Mobile Money and Mobile Health 2: Use Cases, Limitations and Ways Forward

Posted by MohiniBhavsar on Nov 10, 2010

In this two-part series, explores how mobile money services can support health care in developing countries. In part one, we described the key ways in which mobile money services can be adopted by the health sector.

At the primary level of care, subscription-based mobile payment services can create two-way links between patients and health care providers, as summarized here.

  • Patients can pay service providers directly for health care services delivered.
  • Service providers can use mobile transfer platforms to reward patients with monetary or airtime incentives for treatment compliance.

At the district, regional, and national levels, governments and organizations can improve management of funds and introduce better checks and balances by using mobile money platforms. Some uses include:

  • Paying salaries or incentives to health care providers based on services delivered or work performance
  • In conjunction with voucher based systems, reimbursing health care providers for services delivered
  • Paying out conditional cash transfers allocated for health care directly to individuals’ mobile phones

Here, we describe how M-PESA in Kenya has been used for health care financing. We have found very few examples that link mobile financial services to health care, though there is much promise and potential. We also describe the challenges involved in implementing and scaling mobile financial services for health -- a complex endeavor that is complicated by the presence of multiple players. Finally, we outline what needs to happen to catalyze more collaborative innovation in mobile money and mobile health.

Direct Uses of M-PESA for Health Care Financing

Case 1: Prepaid cards topped with M-PESA credit for maternal health care

At Pumwani Maternity Hospital in Nairobi, Kenya, customers can top up prepaid cards with small amounts of money using M-PESA (documented here). Costs for maternal care are deducted from the savings on the card. According to Samuel Agutu, managing director of Changamka Microhealth Limited, this approach fosters a culture of savings for maternal health care needs and for emergencies that may arise in the future.

Case 2: Ad-hoc innovation in Kenya using M-PESA to pay hospital fees

A recent evaluation of community-level effects of M-PESA in Kenya described individual uses of M-PESA to pay for school fees and health services:

“Focus group participants frequently cited M-PESA as a means for helping them to pay school fees and get money for medical procedures. This appeared to help in school attendance and retention, and to seek medical consultation faster than they would have otherwise. Timely payment could also strengthen hospitals and schools, creating a more positive future for school and medical facilities and the potential for deeper outreach over time.”

Yet other than the example cited above, systems are not in place to facilitate direct transactions between M-PESA users and schools or clinics. The authors of the study found that M-PESA users still needed to withdraw cash to pay the health center or make deposits to the school’s bank account. In some isolated cases, when the payees knew the payers well, cashless mobile payments were accepted, “but principals actively discouraged this practice because of a lack of accountability and tracking ability.”

Case 3: M-PESA transfers to pay institutional fees (could be applied in hospitals)

Bridge International Academics is a for-profit primary school franchise that manages low-cost schools in Kenya -- enrollment costs for each pupil are about $4 per month. Bridge is well placed to leverage the ubiquitity of M-PESA in its work. Parents can pay school fees using M-PESA, and the administration pays staff and suppliers using the popular mobile money service as well.

Ignacio Mas, an expert in mobile payments, noted on the NextBillion blog that automation of payments address several problems including cash security, curbing unrecorded side payments, keeping financial records, minimizing errors, and accessing real-time business data.

From an organizational perspective, Bridge suggested it would like to see cheaper rates to transfer money using M-PESA, and would “also like the M-PESA interface to integrate more easily into accounting and operations software, so there is seamless handling of transaction records across the business.” Mas writes:

“Safaricom hasn't published Application Programming Interfaces (APIs) on M-PESA, so Bridge International Academies has had to develop its own interface to the M-PESA website. Electronic payments are indeed a natural entry-point for business management software.”

So, while there are challenges even with a more systematic integration of mobile money services, there are plenty of businesses that recognize the clear benefits of cashless transactions.

Case 4: M-PESA transfers cover the cost of transportation to distant surgeries (Tanzania)

A common barrier to accessing health services is the cost of transportation to health care facilities.  Organizations in Tanzania and Kenya are exploring the use of mobile money services to reimburse transportation and lodging costs to increase access to surgical care.

Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) is the second largest provider of obstetric fistula services in Tanzania. Obstetric fistula is a hole in the birth canal and it can occur during child birth when timely access to emergency obstetric care is not available. Obstetric fistula results in incontinence. Left untreated, the condition can lead to chronic medical, social, and psychological problems, including isolation from partners and family and exclusion from the community.

In 2009, CCBRT performed almost 200 surgeries for obstetric fistula. To reach more women, the provider turned to M-PESA in a pilot scheme to transfer money to pay for transport to the disability hospital in Dar es Salaam. At the hospital, women also receive free consultations, operations, and follow-up care. UNFPA’s Campaign to End Fistula reported on a collaboration with CCBRT:

“Money is sent from CCBRT’s mobile banking account to CCBRT ‘ambassadors’ across Tanzania, who help increase identification, notification and transportation of fistula patients. The ambassadors — usually doctors, nurses or NGO-workers — can retrieve the money at their local mobile company agency and buy the patient’s bus tickets. Upon the patient’s arrival at CCBRT the ambassadors receive a small incentive via the same mobile banking system, called M-PESA.”

In this scheme, payments are not necessarily being made directly to the patient, but to in-between representatives. Interestingly, this scheme includes monetary incentives to health care providers through the same mobile payment.  Previously, CCBRT performed on average 14 surgeries per month. In March 2010, CCBRT counted a record high of 29 surgeries per month. The program was launched in 2009.

Case 5: M-PESA transfers cover cost of transportation to distant surgeries (Kenya)

Similarly, Freedom From Fistula Foundation (FFFF), based in Kenya, also used M-PESA to facilitate travel from rural homes to surgery centers in Nairobi.  A mobile hotline is regularly advertised over the radio to help identify cases of fistula.  Lucy Mwangi, Director of FFFF, briefly explained the process before transfers are made. "Whoever gets the number calls, flashes [beeps], or texts and we call them back and ask a couple of questions to establish if they are fistula patients."

Obstacles for Greater Uptake of Mobile Money in Health

The above examples demonstrate that on a small scale, there have been attempts to leverage mobile money for increasing access to health care. However, almost all of these examples are from Kenya -- "ground zero" of mobile money.  We observe a number of obstacles to large-scale adoption:

  • Large-scale adoption of mobile money in the health sector will depend on how widely customers use mobile payment services.
  • Health organizations are reluctant to integrate new technology into their work.
  • Mobile health and mobile money are growing fields and are still trying to understand the complex patterns of use and impact within their own silos.
  • It is difficult to negotiate between stakeholders with profit margins and those with social interests.
  • Regulatory schemes and complex banking regulations limit fast growth.

To even consider large-scale mobile application to health, there must be a wide uptake of mobile money services by consumers. Ignacio Mas and Dan Radcliffe outline barriers for the scaling of mobile money (see their report) and recommend strategies to reach critical mass. They also note that, "while some deployments have gained early traction in the market, such as MTN MobileMoney in Uganda, Tameer Bank/Telenor's easypasia in Pakistan, and Vodacom's M-PESA in Tanzania, none have scaled at (or near) the level experienced by M-PESA in Kenya."

Mas and Radcliffe suggest that scaling of mobile money requires not incremental, but large early investments in marketing and development of agent networks. To reach critical mass quickly, operators should market "pain points" that mobile money services can meet. (In part one of this series, we identified some of these "pain points" for individuals, organizations, and governments in the health sector.) Operators should look beyond individuals as consumers, view governments as consumers of mobile money services, and negotiate reasonable service charges for transfers.

At the same time, the report suggests that operators should invest in a widespread agent network to deliver the services. To better integrate with the health sector, institutions will have to invest in compatible systems that can accept payments in hospitals. Mobile operators will have to dedicate an agent network to support the sending and receiving of payments. Until then, innovation by consumers themselves will remain ad-hoc, slow, and less likely to scale. From the MMU blog:

"... [I]t is important to build merchant relationships with entities such as schools and hospitals to accept mobile money. If customers could make incremental micro-payments to these institutions over the mobile, then they face less risk in keeping money on hand."

