Mobile Money for Health

1. Mobile Money for Health Pamela Riley, Senior mHealth Advisor, Abt Associates Health Financing and Governance Project mHealth Working Group May 28, 2013

2. Meeting Overview • Pamela Riley, HFG project: Setting the context • MenekseGencer, mPay Connect: How can mobile money improve health outcomes? • Andrew Karlyn, USAID Mobile Solutions: Why does mobile money matter? • Steve Ollis, D-Tree: Zanzibar use case for safer deliveries • Judy Gold, Marie Stopes International: Madagascar family planning voucher use case • Hamilton McNutt, NetHope: Tools to support transition to mobile money • Wrap-up

3. Setting the context Mobile Money for Health • Mobile money defined • mHealth relationship to mobile money • Objectives of Health Finance & Governance project

4. What is mobile money? Digital platform for storing, sending, receiving money • Used for bulk payments, peer transfers, bill & loan payments, merchants • Licensed providers can be banks, mobile operators, software companies Mobile number acts like a bank account, allows fund transfers via SMS

5. mHealth and mobile money currently perceived as parallel sectors mHealth mFinance ≠ BENEFICIARIES mBCC MANAGEMENT Data collection PROVIDERS Mobile job aids

6. Repositioning mobile money for health = mhealth BENEFICIARIES Health insurance premiums Health saving accounts Conditional cash transfers PROVIDERS Perf based incentives Salary payments Training per diems MANAGEMENT Voucher settlement Purchasing credit Audit trails + mHealth is the use of mobile (communications or payments) to improve health outcomes

7. Health Finance & Governance (HFG) project HFG objectives Examples how mobile money can contribute Expand health insurance access to advance UHC Improve accountability, reduce leakage with automatic transaction records Lower transaction costs, by driving cash payments out of system • Improved health financing • Strengthened governance of health sector • Improved public health operations

8. HFG Mobile Money Illustrative Activities COLLABORATE GENERATE RESOURCES CATALYZE USE CASES

9. Office of Innovation and Development Alliances (IDEA) Andrew Karlyn, USAID Mobile Solutions: Why does mobile money matter? The Office of INNOVATION & DEVELOPMENT ALLIANCES

10. Office of Innovation and Development Alliances (IDEA) Global Partnerships Building public-private partnerships for sustainable impact. IDEA Local Sustainability Pioneering local capacity building for stronger communities. Mobile Solutions Accelerating mobile technology for development impact. Development Innovation Ventures Turning bright ideas into global solutions.

11. IDEA/MS Leverages the power and reach of mobile technology to accelerate USAID’s development goals IDEA/MS Mobile Money Mobile Data Mobile Access

12. IDEA/MS Why does mobile money matter? Empowers entrepreneurs Accelerates financial inclusion Mobile Solutions (MS) Underpins good governance practices Enables cross-cutting solutions

13. IDEA/MS What is USAID doing to scale mobile money? • USAID/Afghanistan worked with Central Bank to reduce regulatory barriers, move police and teacher payments onto mobiles. • USAID/Philippines alongside its work with the Central Bank and G2P payments, it has integrated e-payment language into future procurements. • USAID/Malawi is funding a program to provide TA, coordinate the ecosystem, and fund demonstration pilots that cut across sectors. Programs Scale mobile money • Better than Cash Alliance: The Governments of Afghanistan, Kenya, Peru, Philippines, Colombia, Malawi and a host of organizations have committed to move toward a cash-lite society. • USAID-Citi Mobile Money Accelerator: USAID/Indonesia and Citi are working with a fast-moving consumer-goods company to offer mobile banking services throughout its supply chain. Partnerships

14. USAID's strategic approach to mMoney adoption IDEA/MS Creating an Enabling Environment for e/m-Payments Secure host country government participation in the Better than Cash Alliance (BTCA) Provide technical assistance to host government on e/mMoney regulatory environment Participate in or convene multi-sector, multi-stakeholder mMoney working group that meets regularly and has clear objectives Aggregate Demand / Accelerate Use of Mobile Money Collaborate with host government to identify and transition large cash-based payment streams to mMoney Create a dedicated fund or mechanism to support actionable mMoney programs Integrate language for e/m-payments into project design and acquisition and assistance (A&A) planning documents, where appropriate

15. Why does mobile access matter IDEA/MS Why does mobile access matter? M4D apps Gender equality Health services Inclusive growth Job opportunities Education content Financial services Private investment Access enables:

