Mobile health initiatives look to service providers for scale

By Andrea Useem 11 December 2012

Eric Woods, co-founder and CEO of Switchboard, at a 2012 PopTech conference. Switchboard links doctors in Liberia and Ghana via mobile phone. Photo by Thatcher Cook for PopTech (CC by SA-2.0)

This article is produced and published by Devex Impact, a global initiative of Devex and USAID, that focuses on the intersection of business and global development and connects companies, organizations and professionals to the practical information they need to make an impact.


When more than 4,000 mobile-health experts and practitioners gathered this month in Washington D.C. for the mHealth Summit, one malady came up again and again: “pilot-itis.”


“We have many projects that begin without an idea of who will fund them in the long run,” said Dr. Esther Ogara, head of eHealth at Kenya’s Ministry of Health. Pointing out that donors are reluctant to underwrite on-going programs, and that host governments cannot be a catch-all funding mechanism for every pilot, Ogara said partnerships with the private sector offer the best hope for bringing mobile health projects to scale.


Enthusiasm for the idea of private-sector partnership as cure for pilot-itis was palpable when Eric Woods, co-founder and chief executive officer of Switchboard, a San Francisco-based 501(c)3, took the stage and explained how his organization has partnered with mobile service providers in Liberia and Ghana to develop countrywide networks for health workers–all while generating significant profits for those partner companies. After his presentation, the crowd of people waiting to talk with him was ten-deep.


But enthusiasm alone will not bridge the gap between nongovernmental organizations and private businesses.


“The nonprofit health sector often doesn’t know enough about mobile operators to pitch their solutions in a way that is worth it for business, in terms of either reduced costs or increased revenue,” Eduardo Jezierski, the chief technology officer at InSTEDD, a nonprofit research, design and evaluation organization focused on technology solutions.


“’Pilotitis’ happens when you don’t have the technology design or business agreement in place to transform your 100-user or 1,000-user solution into something much bigger,” said Jezierski, who worked for nearly a decade at Microsoft before moving to InSTEDD. “To make a successful partnership with mobile operators, you need to speak their language.”


‘We can’t do it alone’


“In mobile health, we have seen a ton of pilots, but very few programs that have reached scale,” said Trevor Lewis, a program associate at the Center for Health Market Innovations, a global network managed by the Results of Development Institute. One problem is that evidence of mobile-health success is hard to deliver because mobile technology itself is changing so fast, he said.


If private-sector partnerships can be an antidote to pilot-itis, then the latest data from the Center for Health Market Innovations, which reports on innovative health projects happening in low- and middle-income countries, should give mobile-health observers pause. Of the 326 “e-health” projects (a category that includes mHealth), close to half were run by nonprofits alone, while a much smaller percentage involved partnerships between the private sector (for-profit or nonprofit) and government, according to the Center’s 2012 data set.


One of the highest-profile public-private partnerships in mobile health is the Mobile Alliance for Maternal Action, or MAMA, which delivers health-focused text messages to expectant and new mothers in 35 countries. The project, which brings together the United Nations Foundation, Johnson & Johnson, the mHealth Alliance, Baby Center and U.S. Agency for International Development, was applauded the mHealth summit for receiving Fast Company’s “Innovation by Design” award in the service category. Alice Fabiano, a senior program officer at Johnson & Johnson, said that public-private partnerships like MAMA can be a “slog” but remain essential for reaching scale.


“Mobile health by definition is not something we can achieve by ourselves,” said Fabiano. “We have to work together to find that mix of technology and innovative service delivery.”


For another example of a successful public-private partnership in mobile health, Lewis of CHMI pointed to the Wireless Access for Health initiative in the Philippines, which uses 3G technology to improve the electronic medical records system in Tarlac province. By the end of 2012, all 38 public health facilities in the province will be part of the initiative, which enables health workers to rapidly transmit patient information, gives policy makers quicker access to public-health data and enhances patient outcomes, according to a case study written by the Center for Health Market Innovations and the Philippine Institute for Development Studies.


The initiative brings together a notably diverse set of partners, among them multinational Qualcomm, Filipino mobile-phone service provider SMART Communications, provincial and national government agencies, USAID and implementer RTI International.


