estimated to have reached US$603 in 2011 and will rise rapidly to hit US$953 by 2015. The gap between Russia's healthcare provision and advanced markets is substantial and convergence with developed markets will not be achieved for decades. New technologies will have their role in improving Russia's standing in healthcare provision.
100
2005
2006
2007
2008
2009
2010
2011
2012f
2013f
2014f
2015f
2016f
2017f
2018f
2019f
2020f
f = forecast. Source: World Health Organization (WHO), BMI
One of the biggest challenges Russia faces is in enabling communications technology to reach into all areas of the country. Mobile operators have expanded their networks
2021f
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Brazil: Mobile And Wireless Technology Improving Healthcare Provision

Here we assess the prospects (in terms of available infrastructure) for companies looking to invest in telecare in Brazil and highlight the diversity of projects currently in place, highlighting the maturity of the telecare market in Brazil. Increased Mobile Phone Usage... There were 237mn mobile subscribers in Brazil in 2011, up from 202mn in 2010. Although several developed areas of Brazil have passed 100% penetration, there is still ample room for growth, especially in the north and north east regions of the country. Rolling out services to these areas will be difficult and costly, but operators are obliged to reach many of these markets by 2015 under the eight-year plans for network expansion that were issued as part of the 3G licence auction in 2007. As a result, BMI forecasts that by 2016, the number of mobile phone subscribers in Brazil will reach 316mn. ...Providing Infrastructure For Mobile Health Health Monitoring Via Electronic Health Records Health workers (physicians, nurses, and social workers) that are a part of the Brazilian Family Health programme, initiated in the late 1990s have been provided with PDAs in order to increase the quality and efficiency of care provided when they visit low-income homes. Prior to the availability of communication technology, health workers were isolated from the healthcare centres, hospitals and physicians that were able to provide them with information to improve the quality of the services they provide. Each visit associated with the programme previously resulted in a three-page handwritten report, which would be stored in cabinets, with no possibility for information summarisation, statistical analysis, or data mining, which is now possible as the result of electronic data storage. The project was developed at the IME/USP Department of Computer Science, in collaboration with the Schooling and Health Center of Butant, part of the Medicine School of USP, and the Department of Medical Informatics of UNIFESP in So Jose dos Campos. The project was financed by FAPESP and Microsoft Research.
Self Care The Department of Health Informatics at the Federal University of So Paulo carried out a study that sent SMS reminder messages through clinic managers and clinic web software systems to patients at four medical clinics. The research found that non-attendance rates were lower among patients who received SMS messages. More than 29,000 appointments were scheduled between July 1, 2007, and May 31, 2008, and a text message reminder was sent to the patients cell phone for 7,890 of the appointments. The mean rate of nonattendance when no appointment reminder was sent was 25.57%, compared with 19.42% among those who received a reminder. Disease Surveillance The Amazonas state Department of Health, in partnership with Nokia, implemented a disease surveillance system aimed at enabling fast and effective data collection - essential for containing the spread of the dengue virus. In the Amazonas state of Brazil, containing dengue fever is a constant challenge due to heavy rainfall during most of the year and local methods for storing water in homes - both of which have been shown to promote mosquito breeding. The state health department must warn households constantly about the dangers of behaviours that encourage mosquito proliferation. Development of the software began in the first quarter of 2007 and it was piloted in different regions of Brazil during that same year. The Amazonas Health Department undertook the first full implementation of the solution in October 2008. The mobile technology enables health workers to collect and transmit real-time information regarding disease occurrence at a local level, allowing health officials to promptly analyse data and identify trends, enabling them to launch prevention and cure schemes. Increased Internet Connectivity... The Brazilian broadband market added a new subscriber every 27 minutes in 2010, according to data released by Telebrasil, the Brazilian Telecoms Association. These include users on mobile devices such as smartphones, which skews the total somewhat as BMIs figures refer to dedicated broadband connections. In line with data from Teleco, BMI estimates there were just over 13mn
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broadband subscribers using a combination of fixed and mobile infrastructure. If mobile handsets were to be included, then the market would almost certainly have hit the 34mn suggested by Telebrasil, with over half of the connections provided by mobile networks. The Brazilian government has made broadband expansion a major priority as it aims to lower the digital divide. State-owned Telebrs will be launching the new network and BMI expects there to be a short-term positive impact on the markets growth. Lowering the cost of access is of course only one element in generating growth in internet services, but is an important move in encouraging more Brazilians to get online, and ensuring the networks are in place for services such as telecare. Certainly, BMI expects the impact to be largely positive for internet usage growth and we forecast that by 2015 there will be almost 112mn internet users and just under 22mn broadband subscribers.
Regional Mobile Penetration Rate (%)
160 140 120 100 80 60 40 20 0 Regional Mobile Penetration Rate (%) 2009 Regional Mobile Penetration Rate (%) 2010 Regional Mobile Penetration Rate (%) Jun-11
to be one of the markets major driving forces. ...Enabling Healthcare Education And The Creation Of Information Systems Health Monitoring A web application, the HealthNet Telediagnosis service, has been developed to allow health practitioners who live in rural Brazil to interact with medical specialists in city hospitals in order to correctly diagnose patients, potentially reducing treatment costs (as the need for patients to travel is eliminated) as well as the incidence of risks and errors. The initiative has already been deployed in Pernambuco, a state in the northeast of Brazil. Education And Training The Brazilian Telemedicine University Network ( Rede Universitaria de Telemedecina, RUTE ) was established in 2006 as an initiative to link universities and teaching hospitals across Brazil. In its first phase, RUTE connected 19 university hospitals and has since integrated a total of 75 higher education health facilities across Brazil. RUTEs main objectives are: to connect Brazilian university and teaching hospitals to the national research and education backbone (RNP); to create a telemedicine and telehealth nucleus in each hospital; to provide support for dedicated videoconferencing rooms as well as train personnel to use the technology; and to create initial infrastructure for telediagnosis. The Use Of Technology To Provide Healthcare Is Positive For Patients Brazil is a very large country with continental dimensions and many social problems. These two factors hinder the delivery of healthcare to people living in remote and/ or poor areas and BMI believes mobile technology has the ability to support the public provision of healthcare. The country has made significant inroads on public health. By way of illustration, the average life expectancy in Brazil reached 72.3 years in 2006, which is an increase of 15% on the 1980 figure of 62.6 years. The Brazilian Institute of Geography and Statistics (IBGE) attributes the rise to more practising doctors, better access to clinics and hospitals and a greater uptake of medicines, especially vaccines for children. Furthermore,
Digital Divide Remains
North
Northeast
Central West
South
Southeast
National
Source: Anatel, BMI
Brazils IT market also has a distinct regional structure, with most spending accounted for by the south east region, which includes So Paulo as well as Rio de Janeiro. So Paulo alone accounts for around 35% of spending with Rio de Janeiro, Esprito Santo and Minas Gerais comprising 25%. Brazil remains on course to become one of the top four computer markets as an expanding economy lifts millions into a middle class. The fundamentals of rising computer penetration and growing affordability should keep the market on an upward trajectory. Spending on healthcare is expected
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health agencies have dramatically expanded primary care, with each municipal family health team acting as the principal healthcare access point for up to 1,000 families via the Brazilian Family Health Programme. Nonetheless, the state healthcare system remains chronically under-funded, highlighting the attraction of the use of telecommunications in the provision of healthcare. Systems that in the long term can reduce healthcare delivery costs, while at the same time increasing the accessibility of medical care will enable patients to seek treatment earlier and better adhere to prescription regimens, improving their quality of life and ultimately benefiting the countrys economic growth. Positive For Pharmaceuticals And Healthcare Companies Healthcare Expenditure Forecast In 2011, healthcare expenditure in Brazil reached BL347bn (US$207bn) and over the 2011-2016 period, we forecast the sector seeing a compound annual growth rate (CAGR) of 9.75% in local currency terms and 11.46% in US dollar terms. By 2021, we calculate that healthcare expenditure in the country will reach a value of BRL852bn (US$550bn), experiencing a CAGR of 9.39% in local currency terms and 10.24% in US dollar terms.
Telecare Can Boost Growth In Brazils Pharmaceuticals Healthcare Market
Brazil Pharmaceuticals & Healthcare Expenditure
600 Pharmaceutical sales (US$bn) Health expenditure (US$bn) 500
lates that spending on medicines will reach a value of BRL63.82bn (US$41.18bn) at a CAGR of 8.28% in local currency terms and 9.97% in US dollar terms. By 2021, we calculate spending on medicines will reach a value of BRL82.03bn (US$52.92bn), experiencing growth of 6.70% in local currency terms and 7.53% in US dollar terms.
Brazil Mobile Market Historical Data and Forecasts
350,000 300,000 250,000 200,000 150,000 100,000 50,000 0 180 160 140 120 100 80 60 40 20
2003 2004 2005 2006 2007 2008 2009 2010 2011f 2012f 2013f 2014f 2015f 2016f
Positive Growth
Number of Cellular Mobile Phone Subscribers ('000) LHS Number of Mobile Phone Subscribers/100 Inhabitants
e/f = estimate/forecast. Source: BMI
400
300
200
100
Positive For Telecommunications Companies BMI believes the diverse telecare initiatives in Brazil highlight opportunities for the whole spectrum of telecommunications companies. This includes infrastructure providers that will gain new contracts to deploy networks on a national, local or individual scale as well as new services to be created for mobile operators to offer. Furthermore, we note that healthcare IT is a significant area of opportunity with larger budgets in both public and private hospitals. The growing expectations of a more affluent population will drive long-term growth in spending by hospitals and clinics on better patient care and data access and management.
2006
2007
2008
2009
2010
2011
2012f
2013f
2014f
2015f
2016f
2017f
2018f
2019f
2020f
f = forecast. Source: The Brazilian Pharmaceutical Industry Federation (Febrafarma), Group of Executives of the Pharmaceutical Market (Grupemef), World Health Organization (WHO), BMI
Pharmaceuticals Expenditure Forecast In 2011, Brazils pharmaceutical market was valued at BRL42.88bn (US$25.60bn) and by 2016, BMI calcu-
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India: Public And Private Sector Investment Boosting Telecare Growth

