Mhealth Coded in Country Report

The Ubiquity of mHealth And The Android Operating System: Coded in Country And The Power Of Local Knowledge
Paul Allen August 2011
The Ubiquity of mHealth and Coded in Country
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Paul Allen, August 2011
Paul Allen
8/19/2011
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1. Introduction Mobile health (mHealth) is an emerging industry, which is witnessing unprecedented innovation in developing cities from Phnom Pen to Nairobi. Although developed nations have well run health systems, it is the under developed nations that are arguably pioneering in the development of mobile health solutions. The key benefits of Mobile Health are now being felt worldwide. However there is still a need for coherence, due to no regulations existing for the Mobile Health industry. The current rules only concern the submission to mobile app stores such as the Apple and Android stores. The iPhones innovation in user experience has enabled the Mobile Health (herein known under its abbreviation of mHealth) industry to become a reality faster than expected. The Apple App store has placed itself at the forefront of the industry from 2008-present. However it is the Android operating system that i hypothesis in this paper, that will ultimately lead the mHealth industry and become the operating system of choice for mHealth application developers worldwide.
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The innovation in mHealth has been a result of technological advancement in the field of mobile technology, providing the benefits of cost-effective global health care services for all. Smartphones are a revolution in the facilitation of mHealth and various operating systems such as iPhone, Windows Mobile and Android are competing to engage the mobile user. The use of open source technology such as Android allows for the emergence of the Coded in Country phenomena, which promotes the use of in-country technical resources for international development projects. Coded in Country is a software implementation
approach where the technical needs of a project are met by local software developers who are involved in the design, development, and deployment of the solution. This means there is no longer a gap between the developing and developed worlds is terms of technology advancement. On the contrary the major advantage of Coded in Country development is: Local Knowledge: Foreign-based implementers do not know a particular market as well as those who call it home. In some cases this may not be an issue; after all, Gmail is used throughout the world by people of different cultures and languages. Yet, in many cases, particularly when the viability of the project rests on the ability to appropriately understand local customs, Coded In Country offers a distinct
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advantage. When developers and implementers have innate knowledge of the local culture and language, they are better positioned to tailor applications to that particular market (Coded In Country, 2011). As my hypothesis will suggest the ubiquity of the Android operating system allows for mobile developers in Asia, Africa and Latin America to compete on a level footing with developers in Silicon Valley and hypothetically develop better medical applications due to their knowledge of the local health concerns. For this study an analytical and investigative approach has been adopted, focusing primarily on four mHealth case studies: a) Mobile Communications for Medical Care (University of Cambridge, 2011); b) The Future of Medicine: The Doc-in-a-Phone (Connolly, 2011); c) How Smartphones Are Changing Healthcare For Consumers And Providers (Sarasohn-Khan, 2010); d) mHealth For Development (Vodaphone/United Nations 2009). Books, journal articles and internet information have also been used to complete this study. The study concludes that mHealth is no doubt a revolution in the field of healthcare services but also shows that the under developed continents of Asia, Africa and Latin America now have the capacity to lead the field in mHealth application development.
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mHealth broadly encompasses the use of mobile telecommunication and multimedia technologies as they are integrated within increasingly mobile and wireless health care delivery systems. The field broadly encompasses the use of mobile telecommunication and multimedia technologies in health care delivery (Istepanian, 2005).
A definition used at the 2010 mHealth Summit of the Foundation for the National Institutes of Health (FNIH) was the delivery of healthcare services via mobile communication devices (Torgan 2009).
Mobile networks today cover 98 percent of the worlds population. Across the globe, cell phones are used to conduct banking, monitor elections, and teach classes. The technology has broken geographic, socioeconomic, political, and even generational barriers (Connolly, 2011).
mHealth applications have the ability to revolutionise the healthcare systems both in the western as well as developing countries. With this technology healthcare services can be accessible even in the underserved populations. Fast and effective healthcare services can be supplied in a cost-effective manner, public health programmes and research projects can be facilitated, disease can be prevented, chronic illness can be better managed and individuals can be kept out of hospitals. Principal stakeholders and players in this sector include; policy makers (such as governments, health NGOs, and regulators),
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telecommunications operators, system integrators, manufacturers, technology providers and healthcare providers including the insurers. (Cambridge University, 2011)
Figure 1. mHealth Value Chain, Source: Cambridge University 2011
1.1.
Research Question
Can the Android mobile operating system allow the developing world to be on an equal footing with their colleagues in Silicon Valley and can access to such technology have an impact on healthcare in Asia, Latin American, Africa and the rest of the world?
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What are the impacts of Mobile Health (mHealth) on national economies and what is the cost savings associated with the implementation of mHealth? 1.2. Aims and Objectives
