Facilitators and barriers to the implementation of a Mobile Health Wallet for pregnancy-related health care: A qualitative study of stakeholders' perceptions in Madagascar

How prepared is Nigeria digital payment for health workers? A landscape analysis

INTRODUCTION

Stakeholders in the health sector have advocated for the optimization of digital payment channels in low-and-middle-income countries in order to improve program outcomes. We conducted a landscape analysis of the local context, challenges, and opportunities for digitized health worker payments in Nigeria.

METHODS

This study was an exploratory qualitative case study with mixed-methods approach to data collection including; i) desk review, ii) interview of key informants and iii) engagement of stakeholders. In the desk review, the databases searched were MEDLINE (PubMed), Google Scholar and Google. For the qualitative interviews, 17 stakeholders were interviewed between May and July 2022. Audio recordings of interviews were transcribed and analyzed using thematic approach with the Nvivo software. At the stakeholders' (n = 15) engagement, findings from the desk review and interviews were discussed and additional data collected.

RESULTS

Digital payment systems for health personnel described in the reviewed documents included the direct disbursement mechanisms, direct bank transfers and mobile money. Among these-payment methods, direct bank transfer was the most prominent digital payment method. Also, there is a high level of acceptability of digitized means of payment of health workers among stakeholders in the Nigerian health sector. From the regulatory point of view, the Nigerian government has initiated a number of digital payment policies including the cashless policy. Other incentives for digitization of payments were: availability of credible financial institutions, improved financial accountability and transparency, previous experience of under-payment or non-payment of end beneficiaries, to avoid delays in payment and ensure timely retirement of funds. Challenges of digital payments included: delayed resolution of problems associated with digital payment such as failed transactions, cyber security, double payments, and unfriendly bank policies.

CONCLUSION

Digital payment system is being utilized, accepted and would be beneficial for payments for the Nigerian healthcare system. Harnessing its benefits of improved health workers' performance and program outcomes by enacting appropriate policies is recommended.

Contextual success and pitfalls of mHealth service for maternal and child health in Africa: An Intervention, Context, Actors, Mechanism, and Outcome (ICAMO) framework guided systematic review of qualitative evidence

INTRODUCTION

Mobile health (mHealth) interventions have shown potential to improve maternal and child health outcomes in Africa, but their effectiveness depends on specific interventions, context, and implementation quality. Challenges such as limited infrastructure, low digital literacy, and sustainability need to be addressed. Further evaluation studies are essential to summarize the impact of mHealth interventions. Thus, this synthesis focuses on qualitative evidence of the impact of mHealth on maternal and child health in Africa to summarize such evidence to help policy decisions.

METHODS

A qualitative systematic review guided by the concepts of Intervention, Context, Mechanism, and Outcome (ICAMO) was employed in this study. The GRADE CERQual assessment and methodological constraints tools were utilized in the review to ascertain the level of confidence in the evidence and to examine the methodological limitations. The JBI checklist for qualitative research appraisal was also consulted during the review.

RESULTS

The current review contains 32 eligible studies from databases such as CINAHL, EMBASE, MEDLINE, Scopus, Web of Science, HINARI, and Cochrane Library. The review demonstrated substantial improvements in the HCP-woman relationship, communication system, maternal and child healthcare uptake, health-seeking behavior, and HCP skills. Economic capacities, maternal education, and the low quality of existing services challenged participants.

CONCLUSION

mHealth significantly improves maternal and child health outcomes in Africa. This review showed it can improve healthcare access, empower women, and contribute to the region's goal of universal health coverage. However, the challenges such as low partner support, high costs for services, and poor quality of current care as narrated by women need commitment from health authorities in the continent. The evidence from this review suggests that mHealth can be implemented to improve maternal and child health in Africa.

TRIAL REGISTRATION

PROSPERO: CRD42023461425.