Challenges In Providing Healthcare To The Indian Population: A Booming Rural Population The countrys large size (more than 3mn square kilometres) and growing population numbers (reaching 1.2bn in 2010) have traditionally hampered adequate access to medicines and medical services in India. Overcrowded public hospitals are a continuous problem and finances for providing extra beds and facilities remain scarce. The situation is perpetuated by low government spending on health, despite the fact that the majority of the population is forced (by low income) to use public facilities (a quarter of the population lives below the poverty line and 58% of the population earns a living from agriculture).
India Teledensity Urban/Rural Split (%), 2011
Rural Penetration 34.58
Furthermore, according to a study conducted by the FICCI, even though 72% of Indias population live in rural areas, 80% of doctors, 75% of dispensaries and 60% of hospitals are in urban areas. It is hence almost impossible for the residents in rural areas to receive quality healthcare services. A Solution To The Challenge: Telecare BMI defines telecare as the use of mobile and internet technology to provide clinical care and non-clinical services such as health education, disease surveillance and drug monitoring. It is our view that a combination of factors - including the continued growth in demand for and delivery of healthcare, the continued growth in mobile and broadband subscribers and penetration rates and the growing sophistication of the infrastructure of the communication networks - are driving new opportunities in telecare across the globe. We expect this to create significant revenue-earning opportunities for companies operating in both the developed and emerging world. Here we identify the different uses of telecare in India, highlighting the opportunities for companies looking to invest in the sector. It is clear that the Indian government has recognised the potential in telecare, launching initiatives in the fields of disease surveillance, health provision and monitoring and education/training.
Disproportionate
Urban Penetration, 155.96

