pHealth 2015 79

B. Blobel et al. (Eds.)

IOS Press, 2015
2015 The authors and IOS Press. All rights reserved.
doi:10.3233/978-1-61499-516-6-79

mHealth in Low- and Middle-Income

Countries: Status, Requirements and
Strategies
Diego M. LOPZa,1, Bernd BLOBELb
a
Telematics Engineering Research Group, University of Cauca, Colombia
b
Medical Faculty, University of Regensburg, Germany

Abstract. Recent studies demonstrate the potential of Mobile Health (mHealth) to

improve quality of care and efficiency in low- and middle- income countries
(LMIC). However, strong evidence of their impact, especially in large scale
projects is still missing. The objective of this paper is to provide an overview about
the current status of mHealth in LMIC, and to identify Requirements and possible
Strategies to strength their health systems. A search in Pubmed was performed,
which resulted in 427 articles. Restricting the search to review papers published
during the last 5 years, 72 publications were identified and characterized, and the
more relevant articles analyzing mHealth use, impact and/or adoption in LMIC
from a more generic perspective were analyzed in detail. Finally, based on the
literature, and complemented with the authors own reflections and experience,
mHealth challenges and strategies were identified and presented according to the
WHO Health Systems Framework which identifies six main lines of action to
improve the performance of health systems: service delivery, health workforce,
health information systems, essential medical products and technologies, health
financing and governance.

Keywords. mHealth, Low Income Countries, Middle Income Countries,

Developing Countries

Introduction

WHO has defined mHealth as the provision of health services and information via
mobile technologies such as mobile phones and Personal Digital Assistants (PDAs).
The growth of mHealth studies, local and regional projects, and established
implementations is pushed by the exploding number of mobile technology users, rapid
expansion of mobile networks with higher coverage and data transmission speeds, the
decline of devices and service costs, fast and continuous innovations in mobile
technologies including sensors and more recently wearables, resulting in improved
features and functionalities at more accessible price. Mobile platforms are capable to
deliver health services independent of locations of users and healthcare facilities, so
reaching underserved populations, e.g., in rural areas, at home, etc. Furthermore, they
can change health behavior and outcomes including treatment adherence and
compliance with focus on prevention, improve emergency response systems, but also

1
Corresponding Author. Diego M. Lopez, PhD, Professor, University of Cauca, Colombia; Email:
[email protected]
80 D.M. Lopz and B. Blobel / mHealth in Low- and Middle-Income Countries

address skilled workforce shortages, or lack of actionable and timely surveillance

programs. Finally they help overcoming lack of drug inventories and poor supply chain
management, adverse drug reactions, lack of medical diagnostic treatment, deficiencies
in information flow and reporting [1]. All those factors are changing the way health
services are offered.
The phenomena described have been of interest for researchers, donors, and to a
lesser extent, for different countries governments, who have seen mHealth as an
opportunity to improve current health systems. As suggested by many authors, Low-
and Middle-Income Countries (LMIC) are looking to learn from experiences of Higher
Income Countries, and leap frog stages in the development of eHealth projects,
therefore saving cost and improving quality of care [2, 3].
A problem of many initiatives is their unsustainability, not scaling up when the
initial funding is exhausted after the pilot phase, partially caused by the given policy
environments, business models and funding schemes. A way out of this dilemma is to
identify real needs and demands of target beneficiaries, local health priorities and to
take into account the local environment, conditions, stakeholders, policies, settings and
practices when planning, designing and implementing mHealth projects.[1].
Despite the unquestionable potential of mHealth to improve quality and efficiency
of health, strong evidence of their impact in healthcare process, especially for large
scale adoption is missing. According to a survey conducted by WHO member countries
[4], only 12% of countries have reported projects where mHealth interventions are
evaluated. Other barriers are:
x low priority given the m-Health programs, compared to other health
programs funding;
x lack of knowledge and training in these areas;
x the lack of government policies and the lack of evidence on their cost-benefit
[4].
This is valid even today, as most recent studies and systematic reviews published
on the use, impact and/or adoption of mHealth in LMIC support the aforementioned
WHO statements (especially in relation to healthcare quality, quality of the evaluation,
economic impact, equity and safety issues) [2-7]. Also papers like the one published by
Adam et al. [8] do not fundamentally change this statement.
The objective of this paper is to provide an overview about the current status of
mHealth in LMIC, and to identify Requirements and possible Strategies to strength
health systems in these countries.