The aims and objectives of this study include; To examine the impacts of mobile technology on healthcare management To explore the concept and market of mHealth and its global picture To identify the barriers in acceptance of mHealth To investigate impacts of mHealth on national economies To compare mHealth trends in developing and developed world To highlight the implications of Coded in Country initiatives with the success of mHealth in developing countries. To assess the Android operating systems and evaluate its impact on the mHealth industry.
2. Literature Review
Originally the focus of mHealth was simply to facilitate information transfers. However there has been a significant change due to the rapid uptake and acceptance of mobile applications. In the United States, mobile communications already deliver medication alerts and appointment reminders. A clinical trial was
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just launched for patients to track overactive-bladder symptoms with the help of a smartphone.(Connolly, 2011). The overall global picture of mHealth is encouraging. Figure 2 reflects results of a recent World Health Organisation survey regarding mHealth developments globally. The survey showed that there are many mHealth initiatives taking place. The most prevalent of these services include; Toll-free emergency Mobile health call centres Emergencies Appointment Reminders Mobile telemedicine
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Figure 2. Source: Jane (2011)
2.1.
Barriers to Adoption
However, there are certain barriers which hinder the smooth implementation of mHealth worldwide. The most important barrier is competing priorities within the health systems. WHO advises the nations with restricted health resources to allocate these resources on the basis of forecasted return on investment (ROI), such as purchasing vaccines against spending in some mobile health projects. The second most important barrier is knowledge, that is, how mHealth can
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affect public health. Lack of a standard definition of mHealth is also considered a significant barrier. WHO defines it as medical and public health practice
supported by mobile devices, such as mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices (Jane, 2011).
Figure 3 illustrates barriers to the implementation of mHealth.
Figure 3. Source: Jane (2011)
Despite these barriers the future growth of the smartphones is positive and it is expected that by the year 2015 approximately 500 million people will be using healthcare smartphone applications. This correlates to 25% of the total
smartphone user base using mobile applications.
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mHealth market 2015: 500m people will be using healthcare smartphone applications
Figure 4. Source: Lyall (2011)
Figure 5 reflects the growth in the use of smartphones from 2006 to 2009 in the United States, growing from a base of 15% in late 2006 to 42% Smartphone ownership by the end of 2009. This growth has been achieved despite a global economic downturn.
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Consumer Smartphone Ownership
Figure 5. Source: Sarasohn-Kahn (2010)
In 2010 there were approximately 6000 mHealth apps within the Apple App Store. The trend of using smartphones for health is increasing both among the doctors and the consumers. Figure 6 suggests that the iPhone is the brand of choice for Medical Students in the United States. (Sarasohn-Kahn, 2010). However this chart does not take into account the Android OS and is therefore flawed.
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It is evident from the information below that patients are willing to accept new technology. Therefore the old way of healthcare, such as visiting a surgery or hospital is no longer a necessity for many people. The influx of new technology and mHealth is ushering a new era of revolutionary medicine in the 21 st century and this can only be good for all patients.
Medical students who own mobile device by brand:
Figure 6. Sarasohn-Kahn (2010)
It is evident from the information below that patients are willing to accept new technology. Therefore the old way of healthcare, such as visiting a surgery or hospital is no longer a necessity for many people. The influx of new technology
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and mHealth is ushering a new era of revolutionary medicine in the 21 st century and this can only be good for all patients.
The growth in Patients interested in contacting their doctors using technology
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Reflecting this momentum is the variety of ways in which technology can be used to communicate with doctors. Patients in the United States are increasingly interested to use the internet to communicate regarding their health conditions, visits, laboratory investigations and prescriptions.
Consumers interested in using technology to communicate with their doctors
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The use of smartphones is transforming the scene for healthcare trade tools. mHealth applications now encompass stethoscopes, glucometers, and electrocardiogram (ECG) machines. Patients private information can be sent to a secure information/data hub or centre of medical command. This development is allowing healthcare to reinvent its business model, leading to the timely or even early detection of diseases, quicker medical interventions and enhanced compliance. Advanced technological systems using the mobile phone would not only improve the patients health but also reduce health management costs for all countries. A cardiac patient with a tiny chip on their chest can send readings to a nursing station that helps detect an irregularity and also alerts the patient to move to the emergency department. Measures such as these would drastically improve the patients health prospects and reduce the healthcare costs (Connolly, 2011).
If we consider that in the USA, the diabetic patient population is approximately 26 million, we can easily conceive of the advantages that mHealth can have for such sufferers. The disease of Diabetes alone exacts an enormous toll on
healthcare output and budgets. Conceivably mHealth could become a solution for this whole scenario and could help patients and health professionals to coordinate a tailored, diet, drug and exercise regime (ibid.).
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The McKinsey mHealth World Survey 2009 covered 3000 individuals 500 from each of the following countries: USA, South Africa, Brazil, India, China and Germany. The survey revealed that almost 70% of the respondents were willing to pay for mHealth services like drug delivery, phone consultation services and remote monitoring mHealth projects are thriving among many developing countries as shown in Figure 9. Distribution of mHealth Projects Worldwide