But selling any technology to the health sector can be a challenging feat. While tools on the finance side may be straightforward, systems on the health side are more complex to navigate and integrate. The health sector can be especially skeptical when the technology is still fairly new. Dr. Patricia Mechael, an expert interviewed in part one of this series, spoke about this issue:

“Mobile banking hasn’t evolved as quickly and ubiquitously as people think it has. We need to ask ourselves: how mature is mobile banking and if there is value in it for health.”

It can be overwhelming to attempt to navigate mobile money and mobile health as one sphere. Menekse Gencer, an expert in mobile money services, notes:

“Both m-health and mobile financial services (MFS) are service industries that converge with mobile, so they're fairly complicated. There are questions related to infrastructure, policy, operations and business models. When you consider the intersection of m-health with MFS, the level of complexity becomes even greater since this intersection encompasses three industries [mobile, mobile money and mobile health]."

Equally complicated are the multiple stakeholders, scattered pilots, and policies and regulations. Even when a system is established and enabled by mobile services, there remains an underlying challenge of negotiation with all the players. Melissa Ho described some of these challenges during the deployment of ClaimMobile in Uganda:

“We find that in projects with multiple stakeholders, the introduction of a system may disrupt balances of power, particularly around the flow of information and money. As a result, the design of this system, in order to secure positive support from all parties involved, must carefully balance stakeholder incentives.”

Ho explained how negotiations between stakeholders can impede the objectives of a working program:

“However, another source of delay is the administrative and political dynamics by which program administration halts, although health distributors continue to sell vouchers, and health clinics continue to see patients. During these times, payments are delayed unexpectedly for undetermined lengths of time, as can be observed from the early termination of our pre-pilot study."

Perspectives from Practitioners

Practitioners we interviewed noted that there are many benefits to "going mobile" with health payments at the practitioner level. At the same time, the practitioners were frank about the challenges of adding mobile money to their work.


We spoke to Anne Roos-Weil, founder of Pesinet, a non-profit micro health insurance organization based in Mali (see also’s case study). Health workers for Pesinet make home visits to do routine health checks of children and collect basic health data on mobiles that is remotely sent to doctors. To ensure financial sustainability, families have to pay approximately 1 Euro each month to register for the service. This fee covers the cost of health visits, doctor fees, and medication.

Roos-Weil outlined several cash and bank transactions that take place in Pesinet’s work flow that could be enabled via mobiles.

  1. Health workers (or agents) collect the monthly service fee in cash from each family every month.
  2. If families fail to pay the health worker, the program coordinator is responsible for collecting the money.
  3. This pool of money is then allocated to pay the salaries of health workers, the program coordinator, and the doctor. It is also used to pay the monthly fee to use resources at the health care center.
  4. A different pool of money is used to pay for expenses at the health care center pharmacy.

Until Pesinet breaks even, funding from grants is used to supplement expenses. There are also operational and administrative costs.

Currently, Pesinet’s financial transactions are managed through banks and tracked through receipts. But cash flows can be complicated to manage especially in an environment where there is no bank. Mobile money services could be a viable option for programs running in rural areas. Traceability mechanisms can be automatically implemented with mobile money transfers. Roos-Weil said:

“There is an opportunity in mobile money transfers for better control over money exchanges that occur in [Pesinet’s] services. The coordinator could see easily how much money went from the family to the agent and monitor and track transactions. Having cash means you need to have a lot of control, to make sure nothing is leaked. This is resource intensive.”

Although Pesinet offers gains in efficiency and better financial management, Roos-Weil cautioned that the beneficiaries of the service may be different from the payers, and payers may be different from who is registering for the service. Mothers tend to be the main decision makers who register their children for Pesinet, but they often rely on the fathers to provide the cash. 

At the primary level of care, Roos-Weil raised a number of important questions:

  • How is money being used in the family?
  • Do the family members who make decisions for health have a mobile phone? Do they have control over finances?
  • Who are the payers and who are the beneficiaries?
  • What is the degree of mobile penetration and usage of mobile money services in the region?

In Mali, Orange launched the mobile money service Orange Money in May 2010. Roos-Weil noted that its integration with Pesinet's workflow will largely be dependent on the level of adoption among local residents.

