Mobile technology for community health in Ghana: Is maternal messaging and provider use of technology cost-effective in improving maternal and child health outcomes at scale?

Background: Mobile technologies are emerging as tools to enhance health service delivery systems and empower clients to improve maternal, newborn, and child health. Limited evidence exists on the value for money of mobile health (mHealth) programs in low- and middle-income countries. Objective: This study aims to forecast the incremental cost-effectiveness of the Mobile Technology for Community Health (MOTECH) initiative at scale across 170 districts in Ghana. Methods: MOTECH’s “Client Data Application” allows frontline health workers to digitize service delivery information and track the care of patients. MOTECH’s other main component, the “Mobile Midwife,” sends automated educational voice messages to mobile phones of pregnant and postpartum women. We measured program costs and consequences of scaling up MOTECH over a 10-year analytic time horizon. Economic costs were estimated from informant interviews and financial records. Health effects were modeled using the Lives Saved Tool with data from an independent evaluation of changes in key services coverage observed in Gomoa West District. Incremental cost-effectiveness ratios were presented overall and for each year of implementation. Uncertainty analyses assessed the robustness of results to changes in key parameters. Results: MOTECH was scaled in clusters over a 3-year period to reach 78.7% (170/216) of Ghana’s districts. Sustaining the program would cost US $17,618 on average annually per district. Over 10 years, MOTECH could potentially save an estimated 59,906 lives at a total cost of US $32 million. The incremental cost per disability-adjusted life year averted ranged from US $174 in the first year to US $6.54 in the tenth year of implementation and US $20.94 (95% CI US $20.34-$21.55) over 10 years. Uncertainty analyses suggested that the incremental cost-effectiveness ratio was most sensitive to changes in health effects, followed by personnel time. Probabilistic sensitivity analyses suggested that MOTECH had a 100% probability of being cost-effective above a willingness-to-pay threshold of US $50. Conclusions: This is the first study to estimate the value for money of the supply- and demand-side of an mHealth initiative. The adoption of MOTECH to improve MNCH service delivery and uptake represents good value for money in Ghana and should be considered for expansion. Integration with other mHealth solutions, including e-Tracker, may provide opportunities to continue or combine beneficial components of MOTECH to achieve a greater impact on health. Ghana’s estimated population of 24.5 million is spread across 216 districts. Health services in the public sector are delivered through community CHPS facilities, health centers, and district and regional hospitals with varying rates of public sector service utilization. MNCH indicators have improved with the help of policies such as the Free Maternal Care Policy and National Health Insurance; however, maternal mortality (380 per 100,000 live births) and infant mortality (49 per 1000 live births) rates did not decrease sufficiently to reach 2015 targets, and socioeconomic and geographic differences continue to reflect inequalities in health service utilization and outcomes [1,3,21]. Utilization of at least 1 antenatal care (ANC) session is nearly universal, and 84% of women attend 4 or more ANC visits, nearly 30% of deliveries are not attended by a skilled birth attendant, and almost 20% do not receive postnatal care [22]. In an effort to catalyze improvements in the quality and continuity of care during pregnancy and postpartum, the MOTECH program launched in August 2010 in Kassena-Nankana West District in the Upper East Region of Ghana and in 2011 in Awutu Senya District in the Central Region. In 2012, with added funding from United States Agency for International Development and the Bill and Melinda Gates Foundation (BMGF), MOTECH was expanded into new districts: Dangme East in Greater Accra, South Tongu in the Volta region, and Gomoa West in Central region. Gomoa West was selected for an independent evaluation led by Healthcare Innovation Technology Lab in partnership with the University of Ghana School of Public Health. Because of the availability of data on health effects, data from Gomoa West were used in this analysis to forecast the costs and consequences of program expansion to 170 districts across Ghana. Gomoa West is a semirural coastal district of the Central Region with a population of 135,139 [23]. Health services in Gomoa West are delivered through 17 CHPS facilities (1 per 7949 population), 4 health centers (1 per 33,785 population), and 1 district hospital [16]. Population and health systems characteristics for the remaining 169 districts were drawn from the 2010 Population and