Thy End is Near! Revisiting Sustainability and Scale in Mobiles for Development

Sometimes I stay up at night thinking, “What happens when the pilot ends?”. Where does the marketing material go? What do the end-users do? Will they trust us again next time?

During a recent trip to Rwanda, I had the opportunity to meet with Erick Gaju, the national e-health coordinator within the Rwandan Ministry of Health. Erick coordinates all ehealth policy and strategy within the country, making sure all e/mhealth work is aligned. He stressed upon the importance of sustainability and national scale for any health and ICT related initiatives. Similarly, neighboring Uganda is a well-known historical case of “pilot-itis”, whereby the country was strewn with a graveyard of mhealth pilots until the Ministry of Health took some measures to curb all initiatives until they fit within a harmonized ehealth strategy. Some points from the moratorium include “sustainable mechanisms and and ownership”, “interoperability with the DHIS2” and “final review/recommendation by the eHealth Technical Working Group”.

But first question, WHAT is sustainability and what does it look like within mHealth/mGovernance/mEverything?

  1. Money: This seems to be the most likely word that springs into people’s minds when they think about sustainability and scale. WHO will fund the project, now and forever?
  2. Infrastructure: Building systems and processes can ensure the sustainability of programs, even beyond the funding. This could be setting up interoperable applications, installing necessary hardware, developing an enabling regulatory environment etc. This DOESN’T include giving out free phones/laptops/tablets and noted by within this post, “Free phones and airtime for researchers and subjects have been the kiss of death for many mHealth pilot projects as they try to scale up to full-size programs.” Along the same train of thought, building custom software for each program is unsustainable and a drain of resources. Development organizations should not become software developers. Re-usable technology platforms that can be re-purposed across sector and regions make more sense in the long run.
  3. Capacity: Similar to infrastructure, building human capacity is a one way to ensure sustainability of both running projects and innovating new ideas. For example, when imported tech talent leaves, the applications fail to be maintained/upgraded/improved/customized and eventually grind to halt. Building in-country capacity and supporting decision making/buy-in is just as important in promoting a lasting program. Sean Blaschke notes in his blog post It is only when you look beyond the numbers and address the structures required to sustain them that true scale – and sustainability – can be achieved.”

This got me wondering about what ARE the sustainable and at scale models for m4D out there. Within mhealth, as mentioned in my previous blog post, there are mainly projects focusing on behaviour change, data collection, supply chain management, clinical decision making, health financing and training/education tools. These interventions are usually in the form of SMS/IVR messaging, call centers, mobile apps, web-based or computer software. I’ve come up with a list of 5 main types of sustainable projects within the ecosystem of mobiles and impact.

  1. Public-Private Partnerships: One example of a successful initiative is the mHealth PPP in Tanzania which is currently lead by Cardno Emerging Markets USA in partnership with the Ministry of Health and with financial support from CDC. One of the products of the PPP is the Wazazi Nipendeni SMS program which offers information and appointment reminders to pregnant women and mothers of newborn babies (up to 16 weeks of age), as well as to her supporters and information seekers. This PPP brings together partners such as Government of Tanzania, the Centers for Disease Control and Prevention (CDC), CDC Foundation, USAID, Johns Hopkins Bloomberg School of Public Health Center for Communication Programs, Elizabeth Glaser Pediatric AIDS Foundation, Joining Hands Initiative – Aga Khan Health Services, D-Tree and technology partners such as TTC Mobile. To date, 1 million have been reached on the free SMS service and the number of services offered continues to grow. Bringing together such a partnership ensures the longevity of the program, brings about a coordinated effort in terms of innovation/funding/expertise among various partners in a similar space and allows programmatic efforts to be scaled rapidly on the existing platform. Some other possible use-cases could be around agriculture where NGOs, micro-funding enterprises, commodity producers, content experts etc. join forces to create ONE national SUPER agricultural product available on simple feature phones. Farmers can benefit from information on climate resiliency, market information, best farming practices etc. and organizations can benefit from data and outreach.
  2. Mobile Network Operators: One example of a program run by an MNO is Tigo’s Kilimo in Tanzania (similar to the recently launched Vodafone service in Ghana). Kilimo is an agricultural value added service that offers farmers in Tanzania relevant, timely and actionable information via mobile phones across three domains: agronomic practices on major crops, market price information, and weather forecasts. Content can be accessed via three mobile channels: Supplementary Service Data (USSD), Interactive Voice Response (IVR) and helpline.MNOs can run or help run programs through different channels such as through their CSR or foundations such as Vodafone Foundation through which VOTO runs their MAMA program in Northern Ghana. MNOs can also subsidize or eliminate the costs of SMS/Voice messages as was arranged with the mHealthPPP Wazazi Nipendeni program in Tanzania across all networks or through HNI’s 3-2-1 program in Madagascar and Malawi. MNOs stand to benefit from such initiatives through competitive differentiation, attracting new customers through a useful service, retaining existing customers {reducing customer churn} and driving usage of services such as SMS and voice minutes.
  3. VAS Operators: Value Added Services are any services offered on top of mobile network operators’ (MNOs) core services of voice, SMS and data. Mobile VAS is rapidly growing field, for example, in India, the market is expected to reach $11 Billion USD by 2015. VAS services typically includes features such as mobile money, ring tones, etc. VAS providers are usually third-parties that are directly connected to MNOs to generate revenue. Based on their technological know-how, relationships to MNOs and business expertise, VAS providers are in a great position to conduct development focused work and/or assist development partners. For example,in Nigeria, Cellulant runs an electronic wallet programme for the Federal Ministry of Agriculture and Rural Development. They were recently awarded a four-year $7 million contract by Nigeria’s federal government to run an e-mobile registration and validation system for subsidised fertiliser. According to Business Daily Africa, an accredited farmer receives an allocation of fertilizer through a pin to their phone which can be redeemed at a bank for a subsidized rate. The system is expected to boost the average farmers’ incomes from $700 to $1800 over three to four seasons.
  4. End-user funded: In several African countries, most health expenses are out-of-pocket, such as 95% of health spending in Nigeria. This creates a great opportunity for programs that focus on a B2C {business to consumer} model for m/ehealth. A study in 2012 found that 20% of participants were not willing to pay for mhealth services, 27% were willing to pay $1 PER YEAR, 33% were willing to pay $1-$5/year and the rest would pay upwards of $5. An example of a service where end-users pay is in Nigeria. The Mobile Midwife service is paired up with Airtel’s Dial-a-Doctor service, whereby users can speak to professional healthcare workers such as doctors, dentists, psychologists, “Love specialists” etc. for Thirty Naira per minute ($0.15/minute). However, end-user funded projects are still quite rare, especially in low and middle income countries.
  5. Government-funded: To be honest, I had to do quite a bit of digging around to find examples of this, and I’m still not a 100% sure of the funding sources of these examples. One recent example that I read about is in Libya around governance/political processes whereby “the government issued a mandate to the Libyan High National Elections Commission (HNEC) to build the world’s first SMS voter registration system”, according to a case study by Caktus Group. Due to threats of violence, the resources needed to train personnel for in-person registrations and costs involved in such an undertaking in such a vast geography, an SMS system was conceived, enabling 1.5 million registrations {very cool!}. In Rwanda, the Ministry of Health has successfully been using RapidSMS to support maternal, neonatal and early child health at the community level through community health workers.  


By |2015-10-22T14:08:02+03:00October 22nd, 2015|Uncategorized|0 Comments

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