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

Abstract

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.

Factors Affecting the Successful Implementation of a Digital Intervention for Health Financing in a Low-Resource Setting at Scale: Semistructured Interview Study With Health Care Workers and Management Staff

“…The enthusiasm toward digitization in the health sector extends to health financing, widely recognized as a key area of health system reform toward UHC. In particular, mobile money services, which enable resource collection at the individual level, have been launched in many countries, especially in sub-Saharan Africa [ 5 , 6 ]. Beyond mobile money, DHIs targeting the other 2 health financing functions, pooling and purchasing, have been implemented.…”

The Role of FinTech in Sustainable Healthcare Development in Sub-Saharan Africa: A Narrative Review

“…Digital payment systems, such as mobile money, can provide secure and efficient healthcare financing, enabling individuals to pay for healthcare services using their mobile phones [53]. For example, in Madagascar and Uganda, mobile money platforms have been used to pay for maternal healthcare services, reducing the financial barriers to accessing these services and improving maternal health outcomes [55,56]. Digital payments can also support the development of innovative healthcare delivery models, such as telemedicine and mobile clinics, which can increase access to healthcare services, particularly in remote and underserved areas [53,54].…”

“…Another potential benefit of digital payments in healthcare development is its ability to improve the efficiency and transparency of healthcare financing. Digital payment systems can enable the development of new financial instruments, such as micro-insurance and health savings accounts, which can improve access to healthcare financing and reduce the financial burden on patients [55,56]. Digital payments can also facilitate tracking healthcare expenditures, enabling greater transparency and accountability in using healthcare funds [53].…”

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

“…Against this backdrop, the non-governmental organization Doctors for Madagascar developed a mobile health wallet for maternal health care to mitigate or eliminate OOP for health expenditure. We described the Mobile Maternal Health Wallet (MMHW) in detail elsewhere [ 13 , 28 ]. Briefly, the MMHW allows expectant mothers to save, pay, and receive mobile money and electronic vouchers for maternal health services.…”

“…The pilot intervention started in October 2018 and is currently ongoing as of August 2022. Results from the pilot will inform a larger cluster randomized trial in the study area to determine the impact of the MMHW on health outcomes as well as its cost-effectiveness [ 28 ].…”