Source: TRAI
Urban/ Rural Split, 2011
India Population
Urban population, % of total 30.0
The Department of Information Technology has launched telemedicine projects across the country including: a disease surveillance programme in West Bengal; a cancer detection and continuity of care programme through the Kerala Oncology Network; and a telemedicine solution to provide specialty health services to remote areas of north-eastern states of India such as Mizoram and Sikkim. The Indian Space Research Organisation (ISRO) has initiated a number of telemedicine pilot projects which consist of linking remote or rural areas like Jammu, Kashmir and Ladhakh in the north of country near the Himalayas and the offshore islands of Andaman and Lakshadweep with the North Eastern States District Hospitals/Health Centres through the Indian National
Rural population, % of total 70.0
Source: BMI
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Satellite (INSAT), for patient consultations, treatment and healthcare personnel training. The ISROs Telemedicine Network consists of 300 hospitals - 257 Remote/ Rural/District Hospital/Health Centres connected to 43 specialty hospitals in the major cities. The Ministry of Health and Family Welfare has established OncoNET India, a network connecting 27 regional cancer centres with 100 peripheral centres to facilitate a national cancer-control programme through tele-consultations, tele-education, training health professionals and monitoring disease trends. The ministry has also approved a tele-ophthalmology project to provide eye care specialty services to patients in the rural and remote areas of Punjab, Uttar Pradesh and the West Bengal states of India through mobile vans. The Centre for Development of Advanced Computing (C-DAC), an autonomous government scientific organisation, has developed a web-based telemedicine solution that enables the creation of electronic medical records and automated appointment scheduling, realtime patient consultations via video links, reporting and graphical tools and an interface with a wide range of medical devices. We note that the private sector has also implemented telecare initiatives in India. In June 2008, the Apollo Hospitals Group, in partnership with Swedish telecoms equipment vendor Ericsson, set up an advanced mobile telephony system in order to transmit patient information from villages to cities, where experts can diagnose illnesses and prescribe treatments. The initiative was built on Ericsson and Apollos collaboration in 2007 for the Gramjyoti project, which showcased the benefits of mobile broadband applications across 18 villages and 15 towns in rural areas. We note that the private hospital group has also set up a 50-bed secondary care centre with state of the art equipment in Aragonda and, in partnership with the government of Gujarat, has started a mobile telemedicine project in the region. In addition to the Apollo Hospitals Group, the Amrita Institute of Medical Sciences (AIMS), the Asia Heart Foundation, Fortis Hospital, Narayana Hrudayalaya and Escorts Heart Institute and Research Centre
have set up telemedicine projects in India. ZMQ Software Systems is running a programme to provide women with information on prenatal care via SMS. The messages, which are all in Hindi, contain information on vaccinations, exercise, diet, medication and how to deal with emergencies that arrive during pregnancy. In order to educate the population about HIV/ AIDS, the company has also launched a mobile phone game in India, where a cricket match is played between the teams Demons XI and Safety XI, involving balls in the form of condoms, faithful partners, information on HIV and the symbolic AIDS red ribbon. A team wins by avoiding googlies and doosra balls - representing unsafe sex, infected blood transfusions, infected syringes and the company of bad friends. Opportunities BMI believes the diverse telecare initiatives in India, involving both the public and private sector, highlight opportunities for the whole spectrum of telecommunications companies. This includes infrastructure providers that will gain new contracts to deploy networks on a national, local or individual scale, as well as new services for mobile operators to offer. Furthermore, we note that healthcare IT is a significant area of opportunity with larger budgets in both public and private hospitals. The growing expectations of a more affluent population will drive long-term growth in spending by hospitals and clinics on better patient care and data access and management. BMI believes the growth in teledensity is creating the infrastructure for telecare, while at the same time the growth in the telecare industry will provide telecommunications companies with incentives to roll out new services. Furthermore, increased legislation and education on telecare will work towards creating a suitable business environment for companies looking to invest in the sector. BMIs Mobile Forecast For India The latest data released by the Telecom Regulatory Authority of India (TRAI) showed there were 896.94mn mobile subscribers at the end of 2011. BMI expects
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983mn mobile subscribers in India by end-2012, representing a penetration rate of 78.1%. We expect intense competition between operators and price competition to remain the main growth drivers in the short term. This will be facilitated by mobile number portability, which was introduced in January 2011 and has already seen a number of operators including Vodafone Essar and Bharti Airtel benefit at the expense of Reliance Communications. However, we expect operators to shift to a higher-value strategy that involves postpaid subscribers and more value-added services in the long term. We forecast mobile subscriber growth to drop as the total number of mobile subscribers reaches 1.128bn in 2016.
Opportunities For Operators
India 3G Mobile Network
250,000 200,000 150,000 100,000 50,000 0
2012f 2013f 2014f 2011e 2015f 2008 2009 2010
users at the end of 2011. Among the factors which are contributing to Indias fast-growing internet sector are the increasing prevalence of internet cafes, the rapid emergence of Indias middle class and the growing availability of mobile devices, which enable affordable internet access. By the end of 2016 we forecast that Indias internet user base will rise to 214.95mn, a penetration rate of 16.2%. Meanwhile, Indias telecoms regulator reported there were 20.992mn internet subscribers in the country in September 2011. As for the number of fixed broadband subscribers, this totalled 13.300mn in 2011. It is notable that broadband subscribers, as a proportion of Indias total internet subscriber base, has been steadily increasing.
Growing Middle Class Boosting Growth
India Broadband Internet Subscribers
18 16 14 12 10 8 6 4 2 0
50,000 45,000 40,000 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 2008 2009 2010 2011e 2012f 2013f 2014f 2015f
4.0 3.5 3.0 2.5 2.0 1.5 1.0 0.5 0.0
No of 3G Phone Subscribers ('000) LHS 3G Market As % Of Entire Mobile Market

