# Improved Healthcare Access in Low-resource Regions: A Review of
Technological Solutions

Bishal Lamichhane
Rice University
Houston, Texas, USA
<EMAIL_ADDRESS>
Navaraj Neupane
ASML
Eindhoven, The Netherlands
<EMAIL_ADDRESS>

###### Abstract

Technological advancements have led to significant improvements in healthcare
for prevention, diagnosis, treatments, and care. While resourceful regions can
capitalize on state-of-the-art healthcare technologies, there might be
barriers and delays in technology-enabled healthcare availability for a low-
resource region. Unique innovations guided by the constraints of low-resource
regions are required to truly make healthcare technologies ubiquitous and
achieve the goal of "healthcare for all". In this review, we identified
several research and development works that have investigated technology-based
healthcare innovations targeted at low-resource regions. We found three main
pillars of work towards this end: low-cost hardware for the affordability of
medical devices, use of information and communication technology (ICT) tools
for scalability and operational efficiencies in healthcare services, and
mobile health solutions. Several emerging technologies are also promising for
healthcare in low-resource regions, such as artificial intelligence, the
Internet of Things (IoT), and blockchain technology. We discuss these emerging
technologies too in this review.

_K_ eywords Healthcare technology $\cdot$ Low-resource $\cdot$ Developing
Countries $\cdot$ Low-Cost Healthcare $\cdot$ Health Technology

##  1 Introduction

The healthcare burden has been rising globally with increased incidences of
sickness and poor health [1]. We have observed the situation get further dire
in the past years due to the global pandemic of COVID-19. While the healthcare
needs have only been increasing, the skilled human resources required to meet
the associated increasing needs have not been growing proportionally [2].
Technological advancements could help to reduce the burden in the healthcare
system, for example by automating diagnosis and improving operational
efficiencies. The need to improve diagnosis, treat new diseases and provide
care for more people has meant that the state-of-the-art healthcare
infrastructure is getting more complex. This increasing complexity has also
meant rising costs. The standard healthcare infrastructure of today could be
cost-prohibitive in many low-resource regions. Since many people still live in
areas that can be categorized as being low-resource regions [3], efforts
toward making healthcare accessible and affordable in low-resource regions
should also be a priority. This will help to fully realize the global goals of
healthcare for all such as the sustainable development goals of good health
and well-being [4].

Low-resource regions, also referred broadly to as low and middle-income
countries (LMICs), are the geographical regions with a smaller economy and
poor access to basic infrastructures [5]. While healthcare has several general
challenges such as identifying treatments for new diseases, there are some
challenges specific to the low-resource settings. Standard healthcare
infrastructures being highly cost-prohibitive in low-resource settings is one
of such challenges. Even in terms of human resources, the low-resource regions
tend to have a smaller health professional to patient ratio [6]. Skilled
healthcare professionals often chose to live in resourceful regions for better
facilities and remuneration [7]. Hence, it is not uncommon in low-resource
regions that personnel without appropriate training for a healthcare role
still fill in that role due to the lack of available trained professionals. An
example is the non-physician clinicians commonly seen in low-resource regions
[8]. This unavailability of adequate skilled health professionals has
implications on the quality of healthcare. Besides healthcare professionals,
the patients themselves are also a factor in the quality of healthcare
delivery. Generally speaking, people living in the low-resource regions might
have had lesser access to quality education [9]. Thus, they might have less
awareness about health, good practices, and seeking care which has
implications for the effectiveness of the healthcare that they receive.
Similarly, there might be impediments due to cultural and religious barriers
which impact health services and delivery in low-resource regions [10].

Technology can play a vital role in addressing some of the healthcare
challenges in low-resource regions. New devices for diagnosis and treatment
could be helpful to streamline healthcare where adequate healthcare
professionals are not available. For example, a device for automated
respiration rate monitoring could relieve nurses from having to manually
estimate respiration rate [11] and enable them to triage more patients in a
given time. New technological designs and manufacturing improvements geared
for cost reduction can make healthcare devices affordable for low-resource
regions. However, there are also open questions regarding the impact of cost
reduction on the quality and reliability of the devices (solutions).
Information Technology (IT) and automation can also help make healthcare
solutions cheaper by scaling existing healthcare solutions and simplifying
workflows in healthcare delivery. Similarly, automated clinical decision-
making to aid healthcare professionals can increase the efficiency of health
processes and reduce associated costs. An important platform for pervasive and
affordable healthcare solutions could be the currently ubiquitous smartphones
and mobile networks which are getting more accessible in low-resource regions
[12]. Some of the upcoming technologies will also likely contribute to
improving healthcare in low-resource regions. For example, advanced machine
learning and artificial intelligence have already shown promises for improving
and democratizing healthcare [13]. Other emerging technologies like the
Internet of (Medical) Things (IoT/IoMT) and blockchain are also poised to
revolutionize healthcare [14] and likely lead to the advancement of healthcare
in low-resource regions [15].

In this paper, we review some representative works on healthcare technologies
for low-resource regions. In Section 2, we present works on low cost medical
devices. Then the use of IT solutions to scale and democratize healthcare
resources is presented in Section 3. Smartphone applications geared towards
healthcare that could be relevant for healthcare in low-resource regions are
presented in Section 4. In Section 5, we present some of the emerging
technologies that could improve healthcare in low-resource regions. Based upon
the reviewed works, we discuss the current state and outlook of healthcare
technologies for low-resource regions in Section 6.

##  2 Low Cost Medical Devices and Equipment

Medical devices are an important component in the healthcare delivery chain
used across diagnosis, treatment, and care. For example, diagnostic devices
like vital sign sensors and patient monitors, life-critical support devices
like ventilators and pacemakers, among others, are required in general and
specialized healthcare services. Effective healthcare delivery requires
supporting medical devices. However, the cost of medical devices in a
particular care setting can be high. The costs are alarmingly high in higher
acuity care settings like ICU (Intensive Care Unit) or OR (operating room) and
still relatively high in lower acuity care settings like GW (General Ward).
These high costs, both the capital expenditure and operating costs, can in
themselves be a big impediment to the wider reach of quality healthcare
services in low-resource regions [16].