Effect of the COVID-19 Lockdown on Mobile Payments for Maternal Health: Regression Discontinuity Analysis

BACKGROUND

The COVID-19 pandemic resulted in the unprecedented popularity of digital financial services for contactless payments and government cash transfer programs to mitigate the economic effects of the pandemic. The effect of the pandemic on the use of digital financial services for health in low- and middle-income countries, however, is poorly understood.

OBJECTIVE

This study aimed to assess the effect of the first COVID-19 lockdown on the use of a mobile maternal health wallet, with a particular focus on delineating the age-dependent differential effects, and draw conclusions on the effect of lockdown measures on the use of digital health services.

METHODS

We analyzed 819,840 person-days of health wallet use data from 3416 women who used health care at 25 public sector primary care facilities and 4 hospitals in Antananarivo, Madagascar, between January 1 and August 27, 2020. We collected data on savings, payments, and voucher use at the point of care. To estimate the effects of the first COVID-19 lockdown in Madagascar, we used regression discontinuity analysis around the starting day of the first COVID-19 lockdown on March 23, 2020. We determined the bandwidth using a data-driven method for unbiased bandwidth selection and used modified Poisson regression for binary variables to estimate risk ratios as lockdown effect sizes.

RESULTS

We recorded 3719 saving events, 1572 payment events, and 3144 use events of electronic vouchers. The first COVID-19 lockdown in Madagascar reduced mobile money savings by 58.5% (P<.001), payments by 45.8% (P<.001), and voucher use by 49.6% (P<.001). Voucher use recovered to the extrapolated prelockdown counterfactual after 214 days, while savings and payments did not cross the extrapolated prelockdown counterfactual. The recovery duration after the lockdown differed by age group. Women aged >30 years recovered substantially faster, returning to prelockdown rates after 34, 226, and 77 days for savings, payments, and voucher use, respectively. Younger women aged <25 years did not return to baseline values. The results remained robust in sensitivity analyses using ±20 days of the optimal bandwidth.

CONCLUSIONS

The COVID-19 lockdown greatly reduced the use of mobile money in the health sector, affecting savings, payments, and voucher use. Savings were the most significantly reduced, implying that the lockdown affected women's expectations of future health care use. Declines in payments and voucher use indicated decreased actual health care use caused by the lockdown. These effects are crucial since many maternal and child health care services cannot be delayed, as the potential benefits will be lost or diminished. To mitigate the adverse impacts of lockdowns on maternal health service use, digital health services could be leveraged to provide access to telemedicine and enhance user communication with clear information on available health care access options and adherence to safety protocols.

Usability and acceptance of a mobile health wallet for pregnancy-related healthcare: A mixed methods study on stakeholders' perceptions in central Madagascar

BACKGROUND

Several sub-Saharan African countries use digital financial services to improve health financing, especially for maternal and child health. In cooperation with the Malagasy Ministry of Health, the NGO Doctors for Madagascar is implementing a mobile health wallet for maternal health care in public-sector health facilities in Madagascar. Our aim was to explore the enabling and limiting factors related to the usability and acceptance of the Mobile Maternal Health Wallet (MMHW) intervention during its implementation.

METHODS

We conducted a cross-sectional, mixed methods study with mothers and pregnant women and facility- (FBHWs) and community-based (CHWs) health workers from public-sector health facilities in three districts of the Analamanga region in Madagascar. We used a convergent design in collecting and analyzing quantitative and qualitative data. We performed one-stage proportional sampling of women who had signed up for the MMHW. All FBHWs and CHWs at primary care facilities in the intervention area were eligible to participate.

RESULTS AND SIGNIFICANCE

314 women, 76 FBHWs, and 52 CHWs were included in the quantitative survey. Qualitative data were extracted from in-depth interviews with 12 women and 12 FBHWs and from six focus group discussions with 39 CHWSs. The MMHW intervention was accepted and used by health workers and women from different socioeconomic backgrounds. Main motivations for women to enroll in the intervention were the opportunity to save money for health (30.6%), electronic vouchers for antenatal ultrasound (30.2%), and bonus payments upon reaching a savings goal (27.9%). Main motivation for health workers was enabling pregnant women to save for health, thus encouraging facility-based deliveries (57.9%). Performance-based payments had low motivational value for health workers. Key facilitators were community sensitization, strong women-health worker relationship, decision making at the household level, and repetitive training on the use of the MMHW. Key barriers included limited phone ownership, low level of digital literacy, disinformation concerning the effects of the intervention, and technical problems like slow payout processes.