Cooperation among partners wasn’t always easy, said Michael McKay, a technical advisor at RTI International.


“Simply choosing the project’s name may have been more difficult than implementing the technology,” he said, laughing. 


McKay noted that the group faced cultural differences not only across national boundaries, but also across NGO-corporate and corporate-government divides, to name a few.


“Karaoke was one solution,” he said. “Building those personal relationships helped us understand and trust one another so we could push forward with the project.”


For Qualcomm, the San Diego-based telecommunications giant that primarily sells its products to other businesses, the Philippines project is driven by strategic philanthropy.


“Qualcomm’s core business is 3G and next-generation wireless technology, and we know a lot of our growth as a company will come from this 2G to 3G transition, particularly in emerging markets,” said Blake Tye, a staff analyst at Qualcomm. “We work in partnership to find win-win situations where we can demonstrate social and economic impact, and also create business value for Qualcomm and our partners.”


The Philippines project is just one of 20 mobile-health projects supported by Qualcomm’s Wireless Reach initiative. Nested within the company’s corporate affairs office and independent of the company’s philanthropic foundation, Wireless Reach aims to use Qualcomm’s “core technology” to improve the lives of those underserved by technology through more than 70 projects in five sectors, said Tye, who is also a member of the Wireless Reach team.


While the Wireless Access for Health project has expanded through the entire Tarlac province, and now includes direct SMS messaging to midwives and pregnant women, it is only reaching a fraction of the Philippines’ rural population. Local government funding has increased, from 10 percent-20 percent to 50 percent, but major costs require continued funding from Qualcomm and SMART Communications, and expansion to other provinces will depend on increased spending from government and corporate partners.


Perhaps because of these limitations, the commercial mechanisms embedded in Switchboard caught the attention of mHealth summit attendees.


Switchboard’s model


Woods explained the problem – and solution – the Switchboard team found when they looked at the realities of health workers in countries like Ghana.


“These workers are in isolated rural clinics, serving anywhere from 5,000 to 15,000 patients,” said Woods. “They are diagnosing complex cases, performing emergency procedures and managing disease outbreaks in a place where getting test results can take as long as two months. Yet all of them have a mobile phone in their pocket.”


Woods said his team started with a simple question: “What could happen if you are able to collect the mobile phone number of every health worker in the country?” The vision is to create a free network of health workers, so doctors, nurses and other health care workers can call or text each other for free to exchange know-how, provide advice and make referrals.


Switchboard collected the numbers of the health workers – 2,200 doctors in Ghana and 181 in Liberia – and verified the names with the governments’ ministries of health, created a directory, then partnered with mobile operators Vodafone and MTN to create a user group that allowed for free calls. The result so far has been more than 4 million calls among physicians, according to Woods.


The business model revolves around what the doctors do with their phones when they are not using them for work: They pay regular service fees when they call family and friends. As a result, the mobile operators have generated $1.5 million in new revenue – providing an incentive to continue providing the free in-network service to health workers.


“We recognized that doctors were a valuable market segment for service providers,” said Woods, noting that while Vodafone has only 18 percent market share among consumers in Ghana, it claims nearly every doctor as a customer.


Switchboard’s model in innovative in the way it uses program externalities as a financing model, said one mobile-health observer. Where many mobile-health projects look for end-users or government to foot the bill, Switchboard has found a revenue stream independent of the health service delivered.


With funding from, Switchboard is expanding to Tanzania in early 2013, where it aims to create a network not only for the country’s 2,500 urban doctors but also more than 6,500 clinical and medical officers, together with partner Vodafone. “We are creating the largest network of health workers in the developing world,” said Woods.


Switchboard is also working with SMS platform Vumi to allow for text-messaging among health workers. Woods pointed to a randomized controlled trial in Kenya, which demonstrated that when pediatric health care practitioners received text messages about malaria care, treatment improved by more than 20 percent.


Yet even with this innovative model, questions remain.


“Mobile access is an issue of social equity. Your access to health services can’t be determined by which phone company you choose,” said Jezierski of InSTEDD, which was founded in 2006 after director, Larry Brilliant, won the TED Prize.


