revise paper (Babylon: Health Companion in the Use of Rural Populations in Myanmar) revise the paper (2000 words have been completed)(overall 2450 words), draw executive summary (250 words) and conclusion(less than 100 words) 1) Critically evaluate the

2

ADA: Health Companion in the Use of Rural Populations in Bangladesh Executive Summary,

This essay aims to show how ADA, a health companion app, can contribute to the

development of Bangladesh and how this potential can be improved.

Section one and two introduce ADA with special focus on its values and business process.

These also describe ADA’s revenue model by using an example of how it utilizes

partnerships. As a concluding remark, these parts claim that ADA has a huge potential in

complementing professional health services and not replacing them.

In section three, Bangladesh’s healthcare issues are discussed, with special focus on the

shortage of doctors in rural areas. Furthermore, it also shows how ADA is already helping

in this regard by empowering the lay population and decreasing their dependence on the

health care system. Moreover, a pros/cons analysis is also undertaken to describe the

factors and trends that support and hinder the expansion of ADA in Bangladesh.

In section four, the actions and modifications that could help ADA in overcoming the

hindering factors are discussed. First, it shows that a Bengali platform is essential and

that an SMS service would increase the number of potential users. Furthermore, it also

highlights that the existing competition in this market may be disrupted by introducing a

new revenue stream by selling user’s health data to third-parties. However, it implies

several ethical concerns. Consequently, this section ends with some recommendations

on actions that could prevent ethical issues.

In the conclusion section, the importance of further ethical discussion is emphasized.

3

1, Introduction,

ADA is a diagnosing, conversational health companion app and a decision support tool

for medical professionals around the world. Furthermore, it can be used as a telemedicine

app as well in the UK as patients can book an appointment or home visit with a doctor.

After its launch in 2016, in 2017 it became the fastest growing medical app, with over 1.5

million users. Its success it derived from ADA’s sophisticated artificial intelligence engine

and its vast and high quality medical knowledge base that is available on iOS and Android

(Kroeger, 2017).

2, Business process, value proposition, revenue model and business model

According to Daniel Natrath, the CEO and founder of ADA, ADA aims to provide an “AI-

powered health platform [that] can help both patients and doctors by making it possible

for anyone with a smartphone to access high-quality, personalised health information,

while giving clinicians more time to focus on patient care” (Nikolova, 2018). In order to

make its services accessible, ADA provides a free comprehensive medical knowledge

base including thousands of symptoms and related illnesses. Furthermore, to make it

‘personalised’, ADA utilizes artificial intelligence that can learn from the conversations that

the user has with the chatbot and build a personal medical profile, which can help in the

diagnosis. The qualities of artificial intelligence in the process are its self-learning ability

and propensity to handle large amount of data. In other words, during the conversation

with the user, ADA asks about the symptoms and the diagnosis is based on the answers

and the patient’s profile. ADA also gives advice on the further steps of treatment and if

the patient should visit a health professional (Ada, 2018).

Notwithstanding, the utilization of artificial intelligence is not unique or innovative as many

other self-diagnosing apps incorporated this technology even before ADA (Lupton and

Jutel, 2015). To the question of what makes ADA unique, Daniel Natrathm answered that

it “…supports both patients and clinicians. From day one, our team has been focused on

providing very detailed, high quality medical insights and decision support, with more than

4

seven years spent on R&D…” (Nikolova, 2018). From his answer and the website of ADA,

it is clear that the app was developed for clinical use as well as it can help in avoiding

misdiagnosis, documentation of patient portfolios and decision making (ADA, 2018). It

could become a useful tool for doctors by outperforming its already existing competitors

on the basis of the size and quality of medical data. Consequently, its unique value does

not derive from a disruptive innovation but from an evolutionary sustaining one by making

a ‘good product better’ (Christensen, Raynor and McDonald, 2015:5) through seven years

of research supported by more than 100 doctors. In order to maintain its leading position

in this regard, ongoing development is vital for ADA (Nikolova, 2018). Furthermore, ADA

managed to make this vast knowledge available and understandable for lay people by

developing a simple platform and translating “medical terms into patient-friendly words”

(Milburn, 2017). Consequently, ADA’s platform can be described as a content model as

it provides information regarding medical health.

