CELL PHONES & M - HEALTH

By James G. Kahn, Joshua S. Yang, and James S. Kahn

doi: 10.1377/hlthaff 2009.0965

‘Mobile’ Health Needs And

HEALTH AFFAIRS 29,
NO. 2 (2010): 254–261
©2010 Project HOPE—
The People-to-People Health
Foundation, Inc.

Opportunities In Developing
Countries

James G. Kahn (jgkahn@

ucsf.edu) is a professor of ABSTRACT Developing countries face steady growth in the prevalence of
health policy and chronic diseases, along with a continued burden from communicable
epidemiology at the University
of California, San Francisco. diseases. “Mobile” health, or m-health—the use of mobile technologies
such as cellular phones to support public health and clinical care—offers
Joshua S. Yang is an assistant
professor in the Department promise in responding to both types of disease burdens. Mobile
of Health Science at
technologies are widely available and can play an important role in
California State University,
Fullerton health care at the regional, community, and individual levels. We examine
various m-health applications and define the risks and benefits of each.
James S. Kahn is a professor
in the Positive Health We find positive examples but little solid evaluation of clinical or
Program at the University of
California, San Francisco.
economic performance, which highlights the need for such evaluation.

E
conomic development improves
health. It increases life expectancy
and well-being and decreases child
mortality and birth rates.1–3 This re-
lationship reflects the effect of ris-
ing incomes on access to health-enhancing
goods and services,4 such as improved diet, san-
itation, and health care. Further, economic
development drives an “epidemiological transi-
tion,” from a predominance of infectious dis-
eases to chronic, noncommunicable ones.1,5 At
the same time, improved health spurs economic
growth. Better physical and mental health in-
creases labor productivity; reduces days lost to
illness; decreases medical spending; and fosters
investment in education and capital as a result of
longer expected life spans.6–8 Thus, a “virtuous
cycle” exists, with mutual reinforcement of eco-
nomic and health progress.
Mobile health, or m-health—the use of wire-
less communication devices to support public
health and clinical practice—has great potential
to enhance this virtuous cycle. More than any
other modern technology, mobile phones are
used throughout the developing world.9 Innova-
tive applications of mobile technology to exist-
ing health care delivery and monitoring systems
offer great promise for improving the quality of
life. They make communication among research-
ers, clinicians, and patients easier, and as
chronic disease becomes more prevalent, mobile
technologies offer care strategies that are parti-
cularly suited to combating these conditions.
In this paper we propose a conceptual model to
consider the potential contributions of m-health
to help address the huge health care challenges
in developing countries. We examine the rela-
tionship between wealth and health, and we
document the growing burden of chronic disease
in developing countries. We describe ways in
which mobile health technologies can contribute
to a nation’s health care response, at the regio-
nal, community, and individual levels.
Health And Health Systems In The
Developing World
Developing countries face an increasing inci-
dence of noncommunicable chronic disease,
even as communicable disease remains a persis-
tent threat. Diseases formerly concentrated in
developed countries, such as hypertension, obe-
sity, heart disease, and diabetes, are on the rise
(see Online Appendix).10 The combined effect of
communicable disease and chronic or noncom-
municable disease is described as a “dual bur-
den” for developing countries.11 Successful ef-
forts to reduce the dual burden of disease will

