The review revealed that there are very few formal outcome evaluations of mHealth in low-income countries. Although there is vast documentation of project process and uptake, most were evaluations of small-scale pilot studies that were not designed to demonstrate an impact on behavior change or health. There is also a lack of mHealth applications and services operating at scale in low- and middle-income countries. The most commonly documented use of mHealth was 1-way text-message and phone reminders to encourage follow-up appointments, healthy behaviors, and data gathering. Two-way communication applications focused primarily on data transmission with automated feedback response, and few projects were implementing real-time communication. Although some claim that social media can be an effective tool for engaging patients online [54
], others argue that health institutions need to develop clear policies about the use of social media in patient care environments to ensure patient safety [55
]. However, the majority of multiway and social media projects identified in this review were patient/user driven, such as Facebook or Twitter, with little or no involvement of treating physicians or nurses.
A limited number of mHealth projects were found which specifically targeted community health workers. Of the few projects identified, most used a combination of simple mobile phone applications for data submission, job aids to improve diagnostics, and for sending and receiving SMS messages and reminders. None of these projects had evaluated the impact of these tools on community health workers quality of care provided. Most projects used applications that communicated by using 1-way or 2-way SMS, whereas GPRS-enabled applications were rare. Although several projects tested applications that aimed to improve accuracy in community health worker data submission and clinical decision-making skills using electronic job aids [26
], international stakeholders cautioned that these may result in community health workers focusing more on the technology than on the patient [4
The key considerations for successful use of or expansion of mHealth innovations include collaboration, financing, literacy and cultural, partnerships, and technical considerations (). As a young field, mHealth is well positioned to benefit from best practices and available technology documented in various project reports. Sustainability and scalability are still the main challenges to the strategic deployment of mHealth applications, partly reflecting the gap between what application developers are doing on the ground and what the governments see as priorities and initiatives they need to step in and support [2
]. Establishing true partnerships with users and policy makers throughout the design and implementation processes is critical for success and collaboration with operators could ensure technical support, make scale-up possible, and reduce costs to drive mHealth demand and innovation [4
]. This is illustrated by examples from Ghana and Cambodia, where physicians registered with the Ghana Medical Association have access to unlimited calls through the mobile service operator, OneTouch [3
], and where village malaria workers in Cambodia report malaria cases by using free SMS with Mobitel [40
Key considerations for successful use and expansion of mHealth innovations.
The national ownership of mHealth applications cannot be overemphasized. Some good examples of country ownership exist, such as state programs in Ghana and Nigeria, which address maternal and neonatal health using mobile phones [56
]. The challenge is to have health ministers and officials at the same table as mobile service providers, doctors, technologists, and financiers. Coordination among these stakeholders and agreement of incentive structures and responsibilities for meaningful collaboration is needed to better inform public and private investments and the deployment of commercially viable solutions [5
The mHealth interventions often used SMS to provide information, motivate individuals, and encourage self-management or promote disease prevention. However, illiteracy is an issue for text-based prevention interventions [5
]. Culturally specific provision of health information is important because poorly designed campaigns can have negative unintended effects; good understanding of cultural context and strategies to overcome language and literacy barriers are needed. As with other mHealth applications, there is a significant gap in evidence on behavioral, social, economic, and health outcomes of using mobile phones and SMS for improving health in low- and middle-income countries, as demonstrated in a systematic review of the literature [57
Funding in low- and middle-income countries is not adequate to support complex telemedicine in emergency situations. Infrastructural limitations, such as network capacity, also constrain the effectiveness of emergency monitoring and tracking [5
]. However, routine data from all active SIM cards could be used in disaster-affected areas for near real-time monitoring of population movements during disease outbreaks [39
]. Another significant barrier to implementation of mHealth systems is in relation to health worker resistance to new technology and broader discussion and research about health worker benefits, and incentives for use and compliance is required [5
]. This would include ensuring adequate training also remains a critical component for large-scale implementation [5
Addressing security and privacy issues in mHealth has also proven challenging. Guidelines on the rights to data, usage, and storage must be outlined and implemented, with sufficient qualitative data to explain potential findings collected alongside close program monitoring. For mHealth success, cooperation between local communities and regional and national health information systems is essential [3
]. It is also unclear from the review whether SMS projects for health workers need to comply with any national privacy laws because collecting health workers’ private phone numbers to push messages is assuming that they have all given their permission to have the project reach them on their phones.
Limitations related to the landscape analysis should be considered when interpreting the results. The review focused only on 6 major thematic areas for mHealth and it is possible that some mHealth applications and tools have been excluded. Given the bulk of projects piloting mHealth applications in low- and middle-income countries, the first stage of the review only describes a sample of projects and applications tested under each thematic area. However, the second stage of the review, ie, that of mHealth projects targeting community health workers, was deemed systematic and comprehensive. The sources of the information reviewed were primarily obtained from project websites because few peer-reviewed evaluations were identified, potentially resulting in overreporting of positive results and underreporting of challenges or failures.
With partnerships forming between governments, technologists, non-governmental organizations, academia, and industry, there is great potential to improve health services delivery using mHealth in low- and middle-income countries. As with many other health improvement projects, a key challenge is moving mHealth approaches from pilot projects to national scalable programs while properly engaging health workers and communities in the process. By harnessing the increasing presence of mobile phones among diverse populations, there is promising evidence to suggest that mHealth can be used to deliver increased and enhanced health care services to individuals and communities, while helping to strengthen health systems.