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mHealth New horizons for health through mobile technologies Based on the findings of the second global survey on eHealth Global Observatory for eHealth series - Volume 3WHO Library Cataloguing-in-Publication Data mHealth: New horizons for health through mobile technologies: second global survey on eHealth. 1.Cellular phone - utilization. 2.Computers, Handheld - utilization. 3.Telemedicine. 4.Medical informatics. 5.Technology transfer. 6.Data collection. I.WHO Global Observatory for eHealth. ISBN 978 92 4 156425 0 (NLM classification: W 26.5) © World Health Organization 2011 All rights reserved. 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Printed in Switzerland. mHealth New horizons for health through mobile technologies Based on the findings of the second global survey on eHealth Global Observatory for eHealth series - Volume 3 2011Acknowledgments This report would not have been possible without the input of the Observatory’s extensive network of eHealth experts and the support of numerous colleagues at the World Health Organization headquarters, regional, and country offices. Sincere thanks are due to over 800 eHealth experts in 114 countries worldwide who assisted with the design, implementation, and completion of the second global survey. Special thanks to the many authors and reviewers who contributed their expertise to this publication including: Patricia Mechael, Nadi Kaonga, and Hima Batavia from the Center for Global Health and Economic Development at the Earth Institute, Columbia University for their significant contributions to this report; Hani Eskandar of the International Telecommunication Union for his detailed advice on security issues in mHealth Deployment; Joan Dzenowagis for serving as a primary reviewer; and Lilia Perez-Chavolla for writing the case studies. We would like to thank the following professionals who contributed to the case studies. In Bangladesh – Abul Kalam Azad, Ministry of Health & Family Welfare of Bangladesh; Cambodia – Ly Sovann, Ministry of Health of Cambodia; Canada – Kim Fraser, First Nations Inuit Health, Saskatchewan; Deborah Kupchanko, First Nations Inuit Health, Saskatchewan; Christine Labaty, Health Canada; Shirley Woods, Northern Inter-Tribal Health Authority; Ghana – Samuel Quarshie, Ghana Health Service; Eric Woods, Switchboard; Sodzi Sodzi-Tettey, Ghana Medical Association; and Senegal – Adele Waugaman, United Nations Foundation. Guidance for this report was provided by Najeeb Al-Shorbaji, Director of Knowledge Management and Sharing at WHO. The report was reviewed by David Aylward, Chris Bailey, Peter Benjamin, Alison Bloch, Garrett Mehl, Robin Miller, Neil Pakenham-Walsh, Getachew Sahlu, Chaitali Sinha, and Diana Zandi. We are grateful for the financial support and collaboration of our partners: the Rockefeller Foundation, United Nations Foundation, and mHealth Alliance. We acknowledge the important role of our partner organization, the International Telecommunication Union, in the global deployment of mHealth. Special thanks to Jillian Reichenbach Ott for the design and layout, and Kai Lashley for editing. The global survey and this report were prepared and managed by the WHO Global Observatory for eHealth: Misha Kay, Jonathan Santos, and Marina Takane. iv Photo credits: Front cover - Top, Centre, Bottom: ©Dreamstime , PAGE vii - Top, Bottom: ©Dreamstime , PAGE 1 - Left, Centre, Right: ©Dreamstime , PAGE 4 - ©Dreamstime , PAGE 5 - Left: WHO/Nadia Bettega - Centre, Right: ©Dreamstime , PAGE 8 - WHO/Girish Babu Bommankanti, PAGE 9 - Left, Centre, Right: ©Dreamstime , PAGE 18 - WHO/Nadia Bettega, PAGE 19 - Left: WHO/Jessica Otieno - Centre, Right: ©Dreamstime , PAGE 29 - WHO/Nadia Bettega, PAGE 30 - ©Dreamstime , PAGE 32 - Ministry of Health and Family Welfare, Bangladesh, PAGE 36 - ©Dreamstime , PAGE 37 - Brian Levine, 2009 (Courtesy of Switchboard), PAGE 41 - WHO/Damien Walmsley, PAGE 44 - ©Dreamstime , PAGE 45 - UN Foundation/ Dalberg, PAGE 47 - WHO/Nadia Bettega, PAGE 48 - ©Dreamstime , PAGE 49 - Jim Holmes, WHO/WPRO Image Bank, PAGE 50 - Ministry of Health, Cambodia, PAGE 51 - ©Dreamstime , PAGE 55 - WHO/Girish Babu Bommankanti, PAGE 56 - ©Dreamstime , PAGE 56 - File Hills Qu’Appelle Tribal Council, First Nations, Saskatchewan, Canada, PAGE 58 - Touchwood Agency Tribal Council, First Nations, Saskatchewan, Canada, PAGE 63 - Left, Centre, Right: ©Dreamstime , PAGE 70 WHO/ Alberto Aguayo, PAGE 71 - Left, Centre, Right: ©Dreamstime , PAGE 74 - ©Dreamstime , PAGE 75 - Left, Centre, Right: ©Dreamstime , PAGE 78 - ©Dreamstime , PAGE 98 - ©Dreamstime , Back cover - Top, Centre, Bottom: ©Dreamstime. vTable of contents Acknowledgments iv Acronyms and abbreviations viii Executive summary 1 1 Overview 5 1 1 Defining mHealth 6 1 2 Second global survey on eHealth 6 1 3 Overview of findings 7 2 Global results 9 2 1 mHealth initiatives globally 9 2 2 Categories of mHealth initiatives, globally 12 2 3 Adoption of mHealth initiatives by WHO region 14 2 4 Adoption of mHealth initiatives by World Bank income group 16 3 Results and analysis by mHealth category 19 3 1 Health call centres/Health care telephone help line 19 3 2 Emergency toll-free telephone services 22 3 3 Treatment compliance 23 3 4 Appointment reminders 25 3 5 Community mobilization & health promotion 26 3 6 Raising awareness 27 3 7 Mobile telemedicine 34 3 8 Public health emergencies 40 3 9 Health surveys and surveillance 42 3 10 Patient monitoring 52 3 11 Information initiatives 54 3 12 Decision support systems 60 3 13 Patient records 61 vi 4 Barriers to mHealth Implementation 63 4 1 Barriers by WHO region 66 4 2 Barriers by World Bank income group 68 5 Evaluation of mHealth initiatives 71 5 1 Survey results 71 5 2 Relevant literature 73 6 Conclusion 75 7 References 79 Appendix 1 Methodology of the second global survey on eHealth 83 Purpose . . . . . . . . . . . . . . . . . . . . . . 