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

Financial barriers are a major obstacle to accessing maternal health care services in low-resource settings. In Madagascar, less than half of live births are attended by skilled health staff. Although mobile money-based savings and payment systems are often used to pay for a variety of services, including health care, data on the implications of a dedicated mobile money wallet restricted to health-related spending during pregnancy–a mobile health wallet (MHW)–are not well understood. In cooperation with the Madagascan Ministry of Health, this study aims to elicit the perceptions, experiences, and recommendations of key stakeholders in relation to a MHW amid a pilot study in 31 state-funded health care facilities. We conducted a two-stage qualitative study using semi-structured in-depth interviews with stakeholders (N = 21) representing the following groups: community representatives, health care providers, health officials and representatives from phone provider companies. Interviews were conducted in Atsimondrano and Renivohitra districts, between November and December of 2017. Data was coded thematically using inductive and deductive approaches, and found to align with a social ecological model. Key facilitators for successful implementation of the MHW, include (i) close collaboration with existing communal structures and (ii) creation of an incentive scheme to reward pregnant women to save. Key barriers to the application of the MHW in the study zone include (i) disruption of informal benefits for health care providers related to the current cash-based payment system, (ii) low mobile phone ownership, (iii) illiteracy among the target population, and (iv) failure of the MHW to overcome essential access barriers towards institutional health care services such as fear of unpredictable expenses. The MHW was perceived as a potential solution to reduce disparities in access to maternal health care. To ensure success of the MHW, direct demand-side and provider-side financial incentives merit consideration. The study was approved by the Madagascan Ministry of Health and the Heidelberg University Hospital Ethics Committee (No. S-703/2017). Informed written consent was obtained from all participants of the study prior to the interview. The study was conducted in Madagascar, an island country with 26.3 million inhabitants off the coast of East Africa [22]. According to the Human Development Index, Madagascar ranks 161th of 189 countries [23]. Annual income per person is low at US$461, placing Madagascar among the 6 poorest countries globally in 2018 [24]. Poverty is especially prevalent in rural areas where around two-thirds of the population live [25,26]. As of 2018, 41% of the population are below age 14. The government expenditures on education measure 2.1% of the gross domestic product (GDP); an estimated 3.93 million adults are illiterate [27]. Educational deprivation strongly varies across socioeconomic groups: the richest quintile of the population averages 9.8 years of schooling, compared with 1.7 years for the poorest quintile [23]. Located in Central Madagascar’s Analamanga region, the study districts (Atsimondrano and Renivohitra), which include the capital Antananarivo, are primarily urban and were selected due to an extensive phone network coverage and a high population density. Pregnancy and birth related health care services in this area are predominantly provided by Centres de Santé de Base level 1 (CSB1), equivalent to health posts in anglophone African countries, and CSB level 2 (CSB2), equivalent to health centers and district hospitals [28]. We conducted a two-staged qualitative study using semi-structured interviews. In the first stage, we purposively sampled sector experts across health care system levels based on their experience and ability to provide relevant information on health care organization, provision, communication, administration and financing in the study zone [29]. We complemented this approach in a second stage with snowball sampling and ultimately interviewed respondents across different health care and health profession levels, community representatives and telephone provider representatives [30,31]. Semi-structured interview guides were developed in English and translated into French and Malagasy. Data were collected from 28th of November until 12th of December of 2017 by interviewers fluent in Malagasy, English and French, and with graduate-level education and experience in qualitative research methods. All members of the data collection team participated in a one-day workshop and training to ensure a common understanding of all aspects of the MHW intervention. Prior to the start of interviews, we collected basic socio-demographic data of respondents (gender, age, years of experience in the health sector). Overall, 21 stakeholders were sampled including 8 community representatives, 8 health care providers, 3 health officials and 2 phone provider representatives. All in-depth interviews were audio-recorded in a private place of the respondent’s choice. Interviews lasted 25 to 75 minutes. To assure a clear understanding of the concept and aim of the MHW by respondents, a concise description of the MHW was read aloud and interviewees were encouraged to ask questions and seek clarity throughout the interview. Figs ​Figs11 and ​and22 depict the study sample and study themes addressed across interviews, respectively. Topics included general perceptions of the MHW, sector and component experiences, perceptions of obstacles to providing health care, as well as recommendations and expectations for implementing MHWs. Sampling continued until no new information emerged and saturation was reached [32]. Yellow = perception of MHW components, Blue = sector and component experiences, Green = obstacles towards MHW components, Red = recommendations and expectations. All interviews were tape-recorded, verbatim transcribed in the original language and, if in French or Malagasy, translated into English. Transcripts were analyzed by two researchers (NM, AF) who developed a codebook which was validated by a senior qualitative research expert (SM) [30]. Each set of data was analyzed at least twice. Thematic coding was applied by using a partially deductive approach, informed by findings from a previous study, and an inductive coding technique with creation of themes as they emerged from the transcripts [13]. Analysts convened regularly to debate differences in coding and interpretation. During the analysis process, when new codes emerged, coders discussed the new findings and transcripts were recoded as the codebook was refined. In the process of coding, a social ecological model (SEM) emerged as an organizing framework around which to present the data. The SEM is a theory-based framework that considers the interplay of multiple social system levels and interactions from the individual level to the broader environment [33]. The SEM facilitated the exploration of dynamic interactions across different social levels that influence health care seeking behaviors and program acceptance. Emerging themes and subthemes with potential influence on successful MHW implementation were grouped into the following three SEM layers and are presented accordingly in the results section: Coding was performed with the software NVivo 12 [34].