Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 1 | P a g e c REVIEW ARTICLE Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Approach Kevin Oduor1, Stephen Ogweno1, Danor Ajwang’2, Nyawade Okinyi2 1 Stowelink, Nairobi, Kenya; 2 Plan International Corresponding author: Mr. Kevin Oduor Address: Nairobi, P.O. BOX 43844-00100, Kenya Email: oduorkevin@stowelink.com Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 2 | P a g e Abstract mHealth is the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research. An estimated 68% of the world’s population own mobile phones, with Kenya having approximately 80% of mobile phone penetration. This makes it feasible to accelerate the uptake of mHealth interventions to improve health services delivery. While some evidence has shown how various forms of mHealth interventions have been used to transform health services, health outcomes, and health research in Kenya and globally, many remain largely anecdotal or undocumented. This paper examines the various forms of mHealth interventions that have been incorporated into Kenya’s health infrastructure, and their effectiveness in improving health ser- vices delivery in Kenya. A systematic review of peer-reviewed articles, policy briefs, and credible materials published on mHealth have shown that mHealth has succeeded in the health infrastruc- ture such as in collecting and transferring health and patient data, remote diagnosis, treatment, and patient follow-up. The paper also examines the barriers around the uptake of mHealth interven- tions and recommends how these interventions can be integrated into Kenya’s health infrastruc- ture. Even though there is every reason to believe that mHealth can allow limited resource settings to “leapfrog” over more advanced settings in using mobile technologies to improve health services delivery, mHealth is not a panacea. There are limited will and resources to scale up and integrate mHealth into the health infrastructure with attempted integration met with a negative attitude from the strained health workforce who still view mHealth as additional work, among other challenges. Despite the challenges, there may be an opportunity for Kenya’s Government to leverage mobile and wireless devices to improve the delivery of health services to areas that were previously un- reachable, thereby fast-tracking its commitment to achieving Universal Health Coverage. Keywords: eHealth, health systems, mHealth, mobile phones, telemedicine, Universal Health Cov- erage. Conflict of interest: None declared. Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 3 | P a g e Introduction Background of the study The World Health Organization states that universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilita- tive and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hard- ship (1). UHC has continued to gain mo- mentum even as nations around the world move towards protecting their citizens against financial hardships in accessing health care. Kenya has shown great com- mitment towards achieving UHC with Pres- ident Uhuru Kenyatta including it in his big four agenda (2). UHC has been piloted in Kisumu, Isiolo, Nyeri and Makueni coun- ties of Kenya to inform the uptake and the metrics for upscaling (3). But even as UHC is being implemented, one of the questions that linger is how Kenya can leverage the huge mobile phones penetration which stands at an estimated 80 % (4) to accelerate the achievement of UHC. Reliable studies on mHealth around the world strongly sug- gest that mobile phones can be used for in- stantaneous access, for direct communica- tion and for prompt transfer of health infor- mation (5). Mobile technologies are cur- rently being used to monitor patient’s ad- herence to treatments such as TB using apps (6), for patient’s communication, to im- proved access to health services and diag- nosis and for management of chronic dis- eases (7). With evidence of mHealth suc- cess around the world, Kenya too is at a vantage position to reap the benefits that come with its huge mobile phone subscrip- tions. But even as research in this field is growing day by day, information is still limited as to the impact of mHealth interventions at scale (8). As such, a thorough systematic review of the available evidence was greatly war- ranted to inform the parameters of integrat- ing mHealth, especially during this period when the call to achieve universal health coverage is beckoning. To this end, the ob- jective of this study was to conduct a sys- tematic review that established how mHealth intervention could be incorporated into Kenya’s health infrastructure to aug- ment universal health coverage. Statement of the Problem Experts are in agreement that mobile health technologies hold great opportunity to re- vamp the health care industry (9) while ad- dressing the inequalities that have remained so prevalent in Kenya. However, even with the huge mobile penetration for Kenya to leverage on in accelerating UHC, imple- menting the mobile health technologies re- quires more than purchasing a gadget and using them for health. Available studies are only providing evidence of the potential benefits that mHealth offers and not neces- sarily the implementation matrix (8). Though the field of mHealth is rapidly