Understanding barriers of receiving short message service appointment reminders across African regions: a systematic review

OBJECTIVE

Patients frequently miss their medical appointments. Therefore, short message service (SMS) has been used as a strategy for medical and healthcare service appointment reminders. This systematic review aimed to identify barriers to SMS appointment reminders across African regions.

METHODS

PubMed, Google Scholar, Semantic Scholar and Web of Science were used for searching, and hand searching was done. Original studies written in English, conducted in Africa, and published since 1 December 2018, were included. The standard quality assessment checklist was used for the quality appraisal of the included studies. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart diagram was used for study selection and screening, and any disagreements were resolved via discussions.

RESULTS

A total of 955 articles were searched, 521 studies were removed due to duplication and 105 studies were assessed for eligibility. Consequently, nine studies met the inclusion criteria. Five out of nine included studies were done by randomised control trials. The barriers that hampered patients, mothers and other parental figures of children when they were notified via SMS of medical and health services were identified. Among the 11 identified barriers, illiteracy, issues of confidentiality, familiarised text messages, inadequate information communication technology infrastructure, being a rural resident and loss of mobile phones occurred in at least two studies.

CONCLUSIONS

SMS is an effective and widely accepted appointment reminder tool. However, it is hampered by numerous barriers. Hence, we gathered summarised information about users' barriers to SMS-based appointment reminders. Therefore, stakeholders should address existing identified barriers for better Mhealth interventions.

PROSPERO REGISTRATION NUMBER

CRD42022296559.

Patient-reported experiences in primary health care access of Nepalese immigrant women in Canada

Purpose

Canada has a globally recognized universal health-care system. However, immigrants experience a number of obstacles in obtaining primary health care (PHC) that may differ within various communities due to the intersection of culture, gender and other identities. To date, no research has been done on the difficulties Nepalese immigrant women in Canada may face accessing PHC. The purpose of this study was to learn about their perceptions of barriers to PHC access and to share the findings with a wide range of stakeholders, including health-care providers and policymakers.

Design/methodology/approach

The authors conducted a community-engaged qualitative study in Calgary, Alberta, Canada. A total of six focus group discussions (FGD) among 34 participants (each FGD consisted of 5–7 participants) were conducted. The authors collected demographic information before each focus group. The FGDs were audio recorded and transcribed verbatim. The transcriptions were coded and analysed thematically.

Findings

The focus groups identified long wait times as a major barrier to receiving PHC services. Long wait times in emergency rooms, unable to see family doctors when they were sick, tedious referral procedures, long waits at the clinic even after scheduling an appointment, family responsibilities and work all impacted their access to PHC. Further, a lack of proficiency in English was another significant barrier that impeded effective communication between physicians and immigrant women patients, thus compromising the quality of care. Other barriers mentioned included lack of access to medical records for walk-in doctors, insufficient lab/diagnostic services, a lack of urgent care services and unfamiliarity with the Canadian health-care system.

Originality/value

Accessible PHC is essential for the health of immigrant populations in Canada. This study recognizes the extent of the barriers among a relatively less studied immigrant population group, Nepalese immigrant women, which will help effectively shape public policy and improve access to PHC for the versatile immigrant population fabric in Canada.