16. IDEA/MS What is USAID doing to level the technology playing field? • IDEA/MS is working with GSMA, AusAID, and Visa Inc. to reduce the mobile phone gender gap, by enabling mobile ownership and more effective use for women in emerging markets. Support goes for research, technical assistance grants to mobile operators and implementing partners, and design challenges. For more information, visit: www.mwomen.org. Level tech playing field GSMA mWomen Program • IDEA/MS is working with other donors, technology companies, and host country governments to dramatically increase the uptake and use of mobile broadband through the Alliance for Affordable Internet. The overall goal is to reduce costs of broadband to 5% of monthly income to bring the next two billion internet users online. For more information, visit: www.a4ai.org. Alliance for Affordable Internet

17. IDEA/MS Why does mobile data matter? Why does mobile data matter • Improves data quality, reducing data entry errors by up to 40% • Lowers costs up to 75% • Reduces turn-around time, returning data 2x faster • Makes data management and aggregation easier • Improves decision-making by identifying trends across projects, sectors and countries • Empowers citizens by facilitating feedback loops

18. What is USAID doing to increase adoption of mobile data solutions? IDEA/MS Mobile data strategies • IDEA/MS developed and delivered an online course with TechChange about mobile data solutions. • IDEA/MS in conjunction with USAID/Afghanistan has launched an SMS-based technology platform to gather baseline information about payments to teachers and to evaluate the impact of transitioning them to e-payments. • IDEA/MS is working with USAID/Kenya to develop a mobile-phone based platform that receives feedback from beneficiaries about service delivery, program impact and unmet needs and shares information with them. Programs • Five Steps for Success • Build knowledge and technical capacity • Demonstrate effectiveness of solutions • Improve technologies • Develop policies • Integrate platforms into Missions and Sectors Actions

19. Website title slide How can we support your work in mobile solutions?

20. Using mMoney and mHealth to improve women’s health in Zanzibar Steve Ollis Presentation to mHealth Working Group 28 May 2013

21. Develop high quality clinical protocols based on national guidelines Design software to guide the user through correct use of protocols Create Electronic Patient Record to ensure health information is accessible What we do

22. Develop clinical protocols that enable better quality care reproductive health chronic disease child health preventive care • HIV/AIDS • Diabetes • Hypertension • TB • antenatal • post natal • family plan • safer deliveries • pneumonia • diarrhea • malaria • newborn • nutrition • antenatal • immunizations • care and support

23. mHealth for Safer Deliveries • Support from Gates Challenge Exploration grant and Jhpiego • Target areas: <50% facility deliveries • Goal: Reduce the “3 delays” for mothers during labor and delivery • Decision to seek care • Arrival at health facility • Provision of adequate care

24. mHealth for Safer Deliveries • Uses simple java-enabled Nokia phone • Piloted in 2 districts with 1,000 women 2011-2012 • Being scaled up across Zanzibar – over 100 users currently – target of 350 by 2014

25. mHealth for Safer Deliveries • Screening and registering pregnant mothers to identify risk factors or danger signs • Agreeing on birth plans for facility delivery and securing permissions • Establishing community-based referral systems to transport women in labor or in emergency situations • Coordinating payment of transport to health facilities using mobile banking • Visiting the family 3 and 7 days after delivery to for postnatal follow-up for mother and baby

26. How we use mobile money • Transfer funds from D-tree to Community Birth Attendant (CBA) accounts • CBA pays drivers from account using mobile money • CBA withdraws their incentive at end of month • Audit transactions using application records, mobile money accounts and sign-in books at health facilities

27. Results: Facility Deliveries • Dramatic increase in facility delivery rates • 82% of women had a higher risk condition for which facility delivery is recommended • Facility delivery rate increased from approx. 30% to 72% • Average cost per delivery $22 • Use of mobile money is allowing faster scale up, sharing of workload and improved security

28. Stories from the field • Past home deliveries were all unsuccessful • Referred by TBA to Micheweni cottage where she had a prolonged labour.  • This time, she was induced and successfully delivered a healthy baby boy • She indicated that she will not consider delivering at home during future pregnancies. 