83 Survey implementation . . . . . . . . . . . . . . . . . 84 Literature review . . . . . . . . . . . . . . . . . . . 92 References . . . . . . . . . . . . . . . . . . . . . 92 Appendix 2 Member States by WHO region and World Bank income group 93 Appendix 3 Global mobile phone subscriptions of a responding Member States 99 vii Acronyms and abbreviations 3G Third generation mobile telecommunications AIDS Acquired immunodeficiency syndrome DataCol Data Collector eHealth Electronic health EHR Electronic health record EMR Electronic medical record EMRS Emergency medical response systems H1N1 Influenza A (H1N1) HIV Human immunodeficiency virus ICT Information and communication technologies IMCI Integrated Management of Childhood Illness ITU International Telecommunications Union mHealth Mobile health MDGs Millennium Development Goals MMS Multimedia messaging service GMA Ghana Medical Association GDP Gross domestic product GNI Gross national income GOe Global Observatory for eHealth GPRS General packet radio service GPS Global positioning system OECD Organisation for Economic Co-Operation and Development PDA Personal digital assistant RFID Radio frequency identification SIM Subscriber identity module SMS Short message service SQL Structured Query Language TB Tuberculosis UN United Nations WAP Wireless application protocol WHO World Health Organization viiiExecutive summary Executive summary The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe. A powerful combination of factors is driving this change. These include rapid advances in mobile technologies and applications, a rise in new opportunities for the integration of mobile health into existing eHealth services, and the continued growth in coverage of mobile cellular networks. According to the International Telecommunication Union (ITU), there are now over 5 billion wireless subscribers; over 70% of them reside in low- and middle- income countries. The GSM Association reports commercial wireless signals cover over 85% of the world’s population, extending far beyond the reach of the electrical grid. For the first time the World Health Organization’s (WHO) Global Observatory for eHealth (GOe) has sought to determine the status of mHealth in Member States; its 2009 global survey contained a section specifically devoted to mHealth. Completed by 114 Member States, the survey documented for analysis four aspects of mHealth: adoption of initiatives, types of initiatives, status of evaluation, and barriers to implementation. Fourteen categories of mHealth services were surveyed: health call centres, emergency toll-free telephone services, managing emergencies and disasters, mobile telemedicine, appointment reminders, community mobilization and health promotion, treatment compliance, mobile patient records, information access, patient monitoring, health surveys and data collection, surveillance, health awareness raising, and decision support systems. 1The survey shows there is a groundswell of activity. The majority of Member States (83%) reported offering at least one type of mHealth service. However, many countries offered four to six programmes. The four most frequently reported mHealth initiatives were: health call centres (59%), emergency toll-free telephone services (55%), managing emergencies and disasters (54%), and mobile telemedicine (49%). With the exception of health call centres, emergency toll-free telephone services, and managing emergencies and disasters, approximately two thirds of mHealth programmes are in the pilot or informal stage. Consistent with eHealth trends in general, higher-income countries show more mHealth activity than do lower-income countries. Countries in the European Region are currently the most active and those in the African Region the least active. mHealth is most easily incorporated into processes and services which historically use voice communication through conventional telephone networks. This would explain why the majority of countries are already offering health call centres, toll-free numbers and emergency services using mobile communications. The least frequently seen is the use of mHealth in surveillance, raising public awareness, and decision support systems. These require enhanced capabilities and infrastructure to implement, and therefore may not be a health priority in Member States with financial constraints. Competing health system priorities was consistently rated as the greatest barrier to mHealth adoption by responding countries. Health systems worldwide are under increasing pressure to perform under multiple health challenges, chronic staff shortages, and limited budgets, all of which makes choosing