emerging, there is little evidence as to the impact of mHealth when rolled on a large scale and especially in achieving the much- desired universal health coverage. Further- more, UHC in Kenya continues to grapple with inadequate service delivery 2 years af- ter the Kenyan government ambitious plan to improve access to health care (10). As such, this systematic review is greatly war- ranted to inform on how mHealth can be in- tegrated into Kenya’s health infrastructure to augment universal health coverage and subsequently improve service delivery. Justification of the Study This review is particularly important at this time when the call to hasten the achieve- ment of universal health coverage is em- phasized. The aim of this review is to pro- vide evidenced based recommendations on how mHealth technologies can improve service delivery and fast-track the achieve- Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 4 | P a g e ment of UHC. Moreover, findings from this study will help in augmenting universal health coverage to reduce the burden of de- livering health in the long term. And since the field of mHealth is rapidly evolving (11), research in this area is needed to in- form the impact it has at scale and the strat- egies for integration. It will also inform the policy around mHealth by bringing together lessons learned while incorporating mHealth in Kenya. Objectives of the Study The purpose of this study is to systemati- cally review the mHealth interventions in Kenya and establish how they can be incor- porated into Kenya’s health infrastructure to augment universal health coverage. Specific Objectives 1. Examine the various forms of mHealth interventions incorporated into Kenya’s health infrastructure. 2. Assess the effectiveness of mHealth interventions in improving health services delivery in Kenya. 3. Establish the challenges facing the uptake of mHealth interventions in Kenya. 4. Determine ways in which mHealth interventions can be integrated into Kenya’s health infrastructure. Research Questions 1. In what forms have mHealth inter- ventions been incorporated into Kenya’s health infrastructure? 2. Have mHealth interventions been effective in improving health ser- vices delivery in Kenya? 3. What have been the challenges fac- ing the uptake of mHealth interven- tions in Kenya? 4. In what ways can mHealth interven- tions be integrated into Kenya’s health infrastructure? Methodology This review followed the Preferred Report- ing Items for Systematic Reviews checklist. The search criterion was derived from the review’s objectives and the search done on CINAHL and PubMed. To ensure the search was contextual, exhaustive terms in- cluding mHealth, text messaging, Kenya, and low-middle income countries were used. Similarly, the search was limited to studies conducted around health between 2010-2020 that meet the expected threshold of validity and reliability. These studies were in English language. Four authors thoroughly reviewed the articles and their abstracts to establish if they were aligned to the objectives. The articles were cross veri- fied for rigor, authority, and relevance be- fore being subjected to review. Inclusion & Exclusion Criteria The review was conducted using a common search methodology. The reviewed studies and citations were assigned to reviewers be- fore they could be confirmed for review. The review articles and citation conformed with the inclusion and exclusion criteria be- low:  Recent i.e., 2010-2020.  Relevant i.e., ehealth and mHealth.  Quality of evidence (from reputable journals i.e., PubMed EANSO fron- tiers and Hindawi)  Geographical context i.e., low-mid- dle income settings. Data Extraction and Quality Assessment Two authors conducted data extraction fol- lowing an agreed format and criteria. The findings of were then reviewed by two other senior authors. In the data extraction pro- cess, journal, study design, country of im- plementation, main findings, forms of mHealth intervention, challenges facing mHealth interventions, impact and effec- tiveness of mHealth interventions and Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 5 | P a g e mHealth interventions scale up. To assess the methodological correctness, the reviews were evaluated using the Measurement Tool to Assess Systematic Review (AM- STAR). Results The search strategy identified 41,047 cita- tions which were both peer-reviewed and non-peer-reviewed (see figure 1). An addi- tional 25 publications were retrieved through hand searches of blogs from web searches, institutions websites, and from appropriate documents. When we applied the filter to focus on Kenya, we got 142 ci- tations on mhealth and 12 publications from the hand search. The researchers then ap- plied the filter of time to look at research from 10 years ago and 139 citations from research and 8 the hand searchers emerged. The final filtering criteria involved review- ing original randomized controlled research and previous systematic reviews which led to a total of 27 papers of interest for review in addition to the 8 other citations from searches. Finally, researchers met to review the remaining documents and settled on re- viewing 24 total research citations and 5 hand searched citations bringing the total of reviewed articles to 29. Figure 1: Review