29. Stories from the field • Unaware that she was pregnant with twins • When labor started her family called the TBA who arranged transport immediately • She began to have blood pressure problems and the hospital staff transferred her to Wete for a caesarean section • She gave birth to two healthy baby boys, kept at the hospital for 5 days for continued evaluation • She says that had she not been in the project, she would have given birth at home; was unsure if they would have found transport once problems began

30. Lessons learned • Wide network coverage ≠ wide mobile money network • Need to work closely with Telecoms to strengthen network, market services • Mobile money systems still have opportunity for improvement • Online systems could be more user friendly • Systems not always available • Cash management at pay points • Learn about fees up front and be clear who will pay

31. Next steps • Work with Zantel to obtain improved visibility into user accounts • Work with Zantel and software partners to improve integration via mobile money APIs • Continue to integrate operations into district council health plans

32. Thank you! Better Decisions Save Lives For more information: www.d-tree.org Steve Ollis sollis@d-tree.org +1.410.443.3916

33. Using Mobile Money within Health Programmes Judy Gold Innovation and Best Practice Analyst judy.gold@mariestopes.org mHealth Working Group Meeting Tuesday 28th May 2013

34. Acknowledgements • Marie Stopes Madagascar • Boni Ramanantsoa, François Gourraud, Lalaina Razafinirinasoa, Odile Hanitriniaina, Sylvie Ramandrosoa • Marie Stopes Kenya • Agnes Midi, Judy Ojwang • Marie Stopes International • Nick Corby, Anna Mackay, Meira Neggaz, SIFPO-MSI • USAID (SHOPS project)

35. Marie Stopes International

36. Example 1: Madagascar

37. Voucher Payments • Focused on family planning • Variety of methods • Vouchers sold by Community Health Educators • Cost client MGA 200 (USD $0.10) • Redeemable at BlueStar social franchisees • Franchisee reimbursed MGA 7,500 (USD $3.70) for service provision

38. But how to reimburse? • Limited banking facilities • Only three bank branches in regions targeted • Many social franchisees don’t have a bank account • Cash payments present problems • Time • Staff travel, delay in reimbursements • Security • Large amounts of cash, potential for fraud

39. Voucher Payment Process Provider sends SMS with voucher code Mobile phone number verified (automated) Voucher code verified (automated) Mobile payment generated (manual) Internal voucher verification system (manual)

40. Results: Voucher Numbers • March 2011 to December 2012 • 25,880 vouchers sold

41. Results: Time to Payment New rule introduced But still much faster than paper systems…. New rule introduced

42. Key Benefits • Faster payments to service providers • Many voucher programs take one month+ from when service is delivered until providers are reimbursed • Increased financial and administrative efficiency • Reduced travel, access during rainy season • Availability of real-time redemption data • Improved program management

43. Key Lessons • Choose mobile finance provider(s) wisely • Initially only reimbursing using Telma • Required non-Telma customers to collect payments within seven days • Social franchisees would ‘batch’ voucher reimbursements • Consider more than just cost of transfers • Network coverage, kiosk availability

44. Key Lessons • Consider all costs involved • SMS data submission, cost of transferring payments • Electronic systems are not a panacea • Still involve people! • May increase speed, but only up to a point More detail of system available in 2011 report; planning 2013 update http://www.mariestopes.org/data-research/resources/using-mobile-finance-reimburse-sexual-and-reproductive-health-vouchers

45. Example 2: Kenya

46. Community Agent Payments • Currently using mobile money in ad-hoc way • Requires withdrawal of cash and taking to physical agent • Only used in emergency / last minute situations • Planning move from cash to mobile money • Community health workers, youth peer educators • Monthly stipend, activity and training payments • Will integrate online payment system with financial operations

47. Why Now? • Delay in payments reaching workers • Security • Limit intermediaries involved • Ensure beneficiaries receive payment directly • Accountability • Financial monitoring • Increased transparency

48. Why Now? • Changes to community health programming • Scaling up: expanding to more remote areas • Increased coordination: new database of community health agents • Becoming more “digitally enabled”

49. But why not everyone? (1) • Not always clear motivation to change • Requires time outside of ‘day-to-day’ tasks • Financial control is a tricky business • Comfort with old vs risk of the new • Uncertainty about what auditors will accept

50. But why not everyone? (2) • Rapid increase in mobile phone use • Far fewer of our workers would have owned phones just two years ago • Health sector overall slow to adapt to mobile technology • Variations in use of mobile money • Kenya with mobile payments the norm vs Uganda where available but not same level of use and demand • Easier to introduce (and more demand) where population already familiar with service