The 4MOTHERS trial of the impact of a mobile money-based intervention on maternal and neonatal health outcomes in Madagascar: study protocol of a cluster-randomized hybrid effectiveness-implementation trial

Background

Mobile money—a service enabling users to receive, store, and send electronic money using mobile phones—has been widely adopted across low- and middle-income economies to pay for a variety of services, including healthcare. However, evidence on its effects on healthcare access and health outcomes are scarce and the possible implications of using mobile money for financing and payment of maternal healthcare services—which generally require large one-time out-of-pocket payments—have not yet been systematically assessed in low-resource settings. The aim of this study is to determine the impact on health outcomes, cost-effectiveness, feasibility, acceptability, and usefulness of mobile phone-based savings and payment service, the Mobile Maternal Health Wallet (MMHW), for skilled healthcare during pregnancy and delivery among women in Madagascar.

Methods

This is a hybrid effectiveness-implementation type-1 trial, determining the effectiveness of the intervention while evaluating the context of its implementation in Madagascar’s Analamanga region, containing the capital, Antananarivo. Using a stratified cluster randomized design, 61 public-sector primary-care health facilities were randomized within 6 strata to either receive the intervention or not (29 intervention vs. 32 control facilities). The strata were defined by a health facility’s antenatal care visit volume and its capacity to offer facility-based deliveries. The registered pre-specified primary outcomes are (i) delivery at a health facility, (ii) antenatal care visits, and (iii) total healthcare expenditure during pregnancy, delivery, and neonatal period. The registered pre-specified secondary outcomes include additional health outcomes, economic outcomes, and measurements of user experience and satisfaction. Our estimated enrolment number is 4600 women, who completed their pregnancy between July 1, 2020, and December 31, 2021. A series of nested mixed-methods studies will elucidate client and provider perceptions on feasibility, acceptability, and usefulness of the intervention to inform future implementation efforts.

Discussion

A cluster-randomized, hybrid effectiveness-implementation design allows for a robust approach to determine whether the MMHW is a feasible and beneficial intervention in a resource-restricted public healthcare environment. We expect the results of our study to guide future initiatives and health policy decisions related to maternal and neonatal health and universal healthcare coverage through technology in Madagascar and other countries in sub-Saharan Africa.

Trial registration

This trial was registered on March 12, 2021: Deutsches Register Klinischer Studien (German Clinical Trials Register), identifier: DRKS00014928. For World Health Organization Trial Registration Data Set see Additional file 1.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05694-8.

Acceptability, Barriers and Facilitators of Mobile Text Message Reminder System Implementation in Improving Child Vaccination: A Qualitative Study in Northwest Ethiopia

Background

Mobile phone text message-based mHealth interventions have shown promise in improving health service delivery. Despite the promising findings at a small scale and few contexts, implementing new technologies as part of changes to health care services is inherently challenging. Though there is a potential to introduce mHealth initiatives to health systems of developing countries, existing evidence on the barriers and facilitators of implementation in different contexts is not adequate. Therefore, this study aimed to explore the acceptability, barriers and facilitators of implementing mobile text message reminder system for child vaccination in Ethiopia.

Methods

This study applied a phenomenological study design. The study was conducted in north-west, Ethiopia between July 28 and August 19, 2020. A total of 23 participants were purposively selected for the in-depth and key informant interviews. We used an interview guide to collect data and audio-records of interviews were transcribed verbatim. Coding was done to identify patterns and thematic analysis was conducted using ATLAS ti7 software.

Results

The findings indicated that mothers were receptive to mobile text message reminders for their child’s vaccination. Low mobile phone ownership, access to mobile network, access to electricity and illiteracy among the target population were identified as barriers that would affect implementation. Confidentiality and security-related issues are not barriers to implementation of text message reminders for child vaccination service. Facilitators for implementation include stakeholder collaboration, providing orientation/training to users, and willingness to pay by clients.

Conclusion

In this study, using mobile phone text message reminders for child vaccination services are acceptable by clients. Barriers identified were related to inadequate ICT infrastructure and other technical issues. Addressing the potential barriers and leveraging the existing opportunities could optimize the implementation in resource-limited settings. Before actual implementation, program implementers should also consider providing orientation to users on the proposed mHealth program.