Our topic today is mHealth in Developing Countries. My name is Martin Were. I'm an Associate Professor of Medicine at Indiana University. And a research scientist at Regenstrief Institute. Welcome. The objectives of this presentation are, one, to introduce mHealth. Two, to identify the roles of mHealth in developing countries. And three, to discuss considerations around implementing mHealth in resource-limited settings. So let's jump right into it, okay. MHealth, or mobile health, is defined as the practice of medicine and public health, supported by mobile devices. Here mobile devices are small, hand-held devices typically less than two pounds, that somebody can actually have in, have fit in their hand or fit in their palms, okay. We could be talking about feature phones, smartphones, tablets, and more recently, we are seeing wearable devices coming into play. And this is just a sample of some of the mobile devices you have out there. Mobile device subscriptions have obviously increased over the last few years, as you can see from this World Bank data. So if you took about a hundred people in the world, over 90 of them in this day and age would have a mobile device accessible to them. Sub-Saharan African countries are actually not that far behind. As you can see from this other graph from the World Bank the number of mobile device subscriptions in developing countries is also increasing almost exponentially. In fact you have more mobile device subscriptions in Africa right now than in the US for example. Now, as the number of mobile subscriptions worldwide keep increasing, also comes an increase in the number of mobile health initiatives around the world. As you can see, just looking at the number of articles that have come out, this was from 2010, you're also seeing an exponential increase in articles describing mobile health initiatives okay? Now the hypothesis as related to mobile health is that if you have better data, better communication, better information and better access that you'd have improved health outcomes. Now what type of mobile health applications can be used in developing country settings? We are going to spend a good amount of time just walking through the range of mobile health applications that we are seeing being implemented in developing countries just to help provide a sense of the breadth of things you could do with mobile health technology. And what I'm going to show you is some of the work we did as part of the mHealth alliance evidence working group which was constituted between 2012 and 2013. Okay now, we are going to break mobile health applications into three domains in terms of the impact on health. So we'll talk about mobile health applications as related to health systems, we'll tak about mobile health applications as related to provide us and also as related to clans. So let's start with a subset of mobile health applications as related to health systems and we'll just list some of them there. So you can have mobile health applications that are used for real time data access or what is called personal health records or personalized health records. A lot of places are using mobile health applications to collect vital statistics. So birth, death registries and things like that. And also you're seeing a lot mobile health applications being used for disease surveillance out there. These applications obviously are intended to provide particular types of outcomes. In this case, as related to the health systems, they can help improve demographics in health data. They can help with appropriate resource allocations. And they can help with policy adjustments. And again the ultimate goal is to have a responsive health system and also know your outcome impact is to have improved population health. The other outcomes that you can have obviously is improved efficiency and coverage or what we typically call basically health systems strengthening which can also help improve individual client outcomes. Now again, these are connected to some degree between improved health outcomes and improved population health. Other things you can do with mobile health applications in the health space include having mobile applications used for logistics monitoring and tracking. So you can have GPS-based systems that are used out there. You can have mobile finance to help people pay for their health services or to help with insurance. You can have basically systems for reporting quality of services or performance. We see this a lot in drugs [INAUDIBLE] applications. And then you can have electronic health record systems that are actually accessible through a mobile device, okay? Now the outcome and impact of some of this is, obviously you could have better supply chain management. You could have more accurate information. You could help with continuity of care, and potentially have information to evaluate whether the care can be affordable and how to improve the affordability of care itself. Again this set of health systems fixing mobile health applications will improve efficiency and also will potentially improve the quality of care provided. The next set of mobile health applications that you see relate to applications that solve the provider who's offering health services in itself. Here you have your typical walk through management systems, so mobile health applications that help with registration of clients. Making sure that that information is available to the next set of providers, and also even help with assessment of where there are time gaps that could be improved. You have mobile decision support systems, which offer real-time decision support, let's say as a provider is entering data for a patient. So for example if somebody has very high blood pressure. The mobile health application will tell the provider, please refer this patient to a central facility. You have mobile health systems that provide what you call on demand training and assessment. And again, in a lot of developing country settings, the providers don't have access to as much information. So if you have a mobile health application that can offer those educational services to them. You could help improve the quality of care. You have the point of care diagnostics. And again this is not really a big emerge in technology with wearable devices come into play. But now you have a lot of mobile applications that allow you to diagnose a particular condition, potentially even run an algorithm within the mobile device to tell you, for example, if somebody has a particular skin condition or if a chest x-ray's normal or abnormal. But point of care diagnostics are becoming a big part of the mobile health systems we are seeing. And then, of course, the classic remote monitoring using a mobile device. Or a remote consultation where you can be in the field. You see a particular case. Are able to consult another provider safely and securely using a mobile device, and get feedback from them is one of the other things we are seeing as an implementation of mobile health in developing country settings. Again, some of the outcomes that you would expect improving is the competence, improving the accountability, improving the effectiveness. Eventually, all that goes towards improving the quality of care that these providers give. And eventually improving the health outcomes of the population itself. Again, part of the outcomes that we aways look at is improved health behaviors by the clients who were served by the providers. So if the providers are using mobile health technologies to offer these services they're most likely going to be able to change the behavior of their clients, okay? And again a lot of these things end up being interconnected to some degree. Now the last set of applications that we see for mobile health are those that are client-facing. And this is a broad range of applications that in the west actually have a lot more use than places in developing countries. But you can see the use of more bio technology for canceling. This could just be simple sms messages sent to the client to tell them please take your medication or please come to your appointment. Again the next set is appointment scheduling, making sure that