254 H E A LT H A F FA I R S F E B R UA RY 2 0 1 0 2 9: 2
improve quality of life for millions. M-health
offers some hope on both fronts.
The leading preventable causes of noncommu-
nicable diseases globally are tobacco, poor diet,
and low physical activity. They contribute to
heart disease, diabetes, lung disease, and
cancer—conditions that account for half of all
deaths worldwide.12,13 All are projected to in-
crease in the developing world as incomes
rise.14–18 Chronic, noncommunicable diseases re-
quire unique care strategies that may be difficult
to deliver in developing countries19 and that may
benefit from mobile technology. This is the case
for several reasons.
(1) The long latency period for chronic dis-
eases often requires early, broad based commu-
nity health interventions. (2) Reducing chronic
disease often requires rejecting behaviors asso-
ciated with greater wealth (for example, tobacco,
diets high in fat and sugar, and low physical
activity) and thus relinquishing perceived status
value. (3) Treatment of chronic diseases typically
uses complex interventions involving ongoing
interactions with multiple components of the
health system. This requires skilled health pro-
fessionals and coordinated and continuous care.
(4) Chronic diseases often require chronic med-
ication, introducing issues of access, cost, and
quality of pharmaceuticals and adherence to
treatment regimens. Self-care is often required
by people with chronic diseases. Health systems
must equip patients to deliver self-care.
Many factors constrain health system perfor-
mance in developing countries. Infrastructure is
limited, and hospital resources are concentrated
in urban areas (see Online Appendix).10 Disease
burden—that is, incidence of disease and its im-
pact on people’s livelihoods and economic pro-
ductivity—is great.20,21 There are not enough
health care workers (shortages are estimated
at 800,000 for Africa),22 and such workers are
difficult to recruit and retain, especially in rural
areas.23,24 Supervisory and management systems
are often lacking or weak. One review of these
constraints25 identified several areas where mo-
bile health might help by removing physical bar-
riers to care and service delivery and by improv-
ing weak health system management, unreliable
supply systems, and poor communication.
The Promise And Pitfalls Of
M-Health In Developing Countries
We define m-health as the use of portable elec-
tronic devices for mobile voice or data commu-
nication over a cellular or other wireless network
of base stations to provide health information.
Mobile phones are the most ubiquitous type of
equipment in the world: 3.3 billion people—one
of every two of earth’s inhabitants—has at least
one.9 The growth of this technology has been
transformative worldwide. The penetration is
more than 90 percent in the developed world
and more than 33 percent in the developing
world, including close to 90 percent among some
high-risk urban populations.26
Exhibit 1 lists some of the ways in which the
growing presence of mobile technology may be
advantageous and how these technical applica-
tions may greatly influence developing coun-
tries’ health systems. Mobile communication
can foster solutions at different organizational
levels: large geographic areas, local commu-
nities, and individual patients and providers.
As we review this range of m-health opportu-
nities, we include a few illustrative examples.We
identified these examples through professional
networks (m-health meetings and colleagues in-
volved in innovative health service delivery), on-
line searches in the journal database PubMed
(using terms such as “mobile” and “cell phones”)
and Google (for example, “mobile health”); and
scrutiny of bibliographies. A useful resource, in-
cluding capsule summaries of fifty projects, is a
report titled The Opportunity of Mobile Technology
for Healthcare in the Developing World.27
Using the strategies noted above, we found
minimal formal evaluation of m-health. Two sys-
tematic reviews indicated little formal outcome
evaluation of m-health in developing coun-
tries.28,29 Santosh Krishna examined use of mo-
bile calls and short message service (SMS), or
text messaging, in twelve clinical areas and
found “significant improvements in compliance
with medicine taking, asthma symptoms,
HbA1C, stress levels, smoking quit rates, and
self-efficacy. Process improvements were re-
ported in lower failed appointments, quicker di-
agnosis and treatment, and improved teaching
and training.” However, this research was con-
ducted in wealthier countries, except for one
study in China.28 A 2006 review reported that
“there is almost no literature on using mobile
telephones as a healthcare intervention for HIV,
tuberculosis, malaria, and chronic conditions in
developing countries. Clinical outcomes are
rarely measured.”29
LARGE GEOGRAPHIC AREAS The integrated nature
of mobile communication systems provides
unique opportunities for m-health in large geo-
graphic areas. We discuss some specific applica-
tions of m-health below.
▸▸ SOCIAL NETWORKING : Social networking
models (that is, techniques to electronically link
large numbers of individuals) include various
tools, of which mobile text messaging is the most
ubiquitous. At the large geographic level, this
mass communication capacity can be used to
F E B R UA RY 2 0 1 0 2 9 :2 HE A LT H A FFA IRS 255
CELL PHONES & M - HEALTH