This paper suggests that ADA has huge potential to increase its revenue through

partnerships as it offers a simplified technology-driven healthcare that is still

grounded in high quality medical data. However, it has to be noted, that ADA cannot

replace doctors as it does “NOT provide any emergency services, care for acute

medical conditions or in-person diagnosis or treatment” (ADA,2017).

Notwithstanding, due to its availability, user-friendliness, personalized diagnosis and

vast medical knowledge, ADA became popular not only among individuals but businesses

as well. Daniel Natrathm explained ADA’s revenue streams: “We earn revenue by

partnering with these stakeholders to help them deliver more personalised patient -

centric care, by simplifying the healthcare experience” (Nikolova, 2018). In this

revenue model, partners pay ADA for cooperation, for instance for incorporating the

stakeholder’s services in ADA’s platform (ADA, 2018). A good example is Doctap,

which can be reached from ADA’s diagnosis page. Doctap is the ‘Uber for Doctors’,

where users can book private appointments with GP’s (Iamnewgeneration, 2016). In

this regard, ADA’s business model can be seen as brokerage as it brings together

buyers (users) and business providers (Doctap user doctors).

5

ADA’s “…mission is to transform access to healthcare on a global scale - for everyone,

everywhere” (Adahealth, 2018). Its revenue model that acquire profit from partners

enables ADA to achieve this goal as it can offer its diagnosis service for free. However, it

has to be noted that the details of how ADA gains revenue are still unclear, Consequently,

this paper argues that increased transparency would be required to gain more trust from

potential users. Transparency is also crucial regarding its privacy policy that will be

discussed later. Furthermore, in order to achieve its mission, ADA needs to increase its

user base in developing countries, such as Bangladesh as well (Nikolova, 2018).

3, The developmental contribution of ADA in Bangladesh,

This paper argues that ADA contributes to the development of Bangladesh in several

ways, particularly regarding its healthcare. Bangladesh’ health care coverage is low

(Ahmed et al. 2014), especially in rural areas where only 25% of health human resources

work whereas 70% of the population lives in these regions (Nessa et al. 2009). This paper

suggests that ADA is a useful tool to empower the lay population and doctors of these

areas through its diagnosing service. In other words, ADA can provide these patients the

knowledge to play a bigger role in their self-treatment (McDermott and While, 2013; King

et al. 2012) that reduces the cost of healthcare by lessening their reliance on costly health

human resources (Lindberg et al.2013) that is already scarce in these areas (Nessa et al.

2009). Moreover, ADA can also reduce the material and environmental cost and time to

travel between healthcare providers and patients (Jusoh, 2017). Furthermore, ADA can

also help health providers to offer faster and more reliable diagnosis due to the vast

quality medical data that the app provides. The extent to which, ADA could contribute to

the economy by lessening healthcare costs is difficult to determine as the health care

system in Bangladesh is hugely dependent on illegal, out-of-pocket payments

(Bangladesh Health Watch Report,2011). In the next paragraphs, a pros/cons analysis

will be shown to discuss Bangladesh’s social, economic and infrastructural environment

and ADA’s position in this market.

6

Several trends and factors show that ADA can already be a useful healthcare tool for the

remote population of Bangladesh and it has the potential to further advance its position.

First, although the gross national income per capita is only 3790 USD in Bangladesh, it

is steadily growing (The World Bank, 2016) and in 2011, 75% of the rural population had

a mobile phone (Ahmed et al. 2014). Second, mHealth, which refers to the practice of

medicine supported by mobile devices (Afroz, 2012:36), is already widespread and

governmentally supported in Bangladesh (Kay, Santos and Takane, 2011). Furthermore,

the required infrastructure is developing at a fast pace resulting in the fact that in 2017,

the number of internet subscribers in Bangladesh reached 80.483 million (Bangladesh

Telecommunication Regulatory Commission, 2017). In brief, due to several factors

(increasing incomes, mobile phone and internet coverage and popularity of mHealth and

the decline in smart phone prices (Lucas, 2014)), this paper suggests that ADA can be

even more popular in Bangladesh in the future and further support the healthcare in

remote areas.