Incentives through M-PESA for vaccinations

There is a growing discussion about the use of community-level incentives to increase vaccinations in developing countries. The WHO estimated that if access to vaccines and vaccination coverage against childhood diseases was improved to at least 90%, two million deaths among children under five could be prevented.

Dr. Feikin, a researcher at John Hopkins Bloomberg School of Public Health who has lived in Kenya, is using M-PESA to increase vaccinations. This initiative is in the early phases of development. The idea is simple:  use M-PESA to pay incentives to mothers who bring in their children to get vaccinations. Dr. Feikin said:

"In many areas of Kenya, there is low vaccination coverage and late vaccination. A lot of diseases can be prevented if there is no delay. If we can get the system running, we would then look at the impact and ask if we can actually improve vaccination rates and timeliness. The bottom line is the health impact."

In Kenya, the infrastructure already exists for such a system to work. The goal of this pilot is to see if it can actually be done, but there are lot of steps involved and logistical obstacles:

  • How do we obtain the phone numbers of mothers or members of their household who are registered for the M-PESA service?
  • If mothers or families are not registered, how do we encourage them to register for M-PESA to be able to receive payments?
  • Are there enough agents in the area to cash out money without having to travel too far? If the mother has to travel too far, she will not register a child for vaccinations.
  • Zain's Zap is a growing competitor of Safaricom's M-PESA service. Which system should be used to give out payments to maximize reach and health impact?
  • How can we keep track of payments associated with mobile phone numbers? Tracking this prevents a mother from taking advantage of the incentives by exposing the child to multiple vaccinations.

The opportunity to link mobile money services to such health initiatives may be attractive to mobile operators in terms of increasing service usage and revenue, but service charges can be a detriment to scale such programs.

"Service charges involved per transfer could be a disincentive for any program, government or donor that wants give funding, because a portion of each incentive will go to pay the system and not the patient. There has got to be a way of working with the operators to reduce fees per transfer. There is a need for creative solutions at that end."

The challenge lies in working in with mobile operators to negotiate service charges that align with health budgets and organizational and government capacities.

Moving Forward

In our conversations with experts, we noted a general consensus about how to move forward. There was agreement that it is necessary to:

  • Chart out how cash flows through the health sector, and highlight opportunities where mobile money can best be leveraged;
  • Design based on the needs of the health sector to maximize health impacts;
  • Engage mobile network operators to develop open systems that are compatible across different service providers and that integrate with existing technology in the health sector;
  • Understand how systems interact, identify shared and common components and requirements, and develop more open platforms; and
  • Support early trials, invest in the evaluation of pilots, and critically assess health impacts.

Many we spoke with cautioned that mobile money is not the answer for every transaction in health care. Our sources noted that there is a need to carefully assess the context to determine the most appropriate tool at any point in the work flow.  Some technologies may already exist, such as reloadable debit cards. In some cases, adding mobiles may not improve a particular transaction, while in other cases, mobiles and SIM cards may be the way forward because existing methods are nonexistent.

Dr. Mechael recommended that solutions should be designed with a firm focus on the needs of the health sector, instead of haphazardly applying various financial products.

“In relation to introducing technological innovation within the health sector, when things come from the outside, the traction hasn’t been great. As soon as the health sector decides it wants to do something or embrace something, the demand is catalytic. When industry partners try to sell platforms and tools, when well-intentioned NGOs develop and deploy applications independent of the health sector, it doesn’t get very far. Many initiatives have come and gone with limited impact on health due to the lack of buy-in or demand from governments as well as health professionals, administrators, and consumers of health services.”

Mobile network operators are critical players to engage.  Many we interviewed noted that there is a lack of interoperability between payment systems offered by different mobile network operators in the same county. If payment platforms are to be scaled for health services at national levels, interoperability is imperative.

Krugel urged that this is the best time to look at the cross-sections:

“Mobile money is new, mobile health is even newer. Mobile money people are trying to focus on making the money part work and the health people are focusing on what they’re doing, too. The opportune time is now before they reach matured products.”