Figure 9. Source: Textual pulse (2011)
Healthcare services are usually inadequate in developing countries along with the quality, accessibility, affordability and non-compliance with the needs of patients. These issues are forcing the need for healthcare services to rely on mHealth in developing countries (Akter et al, 2010).
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Table 1 reflects primary healthcare services in developing countries in comparison with developed nations. The picture depicted emphasises the dire need for mHealth services to be implemented promptly as a healthcare necessity in developing countries.
Healthcare indicators in developed and developing countries
Table 1. Source : Ivatury et al (2009)
Technology has great capacity to drastically alter healthcare delivery systems in the developing world (Mechael, 2009). The introduction of technology in
healthcare, particularly the application of mHealth, has changed the healthcare delivery system and has made the system more accessible and affordable throughout the developing world. However, lack of reliability, efficiency of the service delivery platform, knowledge, abilities of the service provider, safety and
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privacy of information are some issues which face mHealth (Kaplan & Litwka, 2008).
In the developing world, confidence of healthcare service users is directly proportional to the perceived quality of the service. Growing access or low costs of healthcare services are not sufficient alone to build the confidence of the service users (Andaleeb, 2001). Without trust and confidence the system may remain underutilised, can be bypassed or used as a measure of last resort (Dagger et al., 2007). The area has not been thoroughly researched and the available literature can be mostly anecdotal (Chatterjee et al., 2009). These factors could have a direct impact on the viability of mHealth in some countries and research into health informatics is still limited (Choi et al., 2007).
2.2.
Ageing Populations/Demographics
To gain greater clarity of the issues and success factors facing mHealth we may direct our analysis towards its implications for senior citizens. Literature suggests that unless the 65+ population is successfully integrated into mHealth programmes, mHealth will not succeed (mHealth Insight, 2010). However as most senior citizens cannot use a smartphone, it may be that this review rather overstates the facts. Nevertheless the implementation of mHealth for future generations accustomed to smartphones is of particular interest for research.
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Figure 9 exposes the huge costs that senior citizens exact on healthcare budgets. Statistics such as these only further the need for mHealth to take away some of the pressure and costs of healthcare. This is along with the need to meet the demands of aging demographics in developed countries.
65+ Population V Healthcare Expenditures
Figure 10: Source; (mHealth Insight, 2010)
According to the University of Cambridge (2011) cost drivers are among the key factors to be considered for mHealth systems to be successful in implementation. The mHealth service must be cost-effective; otherwise it will not be considered a viable healthcare tool in developing or developed countries. Figure 11.1 analyses the increasing costs of healthcare from 2020 2050, while
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Figure 11.2 looks at various healthcare spending statistics from around the world.
Projected regional increases in total healthcare spending, 2020 - 2050
Figure 11.1. Source: World Bank (2006) Selected healthcare spending statistics
Figure 11.2: Source: (ITU/UNESCO 2011)
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2.3.
Pakistan mHealth Economics (World Health Organisation)
According to World Health Organisation statistics, Pakistan has 128,000 physicians (approximately 8/1000 people) and around 66,000 community healthcare workers. Providing smartphones to all of these community workers would be a tiny fraction of the annual cost of employing physicians.
Figure 12 shows the cost of mHealth technology versus the cost of a physician in Pakistan over a five year period. It shows definitively the costs that can be saved by distributing smartphones to community workers against the cost of employing the countrys physicians (the assumption is that in Pakistan annual salary increase is 2% while communications and device costs decline by 1% to 3% annually).
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Illustrative scenario for salary costs versus smartphone costs in Pakistan
Figure 12. Source: University of Cambridge (2011)
The developing countries are taking note of statistics such as these and many new social enterprises are flourishing, spurred on by initiatives such as Coded in Country. The United Nations (UN) Foundation and The Vodafone Foundation are supporting the power of mobile technology to be harnessed in support of UN programmes worldwide. Since 2005 it has provided funds for the use of wireless communications to enhance global health, facilitate disaster relief and to further explore how wireless technology can address some of the worlds toughest challenges (Bhatti, 2009).
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The developing world is moving forward in this field and public confidence is being strengthened, with support from multiple foundations. Entrepreneurial innovation is taking place in the development of mobile applications, with programs such as Sana Mobile (Worldwide); a data collection tool for patient data, Telemed (Puerto Rico): Primary health advice by phone and TeleDoc (India): remote diagnosis of rural patients (Appendix Remote Monitoring).
There is a growing importance of mobile phones to both society and healthcare solutions in the developing world and in Figure 13 we see this point illustrated clearly.
Technology and health-related statistics for developing countries (millions)
Figure11. Source: Bhatti (2009)
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The ubiquity of the mobile device can help reduce the skyrocketing healthcare costs, tailor medical and clinical therapies, and even improve the quality of patients lives. A significant factor in the future of mHealth is consumer appetite, which we have seen is considerable. However, it is also important for harmony and synchronisation to exist among the healthcare sector (the medical community), corporate sector (the technology companies), and the supervisory bodies, so that they can surmount their differences if any and achieve success in mHealth (Connolly, 2009).
