A lack of technology greatly limits the benefits of cellphone-centred health initiatives, also known as mHealth, in the country, according to Maurice Mars from South Africa's Telemedicine Association.
Fewer than a third of South Africans own a smartphone that can download applications.
"Even though I'm a strong supporter of it, mHealth can't do nearly as much to improve health outcomes in South Africa as people might think," Mars said. "We are right at the beginning of the movement in South Africa. I don't think that in 10 years or even 20 the so-called digital divide will get smaller. It's getting worse, not better."
mHealth delivers medical and public health services and information through mobile devices.
According to the World Health Organisation, "developing countries are experiencing an unprecedented increase in the number of users of cellphone and internet technologies, as well as a decline in the price of devices and services".
But Mars said the technological environment is not advanced enough to handle many of the proposed mHealth initiatives.
"Some people have said it is the salvation for sub-Saharan Africa, that virtually everybody owns a cellphone. This is junk.
"A large number of people have phones and more will get but what developers need to think about is that people in need won't have access [to applications] as they only have basic or feature phones," Mars said. These phones can perhaps access the internet but can't download sophisticated applications.
A 2011 study conducted by the South African Audience Research Association found that 80% of people in the country own a mobile phone and only 15% own a landline.
"The figure for the adult market alone is probably much higher," said Arthur Goldstuck, an internet and mobile technology analyst who heads the research organisation World Wide Works. "Smartphones [which can download applications] account for only 28% of phones in the country; the remaining 72% is feature and basic phones," said Goldstuck.
Mars said that the high estimates of cellphone penetration in the country are not completely accurate because they are "largely based on sim cards and not people. I personally own seven sim cards".
mHealth via SMS
According to the GSM Association, a group of mobile operators and related companies devoted to supporting and standardising GSM mobile phone systems, there are 83 active mHealth products and services aimed at public health in South Africa, 43 of which address HIV.
But most of these are limited to SMS technology, as applications can't be downloaded on basic phones.
But Mars said that SMS initiatives related to mHealth projects raise medical ethical issues.
"It has been shown in Africa that up to 40% of people are sharing phones — what happens to the confidentiality of the patient when personal medical information is sent via SMS? We don't understand the values of ownership, use or sharing in different communities."
He said SMS health programmes are better suited for the mass messaging of educational information rather than for personal health messages, for example sending patients their HIV test results.
But both Mars and Goldstuck agree that there have been some successes, particularly in the field of SMS-based educational initiatives, such as general messages that remind people to test for HIV or get their blood-pressure checked and telling them why it is important. This is because all phones, even the most basic ones, can receive SMSes.
One such example is Cell Life, a nonprofit organisation that aims to bring health solutions to developing countries through technology. Mars accredits their success to "paying careful attention to the nature of their messages".
Katherine de Tolly, the project manager of mHealth at Cell Life, said: "We can't make assumptions about what kind of phones people have so we do our research before we develop a service for a particular community."
A South African study conducted by the organisation in 2011 found that sending 10 text message reminders to go for HIV testing and for counselling, spread out over every three days for a month, resulted in a 70% higher uptake of testing compared to a control group who did not receive any messages.
"The biggest ongoing mHealth project in South Africa right now is YoungAfricaLife, a Mxit application which acts as a forum for young people to discuss love, sex and HIV," she said.
Mxit is a free instant messaging application service developed in South Africa that requires an internet connection. According to research done by Goldstuck's company, World Wide Worx, Mxit has about 10-million active users.
It cannot run on basic phones because they cannot connect to the internet. "Feature phones have WAP capabilities and can access internet browsers, which allows for the downloading of information, advice and the locations of clinics, for example," said Goldstuck.
Feature phones are more advanced than basic phones but cannot do what smartphones do.
Smartphones, smart health
At the other end of the spectrum, wealthier, middle-class people are contributing to the growing market in smartphones.
"Smartphones are mobiles with an upgradable operating system and which can download applications from an app store," said Goldstuck.
The number of applications available is enormous and varied, ranging from applications to make music and edit photographs to a number of popular instant messaging applications such as Whatsapp.
With these apps, you can monitor sleeping patterns, diagnose skin cancer or, in the very near future, check to see if your child is on drugs.
South African pioneers
A number of young South Africans are at the forefront of developing health applications.
Avi Lasarow, a Johannesburg born entrepreneur and chief executive of Lasarow Healthcare Technologies, has developed a successful smartphone application called MoleDetective, which was launched last year.
"South Africa has the highest rate of melanoma in the world," he said. It is the most dangerous kind of skin cancer. In response to this trend, he developed the application which analyses moles on your skin to check for cancer.
He said that the algorithm (the formula according to which the application assesses moles) is "as good as the dermatologist".
According to Lasarow, the app is designed for people to detect the disease early on: the five-year survival rate for stage one melanoma is 98% but, once it spreads to other organs, this drops to 15%.