Strategy, authors synthesis Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 6 | P a g e Forms of mHealth interventions in the health care system mHealth interventions have taken many forms addressing various needs in the health care delivery system. According to World Health Organization (12), mHealth interventions have taken the following forms i.e., health call centers, emergency toll-free telephone services, mobile tele- medicine, health surveys, surveillance, awareness-raising, and decision support systems. Call centers, SMS and mobile Apps are the most common forms of imple- menting mhealth interventions in the coun- try with SMS being used most predomi- nantly (13-16). Most mhealth interventions are implemented in Nairobi county with about 37 counties in Kenya having at least one mHealth intervention working in the health system (13). mHealth interventions in the form of mobile Apps are also mostly found in cities where there is access to good internet connectivity and higher phone pen- etration while SMS and call centers gener- ally are found in both cities and rural areas (13). Of the 29 mHealth citations reviewed, findings indicate that only 3 projects have been scaled nationally and with one project relying on the use of mobile money systems to achieve its objectives (17,18). Most mHealth interventions in Kenya focus ma- jorly on HIV AIDS, maternal and child health and malaria (7). These interventions are provided from both private and govern- ment service providers including non-gov- ernmental organizations like Pham Access, Safaricom and Ampath bringing mHealth solution ranging from SMS daily remind- ers, HIV drugs compliance programmes and even medical insurance and telemedi- cine (9). A review of the study conducted by Vedanthan et al. reveals that community health workers used smartphones to im- prove linkages to hypertension care (14). However, this study concluded that the strategy has to combine a tailored behav- ioral communication and mHealth (14). Effectiveness of mHealth interventions in service delivery mHealth interventions have shown success in achieving their intended outcomes. From the reviewed citations, mHealth showed success in achieving retention in care (16), behavior change (19) cultural change and adaptation of new health-friendly behavior (15), maternal and child health improve- ments (20). Indeed, mHealth interventions have managed to achieve effectiveness at a small scale. Most mHealth interventions have not been able to successfully scale up nationally to augment health delivery at a national level (13). In terms of cost effec- tiveness, of all the citations that were re- viewed in this study, only two research did a cost-benefit analysis indicating that SMS use for mHealth was a cheap and cost-ef- fective way of achieving certain health out- comes. Text messaging was found to be 35% less expensive compare to the control group through reduction in the workforce involved such as research assistants, wages, salaries required, and communication costs (5,21). In assessing the effectiveness of text messaging in clinical outcomes, the cita- tions reviewed revealed that there is posi- tive outcome demonstrated with moderate- quality evidence of greater improvement in the symptoms score compared to the con- trol group (mean difference 0.36, 95% CI - 0.56 to -0.17) (5). Similarly, a review of this citation further revealed that there are in- creased hospital visits for those in the SMS group compared to the control group. There is also reduction in number of days in hos- pitalization and reported better symptom control using spirometry transmission to health caregiver via SMS and cell/tele- phone counseling (5). Further, out of all the citations reviewed, two reviews yielded that Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 7 | P a g e mobile technology led to fewer symptoms being reported for congestive heart failure (5,22). A randomized control study on cell- phone counseling in Kisumu, Kenya, showed that there was higher retention in the intervention arm than the control arm during delivery (16). The retention rate in the intervention arm was reported to be at 95.2% while that of the control arm was recorded as 77.7%. The 6 weeks postpar- tum was at 93.9% for the interventional arm and 72.9% for the control arm (16). Overall, despite the many mhealth interventions cur- rently happening in the country, very few interventions have been evaluated and very few have been research based making it dif- ficult to track overall effectiveness of mhealth interventions (13). Challenges Facing mHealth Interventions Together with the potential impact that comes with mHealth intervention, there are myriad of challenges hovering around their implementation. Gurupur & Wan in their systematic review indicates that usability is a challenge to mHealth implementation (23). In considering the use of mobile health technologies in providing feedback for researchers, the review submits that is- sues of efficacy, effectiveness and satisfac- tion with which users can achieve specific goals are concerns of usability. In review- ing the study by Gurupur & Wan, we found out that usability has several components which includes learnability, efficiency, memorability, and satisfaction (23). A study by Kariuki & Okanda (24) on the adoption of mHealth and usability chal- lenges in Kenya also seem to have the same argument as that of Gurupur & Wan. The issue of usability is highlighted in the KimMNCHip m-Health application. The application was in English language hence the users who did not understand the lan- guage found it difficult to use it. Further, the study submits that the interoperability was also a challenge as the web interface did not suit every device. The display was rather disfigured and difficult to use (24). The WelTel intervention in Kenya and Can- ada also revealed some of the challenges facing mHealth interventions. In reviewing their study, Bardosh et al reveals that juggl- ing different interest, establishing the most appropriate financing pathways, maintain- ing network growth and “packaging” the in- tervention for impact and relevance is a challenge both in Canada and Kenya where the intervention is implemented (15). Implementing mHealth technologies re- quire more than just procuring the gadgets and using them. There are legal formalities that must be followed to approve their ap- plication (25). In reviewing the article by Ryan (25), it is quite evident that incorpo- rating mobile health solutions into the larger health infrastructure calls for its im- plementation to be harmonized in order to remove potential inequalities that may come with it. In the view of the aforemen- tioned, the long and bureaucratic process that involves the approval of its application is poised to cause considerable timeline challenges (25). Apart from the regulation challenges, security concerns also present another challenge that policymakers are grappling with. From the report submitted by Elliot (26), itis evident that over 400 mil- lion people are using different forms of mo- bile health technologies. With this huge number, a single flaw in the system can ren- der the data available to hackers or mal- ware. The flaw also leads to the breach of the healthcare data (27). Furthermore, mHealth has received a major blow even as critics suggest that without proper guide- lines, mHealth intervention can infringe on patient’s data safety. This is a widespread concern especially in the context of elec- tronic health records (27). Still on the issue of data safety, review of the systematic re- view by Gurupur & Wan reveals that there is inherent problem with cloud computing- storage of data in unknown locations (23). This poses a significant threat to data and can be accessed by unauthorized persons. Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 8 | P a g e Atun et al., indicate that apart from prob- lems with cloud computing, data can also suffer risk of storage in non-secure loca- tions (28). mHealth Integration into Kenya’s Health Infrastructure Our focus in this systematic review was to determine how mHealth can be integrated into Kenya’s health infrastructure to aug- ment universal health coverage. We were concerned about how such integration can improve service delivery and in turn, fast track the achievement of universal health coverage. In our reviewed citations, we found out that mHealth integration is possi- ble due to the increased smartphone pene- tration in Kenya (24). In this study, the au- thors accessed the cost of accessing Uzazi Poa Web application in terms of internet bundles. The accumulative percentage of 100% of the respondents submitted that ac- cess to mHealth application was not expen- sive and they would adopt it at will (24). The authors are in agreement that this was attributed to the prototype being developed using light graphics which ensure prompt transmission of data from the server to the mobile phone of the user (24). In light of the above, one thing that becomes clear is the issue of usability. For mHealth intervention to be fully optimized in Kenya, the different forms of mHealth interventions must ensure efficiency which is a component of usabil- ity (23). Universal Health Coverage as de- fined by WHO seeks to alleviate financial hardships in accessing health care services (1) meaning that mHealth intervention must be as efficient as possible. With the huge mobile penetration in Kenya, addressing the usability concerns opens a pathway for mHealth integration into the larger health care infrastructure. Four of the studies reviewed pointed out to the issue of an effective regulatory frame- work to be developed to inform the imple- mentation of mHealth solutions (13-16,29). The ministry of health in Kenya has the ob- ligation of implementing mHealth commit- tee or governing body because the field of technology and mHealth is ever-changing (29). It is paramount that the Ministry of Health set specific groups to keep up to date with new development in regard to how mobile technologies can be used to fast- track achievement of universal health cov- erage. A proper regulatory framework will help in data security and the protection of individual information. Similarly, integrat- ing mHealth intervention into Kenya’s health infrastructure will require more than just having a governing body. A study on the integration of mHealth in low-middle income settings suggests that governments should produce mHealth strategy and forge partnerships with NGOs implementing mHealth solutions. This partnership