e/f = BMI estimate/forecast. Source: BMI
No of Broadband Internet Subscribers ('000) LHS No of Broadband Internet Subscribers/100 Inhabitants

Basic Service Will Drive The Market

India Mobile Subscriber Forecasts
1,600,000 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0
2011e 2008 2009 2010 2012f 2013f 2014f 2015f
140 120 100 80 60 40 20 0
BMI believes the growing demand for healthcare in India and the challenges associated with providing the population with access to adequate levels of care will provide a demand for telecare. A High Infectious Disease Burden And A Growing Chronic Disease Burden BMI BoDD reveals that non-communicable diseases such as diabetes and cancer are a greater burden in India than communicable diseases such as tuberculosis and HIV/AIDS. In 2010, a total of 94,576,455 DALYs (disability-adjusted life years) were lost to communicable diseases, while 118,910,404 DALYs were lost to non-communicable diseases. By 2030, the number of DALYs lost to non-communicable disease will have
No of Cellular Mobile Phone Subscribers ('000) LHS Number Of Mobile Phone Subscribers/100 Inhabitants
BMIs Internet Forecast For India BMI estimates that India had almost 123.7mn internet
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increased by 24% to 144,498,455. The number of DALYs lost to communicable diseases will have dropped by 33% to 67,022,332. Population Boom To Drive Demand For Pharmaceuticals & Healthcare Indias growing and ageing population is another reason for healthcare spending increasing rapidly. According to the United Nations Population Division, the number of people living in the Asian country is forecast to increase from 1.21bn in 2010 to 1.29bn in 2015 (a rise of 6.6%) and further to 1.32bn in 2020. Between 2025 and 2030, Indias population will exceed that of China and become the largest in the world. The percentage of Indias population aged 65 or over is expected to increase from 4.9% in 2010 to 6.3% in 2020 and 13.7% in 2050. In 2010, Indias pharmaceutical market reached a value of INR613.28bn (US$13.37bn). Through to 2015 and 2020, Indias pharmaceutical market will post local currency compound annual growth rates (CAGRs) of 14.6% and 13.5% respectively, reaching a value of INR1,212.13bn (US$30.88bn) by 2015 and INR2,169.25bn (US$57.09bn) by 2020.
India Pharmaceuticals And Healthcare Market Forecast
120 100 80 60 15 40 20 0
2012f 2013f 2014f 2011e 2015f 2005 2006 2007 2008 2009 2010
By 2020, Indias healthcare expenditure will rise to INR6,739.24bn (US$177.45bn)
High Growth Market
35 Health expenditure (US$bn) Government Health expenditure (US$bn) Pharmaceutical sales (US$bn) 30 25 20
10 5 0
f = forecast. Source: IMS Health, AIOCD Pharmasofttech AWACS, Organisation of Pharmaceutical Producers of India (OPPI), BMIMinistry of Health & Family Welfare, Central Bureau Of Health Intelligence, BMI
In 2010, Indias healthcare market reached INR2,709.76bn (US$59.08bn) and by 2015 we forecast spending on healthcare reaching a value of INR4,434.61bn (US$112.19bn), experiencing a CAGR of 10.35% in local currency terms and 13.84% in US dollar terms.
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Risks
Telecare risks
While it is clear that there are many benefits for different players in the telecare market, new technologies can bring their own troubles. Furthermore, while operators and healthcare providers may be willing, that is not to say that the regulatory environment is enabling, restricting the rate of growth of potential projects. Many pilots have been launched with partnerships between several stakeholders making these a success. However, scaling up these projects and ensuring their manageability is a challenge in itself. Reliability of Infrastructure Many of the challenges that could prevent the success of telecare services relies on the technology needed. With many projects in developing countries aimed at bringing services to rural communities, often simple requirements such as access to power can create difficulties. Devices requiring constant access to electricity or regular charging will therefore be less applicable in the most remote areas. Mobile operators often have to provide their own power sources for their network infrastructure, adding to operating expenditure. Limited power sources could become a major difficulty in rolling out telecare projects, or an occasional difficulty that would need to be factored into decisions. Providing a proprietary power source adds extra costs to a product that is aimed at making healthcare a more viable prospect in poor and remote areas. This could restrict telecare projects for health monitoring and disease surveillance. The political uprising in Egypt in January 2011 highlighted a major risk to projects reliant on internet connectivity. At the height of the protests ISPs were ordered to shut down, seeing traffic drop from around 3,000Mbps to almost nothing in the space of a few minutes. Alternatives include using international numbers to make dial-up internet connections, or satellite connections, but these tend to be expensive and more difficult to set up. Network failure, such as an international submarine cable being cut, could also pose a major risk to some of these services, particularly if data is being sent from one country to another. In markets where accessing data relies on online connectivity, this is certainly a real threat to the roll out of telecare. Technical Understanding The majority of people using the devices and services offered by telecare solutions are likely to be educated, and have access to PCs and mobile phones themselves. This mitigates much of the risk for rolling out services. However, products such as drug monitoring require a minimal level of understanding of basic mobile phone functions. Ensuring software in markets where education levels are lower is simple is key for rolling out services. For this reason, many products under the 'self care' banner will not be appropriate for developing markets. In all cases, sufficient training will be needed. In developed markets where much of the benefit will be in the pensionable population, many potential beneficiaries may be reluctant to try new technologies when they have been used to direct contact with healthcare professionals. Complicated devices will likely put off older users, so simplicity is key. Network Capacity Telecare is reliant on the transmission of data. Smaller packets of data such as SMS use little of a network's capacity, but images and video require greater bandwidth and network speeds. Projects in the drug monitoring area should face limited difficulties if using SMS to verify counterfeit drugs. However, doctors in remote towns and villages wanting to send scans and images to a major hospital for consultation would require reliable high speed connections that allow a large file to be uploaded. Regulatory Environment Harder to measure is the perspective of government regu-
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latory bodies towards telecare. For the most part telecare offers real opportunities for healthcare providers and telecoms operators, which should encourage regulators to ensure the environment is there to promote services. The US' FDA has drafted regulations for medical apps. While this could be seen as restrictive, we believe that approval from a government body can also be important in encouraging trust from potential subscribers in an area as sensitive as healthcare. Like many areas where markets begin to converge, defining what is under which agency's jurisdiction can create delays as well as confusion. For the most part, BMI believes telecoms regulators will not be heavily involved in regulating the telecare environment - it will be a healthcare issue. However, universal services funds to roll out infrastructure into rural areas may be of interest to governments or companies looking to provide services to more remote communities and the possibility of operators entering the telecare market could be restricted by existing concessions. Offering machine to machine based services may come with different requirements.
ing factors include the lack of reliable infrastructure, network capacity and sufficient technical understanding. Furthermore, while operators and healthcare providers may be willing to invest in telecare initiatives, the regulatory environment may be restrictive, holding back the growth of potential projects. Harder to measure is the perspective of government regulatory bodies towards telecare.
A-pportunties For Drugmakers
US Healthcare Expenditure (US$mn)
3,500 3,000 2,500 2,000 1,500 1,000 500 0 60 50 40 30 20 10 0
2006
2007
2008
2009
2010
2011
2012f
2013f
2014f
2015f
Health expenditure (US$bn) LHS Government sector health expenditure, % of total

