This chapter explores three existing financial approaches to scaling mobile technologies in low- and middle-income countries: user-paid services, reverse billing, and zero-rated platforms. As affordability is an impediment to internet access, key strategies focusing around the involvement of mobile network operators and governments are investigated in relation to sustainability, scale, reach, and impact for mobile technology projects in the world. Various examples under each type are explored as a starting point for understanding the risks and benefits of each approach. The chapter also discusses the importance of mobile initiatives in tackling social issues today.
TopIntroduction
With more mobile phones than people in the world, it is possible, and critical, for social change organizations to effectively leverage mobile technologies and platforms to distribute information and services to marginalized and underserved communities in low and middle income countries (LMICs). LMICs are defined by the World Bank based on gross national income. (World Bank, 2017) As an organization working in designing, developing, and creating mobile tools and content, Praekelt.org believes that, in order to reach those most in need, services must be accessible without charge to the end user. This requires understanding the various models of partnerships with mobile network operators.
Even on the basis of limited available evaluation studies, we know that mobile technologies have great promise for improving people’s health and wellbeing. In Jeannine Lemaire’s (2013) second report on scaling up m-health, the author cited a study, showing that two daily text messages to health care workers in Kenya improved pediatric malaria care by 24.5%, and a trial, which identified significantly improved anti-retroviral treatment (ART) adherence after weekly mobile text messaging. Unfortunately, many m-health evaluation studies are limited, as scale-up has been challenging and randomized control trials are not always financially feasible for program implementers.
One thing we have been able to observe via -health programs is the ability to identify gaps in the system, which can help improve care. A recent study published on the MomConnect maternal m-health initiative in South Africa (Barron, Pillay, Fernandes, Sebidi, & Allen, 2016) reported the efficacy of complaints lodged on the mobile platform in identifying iron supplementation shortages at clinics (anaemia contributes to mortality from obstetric haemorrhage, a leading cause of maternal mortality.) In at least two provinces, Gauteng and North West, reports of iron supplementation shortages led to improvements in the overall stock reordering systems at facility level. This is just one example of the power of mobile development interventions, specifically in public health, to support vulnerable communities.
Therefore, the question of access to mobile services when scaling these projects is paramount.
Mobile inventory (e.g., SMS, Voice, and Unstructured Supplementary Service Data/USSD) costs can be a significant challenge for mobile health projects in reaching scale and longevity. In a study on mobile for development, the GSM Association (GSMA), a trade body representing mobile operators globally, shared:
Scale will not be effective in decreasing costs if the SMS/USSD method of delivering services is utilised. As the number of users increases, the costs increase exponentially. Cost efficiencies through scale will only be effective if a maternal m-health programme were to operate via a data or SMS/USSD and data combination, as the incremental costs would be significantly less. (GSMA, 2014a, p. 31)
The epidemic of “pilotitis”, or when mobile health projects do not scale behind pilot stage, exists in part due to the high cost of programs at scale and the lack of financial backing to ensure long term sustainability. Even if they show promising results around impact at the pilot stage, the cost of scale-up and lack of evidence on cost effectiveness make many donors reluctant to fund scale-up.