EXHIBIT 1

Emerging M-Health Applications

Level of application M-health tools Health system functions Benefits Risks

Large geographic Social networking: Disaster aversion and
areas users connected mitigation
via short message
service (SMS),
instant messaging,
or third-party
application
Health promotion
Web surfing: users Information on health
browse Web sites condition diagnosis
and care
Commodity pricing and
purchasing
E-mail lists for Provide information on
communication health topics of
special interest
Web-based data Disease surveillance case
entry reporting
Web-based learning Online courses that allow
novel and independent
learning
Community Social networking Share experiences regarding
local health care system
Peer-to-peer education:
providers and patients
Web surfing Supply pricing and
purchasing (local)
Individual Data transmission: Medical imaging: raw
Send and receive data sent to processing
data center, image returned
E-mail/text Provider-to-provider
messaging communication
Provider-to-patient
communication
Rapidly lower exposure to Incorrect information
ecological or epidemic (through error or
threats; obtain field malfeasance) may
reports; provide advice; create alarm or
coordinate response; havoc
efficiently direct scarce
resources
Promote healthier behaviors Poorly designed
(for example, reduce risky campaigns could
sex or smoking, improve have unintended
diet) effects
Patient self-education can Inaccurate/confusing
speed diagnosis; providers information can lead
in remote areas can obtain to delay or error in
latest information care
Health care providers and Loss of coordinated
individuals pay less for supply chain
supplies and equipment, via
price shopping and buyer power
Shared resources, information Misinformation;
exchange misunderstanding
or not appropriate
literacy
Improved disease surveillance; Incorrect or misleading
increased community information; lacking
awareness and participation granularity of data
Health care workers maintain Loss of human
and improve knowledge and interaction for
skills teaching and
education
Efficiently navigate health care Incorrect or partial
system to best/most information; loss
appropriate provider of confidentiality
(disclosure of
personal health
information)
Locally tailored mutual assistance Loss of confidentiality
and support on health care and
behaviors
Health care providers Loss of coordinated
and individuals supply chain
pay less for supplies
Medical imaging services provided Loss of confidentiality
in remote areas, improved
diagnosis
Share information about care for Loss of confidentiality;
pecific patients; exchange incorrect or
best practices; raise quality misunderstood
information
Answer questions, provide data Burden providers with
and guidance, encourage new channel of
medication and visit adherence patient interaction;
loss of human
interaction, for
empathy/support

SOURCE Authors’ analysis.