1. Current State of the Art

The body of literature documenting mHealth projects and interventions in LMIC

expands to various health areas including diagnostics, prevention, control, research,
training, behavioral change intervention, among others. They have demonstrated their
potential to improve communication and health information management, access to
remote healthcare facilities, health workforce training, teleconsultations and remote
monitoring, and surveillance to improve public health programs, by that way
strengthening health systems around the globe [6-7, 9]. Those projects and
interventions involve the use of a range of mobile technologies from basic text
 D.M. Lopz and B. Blobel / mHealth in Low- and Middle-Income Countries 81

messaging technologies to more complex smartphone applications (Apps), and

connected devices.
A search in PUBMED using the keywords mhealth, mobile health, low-and
middle-income countries, and developing countries was performed, which resulted
in 427 articles. Restricting the search to review papers published during the last 5 years,
72 publications were identified, which discuss applications of mobile technologies for
the diagnosis and management of a wide spectrum of diseases, such as cancer, HIV,
epilepsy, diabetes, kidney failure, but also applications in radiology, ophthalmology,
dermatology, pediatrics, mental disorders, etc. Other mHealth interventions were
focused on the management of risk factors and health promotion and prevention, e.g.,
hypertension, glycemic control, immunization, health behavioral change, maternal and
child health, sexual health. Likewise, other studies found analyzed the impact of mobile
technologies in different countries and regions, while other research works describe
more general eHealth applications and Telemedicine services. A summary of relevant
articles analyzing mHealth use, impact, and/or adoption in LMIC from a more generic
perspective is provided below.
Hall et al. [5] provided a review of evidence of the health impacts of mHealth
interventions, categorized into 12 common applications of mHealth which include
Education and Behavior Change, Sensors and Point of Care Diagnostics, Registries and
Vital Events Tracking, Data Collection and Reporting, Electronic Health Records
(EHR), Decision Support Systems, Provider-Provider Communication, and five more
administration and management related applications. The authors concluded that
existing evidence embraces mainly pilot studies and small-scale implementations, not
providing clear proof on potential mHealth benefits. Education and behavior change
was the most represented domain of application in the review, followed by Data
Collection and Reporting (including Registries and Vital Events Tracking). Clinic-
oriented applications such as Sensors and Point of Care Diagnostics, EHR and
Decisions Support Systems were scare in the reviewed papers. In consequence, more
functionalities and the integration into existing health information systems is demanded.
The use of mHealth for administrative and management applications was also limited,
compared with other dimensions. The review didnt discuss cause and/or strategies to
mitigate the limited evidence on Health interventions in LMIC.
Peiris et al. [3] provided a systematic review of the literature about the impact of
mHealth interventions on health care quality, restricted to non-communicable diseases
in LMIC. The most important conclusion is that a limited number of high-quality
studies exist, which are mainly focused on CVD and diabetes. Behavior change
interventions through the use of text messaging systems are the most common
application. The authors cautioned about the gap in existing literature, trying to
understand the factors that may influence scalability, replication of outcomes in
different settings, and sustainability of outcomes beyond controlled trial settings. The
orientation towards equity and safety issues is also necessary. They recommended that
researchers must provide comparative effectiveness studies using traditional health
care interventions as baseline, measuring process quality and economic outcomes, an
analysis success and failure stories to determine local opportunities, and finally
examine national and regional policy-level barriers to large-scale adoption.
Chib et al. [7] performed a critical review and categorization of 65 articles on
existing mHealth studies in LMIC with special emphasis on outcomes relevant to
health policy design and decision making. They concluded that there is a lack of
accepted theories or measures providing outputs relevant for making policy decisions.
82 D.M. Lopz and B. Blobel / mHealth in Low- and Middle-Income Countries