However, it has to be noted that there are several factors that hinder ADA to become

more popular and profitable in Bangladesh. First of all, ADA is not available in Bengali but

only in English and German. As only 18% of the Bangladeshi populations speaks English

(Pinon, and Haydon, 2010), it is a huge barrier. Second, only 5.2% of the Bangladeshi

population uses smart phones, however this ratio is rapidly increasing (Newzoo, 2017).

Finally, it is possible that in Bangladesh, it will be more difficult to find stakeholders

(partners) due to the country’s scarce resources and high competition on its mHealth

market (Afroz, 2012). Consequently, ADA may need to establish new revenue streams in

order to become profitable in Bangladesh. The coming paragraphs will analyzes what

changes are required to overcome these issues.

4, Required modifications in ADA,

First of all, the most obvious and simplest development that is required for ADA to become

popular in Bangladesh is to translate its platform to Bengali that is spoken by 98.8% of

the country’s population (Central Intelligence Agency, 2018). Second, as only 5.2% of the

7

Bangladeshis (Newzoo, 2017) uses smartphones, but 89% of the urban and 75% of the

rural population had phones including feature ones (Ahmed et al. 2011), it is crucial to

offer service for people who only have feature phones. Especially, as 99% of the

Bangladeshis are under phone network coverage (Afroz, 2012) ADA could reach a huge

portion of the population this way. This paper suggests that the diagnosis service of ADA

can be incorporated into an SMS service, in which users could be diagnosed by the

already developed ADA chatbot. Some revenue would come from the fees on the SMS’s

sent by the users. However, it has to be marginal as other similar, inexpensive services

already exist in Bangladesh, such as health-lines by Grameenphone and by Telemedicine

Reference Centre Limited (Lucas, 2014). However, the biggest competitor would be the

e-Governance of the Bangladeshi government as it established the Health Management

Information System department that aims to utilize Information and Communication

Technology (ICT) in a health information system (Afroz, 2012). A crucial component of

this system is mHealth, in which framework, health experts give basic advice and

diagnosis from a 24/7 call center. As this service is available for no extra charges (Afroz,

2012), ADA faces huge price competition regarding its SMS service. This market can be

described by the notion of hypercompetition as it is ‘characterized by intense and rapid

competitive moves, in which competitors must move quickly to build advantage and erode

the advantage of their rivals’ (D’Aveni, 1994:217–218). In hypercompetition, “firms

compete on price until no one makes more than marginal profits” (D’Aveni, 1994:344).

This paper suggests that a new revenue model can be the key to escape from this price

competition (Sammut-Bonnici, 2015).

This new revenue stream would be the selling of user’s health data to third-party

businesses. The value of ADA would come from the health data of the patients that they

create during their conversation with the chatbot. Other companies like Cinven and Iqvia

already earn revenues through health data brokerage in accordance with the Health

Insurance Portability and Accountability Act (Schiller, 2018). This kind of data is valuable

for many stakeholders, such as for insurance (Sampat and Prabhakar, 2017) and

marketing companies and pharmaceuticals. Furthermore, this information can enable

8

stakeholders to improve healthcare through research (Kaplan, 2016), which in turn can

be beneficial for the public in Bangladesh as well.

However, the ethical dimension of health data brokerage is crucial as it can result in

privacy violations (Kaplan, 2016), especially if vulnerable and disadvantaged

populations, such as rural Bangladeshis are involved. In order to avoid scandals like

the one regarding Deepmind (Burgess, 2017), this paper suggests that ADA should

undertake several cautionary actions. First, informing the users about the purpose and

details of our data collection, including the names of the stakeholders and how they are

going to use the information, is crucial (Desai and von der Embse, 2008). This

transparency is important because in this way, the benefits and potential harms (privacy

issues) of our service can be evaluated and users can make an informed decision

(Kaplan, 2016). Furthermore, transparency is also crucial because it is necessary for