interventions difficult. In order to be considered among other priorities, mHealth programmes require evaluation. This is the foundation from which mHealth (and eHealth) can be measured: solid evidence on which policy-makers, administrators, and other actors can base their decisions. Evaluation is part of a process that can determine cost-effectiveness, involves educating the public about the benefits of mHealth, and leads to government policy – all of which were reported as among the most important barriers to mHealth adoption by Member States. Despite the need for evaluation, the survey found that results-based evaluation of mHealth implementations is not routinely conducted. Only 12% of Member States reported evaluating mHealth services. A concerted effort needs to be made to promote the importance of evaluation and the sharing of results with all Member States. Effective policy will become increasingly important as the field of mHealth matures. Data security is a particularly important issue to address within the area of policy. There are legitimate concerns about the security of citizen information by programmes using mobile health technologies. In particular, message transmission security and data storage security can put citizen information at risk if the necessary precautions are not taken. Policy-makers and programme managers need to be made aware of security issues in the mHealth domain so appropriate policies and strategies can be developed and implemented. Policies will also be vital to efforts in harmonizing eHealth and mHealth initiatives and directions in the short- and long-term. The survey results highlight that the dominant form of mHealth today is characterized by small-scale pilot projects that address single issues in information sharing and access. There were only limited larger mHealth implementations (primarily supported by public-private partnerships). While it is anticipated that large-scale and complex programmes will become more common as mHealth matures, strategies 2 Executive summaryExecutive summary and policies that integrate eHealth and mHealth interoperability into health services would be wise. mHealth is no different from other areas of eHealth in its need to adopt globally accepted standards and interoperable technologies, ideally using open architecture. The use of standardized information and communication technologies would enhance efficiency and reduce cost. To accomplish this, countries will need to collaborate in developing global best practices so that data can move more effectively between systems and applications. Moving towards a more strategic approach to planning, development, and evaluation of mHealth activities will greatly enhance the impact of mHealth. Increased guidance and information are needed to help align mHealth with broader health priorities in countries and integrate mHealth into overall efforts to strengthen health systems. To this end, WHO will undertake several actions. • It will support the use of mHealth in Member States to maximize its impact. This will be achieved by providing information on mHealth best practices and the kinds of mHealth approaches best suited to specific public health scenarios. A series of databases need to be developed which include information on selected national and local initiatives, lessons learnt, evaluations and recommendations, best practices, and cost-effectiveness. • In support of eHealth policy and strategy development, WHO and ITU are creating a National eHealth Roadmap Development Toolkit to support Member States with the development of their own comprehensive eHealth strategies. The Global Observatory for eHealth (GOe) and its partners will work to develop a framework for the evaluation of mHealth programmes, including meaningful and measurable indicators. A global database of selected evaluation research findings will be built for mHealth with a particular emphasis on developing country initiatives. Member States will have ready access to the database when planning projects and preparing project proposals. • WHO in collaboration with the ITU will provide guidance to Member States on the content and scope of data privacy and security policy for mobile telecommunications in health. Mobile health will advance through creating country-based eHealth strategies that incorporate it into the existing eHealth domain. Policies need to be complemented by standards, architectures, and solid partnerships to help pilot mHealth initiatives mature and realize their full potential – utilizing mobile and wireless technologies to improve health and well-being. 