Right after appearing on the United States television show Dr Oz last year, MoleDetective, which costs about R50 to download, racked up R195?000 in sales, mainly from countries like the US, Australia, Germany and South Africa. Smartphone users can download the app from the Apple and Android app stores.
Another smartphone innovation coming out of South Africa is the OculusID project spearheaded by Cape Town-based biotechnologist and entrepreneur Ashley Uys, one of this year's Mail & Guardian's 200 young South Africans to watch.
He is developing an application that can test if a person is under the influence of illicit drugs. By taking photos of a person's eye, the application will be able to tell if the pupil is impaired, which often indicates drug or alcohol use.
"If you shine light on a normal unimpaired pupil, it contracts, unlike an impaired pupil. The reason why a person who's drunk or on drugs can't see right is because his pupil is static — there's no movement and he can't focus light."
The application takes several pictures of the eye. "It compares the size of the movement of the pupil between pictures," he said. "Based on these slight differences, OculusID can give you a probability of the class of drug [the user is on].".
But he warns that this is only a screening test.
"The whole idea is to show impairment firstly and then confirmation testing can be done, he said.
OculusMobi will be ready for use in two months.
Uys is also developing devices like OculusLaw, which is intended for law enforcement officers to screen drivers for drug use, and OculusPro, which is intended for businesses to test employees.
Help is just a phone call away
"I had one situation at a game reserve in Mpumalanga where a kid had seen a doctor face to face and was told he had a viral infection. That night his temperature was high again and the mom was worried about a few symptoms particularly an unusual looking tongue, so I asked her to send me a picture of it," said Johannesburg based medical doctor Simon King. "It looked like scarlet fever so I sent a picture of a classic scarlet fever tongue to her phone and asked her if the tongue looked like this. She said it was exactly like that. I told her we needed to start antibiotics – and a later diagnosis proved it was streptococcal infection [scarlet fever]. The important thing is that these infections can cause permanent damage if left untreated. That's a case where information shared on a phone actually provided a second opinion that benefitted the patient."
King, an expert in the field of telemedicine (the remote diagnosis and treatment of patients using technology), often 'sees' patients who are in outlying areas, where a doctor may be hard to come by. Largely through the incident management company Blackplan, of which he is the managing director, he consults with patients in game reserves which are many kilometres away from towns with hospitals or clinics. He often consults with the help of a paramedic based at the reserve.
Telemedicine a possible solution to doctor shortage
According to the World Health Organisation there is a current global shortage of 2.5 million doctors and nurses with developing countries being worse off: In the UK the ratio of doctor to population is 500:1 and but in South Africa it's 1800:1. King said that telemedicine is one way of addressing the shortage by "task–shifting". "Task–shifting means that lower 'cadres' of health professionals [like nurses and paramedics] can take on jobs that formally only doctors were involved in under the supervision, often remotely, of a doctor. But for this to be safe it has to be done properly and with adequate supervision."
Jamaine Krige, a paramedic formerly employed at Madikwe game reserve, worked remotely with King. "We were on the Botswana border and the closest hospital was over two hours away," she said. "We would often have to wait three to four hours when we called for an ambulance but it's not practical to have a doctor in every game reserve: so I was the doctor's eyes, ears and hands on the ground."
King said that often people think that if a doctor is not there in person he/she's "less likely to make the correct diagnosis'. "The key point however is that you don't always need an actual diagnosis to give sound medical advice. For example, if you tell me you have a headache, it's left sided, it gets worse with light and provide the classic history of migraine – it doesn't matter if you're talking to me on the phone or you're sitting in my office. In either situation I will be able to provide you with advice about what to do," he said.
A study in the British Medical Journal has however pointed out concerns of opponents to telemedicine about it being unsafe and compromising the doctor–patient relationship in terms of confidentiality.
However, King believes, from his experience, that in some cases telemedicine can actually be safer and more effective than face to face medicine. King said that doctors tend to ask fewer questions when in the company of a patient but when on the phone, consulting remotely with less physical contact, a doctor will ask many more questions to get all the information.
"Secondly when you consult in a practice you're often pressurized by time which often pushes you into a 'skill–based' zone where you do things almost on automatic pilot," he said. However, according to King, a doctor has more freedom consulting over the phone. "You can put the phone on speaker and look up guidelines and facts while you're talking to the person – you spend more time in a 'rules–based' zone where you're in a different head space and can access and think more about the evidence."
In 2011 the Health Professions Council of South Africa released a media statement warning patients against utilising "unethical telemedicine" services. This was in response to services which offered a doctor 'just a call away'.
King said that he "supports the HPCSA in applying unwavering standards and insisting on undiluted standards of care even as the profession explores innovative ideas to address medical system defficiencies. After all, the first rule of medicine, taught to all doctors, is 'first, do no harm' and we must ensure that patients' safety and rights are protected whilst we deliver further reaching and more effective medical care."