en- hances reporting and effectiveness more so because the government is involved and has systems to accept mHealth technologies (29,30). The issue of small mHealth project reaching to scale in Kenya can also be made possible if the Ministry of Health consider endorsement of mHealth technologies as providing an acceptable standard of care (30). Changamka’s Linda Jamii health in- surance programme financed through a partnership between the Kenyan govern- ment and Safaricom is an example of how endorsement is critical for adoption and in- tegration (29). Again, for mHealth to be fully integrated into Kenya’s Health Infrastructure to aug- ment UHC, there is a growing body of need for investment in technology and infrastruc- ture (13). The increased mobile penetration in Kenya is not a coverup for internet con- nectivity. It is important that the govern- ment focus on increasing cellular and data coverage and increase data speed and trans- mission even in most remote parts of the country (13). While at it, App developers also have the responsibility of developing applications that are efficient and can fit Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. DOI: 10.11576/seejph-4317 9 | P a g e well into Kenya’s technological infrastruc- ture (28). If mHealth solutions are going to fast-track the achievement of UHC, then it is only making sense if they are feasible and can be integrated into health infrastructure without major bottlenecks. Coming back on the issue of usability, mHealth interven- tions must be continually evaluated and re- assessed to sidestep the potential problems when the intervention reaches scale (28,29). Discussion This systematic review was set out to iden- tify mhealth interventions in Kenya and how mHealth could be integrated into the health system to facilitate and enhance health service delivery with the aim of aug- menting universal health coverage in the country. The authors used various ap- proaches to ensure they extensively review existing projects which fit the research cri- terion. The analysis of the various works in the mHealth sector revealed strong points to which mHealth interventions have indeed improved health service delivery. mHealth interventions have proven effective in achieving various health objectives neces- sary for the achievement of universal health coverage including improving health liter- acy (13), improving compliance to medica- tion (7), enhancing positive behavior change (14,15,19), improving access to health (14,20) and improving health financ- ing and mobile health insurance (29). In the analysis, it was also noted that mHealth in- terventions are a feasible way of improving service delivery (24) due to the supportive environment that the country has, which in- cludes being one of the highest internet con- nection subscription rates (31), and the de- mographic advantage as the country mostly consists of mostly the younger population with median age being 20 years (32). Fi- nally, one of the biggest factors in the mHealth interventions that have the poten- tial to support and highly improve service delivery and universal health coverage is the availability of the various forms of mHealth interventions that have been adopted and implemented in various parts of the country with success (13-16). The various forms of mHealth interventions make it very possible to fast track the achievement of Universal Health Coverage. Some of the identified challenges and limi- tations in the mHealth interventions in- cluded the scalability factor (13). Most mHealth interventions are implemented re- gionally and have not been able to scale up to various parts of the country. Another challenge identified was lack of a national governing body for mhealth interventions (29). Most mHealth interventions have been developed by private entities and until very recently, there was nobody in the gov- ernment charged with streamlining mHealth interventions in the country. Finally, the biggest limitation of this re- search was the fact that there is a huge gap in mHealth research. Despite the numerous interventions, very few have actually been documented and even fewer have been evaluated through research (13). Conclusion In conclusion, this review confirms that there has been indeed a lot of mhealth inter- ventions in Kenya, and mHealth is rapidly catching up and improving with the im- proved mobile internet penetration. There has been a lot of successful mHealth inter- ventions in the country both locally and na- tionally. The adaptation of mHealth has been shown through research to greatly im- prove health service delivery and achieve various health objectives. Despite the in- creased developments in the mHealth space, there has been significant challenges including around perceptions, usability, in- teroperability, funding, and scalability. But since we are just in the beginning stages of mHealth interventions in the country and the region, these challenges are definitely expected. Owing to the findings of in this Oduor K, Ogweno S, Ajwang’ D, Okinyi N. Incorporating mHealth Interventions into Kenya’s Health Infrastructure to Augment Universal Health Coverage, Service Delivery Improvement Ap- proach (review). SEEJPH 2021, posted: 09 April 2021. 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