Studies explaining processes of technology introduction, adoption, and improvements

in healthcare process and indicators are necessary. The authors recommended that
future research should propose theoretical and measurement standards for technology
adoption, with emphasis on  
 perspectives, but developed by
interdisciplinary teams including IT, healthcare and public health experts. An important
challenge identified is to consider particularly sociological factors in the interventions
such as culture and gender.
Finally, Bastawrous and Armstrong [2] provided an overview of the peer-reviewed
literature on the application of mobile technologies in healthcare in both low and high-
income countries, based on the same 12 common applications of mHealth presented by
Hall et al. [5]. Despite not being a systematic review, the article also concludes that
most existing studies in low-income countries lack the quality necessary to offer
scientific evidence to demonstrate the utility of this type of interventions. Also a big
gap in terms of quality of studies, technology used and application domains between
low and high-income countries is demonstrated. However, no strategies or
recommendations are provided apart from suggesting the need for new evidence based
on regulated/expert body guidelines.
Similar reviews have been performed by Wallace Chigona et al. [10].

2. Requirements and Strategies

The literature reviews detailed in the previous section, expose several challenges to be
faced by current and future mHealth solutions which are complemented by the authors
own reflections and experience. Identified mHealth challenges and proposed strategies
are organized according to the WHO Health Systems Framework which identifies six
main lines of action to improve the performance of health systems [11, 12]:
x Health service delivery;
x Health workforce;
x Health information system;
x Essential medical products and technologies;
x Health systems financing, and
x Leadership and governance.

2.1. Health Services

In order to support the delivery of effective, safe, quality healthcare services and
interventions when and where needed, with minimum waste of resources, solid
evidence about the effectivity and impact of eHealth interventions is inevitable.
Unfortunately all revision performed so far demonstrate that current evidence base is
insufficient, at least at the level of large scale projects. Based on registered clinical trial
protocols of large-scale mHealth interventions, Peiris et al. [3] are optimistic about
possibilities to obtain the necessary evidence in the coming years. One big question is
however, how to deal with the urgent need to provide quality mHealth services in
LMIC? Also, how to guarantee quality, efficiency of resources and safety assurance
during mHealth interventions design? Chib et al. [7] claim for new theoretical and
measurement standards for mHealth technology adoption, which in addition needs to
be adapted to the realm of local, regional and national health systems. One possible
 D.M. Lopz and B. Blobel / mHealth in Low- and Middle-Income Countries 83

answer to these concerns is to address the complexity and particularity of health

systems in LMIC by a reference architectural model and framework which individual
countries will use to create country-specific architectures. The Generic Component
Model (GCM) and its framework provide the means needed for successfully
undertaking such endeavor [13].

2.2. Health Workforce

mHealth technologies should support the provision of well-performing human

resources, including, e.g., trained, productive, sufficient and equitably distributed
health staff. According to the revised literature, health workforce training and
education through the use of mHealth applications or mobile technologies (e.g. SMS)
has been one of the main application areas in the field [3, 5], including health personal
education and training [15], as well as routine feedback about ways to improve
performance [15]. These interventions in general have been demonstrated to be
effective. However, one of the main requirements of this dimension, borrowed from
current mobile learning (mLearning) challenges, is how to deal with the need for more
flexible, simple, intuitive interfaces, as well as security, privacy and legal issues [16].
More critical is, however, the pedagogical and didactical challenges for the educators
and health professionals as well. As pointed out by Georgiev et al. [17], the focus of
mLearning is the student who is ruling the learning process. Therefore, additional
difficulties such as health professionals engagement and motivation, demanding
innovative students evaluation and follow-up strategies, are imposed. In this
dimension, also patient empowerment is foremost important, being convinced that the
mobile technology is a tool that supports health professional communication and
healthcare decision support.

