A Mobile Health Wallet for pregnancy-related healthcare in Madagascar: a mixed-methods study on opportunities and challenges.

BACKGROUND: Mobile savings and payment systems have been widely adopted to store money and to pay for a variety of services, including healthcare. However, the possible implications of these technologies on financing and payment for maternal healthcare services - which commonly require large one-time out-of-pocket payments - have not yet been systematically assessed in low-resource settings.

OBJECTIVE: This study aims to determine the structural, contextual, and experiential characteristics of a mobile-phone-based savings and payment platform, the Mobile Health Wallet (MHW), for skilled healthcare during pregnancy among women in Madagascar.

METHODS: We used a two-stage cluster random sampling scheme, to select a representative sample of women utilizing either routine antenatal (ANC) or routine postnatal care (PNC) in public-sector health facilities in two of 8 urban and peri-urban districts of Antananarivo, Madagascar (Atsimondrano and Renivohitra districts). In a quantitative structured survey, we identified saving habits, mobile phone use, media consumptions, and perception of a mobile health wallet with both savings and payment functions. To confirm and explain the quantitative results, we used qualitative data from 6 semi-structured focus group discussions (24 participants in total) in the same population.

RESULTS: Out of 412 randomly selected women attending ANC or PNC, 59.3% (95% confidence interval (CI) 54.5-64.1%) saved towards the expected costs of delivery and, out of those, 64.4% (95% CI 58.6-70.2%) used household cash savings for this purpose. 80.3% (95% CI 76.5-84.1%) had access to a personal or family phone and 35.7% (95% CI 31.1-40.3%) previously used mobile money services. Access to skilled healthcare during pregnancy was primarily limited due to financial obstacles like saving difficulties or unpredictability of costs. Another barrier was the lack of information about health benefits or availability of services. The general concept of a MHW for saving towards and payment of pregnancy-related care including the restriction of payments was perceived as beneficial and practicable by the majority of participants. In the discussions, several themes pointed to opportunities for ensuring the success of a MHW through design features: (i) intuitive technical ease of use; (ii) clear communication and information about benefits and restrictions; (iii) availability of a personal customer support.

CONCLUSIONS: Financial obstacles are a major cause of limited access to skilled maternal healthcare in Madagascar. A MHW for skilled healthcare during pregnancy was perceived as a useful and desirable tool to reduce financial barriers among women in urban Madagascar. The design of this tool and the communication strategy will likely be the key to success. Particularly important dimensions of design include technical user-friendliness and accessible, personal customer service.