Cost reduction of the medical devices can be achieved by several means such
as:

  * •

Re-design the existing devices to reduce components or use low-cost component
alternatives

  * •

Use alternate modalities to achieve similar functionalities as the standard
medical devices

  * •

Innovative operating model to maximize the utilization of costly devices

In this section, we review some works on low-cost medical device development.
The works are categorized based on the approach toward lowering the costs.

###  2.1 Low-cost medical devices with reducing component costs

The overall cost of electronic components goes down every year [17]. The bill
of materials for standard medical devices would thus lower too and possibly
result in devices being affordable for use in low-resource regions. This, for
example, has been presented to be a case by [18] for home-based glucose
monitoring devices. Glucose monitoring is essential for monitoring chronic
conditions like diabetes, a disease of growing worldwide concern and of
increasing concern in low-resource regions too [19, 20, 21]. According to the
authors in [18], the glucose monitoring devices for home use are getting
affordable due to the general trend of lowering prices for semiconductor
technologies. Standard electronic components such as microcontrollers, real-
time clocks, flash memories, etc. have increased functionality while getting
cheaper. This proliferation of semiconductor technologies will further help
reduce the overall costs of medical devices and thus barriers to entry of
medical devices in low-resource regions.

###  2.2 Add-ons to smartphone

Another approach to reducing the cost of medical devices is to use the
ubiquitously available smartphone as an add-on or replacement for some
components of the medical devices. The authors in [22] proposed a low-cost
blood pressure measurement device for low-resource settings. The authors
suggested the use of smartphones for interfacing with a simple sensory front-
end comprising a pressure sensor. With all the signal processing and
visualization done in the smartphone, with the power supply too coming from
the smartphone itself, the cost of the blood pressure measurement device could
be significantly lower than a standard measurement device. Further, the
smartphone as an interface helps to provide customized measurement guidance
based on a person’s medical training, preferred language, etc. Similarly, the
authors in [23] presented an approach to using a low-cost device add-on,
acoustically coupled to a standard smartphone, for realizing a digital
stethoscope. This approach reduced the cost by 150 to 400 times in mass
production. The digital stethoscope can be used for various care conditions
like the remote assessment of heart sounds from a cardiac patient or elderly
patient monitoring at home. A digital stethoscope in the context of the
COVID-19 pandemic to diagnose lung pathologies in the low-resource setting has
been proposed by the authors in [24]. The applicability of digital
stethoscopes in various application areas is still being actively investigated
in several other works too [25, 26, 27, 28].

###  2.3 Alternate modalities of measurement

The price of standard medical devices can also be reduced by developing
alternate modalities for diagnosis and treatment, which are comparatively
cheaper. The authors in [29] developed an intermittent fetal heart rate
monitoring device using Doppler ultrasound. It provided a comparative
diagnostic value to that of a standard reference device such as the
Cardiotocograph, at a much lower cost. The proposed device could operate with
alternate power sources such as wind and solar power which made it further
suitable for low-resource regions. The authors in [30] proposed the use of
wood-lamp technology, a technology for UV light generation, to detect various
skin infections. Early detection of skin infections could be crucial in the
diagnosis of medical conditions like HIV/AIDS. The authors outlined various
challenges related to technology, business model, etc. for the use of the
proposed device. Nonetheless, the proposed diagnosis tool could provide a low-
cost (pre-) diagnosis solution, suitable for use in low-resource settings when
properly designed for easy use. The authors in [31] reviewed various
technologies for cancer diagnosis, treatment, and care in low resource
settings. The authors found, for example, low-cost and portable commercial
ultrasound solutions to be suitable in low-resource settings as a powerful
diagnostic imaging tool.

Low-cost solutions for advanced state-of-the-art technologies have been
discussed in several previous works. The authors in [32] presented a
gyroscope-based gait monitoring system that can be employed for use in a non-
clinical setting also. Gait monitoring has applications in the detection of
the onset of neurodegenerative diseases, among others. IMU (Inertial
Measurement Unit) like gyroscopes and accelerometers provide a cheaper
alternative to standard references like optical marker-based motion capture
technology or force plate sensors. The authors in [32] indeed found that
cheaper alternative methods like gyroscope-based monitoring provided
comparable accuracy to other standard reference methods. Similarly, the
authors in [33] found inertial sensors to be a suitable tool to monitor
physical functioning tasks in low-resource settings.

A smartphone could also provide an alternative to diagnostic devices for
certain medical conditions. The authors in [34] presented a smartphone-based
tool for mental health assessment that could be deployed in low resource
settings. The developed application uses contextual data like actigraphy and
light, along with the available vital sign measurements from third-party
devices and validated clinical questionnaires, to assess and track an
individual’s mental health. As the proposed solution does not require the use
of any other diagnostic devices and can be deployed in a scalable way, it is
well suited as a pre-diagnostic alternative for use in low-resource settings.
Smartphone-based mobile sensing data have been shown to be promising in other
mental health applications like schizophrenia [35], depression [36], bipolar
disorder [37], etc.

###  2.4 Commodity hardware and software to improve efficiency

Technological solutions could also improve workflow and reduce clinicians’
burden where the patient to clinician ratio is commonly high. The authors in
[38] discussed the Humanitarian Technology Challenge (HTC) on using technology
to solve the challenges of healthcare service delivery in low-resource
settings. RFID technology is proposed to identify and link different
healthcare service interactions, e.g., at a clinic or from a mobile health
worker, with a central database of a healthcare resource center. Robust
identification of healthcare service interactions and linking to electronic
health records is aimed at reducing errors in medical decision-making and
enabling proper care planning.

The authors in [39] proposed machine learning techniques for the automatic
identification of clinical conditions like pneumonia using heart rate,
respiration rate, and other clinical information. Such automatic
(pre-)diagnosis will lead to significant workflow improvements and medical
error reduction. These will then reduce the costs in healthcare delivery. With
the commodification of health devices (e.g., smartwatches consisting of
several health sensors), the availability of trained personnel for data
interpretation and diagnosis can still be an impediment to effective
healthcare services in low-resource settings. Automatic data analysis and
(pre-)diagnosis, such as those proposed by [39], can improve the usefulness of
available health data in low-resource settings. Other works such as [40] also
discussed the use of smartphone applications to support patient diagnosis in
low-resource settings, especially where workflow can be burdened by the low
doctor-patient ratio. The authors also proposed a machine learning-based tool
for automated diagnosis of disease. In a similar approach, the authors in [41]
presented a mobile telecardiology system suitable for a low-resource setting.
In the proposed solution, the ECG strip recorded by an ECG technician is
captured as images using a mobile camera and sent to a remote server where it
is automatically processed to extract key ECG features. Recommendations, and
further referral to a trained doctor if required, are provided based on the
ECG parameters and associated automatic assessments of cardiovascular
conditions.