3Overview 1 Overview The unprecedented spread of mobile technologies as well as advancements in their innovative application to address health priorities has evolved into a new field of eHealth, known as mHealth. According to the International Telecommunication Union there are now close to 5 billion mobile phone subscriptions in the world, with over 85% of the world’s population now covered by a commercial wireless signal (1). The penetration of mobile phone networks in many low- and middle-income countries surpasses other infrastructure such as paved roads and electricity, and dwarfs fixed Internet deployment. The growing sophistication of these networks – offering higher and higher speeds of data transmission alongside cheaper and more powerful handsets – are transforming the way health services and information are accessed, delivered, and managed. With increased accessibility comes the possibility of greater personalization and citizen-focused public health and medical care. Governments are expressing interest in mHealth as a complementary strategy for strengthening health systems and achieving the health-related Millennium Development Goals (MDGs) in low and middle- 1 income countries. This interest has manifested into a series of mHealth deployments worldwide that are providing early evidence of the potential for mobile and wireless technologies. mHealth is being applied in maternal and child health, and programmes reducing the burden of the diseases linked with poverty, including HIV/AIDS, malaria, and tuberculosis (TB). mHealth applications are being tested in such diverse scenarios as improving timely access to emergency and general health services and information, managing patient care, reducing drug shortages at health clinics, enhancing clinical diagnosis and treatment adherence, among others. 1 5The field’s potential is recognized by the United Nations (UN) and World Health Organization (WHO). The former included mHealth as a key innovation to achieve the goals outlined in the new Global Strategy for Women’s and Children’s Health launched in New York on 22 September 2010. The latter included a module on mHealth in the 2009 Global eHealth survey. An understanding of this new environment from the perspective of WHO Member States and analysis across World Bank income groups is a critical next step to advancing mHealth globally. This report aims to make policy-makers aware of the mHealth landscape and the main barriers to implement or scale mHealth projects. It combines the results and analysis of the data gathered from the mHealth survey and is complemented by five country case studies and a review of the current literature related to mHealth. 1 1 Defining mHealth mHealth is a component of eHealth. To date, no standardized definition of mHealth has been established. For the purposes of the survey, the Global Observatory for eHealth (GOe) defined mHealth or mobile health 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. mHealth involves the use and capitalization on a mobile phone’s core utility of voice and short messaging service (SMS) as well as more complex functionalities and applications including general packet radio service (GPRS), third and fourth generation mobile telecommunications (3G and 4G systems), global positioning system (GPS), and Bluetooth technology. 1 2 Second global survey on eHealth The second global survey on eHealth was conducted in late 2009 and was designed to build upon the knowledge base generated by the first survey conducted in 2005. A detailed description of the methodology and analysis is included in Appendix 1. One hundred and twelve Member States responded to the 2009 survey. Appendix 2 contains a list of the responding countries by WHO region and World Bank income group, and Appendix 3 shows the level of mobile phone subscriptions for them. While the first survey was general and primarily asked high-level questions at the national level, the 2009 survey was thematically designed and presented more detailed questions in a series of survey modules, including mHealth. The goals of the mHealth module were to document mHealth activity in Member States as well as identify the barriers to its adoption. This included, specifically, identifying and documenting: • the existence and maturity of mHealth activities within Member States; • types of mHealth initiatives being conducted; • status of monitoring and evaluation of mHealth initiatives; and • barriers to implementation. The thematic design of the survey has provided the GOe with a rich source of data that are being used to create a series of eight publications – The Global Observatory for eHealth Series – due for publication during 2010 and 2011. 6 OverviewOverview 1 3 Overview of findings This report will show that: • Rather than strategic implementation, the emergence of mHealth is occurring in many Member States through experimentation with technologies in many health settings. Policy-makers and administrators need to have the necessary knowledge to make the transition from pilot programmes to strategic large-scale deployments. • Many countries reported up to six mHealth programmes per country. • The survey ranked the adoption of the top mHealth initiatives ranging from Health call centres (number 1) to decision support systems (number 14); patterns of adoption were described according to World Bank income group and WHO region. • Many of the top six barriers to mHealth implementation related to the need for further knowledge and information, such as assessing effectiveness and cost-effectiveness of mHealth applications. Other key barriers included conflicting health system priorities, the lack of supporting policy, and legal issues. • Although the level of mHealth activity is growing in countries, evaluation of those activities by Member States is very low (12%). Evaluation will need to be incorporated into the project management life-cycle to ensure better quality results. • Data security and citizen privacy are areas that require legal and policy attention to ensure that mHealth users’ data are properly protected. • Member States will progress further in implementing mHealth if they share global ICT standards and architecture. Cooperation in the development of best practices enterprise architecture will ensure that data can move more effectively between systems and applications. 