“Sometimes it’s tempting to work with one operator exclusively, but you have to look at the reality of lower-income countries, where not every village is covered by every company,” said Jezierski. “We want solutions that will work with all operators, otherwise you end up choosing one company over another and marginalizing a population because their area is not covered.”


Switchboard has an exclusive deal with Vodafone in Ghana, meaning it cannot work with other service providers in Ghana, such as Millicom’s Tigo, though its registration system and messaging platform are open-source and could potentially be used by other operators, according to Woods. Health workers that live outside Vodafone coverage areas can still register their numbers to be part of the network, though their calls to other health workers are not free.


Woods argued that the benefits of working closely with mobile-service providers outweighs the cost.


“If anything, we have found that the highly competitive nature of these markets really pushes telecoms to innovate,” he wrote in an email to Devex Impact. “They understand that being first to market brings a significant business advantage.”


Jezierski said that when exclusivity is a must, NGOs can negotiate with businesses to restrict that exclusivity to six months or some other limited time period.


“That’s where the business savvy comes in,” he said.


The future of working together


If private-sector partnerships are the key to scaling up mobile health projects, then both NGOs and telecoms have to work harder to understand one another, according to Kai-Lik Foh, mHealth program manager at GSMA, the global industry association for mobile-service operators.


Asked by the World Health Organization to survey GSMA members and global health organizations, Foh and his team found a significant amount of mistrust and misunderstanding, he said during his presentation at the mHealth Summit.


Nonprofit health workers perceive mobile operators as a “necessary evil,” bureaucracies that are more focused on good publicity and business objectives than health outcomes, Foh reported. The operators, in turn, reported that global health organizations lacked an understanding of commercial telco business models, were not focused enough on scale, and made proposals that focused too narrowly on getting operators to donate free air time, a business proposition that is “not thrilling” from the operators point of view, said Foh.


Foh also pointed out that “scale” means different things to these two groups. For global health organizations, scale means reaching a large target population and demonstrating health impact. For operators, scale means increasing geographic coverage, replicating results at a lower cost and seeing an increased uptake of existing assets. Operators also told Foh that global health organizations tend to overestimate business value of simply being associated with social-good projects.


The best way for a nonprofit to interest a mobile operator is to approach them with programs “packaged for scale,” said Foh. For example, health is just one of the many topics on which a government may want to communicate with its population.


“If you can package an  mHealth service as part of a larger government enterprise service, then you are talking about the real uptake of core telecom assets across the company’s geographical footprint. That’s a more compelling value proposition,” said Foh.


Nonprofits should learn about a mobile operator’s business priorities before approaching them with a partnership possibility.


“A mobile operator might want to expand network usage within a certain demographic, like youth or small business or people in a certain province, or maybe they just want to increase the amount of minutes or SMS used by their existing customers. If you are pitching an mHealth solution that doesn’t match up with their goals, the conversation won’t get far,” said Jezierski, noting that InSTEDD helped broker a partnership among the nonprofit Malaria Consortium, the Cambodian Ministry of Health and Mobitel, Cambodia’s largest mobile operator.


The most common partnership models are based around revenue sharing: the phone company agrees to provide a new service – say, phone-based advice for health workers – that consumers pay for, and the company shares some percentage of that new revenue with the non-profit or other organization that runs the service, said Jezierski.


Even though private-sector partnerships may be the key to scale, all parties have to remain realistic about the business opportunity.


“We are all enamored of the idea that a great social innovation will make someone incredibly wealthy,” said Jezierski, but so far expectations have not matched reality. “There’s a lot of excitement in this mobile-health space, but when you peel the onion, a lot of times the business model just isn’t there.”


Rather than aiming to design “the next Facebook IPO of mobile health,” Jezierski argued that mobile health practitioners should set a lower bar and design projects that will at least pay for themselves.


“It’s a smaller business, but at least you are sustainable.”


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About the author

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Andrea Useem

As Associate Editor and Content Director for Devex Impact, Andrea creates and manages cutting-edge content on the intersection of business and international development. An experienced multimedia journalist, Andrea served as leadership editor at the Washington Post and spent three years as a foreign correspondent in Eastern Africa reporting for publications including the Boston Globe, Dallas Morning News, and San Francisco Chronicle.

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