In the overall landscape of medical devices, the cost associated with
infrastructure maintenance cannot be overlooked. In [42], the authors
discussed the costs associated with healthcare infrastructure maintenance in a
low-resource setting. The infrastructure in this context encompassed not only
the medical devices but also the related support structures like the
buildings, energy management, waste management support, etc. High costs were
found to be mostly associated with the operating costs. The capital
expenditure could be less in principle, thanks to the various international
aid and support provided to low-resource regions. The authors suggested that
the design and planning of infrastructure should be done according to the
local circumstances of deployment areas. For example, the availability of
components for repair, the possibility of training maintenance personnel, the
availability of energy sources like solar plants, and the available monitoring
unit for proper aid deployment should be taken into consideration. The authors
in [43] discussed some challenges in maintaining computer-based infrastructure
in low-resource settings. The authors also note that the cost of required
trained professionals to sustain and maintain such infrastructure is the most
significant. The authors proposed a centralized technological support model
for cost-effectiveness that could be relevant for healthcare infrastructure
deployments in low-resource regions.

###  2.5 Considerations for low-cost devices

Multiple issues need to be taken care of in the effort toward affordable
medical devices for low-resource settings. Proper considerations of the
underlying technology (suitability/reliability), business and cost models
(sustainability/affordability), associated quality and usage factors, etc.
need to be made. The authors in [44] advocated the need to approach medical
device development for low-resource settings differently from a mere
technology transfer process. A sustainable approach to the introduction of new
technology is suggested by considering different factors such as customer
needs in low-resource regions, the context of device/application usage, viable
business models, etc. The authors in [45] raised various issues that could
arise in low-cost medical device development. The authors suggested that many
of the proposed low-cost devices could be bogus and lack adequate safety
designs. Therefore, proper scrutiny of propositions to ensure patient safety
and quality care is recommended. The authors also remarked that actual device
development costs might not be properly accounted for in many low-cost medical
device propositions. Many low-cost medical device development initiatives are
undertaken in the academic research setting, usually supported by an external
grant. Thus, the research expenditure for a new low-cost device might not
always be transparent and fully accounted for. This has implications when new
device development projects in low-resource regions are planned.

###  2.6 Section summary

To summarize, several works have investigated low-cost medical device/solution
development for low-resource regions. Some works have relied on the decreasing
cost of semiconductor technology to argue that medical devices are getting
affordable for use in low-resource regions. This is true for many consumer-
facing healthcare technologies (e.g., smartwatches and home-based health
monitoring devices). However, much complex medical equipment is still very
costly [46], and it might be a while before the prices for standard medical
devices required in a health care center become affordable in most low-
resource regions. Other works have relied on a smartphone as an add-on for
medical devices, overcoming the need to procure standard devices (e.g., a
smartphone-based digital stethoscope in place of a standard stethoscope).
Though this approach is a viable alternative, e.g., using a smartphone display
as a medical device display, the functionality of the proposed solutions must
be rigorously validated. For example, it should be ensured that the
functionality of the proposed solution/device works across different
smartphone types, network quality, etc. Some works have investigated alternate
modalities for affordable diagnostic and therapeutic solutions in low-resource
settings. These research works should continue as low-cost measurement
modalities might replace costlier alternatives. Other advances we are making
in data science and analytics for robust measurements could be helpful. For
example, thanks to the advances in data science, photoplethysmography (PPG)
from consumer devices can potentially be used for arrhythmia detection [47,
48] and consumer cameras can be used as a vital sign monitoring device [49,
50]. Technological solutions have also been proposed to improve healthcare
workflows and improve efficiency. This reduces the overall healthcare costs
and thus needs further exploration of their applicability in low-resource
settings. Finally, a holistic view of the cost of medical device deployment
considers the cost of infrastructure in low-resource settings. This has been
discussed in some previous works and must be a part of any proposed general
healthcare solution targeted at low-resource regions. Overall, no matter what
approach (or a combination thereof) is used towards low-cost medical devices,
one must ensure that the quality and patient safety aspects are kept as the
priority.

A summary of our observations from the literature regarding low-cost medical
devices for low resource regions is provided in Table 1.

Table 1: Summary of works on low-cost medical devices for applications in low-resource settings. Various approaches have been proposed in the literature for reducing the costs, ranging from using alternative sensing technology to the usage of a smartphone as an add-on for medical devices. Approach for low cost medical devices and healthcare solutions |  Example Clinical Applications and Example Works
---|---
Reliance on reducing the price of the semiconductor technologies for |  Glucose monitoring at home for Diabetes care. e.g., [18].
Smartphones as an add-on for medical devices |  Blood pressure monitoring, Remote cardiac monitoring, and Elderly patient monitoring. e.g., [22], [23].
Low cost alternative for diagnosis and therapy e.g. using alternate signal for diagnosis |  Fetal Heart rate monitoring, Skin infection diagnosis, Cancer diagnosis, Gait monitoring, Mental health assessment. e.g., [29], [30], [31], [32], [34]
Improvement of workflow to bring cost reductions and reduce burden on clinicians |  Automated Electronic health record, Automated Diagnosis, Mobile telecardiography. e.g., [38], [39], [40], [41]

##  3 ICT Tools to Scale Healthcare Solutions

The use of information and communication technologies (ICT) in health services
has been termed eHealth by the World Health Organization (WHO) [51]. Cost-
effectiveness and security are important aspects of eHealth propositions [52].
Healthcare outreach, especially in low-resource regions, could be improved
with ICT to scale and democratize care. For example, ICT could help the rapid
dissemination of clinically relevant information such as a new diagnostic
procedure or matters of public health. In this section, we review some works
that have proposed the use of ICT tools for affordable healthcare in low-
resource settings.