f = forecast. Source: FedStats, Department of Health, World Health Organization (WHO),BMI
FDA To Regulate Medical Apps

While the FDA's decision to increase the regulation of the telecare industry could be seen as restrictive, we believe approval from a government body can also be important in encouraging trust among potential subscribers in an area as sensitive as healthcare. The growth in the number of mobile phone users and wireless subscribers, plus the advances in the innovative application of communication technology to address health priorities, has the potential to transform the delivery of healthcare across the world, providing significant opportunities to companies looking to invest in the telecare sector. A number of telecare pilot projects have been launched across the developed and emerging world, with partnerships between several stakeholders making these a success. However, scaling up these projects and ensuring their manageability is a challenge. There are many benefits for different players in the telecare market but new technologies can bring their own problems. LimitFor the most part, telecare offers real opportunities for healthcare providers and telecoms operators, which should encourage regulators to ensure the environment promotes services. In the US, the Centre for Devices and Radiological Health (CDRH), part of the FDA, is responsible for the regulation of software, medical devices and radiation-emitting electronic products used for telemedicine, and as such plays an important role in the development of the sector in the US. Each of the centre's principal areas of responsibility - premarket review, post-market surveillance, quality systems, standards and science - includes programme activities related to telemedicine. Mobile Applications Highlighting drugmakers' recognition of ways in which smartphone apps can be instrumental to their businesses, multinationals such as Pfizer, Merck & Co, GlaxoSmithKline (GSK), AstraZeneca, Sanofi, Roche, Novartis, Johnson & Johnson, Bayer and Abbott Laboratories have all produced apps for patients
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and healthcare professionals. The apps include disease calculators, educational packages, patient diaries and information about drugs. Apps For Patients GSK - Cancer Trials : This app, available in the US, was developed by GSK Oncology in collaboration with MedTrust Online for patients and doctors to find cancer trials within 150 miles of their location. The app links to MedTrust Online's trial database, which originates from the US' national ClinicalTrials.gov database. Apps For Healthcare Professionals Merck & Co - Temodar Dosing Calculator : This app, also available in the US, was designed to help healthcare professionals determine the appropriate dose of Merck's brain tumour drug Temodar (temozolomide). BMI believes that the development of smartphone applications by drugmakers is an advisable business strategy. Communicate With A Wider Audience, Smartphone Use To Increase With regards the use of smartphones in the world's largest pharmaceuticals and healthcare market, 3G subscription rates in the US reached 144mn in 2011. We forecast this figure reaching 230mn by 2016. Facilitate Improved Patient Outcomes The potential for apps to improve adherence to medication and the management of disease makes their development an almost compulsory investment. In addition to improving compliance to prescriptions, drug companies can use the apps to differentiate their products from those offered by the competition. Improve Interaction With Doctors Drugmakers can use apps to interact with doctors, as well as obtain information such as prescribing habits, without the use of a medical sales representative, aligning with our core view that sales forces will decrease in developed states. FDA Moves To Regulate Mobile Health Apps On July 19 2011, the US FDA published a draft guid-
ance document to inform manufacturers, distributors, and other entities about how it intends to regulate mobile applications. The FDA is proposing to regulate mobile medical apps that are used as an accessory to an FDA-regulated medical device (for example, an app could enable a health care professional to view medical images on an iPad and make a diagnosis) and medical apps that transform a mobile platform into a regulated medical device (for example, an app that turns a smartphone into an electrocardiography machine to detect abnormal heart rhythms). BMI Believes The Proposed Regulation Has Positive And Negative Aspects Mobile medical apps can pose potential risks to public health, specifically as a result of the unique characteristics of the platform. For example, the interpretation of radiological images on a mobile device could be affected by the smaller screen size and lower contrast ratio. The regulation of apps will therefore provide patients with confidence regarding the effectiveness and accuracy of the technology. The regulation will provide companies with guidelines during the research and development phase, therefore working towards reducing the regulatory uncertainty that may inhibit investors from backing the technology. The increased regulation may inhibit innovation. Additionally, the US FDA may not be able to effectively monitor mobile medical apps as a result of the speed of innovation regarding apps. The cost of adhering to FDA regulation may result in the development of a higher priced product - negative for patients. The mHealth Regulatory Coalition, a group of healthcare and information technology organisations (including AT&T, the Continua Health Alliance, Kaiser Permanente, Nokia, Qualcomm and WellDoc) said in an October 19 2011 in a letter to FDA on the draft guidance that it supported the 'step toward appropriate regulation of mobile health technologies, but there is more work to done'.
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Telemedicine Demand Exists, But Does It Work?

