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The Ubiquity of mHealth And The Android Operating System:
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Paul Allen, September 2011
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Paul Allen
p.allen@sussex.ac.uk
University of Sussex
The Ubiquity ofmHealth And The
Android Operating
System: Coded inCountry And The
Power Of Local
Knowledge
9/19/2011
mailto:p.allen@sussex.ac.ukmailto:p.allen@sussex.ac.uk -
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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 QuestionCan 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 ObjectivesThe 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 themHealth 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 smartphone s 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 21st
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 21st
century
and this can only be good for all patients.
The growth in Patients interested in contacting their doctors using technology
Figure 7. Source: Sarasohn-Kahn (2010)
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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
Figure 8. Source: Sarasohn-Kahn (2010)
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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
http://en.wikipedia.org/wiki/Technologyhttp://en.wikipedia.org/wiki/Persuasionhttp://en.wikipedia.org/wiki/Social_influencehttp://en.wikipedia.org/wiki/Social_influencehttp://en.wikipedia.org/wiki/Coercionhttp://en.wikipedia.org/wiki/Persuasive_technology#Fogg2002http://en.wikipedia.org/wiki/Persuasive_technology#Fogg2002http://en.wikipedia.org/wiki/Coercionhttp://en.wikipedia.org/wiki/Social_influencehttp://en.wikipedia.org/wiki/Social_influencehttp://en.wikipedia.org/wiki/Persuasionhttp://en.wikipedia.org/wiki/Technology -
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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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Figure 16. Source: Cell Phones (2010)
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. Source: Cell Phones (2009)
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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Figure 19. Source: Cell Phones (2009)
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 InvestmentAndroid 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 non-
existent. 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. Methodology3.1. 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 ConsiderationsMany 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 FindingsAccording 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.
Conclusion
4.3 Healthcare Budgets Reduced
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
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Android system can allow development to take place in any location rather than
relying on development centres such as Silicon Valley.
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
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significance and impact for social entrepreneurs and new businesses ventures.
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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