2.3. Health Information Systems

Health information systems challenges include the availability of reliable and timely
health information about health determinants, health system performance and health
status. Especially important is the use of mobile technology to support communication
and adequate use of health information. From a technical perspective many challenges
arise. First, despite increased mobile network coverage, there are several inequalities,
even in middle income countries, especially in terms of Internet access and coverage.
Despite decreased price and availability of mobile devices, data, and
telecommunications charges; infrastructure barriers and digital literacy challenges are
still present [18]. According to Internet connection statistics [19], around 60 percent of
the world lacks Internet access. Second, several technical challenges are still unsolved.
mHealth systems have to be flexible, scalable, interoperable, standard based, intelligent,
adaptive, trustworthy, secure, liable. They have to be able to interoperable with legacy
health IT systems and services, including personal and patient electronic health records.
Mechael et al. see an opportunity for mHealth technologies not just to be an
information access point, but to become an integrator of health information across the
entire cycle of care [20]. Here user acceptance is also very relevant because it heavily
depends on the trust, security and privacy of mHealth technology. No less crucial for
the adoption of technologies is user acceptance of solutions. This is quite critical,
especially for developers of mHealth solutions, because it is not possible to know in
84 D.M. Lopz and B. Blobel / mHealth in Low- and Middle-Income Countries

advance what the needs and expectations of users are. In consequence, the analysis,
design and implementation of any mHealth solution must consider user centered
methodologies, e.g., following the recommendations of the ISO 9241-210:2010
specification [21]. Conformance to ISO 9241-210:2010 is foremost important, because
this is an international standard that establishes the principles, recommendations and
activities to be taken into account to provide proper human centered solutions.

2.4. Essential Medical Products, Vaccines and Technologies

mHealth Requirements entail equitable access to essential medical products, vaccines

and technologies including their scientifically sound and cost-effective use. Hall et al.
[5] provided examples of the use of mHealth technology to support supply chains for
medications, vaccines and other materials, therefore improving quality and efficiency
of resources. Regarding medical devices and technologies, beyond mobile phones,
tablets and other communication devices; mHealth embraces the challenge to integrate
innovative sensor and actuators, cameras, GPS, wearables, smart textiles, smart
implants, as well as related body, local and wide area networks up to cloud services.
This is the inevitable transition towards personalized health (pHealth), however, it
pertinence needs to be carefully analyze first, especially in low income countries.
Innovative mobile technologies are pushing IT markets globally, in most cases
innovative technology is expensive, but not always effective. Another open issue is the
unclear border between medical devices and personal health devices (PHD) e.g., fitness
and sport devices. Safety and quality have to be guaranteed in both cases, but the
application scenarios and accessible resources determine the level of quality required.
Medical devices have to comply with safety and quality standards and certifications.
But, Personal Health devices including mobile phones and other devices, if they are not
compromising patient safety and meet some minimum quality requirements, they could
be used for example to provide alerts and remainders, empowering the patient to be
concerned about their own health and looking for further health care when necessary.
Nevertheless, standards and security, safety and ethical aspects are mandatory in all
levels. In the same way, open source software is an important pathway in order to
guarantee support and scalability while being a cost effective. The extended use of
Android operative system (OS) in low and middle income countries is an example.