###  3.1 ICT for Electronic Health Records (EHR)

Proper management of health-related data is crucial in overall healthcare
delivery. Electronic health records (EHR) and other healthcare information
systems provide the required infrastructure for data management and
information flow. However, proprietary healthcare information systems might be
cost-prohibitive for low-resource regions; the burden of software license
costs can sometimes be very high. The proliferation of affordable ICT
solutions with the ongoing open-source movement could prove a boon for
healthcare ICT infrastructure in rural areas. Several works have identified
how ICT advancements can be used for better data management and information
flow for healthcare services in low-resource settings.

In [53], the authors discussed the use of free and open-source software like
Care2x [54] and OpenEHR [55] to build hospital information systems, in the
context of healthcare services for low-resource regions in Tanzania. The
authors in [56] proposed an open-source health information system called
DataPall for rural healthcare solutions in Africa. The DataPall system for
keeping patient care records could run on a PC without internet access. The
authors highlighted the role of healthcare information systems such as
DataPall in providing evidence-based healthcare improvements. The authors in
[57] also proposed an open-source cloud-based system named Eucalyptus to
assist healthcare in low-resource regions. Eucalyptus could support both the
information management needs as well as the elastic computational needs. The
information management solution within Eucalyptus, for example, is obtained by
integrating an open-source hospital management system such as Care2x. The
reliance of low-resource regions on open-source solutions for EHR system
implementations was also discussed in [58]. In particular, the following open-
source EHR/EMR (Electronic Medical Records) systems were reported to be
commonly used: HOSxp [59], OpenEMR [60], and OpenVista [61]. The authors in
[62] identified 8 different data collection systems used for maternal and
neonatal care in the low-resource region of which four were free and open-
source systems, highlighting the importance and prevalence of open-source
healthcare data management solutions in low-resource settings. The authors in
[63] qualitatively compared five popular open EHR systems: OSHERA VistA, GNU
Health, OpenMRS, OpenEMR, and OpenEHR. The OpenEMR was found to be the most
promising open-source EMR solution in comparison. It is generally beneficial
to have multiple open-source projects for an application. A hospital or clinic
in low-resource settings could choose from multiple options of open-source
EMR/EHR depending upon the fit to their current needs. In the meantime, open-
source EHR should be continually improved to be user-friendly, reliable, and
effective, given the increasing usage of these EHRs for critical healthcare
services in low-resource regions, among other places.

It is preferable if most of the (software) components proposed in a healthcare
information system, e.g., within a proposed EHR, are open-source. For example,
the authors in [64] proposed Intelehealth system for telehealth access in
rural India. Intelehealth is an open-source platform enabled by cloud-based
electronic health records. The platform allows proper information flow between
different healthcare professionals and clinical centers. MySQL database,
available at no cost, is used as a component of Intelehealth which makes the
proposition suitable for low-resource regions. In [65], the authors discussed
a teleconsultation system designed for low-resource regions of Bangladesh
which allows the physicians to remotely access patients’ records and provide
appropriate consultations. The system was built using PHP and MYSQL server
components which are both freely available IT tools. Similarly, in [66], the
authors proposed using open-source connectivity and database system for
connecting different healthcare centers and professionals in low-resource
regions of Indonesia. Internet radio packet was used for connectivity and
PostgresSQL for database management. The free/low-cost software components
make the proposition suitable for use in low-resource settings. On the other
hand, the authors in [67] proposed to use an off-the-shelf database like
Filemaker [68] to build an EHR/EMR solution for low-resource settings.
However, the Filemaker solution is not free and the added cost of the database
has to be assessed in the trade-off of costs versus better functionality or
usage benefits that a commercial database could provide.

###  3.2 ICT to improve secondary healthcare functions

ICT tools could help in making secondary healthcare functions like knowledge
management, information dissemination, and policymaking affordable and
accessible. These secondary functions are especially important for healthcare
operations in low-resource regions where the availability of trained personnel
is limited. Several studies have discussed the role of ICT in knowledge
management, information dissemination, and policymaking in the context of
healthcare. Similarly, the role of ICT to improve logistics in healthcare has
also been highlighted by earlier studies. Improved logistics in healthcare
leads to improved accessibility.

The authors in [69] discussed how health information tools have benefited
healthcare services in low-resource regions of Kenya. The improved data
availability for local bodies helped to better assess the current healthcare
systems, identify their bottlenecks, and propose improvements. ICT tools
helping improve policy by monitoring the healthcare system are highlighted. In
[70], the authors discussed the role played by ICT in the maintenance and
operations of healthcare infrastructure deployments in Mozambique. As these
examples depict, information assimilation enabled by ICT helps in policy and
decision-making at a regional/national level. The authors in [71] also
reported how ICT is important for improved healthcare outreach and efficiency
in low-resource regions of Peru and Nicaragua. They also identified the need
for increased access to communication infrastructure, information sharing, and
continuous training of health professionals; ICT will have an important role
in fulfilling these needs too. Interesting examples are shared by the authors
on how ICT could relieve the burden on healthcare professionals. A healthcare
center head, who otherwise would have needed to travel and thus created delays
in the health services, could avoid the travel when facilities for emails and
communications are easily available in a low-resource region. Similarly, many
healthcare professionals could benefit from ICT-enabled solutions that reduce
errors arising from manual paper works in healthcare. In [72], the authors
also discussed the role of telehealth systems built using (open-source) ICT
tools to improve healthcare in low-resource regions of Zambia. The proposed
solution provided improved access to medical specialists, increased
opportunities for education, and logistic improvements like decreased travel
needs for both the healthcare professionals and patients. Though the examples
discussed in this section are sometimes from a work of more than a decade ago,
some analogous technology-based assistance for improved logistics would still
exist today.

###  3.3 Network and server resources for healthcare solutions

The increasing availability of ICT hardware, services, and infrastructures
like telecommunication is a prerequisite for improved healthcare availability
in low-resource regions. Several previous works have reported how the
availability of servers and telecommunications is improving e-health and
telehealth services for low-resource regions. The authors in [52] discussed
the role of telecommunication infrastructure and internet access devices in
the context of health services in Africa. The authors highlighted how a basic
network infrastructure enabled by telecommunication technologies like GPRS,
WiMAX, and VSAT provides a backbone on top of which healthcare services and
information delivery can be deployed. ICT’s role was identified to be crucial
in various areas such as health system performance monitoring, resource
planning, dissemination of health knowledge, policy-making, etc. The authors
in [73] discussed the issue of communication infrastructure affordability. A
combination of a Wi-Fi and WiMAX network was proposed as an affordable network
solution for low-resource regions. Such an affordable yet modern wireless
communication system can enable telemedicine service to bring worldwide
clinical expertise to the point of care in low-resource regions. The authors
in [74] discussed the role of ICT in the context of their EHAS (Hispano-
American Health Link) program. The burden on healthcare professionals arising
due to the lack of ICT tools was highlighted in this work too. The authors
discussed the deployment of custom email servers, working over the Very High
Frequency (VHF) band for communication, to help healthcare establishments in
low-resource regions of Peru. The recent roll-outs of advanced
telecommunication technologies such as 5G, if available in low-resource
regions, can significantly enhance healthcare service delivery in those
regions [75, 76].