Evidently, we should move away from mutually exclusive efforts and should consider a holistic approach. This is especially important to ensure compatibility of technology between the health and finance systems. There is a risk of incompatibility if collaboration does not happen sooner. On this issue, Brown said:

“The market is now taking over. If there’s not an intersection thought about early on as to how payments, financing, billing and reimbursement is going to happen under these systems, and how it might leverage the incoming infrastructure of mobile money, then you might end up with incompatible pieces that ends up costing a lot of money.”

In summary

Innovation is already happening. It is important to support early trials and be transparent about what has worked and what hasn’t worked. According to Krugel, the countries to intervene first are those with more than a million users of mobile money -- Philippines, Thailand, Kenya, and Uganda.

By bringing together the multiple players -- health, finance, mobile health, mobile money, governments, donors, NGOs, and mobile network operators -- and by attempting to shed more light on the area, we can start to think more about the connections that can be made, and how to best create the systems to support innovation.

Undoubtedly, there is room for mobile money services in health care.  For active registered users of mobile financial services, adding mobile money to pay for their health care needs can be valuable. For mobile operators, this could be an opportunity to increase revenue from existing users as well as a way to attract new customers and reduce churn. For health care providers, a mobile payment scheme to pay for services delivered could guarantee revenue from patients and reimbursements from governments. Automation of transactions for salary payments and conditional cash transfers directly to mobile phones can reduce leakage and improve accountability.

Mobile money services are growing worldwide. While there are limited documented cases of mobile money services in the developing world for health care financing, it is likely innovation will happen.

Both governments (potential consumers of mobile money services) and mobile network operators (providers of mobile money services) can experience long-term benefits by adopting mobile payments for transactions in the health sector. But by waiting too long to have these substantive discussions, they run the risk of mobile money platforms becoming incompatible with existing systems in the health sector. Already, payment systems are not interoperable within countries.

This can make integration too costly or unfeasible to implement at a national scale. Both mobile money and mobile health care systems are complicated, new, and growing.  Likewise, each field is still trying to understand customer usage, feasibility, financial models, and impact.  Instead of focusing inward, the two industries need to collaborate to map the cross-sections. In doing so, programs, organizations, and governments can work with mobile network operators to create the infrastructure needed to take advantage of the possibilities.

Not that I am aware of

Panthea - totally agree. A couple of things:  Concern did a pretty extensive evaluation of its program using mobile payments for cash aid delivery - see the PDF in this post:  There is a bit more information about the metholodology, limitations, and results of the program there.

However, that said, I am not aware of any reliable or valid studies that investigate the impact of mobile money in health.  All of the programs we mentioned are extremely preliminary, small in scale, and pilots at best.  I don't think many (if any) are, at this point, integrating any solid M&E efforts in the work as they are so very experimental.

I agree with you that this is needed but, as we have seen in the m-health field, there is a scarcity of solid M&E even there and it's a more mature field.  I think this is something to address and push for - ICT4D researchers are gathering in December in London. Maybe we should organize an ad-hoc session on "what's missing in ICT4D research and can you please get on with some good data in these areas?"


Integrated M&E for richer, immediately actionable results?

Thanks for this great series!

Have a quick question: Recognizing that both mHealth and mobile banking are relatively new fields (and thus their intersection more so), I was wondering whether you'd come across any examples of linked M&E with a view to demonstrate causation/correlation between elements of a mHealth/MFS programme?

My interest in this was piqued after reading a Concern blog post. They're doing some pioneering stuff re: integrating mobile money in programming, mostly for emergency relief but with natural implications for health. As part of an emergency cash distribution project (in response to Niger's food crisis), they were tracking participants in both their nutrition and their cash transfer programs, and then analyzing the combined results. In doing so, they are hoping to determine the effectiveness of cash interventions in food crises and their direct impact on malnutrition rates. I'm not sure the scale of this particular initiative, how they've designed the study, etc, but am keen to learn more, and to see if others are thinking along similar lines.

I think there are many use-cases where the mHealth+MFS would make sense. That said, the ability to isolate and critically assess the impact of mobile money in health programming will be key; the latter already has quality, clearly defined metrics for progress, so how do we integrate two to derive more value? And how do we take advantage of the real-time data that is available to us? If we're able to more easily test, track, and analyze the effect of various cash incentives (for both patients and healthcare providers/workers), we will be able to more efficiently rejig programming til it's right.

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