accountability, which refers to the need to justify our actions and accept the responsibility

for them (Lapadatu and Pirnau, 2009). The information regarding data collection and use

would be given to the users each time when they use our services either in the form of

text message or disclaimer in the app. Second, ADA should change its privacy policy in

to allow selling anonymized data in accordance with the regulations. It is especially

important as the current privacy policy of ADA is controversial. In the FAQ section it claims

that “Ada does not share your data with anyone” (ADA, 2018b), and the Privacy Policy

states that “We may use medical data that has been dissociated from your identity (the

pseudonmisation of personal data) for research purposes…” (ADA, 2018c). The details

of how these data are used and for what exact purposes remain unclear.

5, Conclusion,

This paper described a potential way in which ADA could increase its competitiveness,

popularity and therefore its positive contribution to the economy in Bangladesh. Most of

the changes can be regarded evolutionary, such as the translation of the app to English.

However, the new revenue stream can be disruptive and also dangerous as selling users’

health data to third-parties can cause ethical tensions, hence decrease in the number of

9

users. Consequently, this paper suggests that the key to ADA’s success in Bangladesh

would rely on further investigations and discussions on the ethical aspect of this revenue

stream.

Word count: 2197

10

References,

ADA (2017) Ada Digital Health’s Terms and Conditions. [ONLINE] Accessible from:

https://ada.com/terms-and-conditions/ Accessed: 01.05.2018.

ADA (2018) [ONLINE] Accessible from: https://ada.com Accessed: 01.05.2018.

ADA (2018b) Frequently Asked Questions. Accessed from: https://ada.com/faq/

Accessed: 01.05.2018.

ADA (2018c) Ada Digital Health’s Privacy Policy. Accessed from: https://ada.com/privacy-

policy/ Accessed: 01.05.2018.

Adahealth (2018) About ADA Health GMBH. [ONLINE] Accessed from:

https://adahealth.workable.com Accessed: 01.05.2018.

Afroz, T. (2012) Delivery of Mobile Phone Aided Health Services in Rural Bangladesh: A

Study on Two Upazilas. Master Thesis. North South University: Bangladesh.

Ahmed, T., Lucas, H., Khan, S. A., Islam, R., Bhuiya, A and Iqbal. M. (2014) eHealth and

mHealth initiatives in Bangladesh: A scoping study. BMC Health Services Research.

14(1) 260-270.

Bangladesh Health Watch Report (2011) Moving Towards Universal Health Coverage.

Dhaka: James P Grant School of Public Health, BRAC University.

Bangladesh Telecommunication Regulatory Commission (2017) The total number of

Internet Subscribers has reached 80.483 million at the end of December, 2017. [ONLINE]

Accessible from: http://www.btrc.gov.bd/content/internet-subscribers-bangladesh-

december-2017 Accessed: 01.05.2017.

Burgess, M. (2017) DeepMind accused of accessing NHS data on an 'inappropriate legal

basis'. Wired. [ONLINE] Accessible from: http://www.wired.co.uk/article/deepmind-nhs-

data-sharing-privacy-concerns Accessed: 01.05.2018.

11

Central Intelligence Agency (2018) The World Factbook: Bangladesh. [ONLINE]

Accessible from: https://www.cia.gov/library/publications/the-world-

factbook/geos/bg.html Accessed: 01.05.2018.

Christensen, M. C., Raynor, M. and McDonald, R. (2015) What is Disruptive Innovation?

Harvard Business Review. December, 2015.

D’Aveni, R. A. (1994) Hypercompetition: Managing the Dynamics of Strategic

Maneuvering. Free Press: New York.

Desai, M. S. and von der Embse, J. T. (2008) Managing electronic information: an ethics

perspective . Information Management & Computer Security. 16(1) 20 –27.

Iamnewgeneration (2016) DocTap – Alex Hamilton. [ONLINE] Accessed from:

https://www.iamnewgeneration.co.uk/doctap-alex-hamilton/ Accessed: 01.05.2018.

Jusoh, S. (2017) A Survey on Trend, Opportunities and Challenges of mHealth Apps.

iJIM. 11(6) 73-85.