256 HE A LT H A FFA IR S F E B R UA RY 2 0 1 0 29:2

mitigate disasters. For example, a message that
alerts millions of people about an impending
storm or tsunami, or a simple instruction to
move 100 yards inland or seek cover, may save
hundreds of thousands of lives and reduce an
extraordinary unplanned health burden. (To
be sure, false alarms—due to erroneous or ill-
timed alerts—are a risk of this tool.) After a nat-
ural or other disaster, the same tool could be
used to conduct damage assessments; coordi-
nate relief efforts; and reunite individuals and
direct them to safe havens, clean water, health
care, and other essential items. Social network-
ing tools can share information about how to
treat injuries and prevent the emergence of com-
municable diseases. Personal digital assistants
(PDAs) can be used to tabulate and report survey
and surveillance data.
Social networking can also be effective in
health promotion, such as in encouraging
healthy behaviors through carefully crafted mes-
sages disseminated via text messaging. Health-
oriented media campaigns that traditionally use
billboards, television, and radio can be expanded
to include cellular networks. In rural areas, such
networks may be the only efficient channel avail-
able for public information campaigns. Project
Masiluleke in South Africa, for example, sends a
million text messages per day to encourage peo-
ple to be tested and treated for HIV/AIDS. Mes-
sages are sent in local languages, directing reci-
pients to the National AIDS Helpline, which
provides information about testing services
and locations.27 Messages can target tobacco
use prevention, smoking cessation, improved
dietary choices, avoidance of risky sex behavior,
and violence and injury prevention. A potential
downside, though, is that poorly designed or
implemented messaging risks antagonizing, de-
sensitizing, or confusing the public.
▸▸ WEB SURFING : The Internet has made once-
specialized information, including medical in-
formation, widely available. Accessing informa-
tion through Web surfing allows patients to learn
more about medical conditions. This can ease the
burden on health providers (by providing an
alternative path for patients to obtain informa-
tion), speed diagnosis, and improve interactions
between patients and providers. Similarly, pro-
viders can use the Internet to obtain information
about advances in medical practice, clinical best-
practice guidelines, and information on rare dis-
eases, even in physically remote areas.
However, expanded access to information
without controls over the quality of information
can result in the consumption and spread of in-
accurate information. Without proper training,
some people might not fully understand infor-
mation or interpret it accurately. This can lead to
misdiagnosis and delayed care seeking, incor-
rect self-treatment, conflict over appropriate
care, or nonadherence to essential treatment
plans and medications.
The Internet is also a source of information on
health commodities, such as medicines and de-
vices, cost, quality, and suppliers. This m-health
approach may interfere with a coordinated sup-
ply chain, replacing a single supplier and single
delivery system with multiple suppliers and di-
verse logistical needs for delivery.
▸▸ ELECTRONIC MAILING LISTS : Electronic
mailing lists among a community of subscribers
(often managed using Listserv software) can be
used to help spread information gleaned from
the Internet or developed in clinical settings
among providers or patients. Such mailing lists
operate as channels for the diffusion of informa-
tion, innovations, and resources to improve
care. However, they are also susceptible to mis-
information and misunderstanding, which
can lead to confusion, incorrect application of
information, or divisiveness through disagree-
ment regarding information exchanged.
▸▸ WEB - BASED LEARNING : Web-based learning
is a tool to provide core and continuing training
to increase the number and skills of health care
workers. Less constrained by limitations on the
number of instructors and facilities, this learn-
ing method allows for decentralized training at a
pace matched to students’ circumstances, needs,
and skill levels. It may also help reduce the fi-
nancial barriers to training and expand oppor-
tunities for professional continuing education
and satisfaction. Potential downsides are the ab-
sence of face-to-face interaction and limited op-
tions for advanced training that requires direct
patient interaction. These make Web-based
learning a valuable adjunct to but not a replace-
ment for traditional training methods.
▸▸ WEB - BASED DATA ENTRY : Web-based data
entry and storage allow for large databases to
be available online. This can enhance the com-
pleteness and timeliness of disease surveillance.
Immediate access to disease reports by key
health officials can lead to timely identification
and control of disease outbreaks, as well as more
efficient long-term surveillance of endemic con-
ditions. In this context, m-health is a tool that
allows providers to send data to a central repos-
itory; data can be sent from a central location to