Demand for products to aid non-institutional chronic disease management and improve independence among elderly patients will increase. The expected growth of the world's ageing population over the next 50 years is to have an unprecedented effect on the provision of healthcare. The elderly require more medical check-ups and care than young people as the result of an increased prevalence of chronic disease with age, and therefore consume a disproportionately large share of healthcare services. The majority of US patients support the use of home medical devices to manage and improve their chronic diseases, according to a 1,008-subject survey conducted by GfK Roper for Practice Fusion, an electronic health record company. Home medical devices are generally inexpensive and easy to use. For example, scales are recommended for use by patients with congestive heart failure to track weight fluctuations that signal dangerous condition changes. Glucometers can help diabetic patients record their blood sugar levels and online mood trackers can assist bipolar and depression patients with the dosage and type of medication they require. Key Study Findings: Over 62% of participants said communication with their doctor using home medical devices would improve their health; Up to 57% of respondents between the ages of 25 and 49 were interested in home medical devices; However, just 35% of those aged over 65 were interested in home medical devices; Men with chronic conditions were more interested in home monitoring devices (52%) than women (41%). Home medical devices are a component of telemonitoring, which was recently adjudged to be ineffective. A group of US researchers conducted a multicenter,
randomised, controlled trial - Telemonitoring to Improve Heart Failure Outcomes (Tele-HF) - to determine whether telemonitoring would reduce the combined endpoint of hospital re-admission or death from any cause among 1,653 patients recently hospitalised for heart failure. Telemonitoring was accomplished by means of a telephone-based interactive voice-response system that collected daily information about symptoms and weight for review by the patients' clinician. Re-admission for any reason occurred in 49.3% of patients in the telemonitoring group and 47.4% of patients in the usual-care group. Death occurred in 11.1% of the telemonitoring group and 11.4% of the usual care group. Therefore, outcomes did not improve using telemonitoring, leading the study authors to highlight the importance of a thorough, independent evaluation of non-institutional disease-management strategies before their adoption. [1] [1] The New England Journal of Medicine. November 16 2010. Telemonitoring in Patients with Heart Failure. SI Chaudhy et al. http://www.nejm.org/doi/pdf/10.1056/ NEJMoa1010029
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Appendix: Results of BMIs Telecare Matrix

The methodology behind these opportunity matrix tables is detailed on page 13 of this report. The tech base component assesses the level of infrastructure in place for the telecare service (each market is assigned a grade of excellent, average or poor). The market opportunity component assesses the demand for the telecare service (each market is assigned a grade of high, medium or low). TABLE: HEALTH monITorIng
Tech Base
Malaysia Romania Estonia United Arab Emirates Slovenia Poland Oman Latvia Lithuania Sweden Australia United States Portugal Moldova Kazakhstan Turkey Slovakia Serbia Jordan Japan Bahrain Canada Colombia Belarus Kenya Egypt China Saudi Arabia Namibia Nicaragua Zimbabwe Tanzania Zambia Angola Cameroon Mozambique Sudan South Africa Russia Botswana Gabon Iraq Sri Lanka India
Source: BMI
Market Opportunity
Medium High Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium High High Medium Medium Medium Medium Low Low Medium High High High High High Medium High High High High High High High High High High High High High High High High Bangladesh Pakistan Venezuela Bulgaria Croatia El Salvador Philippines Spain France South Korea Singapore Israel United Kingdom Netherlands Belgium Mexico Germany Peru Iran Algeria Hungary Czech Republic Cambodia Guatemala Honduras Indonesia Uganda Morocco Nigeria Ghana Thailand Cote d`Ivoire Uzbekistan Greece Switzerland Panama Qatar Kuwait Italy Vietnam Brazil Argentina Chile Costa Rica
Tech Base
Poor Poor Poor Average Average Poor Poor Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Average Excellent Poor Poor Poor Average Average Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Excellent Excellent Poor Average Average Average Poor Average Average Average Poor
Market Opportunity
High High High Medium Medium High High Low Low Low Low Low Low Low Low Medium Low High High High Medium Medium High High High High High High High High High High High Low Low Medium Low Low Low Medium Medium Medium Medium Medium
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Average Average Excellent Excellent Average Average Excellent Excellent Excellent Average Average Average Average Average Average Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor
61
GLOBAL TELECARE
TABLE: drug monITorIng