Kaplan, B. (2016) How Should Health Data Be Used? Privacy, Secondary Use, and Big

Data Sales. Bioethics and Information Technology. (25) 312-329.

Kay, M, Santos, J., and Takane, M. (2011) mHealth New horizons for health through

mobile technologies. In: Global Observatory for eHealth series, Volume 3. Geneva: World

Health Organization.

King, D. K., Toobert, D. J., Portz, J. D., Strycker, L. A., Doty, A., Martin, C., Boggs, J. M.,

Faber, A. J., Geno, C. R. and Glasgow, R. E., (2012) What patients want: relevant health

information technology for diabetes self-management. Health and Technology. 2(3) 147-

157.

Kroeger, C. (2017) "German Accelerator Life Sciences (GALS) Partner Ada Health

Expands to the US Upon Closing $47M Funding Round ". German Accelerator Life

Sciences.

12

Lapadatu, V. G. and Pirnau, M. (2009) Transparency in Financial Statements (IAS/IFRS).

European Research Studies. 12(1), 101-108.

Lindberg, B., Nilsson, C., Zotterman, D., Seoderberg, S, and Skear, L. (2013) Using

information and communication technology in home care for communication between

patients, family members, and healthcare professionals: a systematic review.

International Journal of Telemedicine and Applications.

Lucas, H. (2014) New technology and illness self-management: Potential relevance for

resource-poor populations in Asia. Social Science & Medicine. (145) 145-153.

Lupton, D. and Jutel, A. (2015) ‘It's like having a physician in your pocket!’ A critical

analysis of self-diagnosis smartphone apps. Social Science & Medicine. 133(1) 128-135.

McDermott, M. S. and While, A. E. (2013) Maximizing the healthcare environment: a

systematic review exploring the potential of computer technology to promote self-

management of chronic illness in healthcare settings. Patient Educ. Couns. 92(1) 13-22.

Milburn, S. (2017) This doctor is transforming healthcare with an intelligent app. [ONLINE]

Accessible from: https://chatbotslife.com/this-doctor-is-transforming-healthcare-with-an-

intelligent-app-55d73af4c33a Accessed: 01.05.2018.

Nessa, A, Ameen, M.A., Ullah, S. and Kwak K. (2009) Applicability of telemedicine in

Bangladesh current status and future prospects. ICCIT. 8(1) 948-953.

Newzoo (2017) Top 50 Countries by Smartphone Users and Penetration. [ONLINE]

Accessible from: https://newzoo.com/insights/rankings/top-50-countries-by-smartphone-

penetration-and-users/ Accessed: 01.05.2018.

Nikolova, S. (2018) Is AI already good enough to transform healthcare? – Interview with

Daniel Nathrath, Founder and CEO at Ada Health. Research 2 Guidance. [ONLINE]

Accessible from: https://research2guidance.com/is-ai-already-good-enough-to-

transform-healthcare-interview-with-daniel-nathrath-founder-and-ceo-at-ada-health/

Accessed: 01.05.2018.

13

Pinon, R. and Haydon, J. (2010) The Benefits of the English Language for Individuals and

Societies: Quantitative Indicators from Cameroon, Nigeria, Rwanda, Bangladesh and

Pakistan. Euromonitor International.

Sammut-Bonnici, T. (2015) Hypercompetition In: Wiley Encyclopedia of Management.

John Wiley and Sons.

Sampat, H. B. and Prabhakar, B. (2017) Privacy Risks and Security Threats in mHealth

apps. Journal of International Technology and Information Management. 26(4) 126-153.

Schiller, B. (2018) Can this app that lets you sell your health data cut your health costs?

Fast Company. [ONLINE] Accessed from: https://www.fastcompany.com/40512559/can-

this-app-that-lets-you-sell-your-health-data-cut-your-health-costs Accessed: 01.05.2018.

The World Bank (2016) GNI per capita, Bangladesh. [ONLINE] Accessible from:

https://data.worldbank.org/indicator/NY.GNP.PCAP.PP.CD?locations=BD&year_high_d

esc=true Accessed: 01.05.2018.