the periphery as well. One study suggests that
this approach to monitoring for malaria out-
breaks in East Africa could be economically at-
tractive.30 However, once again there is a poten-
tial downside. This form of m-health risks the
importation of incorrect or misleading data that
may lead to false action on disease outbreaks or
the mismanagement of individual patients,
F E B R UA RY 2 01 0 2 9 :2 HEA LT H AF FA IR S 257
CELL PHONES & M - HEALTH
although these risks may be no higher than with
current systems. Patient privacy must also be
addressed in Web-based data entry systems.
COMMUNITY At the community level, social net-
working can be used to exchange information
about the local health system. People in the com-
munity can share experiences about how to ob-
tain health system resources they need, identify
scarce resources, and exchange information (for
example, on price, the experience of care, and
quality) for specific providers. The “Smile for
You” campaign to provide cleft palate surgery
for children in South Africa used “Please Call
Me” text messages, which mobile phone users
send at no cost, to identify potential candidates
for this free care. (Vodacom, the local telecom-
munications company, donated spare space in a
million “Please Call Me” messages to ask recipi-
ents if they knew of children needing this spe-
cialized surgery.) Phone and text message inqui-
ries rose tenfold, and forty-two children were
identified for surgery—more than three times
the number identified during a traditional media
campaign lasting six weeks.27
Effective messaging can connect people to
needed and available services. Sharing service
information can also encourage providers to im-
prove services or lower prices. The risks involved
include the exchange of incorrect or partial in-
formation that may misdirect patients seeking
care. There is also the potential for a loss of
confidentiality as users share their own experi-
ences and those of others.
Social networks can also foster peer-to-peer
interactions among both providers and patients.
Discussions can extend beyond a local area to
include clinician specialists and can provide sup-
port for improved health care practices. Simi-
larly, patients (or community members) can sup-
port each other on specific behaviors—whether
preventive (such as smoking cessation) or man-
agement of a common disease (such as diabetes).
This model of interaction is, of course, open to
miscommunication as well as to contentious dif-
ferences of opinion.
Social networks created among health care or-
ganizations and individuals can be used to share
information. They potentially create economies
of scale at the local level to purchase supplies and
equipment. The risks involved in this approach,
however, are miscommunication among local
organizations, leading to overexpenditures,
and, as noted above, an uncoordinated supply
chain that can lead to system inefficiency.
INDIVIDUALS For individuals, m-health offers
improved communication, access to diagnostic
tools, and ability to store and access personal
medical data in central repositories. Advances
in cellular technology allow for transmission
258 H E A LT H A FFA IRS F E B R UA RY 2 01 0 2 9 :2
of large data files, including medical imaging
data, from remote areas to processing centers
or higher-level medical centers. This can lead
to more rapid and potentially better diagnosis
and care.31 For example, Aravind Eye Systems
(Madurai, India) established a regional wireless
network to support nonphysician providers in
thirty-one dispersed eye care centers. Each
patient is examined by a nurse on site, followed
by a one-to-two-minute consultation with an
ophthalmologist at the main hospital, including
transmission of a slit-lamp photograph if
needed.32 Use of m-health in this way must en-
sure that patient confidentiality is not compro-
mised in the transmission of images.
E-mail can strengthen communication be-
tween individuals in the health care system. Bet-
ter provider-to-provider communication can im-
prove patient care coordination, including team
management of chronic disease. It can also allow
exchange of best practices and can raise quality
standards through professional consultation.
PDAs may also serve this purpose.33 Good provi-
der-patient communication is essential for
chronic disease management. M-health offers
the chance to ask and respond to questions, send
key data and guidance, and act as an avenue of
case management once patients leave the clinical
setting.
The complex care required for people living
with HIV/AIDS has fostered use of m-health
tools. Several groups have reported increased
mobile access among such people, with some
evidence of resulting improvements in medica-
tion adherence and health.26,34 Other applica-
tions include automated medication adherence
reminders,35 in-the-field consultations for provi-
ders,36 and encouraging healthy behaviors.37,38
Perhaps the most common documented use of
m-health is text-message and phone reminders
to encourage follow-up appointments and
healthy behaviors. In the United Kingdom, use
of text-message reminders in a sexually trans-
mitted infection clinic had two important bene-