Housing Census, including district-division and population statistics, data on the number of health facilities, and human resources [23,24]. This study received ethical approval from the Ethical Review Committee of Ghana Health Service (GHS) as well as the Johns Hopkins School of Public Health Institutional Review Board. Requirement of informed consent was waived. MOTECH, a partnership between Grameen Foundation and GHS, aims to improve service delivery and access to MNCH services through 2 components: Mobile Midwife and Client Data Application (CDA). Mobile Midwife is a demand-side intervention, which aims to improve client knowledge and awareness of key health information during pregnancy and postpartum, with the goal of stimulating best practices and encouraging timely and appropriate service utilization. Under Mobile Midwife, registered pregnant women and mothers of infants are provided with a MOTECH identification number and receive weekly local-language interactive voice response messages on pregnancy and infant care and appointment reminders for routine clinical visits on their mobile phones (Multimedia Appendix 1). To complement demand generation through Mobile Midwife, the CDA of MOTECH allows frontline health workers affiliated with CHPS facilities and health centers to use mobile phones to digitize clinical care information to better track and deliver care to women of reproductive age, including pregnant women and children <5 years of age. CDA consists of simplified digital registers consolidating information previously collected in over a dozen paper-based registers in health centers and CHPS facilities. Data elements recorded onto mobile phones are used to generate monthly reports as well as care reminders and alerts sent to both the clients and nurses along with a weekly list of care defaulters in need of follow-up in their catchment area [16]. The input of digitized health data activates the automated system to cross-reference national care protocols, identify appropriate reminders or alerts to clients and nurses, and send voice messages. The MOTECH program also facilitates data reporting by summarizing facility statistics for a report to the district, although the reporting system is not directly interoperable with the government health information system. As part of this analysis, we forecasted the costs and consequences of scaling up MOTECH activities to 170 districts across Ghana, mirroring the implementation activities conducted in Gomoa West. Program activities were provided in 3 phases: development (6 months), start-up (6 months), and ongoing support to implementation (Table 1). Development encompasses all central activities, such as national stakeholder meetings, which are necessary to prepare for the initiation of the program. Start-up includes all central- and local-level activities required to initiate the program, including district profiling, content localization, orientations, and training. Implementation refers to ongoing activities required to sustain the program and includes salary support for personnel at all levels for ongoing monitoring and evaluation as well as recurrent telecommunications and data usage costs, which assume no fluctuation for agreements with mobile network operators from what was established in the MOTECH program in Gomoa West. Development and start-up phase activities occur at the program’s inception and are considered capital investments that are annualized across the life of the program. Some activities were modified for national scale from the original Grameen Foundation MOTECH project in Gomoa West: instead of mass registration campaigns for enrollment, the national program would assume point-of-care enrollment at health facilities. Recurring costs such as personnel, utilities, and vehicle maintenance are included in all phases. Program costs by phase and activity for the gradual rollout of Mobile Technology for Community Health (MOTECH) to 170 districts from 2015-2024. a6 months in duration per district. b6 months in duration per district. c9 years of implementation annual costs for 45 districts in which MOTECH program activities were initiated in 2015, 8 years for 67 districts in which MOTECH program activities were initiated in 2016, 7 years for 58 final districts in which MOTECH program activities were initiated in 2017. To initiate MOTECH activities at scale, a 3-year national rollout plan was designed to begin in 3 regions, with 5 districts in each region conducting start-up activities simultaneously supported by key central and regional support staff for training, program administration, and technical support (Table 2). Additional districts could be brought on board within those regions once the first districts completed all development activities and had moved on to start-up or implementation phases of the program. GHS successfully upgraded from District Health Information System (DHIS) version 1 to