people don't default or miss their appointments or show up on time. And if they miss their appointment, you can actually remind them using their mobile devices to come to those appointments. Mobile health systems targeting client education is becoming a very important space, especially if you have a population which is difficult to access. So you can send, videos, media based educational materials, to the clients. And again, this can be targeted based on what the client's condition is. A lot of the mobile health applications now can really be used in a remote fashion to help educate the provider, sorry educate the client. And of course you have on demand information and help lines where the client can, sms or request for information at a remote site. And that information can be sent back to them on their mobile device. This could include, where can I get particular type of services? Which facility has medications in stock? And things like that. Again, the mobile health applications that serve clients will go to obviously improve the effectiveness with which the providers actually provide the care to their clients. But more importantly it will increase the clients' knowledge and self-efficacy, improve their behavior and also improve the quality of care that the clients get. So this year is just a very high level overview of some of the potential things we could do with mobile health technologies in a developing country setting. You can see from this diagram here, that we are actually not talking about the mobile health technologies themselves. So, now whether we are talking about apps on smartphone devices. Whether we are talking about using SMS based technologies or USSD. Again, you can combine these technologies in different ways to help meet these different needs for mobile health applications. So think about the range of mobile health technologlies out there and then using them innovatively to meet some of these needs for the clients that will be solved. Here are some of the considerations for income okay that so if you're going to be implementing mobile health applications in developing countries or in any place, there are some things that are worthwhile to think about. The major one, which if you interviewed a lot of people around what their concerns for mobile health applications are, they will tell you security and privacy. Obviously if you have more backup devices with protected personal health information, you don't want it to be accessible to other people so, if you are going to be implementing an application, you have to be very sensitive to the security and privacy issues and this is a whole set of discussions in itself that could be elaborated in other basically talks in the future. The other issue to really pay attention to is there evidence of impact of the mobile solution that is being implemented? Now, the evidence working group of the mhealth at last actually looked at this a couple of years back. And a lot of times we see applications being rolled out without real clear evidence that they actually impact care or improve things in a positive way. And so, anytime someone is implementing a mobile health application, at the back of our minds we have to ask what's the evidence of impact for this solution. And they have plans to evaluate that evidence or the evidence of impact if it's not already there. You could have an application that works very well. But once you start using it across a large number of communities, health centers, or use it for a lot of individuals you find that it doesn't scale as well. It's either slow. It's clumsy. Having a vision towards scaling your application right from the outset would help you develop and implement applications that go to solve the mission in which it is supposed to do in a little bit more of an effective way. Again, mHealth solutions don't live, in and of themselves. When you're talking about a patient, their records usually sit as part of a large electronic health records system. There are multiple sources of the healthy information. So as you build and implement your mobile applications, you really have to think about how your application interoperates with other systems, which means can it exchange data with the other systems. So for example, can you transfer data to an electronic health record? In countries, we start thinking about broader health information exchanges, with the the mobile health application being just one small component of the larger health enterprise. You have to think about whether your application can send data for reporting to the government or other stakeholders, if that's a requirement. And also you have to think of applications which can potentially be used across multiple disease or multiple domains, instead of being very specific to one particular thing. So for example you shouldn't have an application that can only take care of an HIV patient and not be able to collect other data relevant to the client because the client is not just HIV patient. They have most likely other conditions for which you need to collect data. And again, these are standard things around health information systems in general, and you have to employ them when you're thinking about your mHealth applications. Obviously, you have to think about the cost. You have to think about who's paying and who's benefiting, because often times the person who's benefiting might not be necessarily the person who's paying. So if a country says we need to send SMS messages to clients. But then now they're asking mobile operator to bear the costs, well it's the government who's benefiting. You have a disconnect sometimes and that potentially disincentivizes partnerships with operators and people who might potentially have pretty good impact in making sure that your email applications successful. This conversation is important because you have to make a value proposition for every player in the mobile space to help them walk with you in a collaborative fashion. And again, when you are thinking about implementing your mobile application. Especially in a developing country context. You have to think about what policies are in place. Did they have mobile health or e-health strategies for which you have to comply with? And what are the other ethical considerations as you implement these systems. We already talked about privacy, confidentiality. A lot of these countries, people share phones, so you have to think about how to make sure that the person you are targeting actually is not inadvertently harmed because the message was seen by the wrong person for example. And also given issues around digital divide as you're implementing mobile systems you're naturally selecting some people who have mobile devices while other people don't. You just have to think about how to accommodate those people who potentially might not be rich by this technology. Again this is not necessarily an exhaustive set of issues around mobile health but it gives you an idea about some of the things to think about. In summary we think more than a half has great potential to improve healthcare in developing countries. Obviously, mobile devices are quite pervasive in that settings, and leveraging in innovative ways can potentially help improve the quality care, strengthen the health system, and make the providers there perform much better, okay? We have a whole range of applications as now we've tried to describe today that you could use for mobile health and new innovative applications are coming as the technologies themselves evolve. But as you're implementing mobile health applications or even evaluating a mobile health application that's been considered for developing country setting. The few key things you have to think about, to ensure that they can be successfully implemented, and that they can be successfully scaled. And, I want to thank you, for allowing me to just give you this very high level overview, of mobile health systems in developing countries. This is a very involved and deep topic in a lot of ways and the hope is that this lecture at least gives you just a starting to initiate a comprehensive and cohesive composition around mobile health. Thank you very much.