Pop Quiz: What Does it Really Cost to Run mHealth Projects?

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One of the stated reasons for implementing mHealth projects is that they are more cost effective than the status quo of using paper or nothing at all to support health programming in developing countries.
Yet there is one glaring question that comes forth if we position our work as a cost-effective intervention:
How much do mHealth projects cost?
Thanks to the Malawi Ministry of Health and Population, we now have one answer. They commissioned mHealth 360 Analysis, a mobile health landscape analysis and technical feasibility study based on the 31 mHealth projects officially registered with the Ministry.
First, the 12 registered projects that submitted costing data had an average $158,931 annual cost and ran for 5 years, meaning the average mhealth project had a total cost of $794,657. Then the mobile health projects reached an average of 459 users per year.
Finally, this results in in an average cost per active user per year of $346.26.
What is in $346.26 annual mHealth cost?
While this is an interesting number, what does it really mean? We have very little context to understand how this cost number was calculated, beyond a generic average.
mHealth Cost Drivers
The study claims that software development costs accounts for the largest portion of budgets, an average of $115,076 over 5 years, or 15% of the $794,657 average total mHealth project budget. Motioning and evaluation costs are second at $78,597 or about 10% of the total costs.
Interestingly, the average cost per device per user is $96 with an average of 6% of hardware being replaced each year due to hardware being lost, stolen, or damaged. That 6% replacement rate is lower than the 10% I would’ve expected and contradicts a common perception that mobile phones will be lost or damaged by mHealth project constituents.
mHealth User Types
The study found that 23 out of 31 mHealth projects focused on Health Surveillance Assistants and Community Health Workers, with supervisors, district staff, and project-specific staff in the next largest cohort of users. However, there is no correlation mentioned between the 23 projects focusing on HSAs and CHWs, and the 12 projects with costing data.
The majority of mobile health projects focused on Reproductive Maternal Neonatal and Child Health (RMNCH), and Integrated Management of Childhood Illness (IMCI), and supplying surveillance, promotion, prevention, and curative services.
Is $346.26 Cost Effective mHealth Spend?
In addition to a vague calculation, we are also challenged to understand the context we might use this number to evaluate the cost-effectiveness of a mobile health activity.
Status Quo Cost
Of course the first test would be to understand the cost of not doing an mHealth intervention. One could argue that the status quo costs $0, so a $345.26 mHealth intervention is very expensive compared with an average GNI of $320 per person.
However, what cost would you assign the death or debilitation of a Malawian? If a mHealth intervention improved the lives of 360 Malawians enough to keep them in the workforce, then one could argue that an mHealth intervention is at least break-even.
Alternatives Cost
A better question might be to ask how else the projects could achieve similar outcomes. One might be able to argue that a radio program replace SMS texts to phones with greater cost-effectiveness.
However, surveillance activities might be more difficult without mobile phones, and analog CHW decision support tools and paper-based reporting are much less effective than digital solutions.
Direct Comparison Costs
I can easily argue that this study lumped together several different types of interventions, which confuses potential comparisons.
For example, 6 costed projects used SMS text messages to communicate with constituents, while 8 projects were mobile application based interventions. Just at this level of differentiation, we see a large disparity in costs per users:

  • SMS projects averaged $507,247 in total costs and reached 7,772 users for a $65 average cost per user.
  • Mobile app projects averaged $1,159,959 in total costs and reached 2,244 users for a $517 average cost per user.

Next, there is a huge goal and impact difference between a Reproductive Maternal Neonatal and Child Health project that focuses on mother education though sending SMS text messages while she is pregnant, and a decision support and activity reporting mobile application for community health workers to monitor a mother and child’s health from conception through the first year of a child’s life.
I would argue that the disparity is so great that one should only make direct comparisons between projects with the same stakeholders and goals, using similar modalities and methodologies.
We Still Do Not Know True mHealth Costs
While I commend the Malawi Ministry of Health and Population for this study, and it builds on related work to find out What Does It Really Cost to Run an ICT for Education Program? I find that both studies raise more questions than they answer.
In fact, there are so many unanswered questions, that I cannot agree with the study’s cost conclusions.
I see the $346.26 average cost per user per year as a vague data point that lacks the needed context to be useful, and I worry that it could be used incorrectly as a benchmark for what a mHealth project should cost.
What do you think? I’d love your thoughts in the comments.
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