Some specific features of ICT software advancements e.g. features in the
database have also been advantageously applied in some works. In [77], the
authors discussed their software tool Health Agent which is useful to automate
telemedicine in rural areas. The functionalities of a relational database
system, e.g. SQL triggers, are utilized for case-based alarming in the
proposed solution. The data model for proper storage and access to health
information is also discussed. These data model development utilizes relevant
advances from the larger internet technology developments.

###  3.4 ICT for healthcare knowledge and language tools

The role of ICT tools in knowledge management and training of health
professionals has also been a subject of discussion in some previous works.
Proper knowledge management and affordable training are important for
healthcare in low-resource regions because of the general lack of trained
professionals and knowledge resources. In [78], the authors proposed a digital
library solution to assist healthcare in low-resource regions. The library
consists of reading materials on healthcare physiology, tools maintenance,
operations, etc. This information is made available in the local language
using an automatic language translation service. The authors in [79] presented
an open learning platform called Openlearn to provide free training materials
on healthcare management. A free training platform could in particular be
beneficial for personnel in low-resource healthcare settings who cannot afford
or access training with high costs. In [80], the authors presented different
ICT innovations to support primary healthcare in India (relevant for low-
resource regions also). Replacing manual healthcare information management
with automated (ICT) solutions for efficiency is highlighted. Similarly,
software-as-a-service deployments and mobile applications for improved
connectivity of mobile midwives are presented to make the maternity healthcare
system more efficient. For any innovation, the availability of multi-language
tools, e.g., owing to open-source tools and technologies for language
translation [81], is considered important. In general, the need for healthcare
information and user interface tools in local languages is identified as very
crucial for healthcare services in low-resource regions where English might
not be the primary language of the majority. These intuitive user interfaces
and language translation tools are directly linked to ICT innovations. In
[82], the authors discussed the role of an ICT-based knowledge management
system for improved healthcare access in low-resource regions of Srilanka. The
need for a knowledge management system for making healthcare pervasive in low-
resource regions is made clear. Still, some problems like the skeptical
attitude of some clinical professionals in using ICT resources, general
unavailability of good systems and software, etc. were raised. New
propositions should consider user-centric ICT propositions that are adapted to
local needs to improve the trust and usability of developed propositions.

###  3.5 Section summary

To summarize, several propositions have used ICT advancements for improving
healthcare access and affordability in low-resource regions. The open-source
software tools, increasing access to network/communication infrastructure,
easy access to health information library, etc., are all ICT advancements also
helping healthcare in low-resource regions.

Some studies have shown the direct relation between ICT advancements and
feasible healthcare innovations. In [83], the authors studied the quantitative
relationship between IT infrastructure and telemedicine readiness in the
context of healthcare systems in Libya. A positive correlation of 0.44 was
obtained, highlighting the direct impact of ICT infrastructure on enabling new
healthcare innovations in low-resource regions. Besides the general
availability of ICT infrastructures, the authors also highlighted the need for
associated trained professionals for its operation and maintenance. In [84],
the authors interviewed several healthcare professionals working in low-
resource regions of the Philippines. A need for proper access to clinical
practice guidelines, health news, and events, health education policies, etc.
were identified from the interviews. This information is made accessible with
ICT infrastructures, and thus the role of ICT for healthcare in low-resource
regions is highlighted.

##  4 Mobile Health

Mobile Health (mHealth) refers to the practice of health solutions and
services supported by mobile devices such as mobile phones, tablets, PDAs, and
wearable devices. The mHealth field has emerged as a sub-segment of eHealth.
The services generally considered under mHealth include the use of mobile
devices in collecting community and clinical health data, delivery of
healthcare information to practitioners, researchers, and patients, real-time
monitoring of the patient, and direct provision of care (via mobile
telemedicine).

mHealth has emerged in recent years to be suitable for developing countries,
resulting from the rapid rise of mobile phone penetration in the low-resource
regions also. It can enable wider healthcare access to a larger segment of the
population in low-resource regions by improving the capacity of health
systems. Here we discuss some works that have focused on mHealth. We also list
several health-related mobile applications that could be relevant for
deployment in low-resource regions or regions with limited access to
conventional healthcare services.

The authors in [23] highlight how mobile devices can be used as medical
devices. The use of the available capacity of smartphones, e.g., the onboard
sensors, web connectivity, and powerful processing unit, has made these mobile
devices not just a medium of communication but also a medical device.
Providing proof of concept with a digital stethoscope, the importance of
available infrastructure to cope with critical diseases related to heart
patients has been discussed. In the low-resource settings, mHealth could be
the only way to offer services that would otherwise be unavailable [85].
Mobile phones with affordable network connectivity could be a vector for
enhancing the continuity of care before the diagnosis and after the
hospitalization for a continuous follow-up. mHealth applications allowing
networking and video conferencing could help to increase efficiency (better
logistics, more contact, etc.), quality of patient care (e.g., due to more
follow-up even if remote), and patient satisfaction. There might be some
constraints on mHealth applications when considering their usage in low-
resource settings. The authors in [86], for example, investigated the
effectiveness of mobile apps in rural areas with low literacy. Visual-based
apps were recommended for better meeting the needs in low-resource regions.

We list some example mobile/smartphone applications (mobile apps) in Table 2,3
and 4 that could be relevant for healthcare in low-resource settings. We
categorized the applications based on the target complications they address.
Furthermore, we classified the apps based on their feature type. These apps
can be used either directly by the patients and families, or by midwives and
doctors.