Tech Base
Pakistan Bangladesh Cambodia Mozambique Zambia Philippines Vietnam Belarus Indonesia Uzbekistan Tanzania Nicaragua Iran Algeria Honduras Kazakhstan Sri Lanka Moldova Iraq Morocco Thailand Lithuania Romania Panama Colombia El Salvador Guatemala Kenya Uganda Cameroon Cote d'Ivoire Sudan India Nigeria China Zimbabwe Brazil Venezuela Gabon South Africa Egypt Ghana Peru Costa Rica
Source: BMI
Market Opportunity
High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High High Medium Botswana Serbia Namibia Argentina Bulgaria Jordan Malaysia Saudi Arabia Oman Mexico Angola Croatia Czech Republic Slovakia Kuwait Russia Poland Latvia Bahrain South Korea Chile Estonia United Arab Emirates Turkey Slovenia Qatar Israel Singapore Belgium Sweden Netherlands Switzerland Portugal Hungary Germany Greece Italy Spain United Kingdom France United States Australia Japan Canada
Tech Base
Average Average Average Average Average Average Average Average Average Average Poor Average Average Average Average Average Average Average Average Average Average Average Average Poor Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Poor
Market Opportunity
High High High High High High High High High Medium High Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Average Average Average Average Average Average Excellent Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average
62
special report
TABLE: ouTpATIEnT CArE

Tech Base
UK Germany France Spain Portugal Japan Italy US Sweden Switzerland Belgium Greece Netherlands Canada Slovenia Hungary Singapore Israel Australia Croatia Estonia Lithuania Czech Republic South Korea Bulgaria Romania Poland Russia Latvia Serbia Belarus UAE Slovakia Chile Argentina China Brazil Malaysia Egypt Bahrain Qatar Saudi Arabia Turkey Mexico
Source: BMI
Market Opportunity
High High High High High High High High Medium Medium Medium Medium High High Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Low Medium Medium Medium Medium Medium Medium Medium Low Medium Medium Medium Medium Thailand Kazakhstan Colombia Iran Moldova Panama Sri Lanka Kuwait Oman Jordan Venezuela Vietnam Philippines South Africa El Salvador Peru Morocco Algeria Guatemala Uzbekistan Iraq Costa Rica Indonesia India Nigeria Pakistan Bangladesh Zimbabwe Honduras Nicaragua Botswana Gabon Namibia Kenya Cambodia Ghana Sudan Cote d'Ivoire Angola Cameroon Tanzania Uganda Mozambique Zambia
Tech Base
Poor Average Average Poor Average Poor Poor Average Average Average Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor
Market Opportunity
Medium Medium Medium Medium Low Medium Medium Low Low Low Medium Medium Medium Medium Medium Low Low Low Low Low Low Low Medium Medium Medium Medium Medium Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Average Excellent Average Average Average Average Average Average Average Excellent Average Average Average Average Poor Average Average Average Average Average Average Poor
63
GLOBAL TELECARE
TABLE: sELF CArE

Tech Base
UK Japan France US Germany Italy South Korea Australia Spain Canada Russia Brazil Netherlands Turkey Poland Belgium Switzerland Greece Sweden China India Argentina South Africa Singapore Israel Mexico Indonesia UAE Venezuela Malaysia Portugal Czech Republic Saudi Arabia Chile Slovakia Bahrain Slovenia Estonia Vietnam Iran Thailand Qatar Romania Kuwait
Source: BMI
Market Opportunity
High High High High High High Medium Medium Medium Medium High High Medium High Medium Low Low Low Low High High Medium Medium Low Low High High Low Medium Medium Low Low Medium Medium Low Low Low Low Medium Medium Medium Low Medium Low Croatia Hungary Egypt Philippines Latvia Oman Kazakhstan Nigeria Pakistan Bangladesh Bulgaria Serbia Lithuania Colombia Morocco Algeria Jordan Panama Peru Sri Lanka Uzbekistan Ghana Cote dIvoire Belarus Moldova Kenya Iraq Sudan Angola Tanzania Uganda Mozambique Costa Rica El Salvador Honduras Guatemala Nicaragua Botswana Gabon Namibia Cambodia Zimbabwe Cameroon Zambia
Tech Base
Average Average Poor Poor Average Average Average Poor Poor Poor Average Average Average Poor Poor Poor Average Average Poor Poor Poor Poor Poor Average Average Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor
Market Opportunity
Low Low Medium Medium Low Low Medium Medium Medium Medium Low Low Low Medium Medium Medium Low Low Medium Medium Medium Medium Medium Low Low Medium Medium Medium Medium Medium Medium Medium Low Low Low Low Low Low Low Low Low Low Low Low
Excellent Excellent Excellent Excellent Average.9 Excellent Excellent Excellent Excellent Excellent Average Average Excellent Average Average Excellent Excellent Excellent Excellent Poor Poor Average Average Excellent Excellent Poor Poor Excellent Average Average Excellent Excellent Average Average Excellent Excellent Excellent Excellent Poor Poor Poor Excellent Average Excellent
64
special report
TABLE: dIsEAsE surVEILLAnCE