2.4.
Pervasive Technologies
The ubiquity of the smartphone also allows it to become a pervasive technology. Persuasive technology is broadly defined as technology that is designed to change attitudes or behaviours of the users through persuasion and social influence, but not through coercion (Fogg 2002).While persuasive technologies are found in many domains, considerable recent attention has focused on behaviour change in health domains. Digital health coaching is the utilization of computers as persuasive technology to augment the personal care delivered to patients and is used in numerous medical settings. Pervasive technology looks at how mobile phones can be platforms for persuasion. In particular we are interested in how mobile devices can be used to improve the health of everyday people. We focus on what is really working to change peoples health
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behaviours, right now. (Persuasive Technology Lab 2010)
All of this research
builds on the foundations of research into the area of Captology. Captology is the study of computers as persuasive technologies. This includes the design, research, and analysis of interactive computing products (computers, mobile phones, websites, wireless technologies, mobile applications, video games, etc.) created for the purpose of changing peoples attitudes or behaviours. (B J Fogg 2002) Designing for behaviour change via social and mobile technology is new, with no leading books or conferences to provide guidance. The goal is to explain human nature clearly and map those insights onto the emerging opportunities in technology. This indicates a future of persuasive technology and Captology, where change will not only be brought about in health, but also in society as a whole. (Persuasive Technology Lab 2010)
Figure 14 Captology Model:
(Persuasive Technology Lab 2010)
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2.5.
Android Operating System
A large part of these changes will also be seen due to open source technology and the Android operating system. This has allowed mobile developers around the world to develop applications relevant to their countrys needs. Google has facilitated the ubiquity of Android by giving it away at no cost to the original hardware manufacturers. This will allow Android technology to be extended to Google television, as well as many of the major hardware manufacturers such as Huawei, Lenovo and Samsung. The combination of the Smartphone, Tablets and Internet TV should bring about a tipping point for mHealth, bolstered by Androids open source capabilities. A group of hardware, software, and telecommunication companies known as the Open Handset Alliance has also been established by Google along with a group of major hardware, software, and telecommunication companies, with the aim to achieve the goal of contributing and adding value to Android development. Many members of this group also have the goal to make money from Android technology which can be achieved from mobile applications (Karch, 2011).
2.6.
Competing Mobile Operating Systems
To gain an understanding of how fast the smartphone industry is moving, we may start by focusing from 2009 - 2011. Android was only launched as an
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operating system in 2009 and Figure 15 reflects its market share v other operating systems upon its launch into the market.
Mobile Phone Operating Systems Worldwide Market Share:
Figure 15. Source: Cell Phones (2009)
As shown the initial growth in Android was on a sharp trajectory from the outset. Although Androids market share looks small in comparison to its competitors, if we consider this was the year it was introduced, it gives an indication of the hyper growth to come. In concerns to Smartphone platforms in the United States, Android also started from a low, albeit impressive base as seen in Figure 16.
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2009 data reveals that the global picture of mobile phone operating systems was largely led by Symbian (Nokia) and the iPhone operating system. Symbian was mostly dominant in the developing continents of South America, Africa and Asia, while the iPhone captured the developed continents of North America, Europe and Oceania. This reflects the enormous task that faced Android upon its launch and why the decision to make it open source and freely available to hardware manufacturers has been so crucial to its strategic aims.
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Figure 17. Source : Cell Phones (2010)
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Figure 18 shows that the iPhone and Symbian were by far the most popular operating systems in 2009. However initiatives such as Coded in Country have given their support to the Android operating system and Figure 19 gives us an indication as to why poorer developing countries would favour Android, when we look at the costs associated with competing app stores. Androids developer fee is by far the lowest in the industry, thereby incentivising developers in developing countries, to use the Android open source operating system.
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The use of Android technology for mobile medical applications can help the developing world to establish itself at the forefront of the mHealth industry. For example, South Africa has initiated multiple mHealth projects (Appendix Remote Monitoring). Their aim is to improve access and lessen the financial burden on the healthcare system. This would also lessen the overall impact of the fragile global outlook on national economies.
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Currently basic cellphones are utilised for the purpose of mHealth in South Africa, due to the fact that many people still do not own a smartphone. Many mHealth initiatives in Africa and Asia are collaborations between the public and private sectors. South Africa considers that mHealth can alleviate the strain and burden on its healthcare and medical resources. As a result it is believed that in the near future South Africans will be using smartphones to communicate with their healthcare provider regarding their health issues and well-being (Kumar, 2011). The reduction in the price of smartphones and especially Android Smartphones will help in this endeavour. The likelihood that mobile phones can enliven health in developing nations is unquestionable. However, there needs to be a system to absorb the rapidly changing technology, to enable the success of the mHealth industry (Bontempo, 2011).
2.7.
Nokia Investment