Table 2: Some example smartphone applications developed for health monitoring and diagnosis. These applications are low-cost and could be useful to aid healthcare services in low-resource regions. Name |  Target Complication
---|---
iASHA [87] |  Pregnancy (A decision support system to enable health workers to provide maternity healthcare services efficiently and transparently.
mBody Health [86] |  Diagnose disabilities
Mobile Stethoscope [23] |  Monitor Heart rate to diagnose heart disease
Cardiax Mobile ECG [88] |  12 channel personal ECG system to diagnose and monitor heart condition
Runtastic Heart rate [89] |  Measures heart rate on a real-time basis
Heart rate monitor [90] |  Checks heart rate on a real-time basis
Blood pressure watch [91] |  Collects, tracks, analyzes, and shares blood pressure data
Finger blood pressure [92] |  Measures blood pressure based on imaging of fingertip
Finger Print Thermometer [93] |  Determines body temperature based on contact at fingerpoint
Body temperature [94] |  Keep track of body temperature and identify severity
iOximeter [95] |  Pulse rate calculator
Eye care plus [96] |  Test and monitor vision
Test your hearing [97] |  Test hearing
uHear [98] |  Self-assessment of hearing
Table 3: Some example smartphone applications for healthcare record-keeping. Measurement and tracking of health through record keeping are crucial aspects of healthcare delivery. Name |  Target Complication
---|---
iASHA [87] |  Pregnancy
mBody Health [86] |  Monitor disabilities
Mobile Stethoscope [23] |  Monitor heart disease
Health assistant [99] |  Monitor BP, weight, water, temp, glucose, etc
Asthma tracker and log [100] |  Asthma tracker
Diabetes Diagnostics [101] |  Diagnose diabetes subtypes
Table 4: Example smartphone applications related to lifestyle and healthy behaviors. The concept of healthcare is a continuum that includes the day-to-day life of an individual and thus applications helping in lifestyle and healthy behaviors are relevant for improving healthcare overall, including in the low-resource regions. Name |  Target Complication
---|---
Health assistant [99] |  BP, weight, water, temp, glucose, etc.
Water Your body [102] |  Reminds user to drink water
Medisafe Meds & Pill Reminder [103] |  Reminds user of medication times
Dosecast indication Reminder [104] |  Drug management
MyFitnessPal [105] |  Keep track of food habits
SleepCycle [106] |  Keep record of sleep time
FitBit [107] |  Track daily goal and progress over time for steps, distance, calories burned and more.

##  5 Emerging Technologies

Some of the emerging technologies like artificial intelligence (AI), Internet
of Things (IoT), Blockchain, etc., have already shown great promise for
healthcare. The technologies also have a role in making healthcare inclusive
and affordable. In this section, we review some works where emerging
technologies for healthcare have been discussed. Though not always explicitly
stated, these works have the potential translation of their usage for
increasing the outreach of healthcare in low-resource settings.

###  5.1 AI for Healthcare

AI has shown its potential in a broad set of use cases. Much of this success
is due to the availability of data, easily available computing power, and an
improved understanding of different AI algorithms. Machine learning, which is
concerned with learning from data, is one of the enablers of AI. Many
advancements in healthcare due to AI have been brought by machine learning
advances. In recent years, deep-learning, a type of machine learning based on
multi-layered neural network architectures, has provided even clinician-grade
solutions, e.g., to analyze medical images and physiological signals. For the
healthcare application, AI has a role in several areas like automated
diagnosis, clinical decision support, clinical workflow optimization, resource
utility maximization, etc.

The use of AI for diagnosis has been one of the most explored application
areas. The typical data flow for such a solution is shown in Figure 1. Data
from a (multi-) sensor front-end is consumed by an AI application to produce
diagnosis and decision support outputs. Based on a usage area, AI for
diagnosis can be categorized into: (i). Inside-hospital application and (ii).
Outside-hospital application.

Figure 1: Generic data flow for AI-enabled healthcare diagnosis and decision
support applications. The data collected from a sensor front-end, or
retrospective data from electronic health records, are sent to a computing
platform running an AI application. This computing platform could be a
smartphone, cloud, edge device, or any other computing device. AI application
in the computing platform takes the input data and provides diagnosis and
decision support as output. The output is provided either to the user (e.g.,
for smartphone applications) or to the clinician and caregiver. The output can
also be linked to the patient’s/user’s Electronic Health Records to keep track
of his/her health.

####  5.1.1 Inside-hospital applications

The inside-hospital applications use AI for aiding diagnosis for day-to-day
clinical workflows. Several innovations in this area are, for example, in the
field of radiology. An example application is tumor/nodule detection in the
lung CT scan [108]. In [109], the authors identify several application areas
where AI could assist in radiology-based diagnosis. Some of those areas are
thoracic imaging for lung nodule detection, abdominal and pelvic imaging for
liver lesions detection, colonoscopy for colonic polyps detection, brain
imaging for brain tumors detection, etc. While the radiology equipment might
be a significant cost burden for low-resource settings, at least the
automation of (pre-)diagnosis could offset the cost required for well-trained
radiologists. Besides radiology, other application areas of AI in clinical
diagnosis and decision making include for example hospital discharge or
readmission prediction [110, 111, 112] using available clinical data, or
arrhythmia detection using ECG (Electrocardiograph) signal [113, 114, 115].

####  5.1.2 Outside-hospital applications

The outside-hospital application categories are concerned with taking the
(early/pre-) diagnosis to the ambulatory settings of free-living. A
representative work is presented by the authors in [116]. The authors propose
a camera-based system to provide a clinical-grade diagnosis of skin cancer. A
motivation for such a system is the possibility to extend the reach of
dermatologists outside of the traditional setting and enable low-cost
healthcare on top of ubiquitously available smartphones. The authors of [117]
describe a deep-learning-based atrial fibrillation detection solution using
photoplethysmography (PPG) signals in an ambulatory setting. These example
applications show how the power of AI can help take the clinical diagnosis to
ambulatory settings. Such a step is crucial to bringing quality diagnosis
solutions to low-resource areas. We refer to the review works in [118, 119,
120, 121, 122] for the application of AI/machine learning in healthcare areas.

