Scale, sustainability and impact—an uneasy triad

Johnson & Johnson’s commitment aimed to demonstrate that programmes could be launched to reach scale, sustainability and impact. This is not an easy triad to achieve, because the three dimensions are often at odds—for example, scale may threaten financial sustainability by driving up programme costs. In lower-income populations, mobile phones are commonplace, but most are used for the simple functions of voice calling and text messaging. Programmes attempting to deploy these universally accessible technologies to large numbers of users quickly earn a hefty price tag due to the fixed per-unit pricing of these modalities, with no economies of scale. Though usage of more cost-effective mobile web and data services is increasing at a rapid rate,6 programmes need to be cautious about shifting completely to technologies that exclude those women and families at the low end of the socioeconomic spectrum who need information services the most.

This frequently creates a funding gap when early catalytic grant funding has been spent, but programmes have been unable to secure the resources required to support implementation at national scale. Larger—typically risk averse—donors and payers (such as bilaterals and national governments) seldom engage without clear evidence of programme effectiveness, but despite high reported rates of user satisfaction and empowerment,7 clear evidence on behaviour change to improve maternal and infant survival (though emerging8 9) has been slow to obtain.10 11 It is also very difficult to build a commercial business case around behaviour change communication to a low-income audience, because direct user fees discourage adoption of preventive health products and services.12

Seven years after the initial Johnson & Johnson commitment, three of the six country programmes (Bangladesh, India and South Africa) have reached more than a million mothers each, illustrating that it is possible for messaging programmes to be implemented at significant scale. Sustainability and impact will take longer to demonstrate reliably.

The case of MomConnect

MomConnect, South Africa’s maternal mobile messaging service, may be the first programme on a course to achieving all three dimensions—scale, sustainability and eventual health impact— though not always in the ways that were originally envisaged. The South African National Department of Health runs and endorses the service as an official instrument of the state health system; hence, the programme is no longer aiming simply for large numbers, but rather for true universal coverage. It has achieved over 60% coverage of the pregnant population through 95% of South African public health clinics.

This has required some critical adjustments to the programme from its origins in several non-profit-led initiatives.13 For example, MAMA South Africa—a precursor programme to MomConnect funded by Johnson & Johnson between 2011 and 2013—reached over 600 000 users, but did so through a mobile website that was completely inaccessible to 25% of the South African population using the most basic mobile phones. This approach prevented formal integration into the national health system because this would have denied service to an important segment of the population.

MomConnect, by contrast, is accessible through all mobile phones. To achieve this, the programme had to make choices that were counter-intuitive for long-term financial sustainability, particularly in the use of short message service (SMS) and reverse-billed unstructured supplementary service data (USSD) for user registration and messaging.

In addition, the service is no longer just one way, but instead includes mechanisms for two-way interaction between the pregnant mother and the health system through USSD-based surveys and a help desk. This enables real-time data collection on user knowledge, attitudes, practices and experiences of service delivery to inform healthcare improvements.14 Early research has demonstrated the feasibility of further help desk automation through machine learning and artificial intelligence.15

MomConnect messaging engages and empowers users and fosters a relationship of trust with the service and the health system itself. In a sample of nearly 10 000 women telephonically surveyed, with a response rate of over one in five (n=1 999), 98% found the messages helpful, 77% felt better prepared for delivery, 81% shared their messages with family and friends and 70% wanted more messages per week.16

Most importantly, by engaging holistically with both demand and supply sides of the health system, the value proposition of MomConnect has changed. The most significant impact of MomConnect may not be achieved via the direct effect of the messaging itself, but rather by creating a national platform that directly connects to over a million mothers and that has been designed to permit easy integration with other information systems.17 In the future, as MomConnect links with other systems such as electronic medical records, the National Health Laboratory Service, the population database and Department of Social Development databases, a mother’s enrolment in MomConnect could become her first step towards accessing a continuum of support that extends from her first antenatal appointment right through to social grants and early learning subsidies for her child.

This has only been possible through a substantial donor investment in MomConnect and a government commitment to going to national scale right from the start. MomConnect has established a simple platform that can be adapted over time to add features and functionality of increasing complexity. The service is far from perfect, but as the mobile market evolves and smartphone penetration increases, more sophisticated and less expensive technology options can be added to incrementally shift eligible users away from USSD and SMS, while reserving these modalities for the most vulnerable users.

The role of public–private partnership

Government stewardship and integration into the health system have both been identified as enablers that allow mobile health programmes to scale.18 19 Many donor-funded programmes aim for eventual government adoption, but few get there. MomConnect is an unusual example of a true public–private partnership. Private funders, with a larger appetite for risk, have contributed upfront investment and technical know-how, but only in the context of public leadership and an enabling policy environment. As the programme demonstrates its value, public funding has been committed to take over the core elements of registration, messaging and the help desk. However, as a technology platform MomConnect needs to continue to be agile and to evolve in line with the technology landscape and the habits and needs of its users. It will therefore always require some degree of private risk capital to fund innovation at the margins of the service.