Android is not the only competitor to the Apple App Store, in bringing about the reality of a ubiquitous mHealth world. Nokia has recently become a strategic investor in the Vision+ fund, which will fund apps for mobile platforms that Nokia supports, in particular the Windows phone system platform. This reflects Nokia recent agreement with Microsoft to use the Windows phone platform. Today, developers, operators and consumers want compelling mobile products, which include not only the device, but the software, services, applications and
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customer support that make a great experience (Elop, 2011). This bodes well for the future development of the mHealth industry due to Nokias presence in the developing world. However the move away from an open source system such as Symbian may just point to how out of touch Nokia executives are with the future of mobile application development. Nevertheless news such as this is always welcome in supporting the growth and prevalence of mobile health applications. Additionally the fund will share revenue streams with developers and allow developers to retain their own intellectual property in startups that Nokia funds. Nokia Advert For Mobile Application Development
Figure 20. Source: Dolan (2011)
Vision+ will foster innovation for the mobile developer ecosystem where the next big opportunity will be local application development. The Nokia developer program will provide strong support for local developers and it will aim to have
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the most local application portfolio. Thus the initiative is a great addition to developer activities, including those with Microsoft. We look forward to more and more innovative applications from creative entrepreneurs in the mobile space Argenti (2011), cited in Dolan (2011). Vision+ will give a fantastic opportunity to leverage strong industry relationships and versatile experience built up within Nokia and the surrounding mobile ecosystem. Vision+ will be able to provide support to developers and entrepreneurs when they plan to introduce the best visions and product concepts into global and local markets. Working together with these companies will help them target and monetize their great ideas Ojanper (2011), cited in Dolan (2011).
The support of all the mobile operating systems is vital to the future of mHealth but also the future detection of diseases. Harvard Medical School recently published a paper called Lab on a Chip which describes new techniques to read ELISA results with a cell phone camera. Additionally, interpreting results can be done using a mobile app:
Detecting Disease via the smartphone
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Figure 21. Source: Sinnige(2011)
Overall results are promising, paving the way for improved diagnostics, treatment and patient monitoring. Applications such as these can help in the detection and prevention of many diseases. Michigan State University (MSU) has developed a low cost device which is able to perform genetic analysis on microRNAs. The device, which is called Gene-Z, operates with an iPod Touch or Android-based tablet and can be charged using solar energy. This makes it a perfect tool to use in low-income and resource-limited countries. It makes it possible to screen for cancer markers in rural areas where the pathology department is far out of reach or non-existent Hashsham (2011) cited in Sinnige (2011). Cancer is emerging as a leading cause of death in underdeveloped and developing countries where resources for cancer screening are almost nonexistent. Until now, little effort has been concentrated on moving cancer detection to global health settings in resource-poor countries. Early cancer detection in these countries may lead to affordable management of cancers with the aid of new screening and diagnostic technologies that can overcome global health care disparities Nassiri (2011) cited in Sinnige (2011).
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Gene-Z: Ipod-Based Tablet Performs Genetic Analysis on microRNAs
Figure 22. Source: Sinnige 2011
Existing pervasive technologies such as Smartphone and Tablets can make a huge difference to the growth and establishment of the mHealth industry. This will put less strain on national economies and allow service users and stakeholders to use technological advancements in the long run even in resource limited settings globally (Bontempo, 2011).
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The ubiquity in the spread of mHealth is also being driven by other innovations such as Groupon which is allowing medical services to grow in popularity. In the first quarter of 2011, there were more than 2,500 medical, health and dental offers published on daily deal sites in the U.S. an eight-fold jump over the 300 offered during the same period a year ago. Hess (2011) cited in Shulz (2011) In fact, the smartphone has helped drive the growth of this market, since notifications of daily deals, or daily deal alerts are sent to your phone and the actual codes can be redeemed directly off of the device (Shultz, 2011).
Medical Services deals on the Smartphone
Figure 23. Source: Shultz 2011
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The example of Groupon allows us to speculate just how large the magnitude of Mobile Applications can be. There is clearly a massive opportunity to be the most prominent company in Mobile, as shown by Googles strategic move to secure its Intellectual Property with its recent acquisition of Motorola. Google has now transferred patents to Taiwans HTC, which makes use of the Android mobile phone operating system (although none are patents from Motorola). Strategic moves to secure the 17,000 patents owned by Motorola can only lead to Android winning the mobile operating system conflict, especially if Google transfers patents to other Smartphone manufacturers. A stronger patent
portfolio would enable the company to better protect Android from anticompetitive threats from Microsoft, Apple and other companies Page (2011) cited in Kwong (2011). With Googorola stepping in to support the Android ecosystem, the chances that Apple forces major workarounds or gets meaningful royalty payments become very unlikely Ferragu (2011) cited in Kwong (2011). The security of the Android as an open system operating also gives further weight to the Coded in Country initiatives around the world, many of which rely upon Android for the development of mHealth medical applications.
2.8.
Coded In Country Projects
Coded in Country mHealth project application areas include:
Education and awareness