2.5. Financing

Financing defines the need to ensure sufficient funds for health, but also rational and
efficient use of available resources. Unfortunately, eHealth financing is not a top
priority in most LMIC. Apart from demonstrating clinical effectiveness and quality,
mHealth interventions have to be cost effective in order to convince policy and
decision makers. However, very few economical evaluation studies are available. The
proposed strategy is to develop robust business models for eHealth services. Those
business models have to consider costs of eHealth infrastructure, incentives to
encourage mHealth use, and private capital investment and programs for the local
development of Health IT technology, e.g., by creating an ecosystem of start-ups. This
strategy has to be accompanied by specialized training in biomedical informatics
provided by local Universities in partnership with specialized centers abroad, with
emphasis on open technologies, architectures and standards. A clear example of this
approach is the Sana Initiative promoted by MIT [22].
 D.M. Lopz and B. Blobel / mHealth in Low- and Middle-Income Countries 85

2.6. Leadership and Governance

mHealth technology has to be part of strategic policies combined with effective

oversight, coalition building, regulation, attention to system design and accountability.
This part, although challenging, has a paved pathway because of existing frameworks
for National eHealth Strategies, such as the joint effort between WHO and the
International Telecommunications Union (ITU) with the National eHealth Strategy
Toolkit [23]. The three-part toolkit describes mechanisms to be used by countries to
define a vision and an action plan to finally implement, monitor and evaluate that
strategy. The countrys eHealth/mHealth strategy should be based on national health
priorities, available and potential resources, and current state of eHealth (ICT and
enabling eHealth environments). The framework helps to identify and evolve from
different states of eHealth/mHealth adoption from experimentation and early adoption,
to developing and building up, up to scaling up and mainstreaming. In addition, it
describes seven core components for designing the national eHealth/mHealth strategy
including technological aspects of related information systems:
x Leadership, governance and multi-sector engagement,
x Strategy and investment,
x Legislation, policy and compliance,
x Workforce,
x Infrastructure,
x Standards and interoperability,
x Services and applications.
These dimensions closely correspond to the six dimensions of the WHO Health
Systems Framework here explained.

3. Conclusions

Mobile Applications and devices are being increasingly used in health due to the great
advances in these technologies, the rapid expansion of communication networks, and
increased mobile Internet access. However, a broad adoption of mHealth solutions,
especially in LMIC, is hindered by the weak evidence on the clinical and economic
impact, healthcare quality improvement, equity and safety as well as security and
privacy issues, which prevents countries to scale up from mHealth pilot projects to
nationwide implementations. The proposed strategy for LMIC is letting mHealth play a
central role in Health Systems Strengthening by addressing the six axes of the WHO
Health Systems Framework: health service delivery, health workforce, health
information system, essential medical products and technologies, health financing, and
leadership and governance. All axes are mutually interconnected. Until evidence of
large scale mHealth adoption is available, LMIC should strength the different strategic
areas presented in the WHO Health Systems Framework, using available technology
and resources, keeping it as simple as possible. Especially important is the leadership
and governance dimension, as mHealth has to be part of national policies. The
WHO/ITU National eHealth Strategy Toolkit is a starting point for mHealth/eHealth
policy development. However, the conceptual approach has to be accompanied by a
systems approach, a) recognizing the different domains of knowledge involved
(multidisciplinary approach), b) describing the systems architecture consisting of the
86 D.M. Lopz and B. Blobel / mHealth in Low- and Middle-Income Countries

mHealth/eHealth components and subcomponents, their functions, and interrelations,

and c) deploying a coherent development process to provide workable and
interoperable mHealth solutions. This approach is only feasible with a comprehensive
reference architecture model and framework like the Generic Component Model.
For enabling long-term, large-scale, economically viable and sustainable initiatives,
the solution must be locally appropriate, supported by the key stakeholders, aligned
with local and national health priorities, integrated into local healthcare structures, and
follow international data and interoperability standards. A global network, openly
accessible repositories with best practice information, recommendations, frameworks
and evidence bases for success (and failure) are inevitable

Acknowledgement

The work has been partially funded by University of Cauca, PhD Program in
Telematics Engineering and Colciencias Call 569-2012 under the project SIMETIC:
Una estrategia para la caracterizacin y autocuidado de pacientes con Sndrome
Metablico soportada en Tecnologas de la Informacin y la Comunicacin (TIC).

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