the current DHIS 2 in only 6 months, and although this is promising for the capacity and experience with digital health solutions, the roll out of MOTECH activities at scale would require significant oversight capacity for additional health worker training, equipment replacement, and data monitoring [25]. Rollout plan for the Mobile Technology for Community Health program: Reaching 170 districts over 3 years. aNo start-up costs were being incurred in this district. Economic costs were estimated from a program perspective for a 10-year analytic time horizon (2015-2024). Program costs were defined as the costs required to develop, start up, and support ongoing implementation. Costs associated with MOTECH activities from 2012-2014 in the district of Gomoa West were used to generate estimates of the resources required to scale up and sustain implementation into 170 districts. Drawing from Grameen Foundation project financial records in Accra, which detailed capital and recurrent expenditures over time for MOTECH in Gomoa West, as well as informant interviews with program staff, we used an ingredients approach to forecast estimates of costs by activity and level of the health system (central, regional, or district) over time for each district. District population estimates were drawn from the 2010 census in Ghana and the model adapted to incorporate differences across districts in numbers of CHPS facilities and health centers [23]. Once collected, costs were converted into US $ , using month-appropriate market exchange rates, and then adjusted into 2014 US $ using the 2014 Consumer Price Index for Ghana [26]. Capital costs were annualized over the lifetime of the project or life span of the item as appropriate and discounted at 3% [27]. Development and start-up phase costs were viewed as one-time activities and similarly annualized over the lifetime of the project. Variable costs were anticipated to change with the number of facilities or nurses (mobile phones purchased, refresher training, etc) and adjusted based on population rates in Gomoa West. Health effects were modeled based on the average intervention effects observed as part of the independent evaluation of MOTECH carried out in Gomoa West and 1 comparison district. Secondary analyses of exit interview data conducted by our team sought to generate an estimate of the average treatment effect of the MOTECH program based on propensity score values. Findings from this analysis suggested a significant increase in the coverage of skilled birth attendants (11%), facility delivery (10%), and measles immunization (6%) following program implementation. No significant changes were observed in pregnant women reporting 4 or more ANC visits, exclusive breastfeeding, the use of modern methods postpartum family planning, and other indicators. Indicators with significant increases in health effects were inputted in to the Lives Saved Tool (LiST) in Spectrum version 4.7. Increases in coverage were assumed to increase linearly but not anticipated to increase at the same rate over time. When intervention coverage surpassed 75%, the rate of coverage increase was adjusted by half; above 90% overall intervention coverage, the rate of increase is again halved; and for any intervention, cannot increase beyond 99%. These breakpoints help to adjust expectations of increases in coverage with the model’s time horizon. The disability-adjusted life years (DALYs) averted were calculated with a 3% discount rate, no age weighting, and life expectancy of 65.5 years as reported in the 2010 Census [23,28]. In the absence of data on disabilities, DALYs are based on years of life lost only. Analyses of incremental costs and effects were conducted in Microsoft Excel. To test for uncertainty, one-way and probabilistic sensitivity analyses were conducted. The latter was carried out in Microsoft Excel using Monte Carlo simulation with 1000 iterations per analysis. The resulting mean point estimate was obtained by dividing mean costs by mean effects and presented along with the 95% CI. A cost-effectiveness plane and cost-effectiveness acceptability curve (CEAC) were used to calculate the probability that the intervention would be cost-effective for each of a number of standard thresholds of cost-effectiveness. Cost-effectiveness was ultimately determined according to thresholds set forth by the Commission for Macroeconomics and Health and World Health Organization in 2002, which stipulate that an intervention is “highly cost-effective” and “cost-effective” at 1 and 3 times the value of per capita gross domestic product per DALY averted, respectively. To facilitate comparison with alternative resource uses, we additionally compared findings against those available in the literature, including the Disease Control Priorities Project, third edition that highlights low-cost, high-priority interventions for key regions for the world, including sub-Saharan Africa.