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Project Masiluleke (South Africa): An estimated 25% of South Africans are HIV positive, but only 3% know their status. Project M is a text messaging -based service designed to increase the number of South Africans who get tested and receive the countrys free antiretroviral treatment. Ninety percent of South Africans have access to a mobile phone (mHealth For Development, 2009).
Remote data collection EpiSurveyor (Sub-Saharan Africa): In many developing countries, a lack of accurate health data is the largest barrier to overcoming health challenges. EpiSurveyor is a free, open source data collection tool for mobile devices being rolled out in over 20 Sub- Saharan African countries to track and contain disease outbreaks, monitor vaccine supply and identify immunization coverage rates (ibid.).
Remote monitoring Phoned Pill Reminders (Thailand): Deaths by tuberculosisa leading cause of preventable mortality in the developing worldis frequently due to a failure of effective drug regimens. In the Chang Mai province in northern Thailand the public health department piloted a mobile phone-based program where patients received reminder calls to take their medication. The three-month program achieved a 90% drug adherence rate (ibid.).
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Communication and training for healthcare workers ENACQKT (Caribbean): In the Caribbean, nurses often lack basic resources, work remotely, and are isolated from learning centers, making data-sharing challenging. Enhancing Nurses Access for Care Quality and Knowledge through Technology (ENACQKT) empowers nurses by providing remote training and support via PDAs (ibid.).
Disease and epidemic outbreak tracking FrontlineSMS (Global): FrontlineSMS, a PC-based software application used for sending and receiving group text messages, is used by NGOs in a variety of contexts. It has been used to transmit urgent health data, such as in Africa where it was used in reporting and monitoring avian flu outbreaks (ibid.).
Diagnostic and treatment support M-DOK (Philippines): To overcome the limited access to medical specialists in remote communities, the M-DOK program uses text messaging to transfer diagnostic and treatment information to specialists in urban areas (ibid.).
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All of these mHealth programs outline the potential for mobile phones to improve health in the developing world and identify successful, sustainable and scalable mHealth applications.
3. Methodology 3.1. Study Design
The study design used for this report is a literature review which is a type of secondary research. To carry out this secondary research, an analytical and investigative approach has been used. The review of the literature has focused on 4 influential mHealth case studies as an extensive representation and explanation of mHealth. It includes an appraisal and evaluation of the facts, figures and data regarding mHealth. The basic idea is to pull together the existing data and information with current literature on mHealth along with rationalisation and justification for future research into the area. This type of research can serve multiple purposes such as exploring the issues surrounding the Coded in Country phenomenon and answering the research questions. Moreover, it can also describe and illustrate a given issue or problem from the viewpoint of the population that is concerned with the research (Mack et al, 2005).
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It has been highlighted by Dubey (2009) that in order to satisfy the requirements of analytical and investigative approach, data and information has to be extracted in the form of facts and figure. This information has then been used to undertake a critical assessment and evaluation of the mHealth industry.
There are a number of advantages to using secondary research. It is economical, cost-effective, commonly the single source and method to access, analyse and examine large-scale trends (Marrelli, 2005). The popularity of literature reviews is increasing as an answer to research questions by summarising facts and figures in a comprehensive way (Aveyard, 2010). Due to the emerging nature of mHealth, this report has been limited to secondary research from 2009-2011 including; journal articles, reports, books, published statistics, media, published texts and online resources.
3.2.
Ethical Issues and Considerations
Many ethical issues and concerns are related to secondary research. These ethical issues include; access and acceptance, informed consent,
privacy/confidentiality and misrepresentation of the information and the data. The research has been carried out in a way so that it does not cause any emotional, psychological, or financial harm. Responsibility for all methods,
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processes, procedures and ethical issues/considerations in relation to the research lies with me as the author. Research was undertaken in such a way as to encourage the potential for future research. As this research study is concerned with the emerging area of Mobile Health, it has been conducted by consulting my supervisor who encouraged me to pursue this area.
4. Results and Findings According to University of Cambridge (2011) mHealth markets are now being established in both western and developing countries. In most of the developed world, mobile network coverage is ubiquitous while in the developing world the mobile network gives considerably better penetration of the population, compared to the fixed telecoms networks and thus allows communication with potentially millions of patients, even in remote areas. The capabilities and speed of wireless mobile networks are growing fast in a number of countries expanding the scope of mHealth applications. Being a personal device, the mobile phone is constantly with a patient, opening opportunities for private personalised communication. However, in certain developing countries such as Africa, the mobile phone is already employed as a robust tool for frontline health workers. The deployment of cheaper Android smartphones is also facilitating the uptake in mHealth applications in the general population, to the extent that Asia and
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Africa has emerged as the fastest growing markets for mobile phones in the world. Africa has the fastest-growing mobile phone market in the world and most of the operators are local firms. In countries like South Africa, for example, mobile phones outnumber fixed lines by eight to one. In Kenya there were just 15,000 handsets in use a decade ago. Now that number tops 15 million. (Greenwood 2009) Innovation is being encouraged particularly in mobile application development across the world. Applications directly related to health/healthcare are crossing over into use with other applications such as gaming, banking, payments and marketing. Mobile Health applications are also leading patients to be more health conscious, led by the emergence of wellness applications which can monitor such activities as diet and sleep activity.
4.1.
Mobile Medical Application Rules and Guidelines
Mobile Application development guidelines and rules are currently in consultation to distinguish the difference between wellness and genuine healthcare applications. This is being led by the Food and Drug Administration in the United States: Draft Guidance for Industry and Food and Drug Administration Staff - Mobile Medical Applications (FDA 2011).
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However all the statements in the guide contain nonbinding recommendations, therefore it is a draft and not for implementation. This shows that the mHealth industry is in the infancy stage and due to this there is a grey area as to what is permitted and what is not allowed. However as with any emerging industry, this creates opportunities for innovation and entrepreneurship, as can be seen taking place in all the three developing continents of Asia, Africa and Latin America.