7Global results 2 Global results The 2009 survey results and analysis are presented from a global, regional, and economic perspective, 2 through the lens of the WHO regions and World Bank income groups. Each mHealth initiative is presented independently. Evidence from the literature is presented along with the results to provide a more complete picture. 2 1 mHealth initiatives globally Key findings „ One hundred and twelve Member States completed the mHealth module of the survey. A vast majority (83%) reported at least one mHealth initiative in their country. „ Of this 83%, most Member States reported implementing four or more types of mHealth initiatives. „ Responding low-income countries (77%; n=22) reported at least one mHealth initiative compared to 87% (n=29) of high-income countries. 2 9The survey found that most Member States use mHealth initiatives: 83% of the 112 participating Member States reported the presence of at least one mHealth initiative in country (See Figure 1). Of these, three quarters reported four or more types of mHealth initiatives. Only 19 responding countries did not report the presence of an mHealth initiative. It is important to note that a Member State reporting zero mHealth initiatives does not indicate that no mHealth initiatives are being conducted in the country. Local projects being executed by small organizations or nongovernmental organizations (NGOs) may not be widely known and the expert informants completing the survey may not have been aware of them. In addition, the survey was limited by the fact that respondents could only provide one example for each mHealth category. Thus, the number of initiatives reported depicts the breadth of mHealth activity in a country but does not represent the depth of activity within each category. Figure 1. Member States reporting at least one mHealth initiative, by WHO region 100 80 60 40 20 0 South-East Americas Europe Eastern Western Africa Global Asia Mediterranean Pacific WHO regions 10 Global results Percent of countriesGlobal results At least 75% of participating Member States from each WHO region reported the presence of one mHealth initiative in the country (Figure 1). Countries in the African Region reported the fewest initiatives, while those in the South-East Asia Region reported the most. Analysis of the survey results by World Bank income group is shown in Figure 2. The low-income group reported the fewest participating Member States with at least one mHealth initiative (77%); however, this was not significantly lower than that for the high-income group (87%). Based on the wide distribution of reported mHealth activity both geographically and economically, it appears that mHealth is an approach with global appeal. Figure 2. Member States reporting at least one mHealth initiative, by World Bank income group 100 80 60 40 20 0 High income Upper-middle Lower-middle Low income World Bank income groups 11 Percent of countries2 2 Categories of mHealth initiatives, globally Key findings „ The most frequently reported types of mHealth initiatives globally were health call centres/ health care telephone help lines (59%), emergency toll-free telephone services (55%), emergencies (54%), and mobile telemedicine (49%). „ The least frequently reported initiatives were health surveys (26%), surveillance (26%), awareness raising (23%), and decision support systems (19%). In order to help classify the use of mobile technology in a health care system, eight categories were created to reflect the most well-established mHealth interactions between the health system and the public and within the health system itself. Countries were asked to report whether a certain type of mHealth initiative was taking place in their country, provide an example, and its stage of development according to the following definitions: • Informal: not part of an organized health programme but involves the use of mobile technology to communicate for health-related reasons • Pilot: testing and evaluating the use of mHealth in a given situation • Established: an ongoing health-related programme using mHealth Table 1 lists the types of mHealth initiatives covered in the survey. Table 1. mHealth categories used in the 2009 survey Communication between individuals and health services • Health call centres/Health care telephone help line • Emergency toll-free telephone services Communication between health services and individuals • Treatment compliance • Appointment reminders • Community mobilization • Awareness raising over health issues Consultation between health care professionals • Mobile telemedicine Intersectoral communication in emergencies • Emergencies Health monitoring and surveillance • Mobile surveys (surveys by mobile phone) • Surveillance • Patient monitoring Access to information for health care professionals at point of care • Information and decision support systems • Patient records 12 Global results