Tech Base
Russia Argentina Malaysia Guatemala Brazil Philippines Egypt Mexico Turkey Peru Uzbekistan Ghana India Iraq China Cote d`Ivoire Sudan Kenya Pakistan Nigeria Tanzania Bangladesh Zimbabwe Angola Zambia Uganda Cameroon Mozambique Saudi Arabia Romania South Korea Sri Lanka United States Botswana Vietnam Morocco Thailand South Africa Iran Indonesia Algeria Cambodia Venezuela Colombia
Source: BMI
Market Opportunity
High High High High High High High High High High High High High High High High High High High High High High High High High High High High Medium Medium Medium Medium Medium High High High High High High High High High High High Namibia Panama Canada Gabon El Salvador Honduras Kazakhstan Italy Germany United Kingdom Spain Belarus France Japan United Arab Emirates Bahrain Qatar Oman Croatia Bulgaria Lithuania Serbia Australia Chile Israel Czech Republic Poland Kuwait Portugal Singapore Sweden Switzerland Estonia Jordan Latvia Hungary Slovakia Slovenia Moldova Nicaragua Costa Rica Greece Netherlands Belgium
Tech Base
Average Excellent Excellent Average Average Average Average Excellent Excellent Excellent Excellent Average Excellent Excellent Excellent Excellent Excellent Average Average Average Average Average Average Average Average Average Average Average Average Average Average Average Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor Poor
Market Opportunity
High Medium Medium Medium Medium Medium Medium Low Low Low Low Medium Low Low Low Low Low Medium Medium Medium Medium Medium Medium Medium Medium Medium Medium Low Low Low Low Low Medium Medium Medium Medium Medium Medium Medium Medium Medium Low Low Low
Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Excellent Average Average Average Average Average Average Average Average Average Average Average
65
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All information, analysis, forecasts and data provided by Business Monitor International Ltd is for the exclusive use of subscribing persons or organisations (including those using the service on a trial basis). All such content is copyrighted in the name of Business Monitor International, and as such no part of this content may be reproduced, repackaged, copied or redistributed without the express consent of Business Monitor International Ltd. All content, including forecasts, analysis and opinion, has been based on information and sources believed to be accurate and reliable at the time of publishing. Business Monitor International Ltd makes no representation of warranty of any kind as to the accuracy or completeness of any information provided, and accepts no liability whatsoever for any loss or damage resulting from opinion, errors, inaccuracies or omissions affecting any part of the content.
analysts: Kaushal Shah, Laura Holland editor: Lyndsey Anderson Production: Neil Murphy, Reema Patel Publishers: Richard Londesborough, Jonathan Feroze copy Deadline: 2 April 2012

BMI Special Report Global Telecare Healthcare For The Digital Age 2012-04-01

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GLoBaL teLecaRe: HeaLtHcaRe FoR tHe DIGItaL aGe

Published by Business Monitor International Ltd.

Methodology ......................................................................................................... 13 Opportunity Matrix ................................................................................................ 13

1. Health Monitoring ....................................................................... 15

Rwanda: Mobile And Wireless Technology Improving Healthcare Provision ....... 18

2. Drug Monitoring .......................................................................... 25

Drug Monitoring: Case Studies ............................................................................. 27

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Ghana: HP To Work With mPedigree To Combat Counterfeits ............................. 27

4. Self Care ...................................................................................... 32

5. Disease Surveillance ................................................................... 37

Company Focus ................................................................................ 41

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New Zealand: Bupa Adopts Telecare.................................................................... 42

Country Focus: BRICs ....................................................................... 45

Russia: Telecare Creates Opportunities ................................................................ 48

Brazil: Mobile And Wireless Technology Improving Healthcare Provision .......... 50

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Appendix: Results of BMIs Telecare Matrix .................................... 61

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Opportunities In The Developed And Emerging World

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140 120 100 80 60 40 20 0

Subscribers ('000) (LHS)

Average Penetration Rate (%) (RHS)

e/f = BMI estimate/forecast. Source: BMI, Regulators, World Bank (ITU)

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Markets with greatest opportunities for Health Monitoring

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For full results of BMIs Telecare Matrix, please see Appendix.

Health Monitoring: Case Studies

ARPU Vs Health Care Expenditure Per Capita (US$)

e/f = BMI estimate/forecast. Source: World Health Organization (WHO), BMI

Zantel Carving Out Its Niche

Vodacom 42.9% Airtel 28.2%

Source: BMI, Operaotrs, TCRA

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Rwanda: Mobile And Wireless Technology Improving Healthcare Provision

Rwanda Internet Use Growth

30 Internet Users RHS

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TABLE: InsTITuTIons supporTIng ArV TrEATmEnTs In rwAndA: CurrEnT ICT sTruCTurE

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f = forecast. Source: World Health Organization (WHO), BMI

Rwanda Millennium Development Goals

Canada: Ontario Expands Telehealth Services

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Middle East: Mobile Baby - A Growing Trend In MENA

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Countries with greatest opportunities for Drug Monitoring

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Countries with good opportunities for Drug Monitoring

For full results of BMIs Telecare Matrix, please see Appendix.

Drug Monitoring: Case Studies