In order for mHealth applications to provide solutions to healthcare there certainly needs to be rules and guidelines. However a stringent enforcement of the rules and regulations by the FDA regarding mobile application development could quash any innovation in the market and lead to a monopoly by the big corporate software companies. This would certainly not have the desired effect in terms of the growth of entrepreneurial ventures, however the FDA rules will only apply to mHealth applications in the United States, thereby conceivably leaving the door open for developing countries to lead the mHealth industry in regards to less stringent controls. There is certainly a powerful argument that this will be the case. This argument is further backed up with case study examples such as Medicalhome in Mexico which is a service offered by a Mexican cell phone company, offering 24/7 medical consultations and deep discounts on items such as lab work and medications for a monthly fee of about
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$5. More than 13.2 million households subscribe to the service (Connolly, 2011). The increasing costs of healthcare across the world will see such innovative services as Medicallhome spread across the globe, with a reduction in costs due to patients not having to visit a hospital.
University of Cambridge (2011) also reveals the extension of applications for mHealth which include; mobile-enhanced appointment booking systems, drug authentication and tracking, remote diagnosis or diagnosing epidemics and endemics in any geographical area, as well as well-being applications. Such applications help reduce healthcare management costs in addition to offering solutions for ailments, reducing hospital waiting lists and saving patients time. Additional applications include sensor-based applications, mobile-enabled phonecare, intelligent public health messaging, and aggregated private data for public health benefit.
All of these applications are being developed across the globe further reducing the technology chasm between the west and developing countries. Low income countries are beginning to overtake the richer nations in mHealth application development due to initiatives such as Coded in Country and it seems unlikely that the pace of innovation will be reversed.
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Remote consultation is also a revolutionary innovation for developing nations, including the majority of the worlds impoverished people who are too sick to walk to a hospital, especially in remote areas.
4.2.
mHealth in the United Kingdom
In regards to richer countries the University of Cambridge (2011) focuses upon the UK and describe examples of remote consultation, suggesting the possibility of much more efficient healthcare services. The 3G Doctor service provided by 3gdoctor.com in the UK, provides two essential services. One of these services allows the service users to develop online personal health records and the only charges are the fee from the mobile service provider. The second service facilitates access to a remote video consultation with a health professional with consultation charges of 35. Such a service requires the patient to have a Smartphone with 3G network access and a camera. The validity of such a business model is backed by statistics that show that online video has the highest number of users of any mobile application, as shown by data from Akamai in Figure 24.
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Average Mobile Application Volume Shares
Figure 24: Source: Akamai 2011
Similar business models can be seen with China Mobiles partner company, Yihe, which offers a remote consultation services in China, enabling support through text messaging and voice messaging (University of Cambridge, 2011).
In the developing world less expensive mobile technology has already launched such as the Huaweis $100 Androids IDEOS phone, which has quickly become a best seller in Kenya (Jindenma, 2011). Initiatives such as a Huaweis Smartphone built on top an Android operating system will enable the introduction of services
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such as 3G Doctor into developing countries.
The cost of smartphones is
expected to fall dramatically in the future due to the introduction of newer Android models.
5.0 Conclusion
The recent global economic downturn and recession has impacted nearly all economies worldwide. This factor has also affected the health sector. Governments are reducing investment in health and are using budgetary cuts to curtail the health sector. To help survive budgetary cuts, cost reduction strategies have been initiated. However we also need to consider the impact these global cuts will have on the worlds poor.
As with any recession, there also is the opportunity to take advantage of change through entrepreneurial ventures. The biggest opportunity in todays society is the changes brought about by the mobile revolution and the open source movement, led by the Android operating system. Throughout this paper we have looked at the advantages and solutions offered by mobile development in developing countries and Coded in Country initiatives, along with how the Android system can allow development to take place in any location rather than relying on development centres such as Silicon Valley.
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It is clear that the mobile revolution can also bring about innovation in healthcare and offer solutions in developing countries to the disparity between rich and poor. In developed countries it can offer an answer to the health concerns of an ageing demographic.
In this report my analysis and discussion are on mHealth being the answer to these disparities and of the cost advantages this can bring to both developing and developed countries.
Banishing Adobe, a very important complementor, from the iPhone world drove a neutral party with enormous software capabilities toward the Android world. Whether or not it is true that Flash would have allowed software vendors to sell directly to iPhone users and not be forced to go through the Apple Apps store, it created an instant and unforeseen ally for Android. At the moment, no single dominant design has emerged, but Android is threatening to become dominant. The emerging Asian manufacturing giants Samsung, LG, and HTC that have found it difficult to create globally acceptable software and user interfaces can use the global-class Android operating system, and concentrate upon their manufacturing prowess and their ability to source a significant number of components in house (Kenney and Pon, 2011).
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Figure 26. Source: Nielsen (2011)
Androids key advantages are the open source, many handset choices, multiple phone service options, and an open developer market. However Android must determine how to be open yet control the quality of the user experience. If it resolves these issues and developers continue to create quality applications for the Android platform, Android will be the clear winner (Butler, 2011).
In an ideal world mHealth can also revolutionise healthcare in the developing world and offer the promise of equality in health to the poor. mHealth has significance and impact for social entrepreneurs and new businesses ventures.
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Open source code, in particular the use of the Android operating system, allows mobile developers anywhere in the world to be on an equal footing. It is my hypothesis that Android allows the developing continents of Asia, Latin America and Africa to take the lead in the mHealth industry and offer real answers and solutions to patients. Coded in Country initiatives will allow mHealth to bring about ethical 21st century medicine that will move the paradigm from healthcare to health.
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The Ubiquity of mHealth And The Android Operating System: Coded in Country And The Power Of Local Knowledge