Besides diagnosis and clinical decisions, AI could be advantageous in other
aspects of the healthcare delivery chain. Any AI-based solution to improve the
healthcare delivery chain can translate to a direct benefit towards healthcare
for low-resource settings. The benefits can be cost reduction, improved
efficiency, the requirement of lesser resources and manpower, etc. An example
discussing the use of AI to improve the entire healthcare delivery chain is
the work of [123]. The authors discuss how AI can be used for the diagnosis
and treatment of Tuberculosis (TB) by improving all the aspects of the
healthcare chain. AI technologies can help assure medication adherence using
automated gesture detection technologies (e.g., from video surveillance). AI
can be useful for the whole program management of TB containment and treatment
in an area e.g., in the context of resource planning and monitoring. For an
application like TB, raising awareness of the patients and population is also
very important. For this purpose, using AI for the automated generation of
educational audio-visual materials can be helpful. Other works have also
outlined how AI and optimization can be helpful in aspects other than core
clinical tasks like diagnosis and treatment. The authors in [124] have
proposed optimized planning for scheduling the work of Community Health
workers where AI can play a role in the optimized scheduling. AI can be used
in different health resource planning works like referrals, management of
immunization programs, and several population/public health initiatives. Such
efficient planning can be crucial when it comes to reducing the cost of
healthcare in low-resource settings and improving throughput/efficiency. The
authors in [125] also discuss how AI can have a role in healthcare in low-
resource settings for various functions like diagnosis, administration,
resource planning, monitoring, etc. Specific example deployments like AI-based
chat-bots to support medication has been presented. The challenge concerning
the cost of AI-based solutions is raised but it has also been noted that
overall cost reduction can be expected, justifying the fit of AI-based systems
for healthcare in low-resource settings. An advantage for AI deployment in
low-resource settings could be the relative policy-level ease of deployment.
The example of clinical drone usage in Rwanda has been presented to show this
point.

To summarize, the growth and increasing adoption of AI can prove to be very
helpful for increasing the outreach of healthcare in low-resource settings. AI
as a technology is being widely investigated to improve clinical diagnosis and
decision making, either inside the hospital or outside. Besides diagnosis, AI
can also assist in reducing costs and improving efficiency for other aspects
of the healthcare chain. Though the initial cost factor and required
technological knowledge for solution deployment can seem like a hindrance to
getting AI technologies to the low-resource settings, AI provides several
other benefits which could pay off overall.

###  5.2 Internet of Things (IoT) for healthcare

Connectivity and computational power are getting cheaper and more ubiquitous.
This has led to a myriad of devices around us being more intelligent and
inter-connected. The connectedness of everyday items and devices around us,
which also get smart and intelligent, is referred to as the Internet of Things
(IoT). Think of an automatic watering unit for the plant enamored by
environmental sensors that we can monitor and control using a mobile
application. Or a refrigerator that has an inbuilt camera to detect missing
groceries and update the shopping list on our smartphone. IoT is already a
reality today, and only growing in terms of scale and usage.

Healthcare is one of the areas where IoT can enable new solutions. Most of the
research work on IoT for healthcare has mHealth or a wireless body area
network (WBAN) application deployment scenarios. Wearable physiological
sensors connected to the cloud and made available for remote access by the
clinician is a typical application scenario. This, for example, has been
discussed by [126, 127, 128, 129, 130, 131, 132, 133, 134]. Innovative
deployments have been discussed in works like that of [135] where the authors
present a health-kiosk available for healthcare in remote regions of India.
These kiosks consist of multiple physiological sensors which can make the data
available for remote access through cloud services. The authors in [136]
discuss the possibility of an intelligent edge device within an IoT deployment
of personal physiological sensors in low-resource settings. The edge device
can provide various useful functionalities like smart data filtering to only
forward relevant information to the clinicians in a remote location. It can
also automatically detect any health criticality among the monitored
population. Such deployments increase the (virtual) outreach of clinicians. An
interesting extension of this smart edge-based IoT deployment is the
possibility to monitor the entire (sub) population in the region, leading to
population health analytics solutions. Besides personal physiological sensors
monitoring the health of individuals, other devices can be a part of the IoT
like a visitor counter device at the local health center, an EMR server of the
health center, etc.

A review of IoT for healthcare, though not specific to low-resource settings,
has been presented in the work of [137]. The authors discuss various IoT use-
cases for healthcare applications. The potential of large-scale IoT for
applications in community health monitoring discusses concepts like
interactions between multiple body area networks. An interesting use case is
IoT’s use for emergency healthcare services during a disaster. In low-resource
settings where the reach of standard healthcare services is limited,
connectivity of devices could help monitor and plan resource utilization,
casualties mapping, etc. One other use case discussed is the possibility to
track population-level information on adverse drug reactions. This can
immediately be extended to applications specific to low-resource settings
e.g., tracking outbreaks and the spread of specific diseases related to low-
quality water supply, for example. IoT can also be applied for awareness
campaigns by providing a platform for easy dissemination of information.

###  5.3 Blockchain technology for healthcare

One of the recent technological advancements with huge potential in the
healthcare sector, positively impacting the increase of the outreach in low-
resource settings, is blockchain technology. Blockchain technology enables a
way to keep a record of the transaction without a need for an intermediary.
This mechanism opens up various applications in healthcare that would
otherwise have been difficult to deploy. As blockchain provides a trust
mechanism between multiple parties, one of the most explored applications of
blockchain in healthcare is the sharing of data. This application is very
relevant for low-resource settings for two reasons. First, as healthcare
services and providers are not resourceful, sharing data between different
entities is difficult. E.g., healthcare facilities might not have enough
software and resources to open up their data to third parties without
incurring a major security and privacy threat. Second, the new applications
that can be enabled with easy data sharing would be crucial in low-resource
settings to enable applications like automated diagnosis, telemedicine, or any
general mHealth applications.

The authors in [138] discuss how blockchain could provide privacy,
traceability, value-management, and trust mediation for enabling mHealth
applications in South Africa where the requirements for healthcare access
extends to some deep rural settings also. In [139], the authors propose the
use of blockchain to manage distributed information in EMR, providing the
security and trust mechanism for sharing information. This is discussed in the
context of managing EMR for cancer patients. Given the lack of inter-
connectivity or secure direct connectivity between different data/information
nodes, blockchain can provide a secure gluing layer. The benefit of
decentralization to improve healthcare in low-resource countries has been
discussed in [140]. Though not explicitly mentioned, blockchain can be the
technology upon which a distributed healthcare infrastructure is built. The
use of blockchain for data sharing providing functionalities like patient
pseudo-anonymity, workflow automation, data integrity, accountability, etc.
has been presented in the paper of [141]. Similarly, the authors of [142]
present how the blockchain technology in a mHealth application provides the
solution for the right data ownership, security of the shared data,
convenience of sharing, etc. The authors in [143] uses blockchain and smart
contracts as a mediator to enable data-sharing across the providers (ensuring
interoperability) to make healthcare more cost-effective and sustainable. In
the MedicalChain whitepaper [144], the use of blockchain and smart contract
platform enabled by blockchain for data exchange for solutions like
telemedicine is discussed. The use of blockchain in healthcare, in general,
has been reviewed in several works [145, 146, 147, 148, 149].