fits: decreasing time to treatment for chlamydia,
and decreasing appointment no-show rates
(with increased revenue of rebooking far exceed-
ing implementation cost).39,40 In Hangzhou,
China, text message and telephone reminders
improved appointment attendance by 7 percent,
and messaging cost less than telephone remin-
ders.41 A recent randomized controlled trial of
patients with chronic diseases in Malaysia found
that nonattendance rates were about 40 percent
lower in the text-messaging and phone groups
than in controls.42
In Zambia, Population Services International
uses m-health for several aspects of male circum-
cision services. The circumcision service sends
fifteen text messages as postoperative reminders
to patients to encourage appropriate behavior to
protect wound healing, and it conducts service
satisfaction surveys. New messaging services
include a referral system, appointment schedul-
ing, and addressing patients’ clinical ques-
tions.43 The risk for these types of interven-
tions is that they may complicate clinical practice
with more communication options/burdens,
and decrease the important element of direct
human interaction.
Discussion
The positive potential for m-health is huge,
although not without risks to be monitored
and minimized. Several broader points bear em-
phasis. First, rigorous evaluation is essential.
Evidence for the value of m-health remains
scarce, especially for the developing world. On-
going evaluation of specific initiatives should
guide m-health growth. A mixture of random-
ized controlled trials,35 natural experiments,
and other designs will be needed.
We believe that the field would benefit greatly
by the establishment of an m-health evaluation
registration, similar to registration of clinical
trials at http://ClinicalTrials.gov, a service of
the U.S. National Institutes of Health, which lists
federally and privately supported clinical trials
around the world. Global health coordinating
bodies such as the World Health Organization
(WHO) could contribute importantly by foster-
ing research using comparable outcome mea-
sures and disseminating findings.
Finally, economic outcomes are important.
For example, lowered costs, even absent im-
proved health outcomes, could justify m-health
strategies. If m-health is to compete with other
health interventions, it will need to be measur-
able in terms of cost per disability-adjusted life-
year (DALY) averted,44 which is increasingly the
accepted measure of health intervention perfor-
mance (see Appendix Figure 2).10 An economic
evaluation framework for m-health would char-
acterize the interventions, their costs, and their
intended clinical outcomes and potential ad-
verse effects.
Assessment of m-health should also include
awareness of practical issues, such as sustain-
ability. Real-world challenges greatly influence
the ability of programs to survive and grow.45
Issues include participating organizations, tech-
nical capacity, and financing. The WHO and
other organizations should develop guidance
on best m-health practices and support coun-
tries’ implementation efforts.
Vigorous expansion of m-health may also have
a nonhealth benefit: fostering local economic
development beyond health care. Although tech-
nological advances in hardware often occur in
developed countries, advances in software are
more widespread. Thus, m-health innovation
and implementation are unlikely to be limited
to external consultants. M-health software appli-
cations will be designed and employed in strate-
gic partnerships with governments, health sys-
tems, individual businesses, professionals, and
communities in developing countries. M-health
platforms will be tailored, refined, and expanded
by and in consultation with local experts.
To implement m-health, local technical capa-
city and training will be necessary. Thus, m-
health should foster local microenterprise, creat-
ing upgraded platforms and new functionalities
that will generate ongoing economic opportu-
nities. Ultimately, increased economic opportu-
nities in turn would contribute to improved
health. The “virtuous cycle” would continue,
with m-health at the very center of it. ▪

A version of this paper was presented
at the Rockefeller Foundation
conference Making the eHealth
Connection: mHealth and Mobile
Telemedicine, Bellagio, Italy, 13 July–
8 August 2008. Funding was provided
by the United Nations Foundation, with
additional support from the National
Institutes of Health (NIH) National
Center for Research Resources–
University of California, San Francisco,
Clinical Translation and Science Institute
Grant no. UL1 RR024131-01;
Commonwealth Fund Grant no.
P0014838; and NIH Grant no.
5K24RR24369-7. The views expressed
are not necessarily those of the funders.
The authors thank Jesse Marseille for
online searching for reports about
recent m-health projects and
evaluations. They also thank R.D.
Thulasiraj of Aravind Eye Systems
(Madurai, India) and Steve Gesuale of
Population Services International for
information about mobile health
activities in clinical care in their
respective projects.

NOTES

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