Paul Allen August 2011

The Ubiquity of mHealth and Coded in Country

Figure 1. mHealth Value Chain, Source: Cambridge University 2011

Figure 2. Source: Jane (2011)

Figure 3 illustrates barriers to the implementation of mHealth.

Figure 3. Source: Jane (2011)

smartphone user base using mobile applications.

Figure 4. Source: Lyall (2011)

Consumer Smartphone Ownership

Figure 5. Source: Sarasohn-Kahn (2010)

Medical students who own mobile device by brand:

Figure 6. Sarasohn-Kahn (2010)

The growth in Patients interested in contacting their doctors using technology

Figure 7. Source: Sarasohn-Kahn (2010)

Consumers interested in using technology to communicate with their doctors

Figure 8. Source: Sarasohn-Kahn (2010)

Figure 9. Source: Textual pulse (2011)

Healthcare indicators in developed and developing countries

Table 1. Source : Ivatury et al (2009)

65+ Population V Healthcare Expenditures

Figure 10: Source; (mHealth Insight, 2010)

Projected regional increases in total healthcare spending, 2020 - 2050

Figure 11.2: Source: (ITU/UNESCO 2011)

Pakistan mHealth Economics (World Health Organisation)

Illustrative scenario for salary costs versus smartphone costs in Pakistan

Figure 12. Source: University of Cambridge (2011)

Technology and health-related statistics for developing countries (millions)

Figure11. Source: Bhatti (2009)

behaviours, right now. (Persuasive Technology Lab 2010)

All of this research

Figure 14 Captology Model:

(Persuasive Technology Lab 2010)

Android Operating System

Competing Mobile Operating Systems

Mobile Phone Operating Systems Worldwide Market Share:

Figure 15. Source: Cell Phones (2009)

Figure 16. Source: Cell Phones (2010)

Figure 17. Source : Cell Phones (2010)

Figure 18. Source: Cell Phones (2009)

Figure 19. Source: Cell Phones (2009)

Figure 20. Source: Dolan (2011)

Detecting Disease via the smartphone

Figure 21. Source: Sinnige(2011)

Gene-Z: Ipod-Based Tablet Performs Genetic Analysis on microRNAs

Figure 22. Source: Sinnige 2011

Medical Services deals on the Smartphone

Figure 23. Source: Shultz 2011

Coded In Country Projects

Coded in Country mHealth project application areas include:

Education and awareness

3. Methodology 3.1. Study Design

Ethical Issues and Considerations

Mobile Medical Application Rules and Guidelines

mHealth in the United Kingdom

Average Mobile Application Volume Shares

Figure 24: Source: Akamai 2011

such as 3G Doctor into developing countries.

The cost of smartphones is

Figure 26. Source: Nielsen (2011)

healthline-pakistan/ (Accessed 3 September 2011)

http://www.codedincountry.org/ (Accessed 15 July 2011)

health-fund/ (Accessed: 08/09/2011)