As more works are pursued on the usage of blockchain in various aspects of
healthcare like diagnosis, treatment, clinical workflow, logistics,
prescription management, logistics management, etc., it would become clearer
what promises this new technology will bear for healthcare in low-resource
settings. From what we have already started to see, blockchain technology has
the potential to bring positive changes to healthcare in a low-resource
setting also.

##  6 Discussion

Quality healthcare access should be available for all. However, due to higher
costs associated with healthcare resources and infrastructures, we are yet to
reach the utopian dream of getting everyone on the radar of good healthcare
access. In this work, we reviewed various works that have been geared towards
making healthcare widely accessible in low-resource settings.

A major effort to control healthcare costs concerns reducing the price of
costly healthcare devices. This is becoming feasible due to the reducing cost
of semiconductors, the pricing reduction possible with improved mass
manufacturing, and the investigation of new designs with the cost factor taken
into consideration. We found that several efforts have been focused on
building an add-on for the smartphone, so that the smartphone itself can act
as a healthcare device, for example for early diagnosis. These works rely on
the wider availability of smartphones in a low-resource setting. The reach of
smartphones has been growing very rapidly even in the rural and low-resource
settings [12] and thus the smartphone as an add-on could be transformative.
The end-to-end healthcare delivery chain requires several devices. Therefore,
reducing the costs of these devices is a major step, and a crucial one,
towards universal healthcare access. However, the pressure of cost reduction
should not compromise the device quality. The quality reduction might lead to
an adverse outcome for the patient. The concern of quality is especially
relevant for low-resource settings because these areas generally lack good
regulations for devices and/or are lacking in trained personnel to enforce
quality guidelines or maintenance [150, 151]. Another point to be noted is the
overall representation of the device cost in the financial equation of the
healthcare delivery. It might as well be that the device costs represent only
a small portion of the overall healthcare costs, in a given care setting.
Also, the device costs might be only a one-time capital expenditure which is
overshadowed by the recurring operational costs. Therefore, all efforts toward
affordability of the healthcare device have to take the following factors into
account in further investigations: What fraction of the healthcare delivery
cost is represented by the device costs?, Can the cost reduction be done
without reducing quality?, How is the distribution of the capital expenditure
and operation cost of the device? And how does new low-cost design impact
these two factors?.

A development for increased healthcare access in a low-resource setting is
also the parallel development, or rather an explosion, of IT tools and
technologies. Software-based services and telecommunication infrastructure can
provide a carrier for innovations in healthcare targeted at low-resource
settings. If we think of novel healthcare offerings like telehealth, these
offerings have a good landing spot in the context of healthcare for low-
resource settings. Several studies have already investigated how the
availability of a new generation of telecommunication technology is going to
help revolutionize healthcare [152, 153, 154, 155]. A bit of that revolution
will be shared by healthcare for low-resource settings. Another development is
in the field of open-source IT tools. An example is OpenEMR which has been
positioned to provide a reliable EMR solution. Open-source solutions such as
OpenEMR could fill the void created when the healthcare organizations in the
low-resource settings cannot afford proprietary EMR solutions. Needless to
say, when it comes to the use of open-source software and tools for
healthcare, utmost care should still be provided to various aspects like
quality, privacy, etc. It would be unfortunate if the cost factor of a
software tool is used to overlook any impending harms like compromised patient
privacy or even patient safety. The efforts of healthcare for low-resource
settings should embrace developments in the open-source world but with caution
due to the criticality of the healthcare sector in general. Even though some
recent studies have found the privacy and security concern to be of less
significance to eHealth users in low-resource settings [156], this might only
reflect the notion that having the resources/infrastructure is of the highest
significance in regions where these are missing. Some studies have, however,
found that patients in low-resource regions are concerned by the unauthorized
secondary use of their protected health information [157]. Greater awareness
about the implications of security and privacy breaches on one’s health
information will likely increase the concern of patients on these factors.

A major carrier for increased healthcare access in low-resource could be
smartphones. The smartphone revolution will likely usher changes in healthcare
delivery, with a positive impact on cost reduction and affordability for
people in low-resource settings. In section 4, we reviewed several healthcare-
related smartphone applications. Various aspects like diagnosis, record-
keeping, improving lifestyle towards a healthier life, etc., are covered by
existing and upcoming applications. The smartphone has inbuilt sensors like
cameras and microphones that could work as health sensors, something which has
been receiving a lot of attention lately. For example, cameras could extract
heart rate variability and other physical health parameters [158]. Similarly,
the microphone can be used in speech-related applications, for example, to
assess sociability for depression severity estimation [159]. The smartphone-
based applications that we reviewed in Section 4 covered a wide range of
clinical conditions for cardiac care, optical care, pregnancy monitoring,
thermal monitoring, and many more. The smartphone revolution can thus have a
wide impact on healthcare. Though the concept of a simple application to
diagnose a disease at home sounds lucrative, it is important to ensure the
accuracy of such applications by validating with current standard devices.
Similarly, most of the applications will be customer-facing. Therefore it is
also important to think about how the accessibility is not impeded by factors
like the literacy level of people in a particular region. Just like the mature
technologies such as smartphones and telecommunications which have been
helping improve healthcare access in low-resource settings, one can also
remain upbeat with many upcoming technologies. In Section 5, we identified
some technologies like IoT, Blockchain, and Artificial Intelligence which will
all bring in another wave of revolution in healthcare. We reviewed different
literature where the authors are investigating how new technologies will
change healthcare services. It might not be too early to speculate that these
new technologies will further help improve healthcare access in low-resource
settings. Some recent works concur, for example with the potential of
blockchain technology to reduce health disparities and improve global health
[160].

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