Managing airtime with community health workers


Throughout Africa the vast majority of phone subscriptions are pre-pay. Usually that means you buy a voucher like the one pictured above and enter the voucher PIN into your phone to redeem units of airtime (rather than using a certain amount of airtime and paying at the end of the month). One of the big challenges in my work is figuring out how we can let our community health workers continue to use their phones in this way, while also reimbursing them for work or hospital related airtime. A week or two ago I posed these questions to the ICT4CHW mailing list:

Option 1: has anyone come across a telecom that offers zero-rated SMS or data lines – analogous to a 1-800 number in the USA – as a standard service? This approach is very appealing but for the fact that usually you need to negotiate this on a special basis with the telecom which can take time, requires clout, etc. Is there any way we could collaborate to make negotiation for this service easier and/or convince more telecoms to offer it as a standard service?

Option 2: Brian of ComCare mentioned bulk buying data for their program and fortunately the CHWs weren’t using data services personally so they didn’t use program airtime for personal use – clever! Has anyone else tried this approach?

Option 3: At one of Medic’s projects in Malawi we set up an automated top-up system where CHWs could text in their ID and have airtime sent automatically to their phone. It was easy to manage and was very infrequently abused, in retrospect this was due to the strong relationship between the hospital we were working with and their CHW program, and because we had explained to the CHWs that their airtime requests were monitored after the fact – if they requested more airtime than they should have needed based on the number of messages they were sending to the hospital, they would be removed from the program.

This approach isn’t foolproof though. Here are some issues:
You may send enough airtime for 10 SMS and find that CHWs only use 1 or 2 SMS for program use and spend the rest on their own stuff, then request more airtime. You could switch to a system where a CHWs is initially given enough airtime for say 10 SMS, and they are automatically credited 10 more SMS (via USSD) as soon as the tenth SMS is received by the system. This does prevent abuse… but it also just halts your program if CHWs spend their initial airtime on personal stuff and it is beyond their means/will to buy more so that they can keep sending SMS to the hospital.

Another option is to send smaller amounts of airtime each time you request a CHW activity that will require them to respond to you, and say they can have for personal use whatever they don’t use in responding to that specific task. This has a high transaction cost though; in places like Malawi where the transaction cost for a USSD airtime transfer is the same as the cost of one SMS, you can basically doubles the cost of your program’s SMS.

Have others encountered similar circumstances? In the long run we should probably invest more time in figuring out Option 1, but we are really trying to develop models that can be replicated by normal health care folks – people who aren’t professional mHealth practitioners like us – and so we’d like to find a solution that doesn’t involve negotiating with a telecom. I feel like a human and work flow solution is may be necessary here, it’s hard to replace basic health worker trust and discipline, but I’d love to hear ideas any others have!

Other mHealth practitioners seem to be dealing with these issues as well – we had a lively discussion over 32 posts to the list. Here’s my summary of a few key points:

    Reverse billing, short codes etc are possible, and usually the best option if your project is large and you have staff who can make a good business pitch to the local telcos.

    Smaller projects, those that need to get up and running quickly, or project that lacks the savvy to pitch to/negotiate with a telecom will usually want to reimburse their health workers manually. The key to success here may be in creating proper incentive structures. For example, allowing some extra airtime for personal use, making airtime a collective resource so that peers in the community enforce prudent airtime use, or modifying salaries (bonuses or salary deductions) according to whether airtime use was appropriate.

    To “reimburse manually” could mean handing out paper scratch-off airtime vouchers, sending airtime directly from facility SIM to CHW SIM, distributing voucher pins via SMS, or having a telco or kiosk vender send out airtime for you. The most appropriate method may depend on your incentive structure.

    There are also technical hacks – for example only buying data bundles among CHWs who don’t use data, getting smart phones that can restrict which numbers may be called/SMSed, or working with a telco to restrict sms/voice/gprs services and outgoing numbers (the reality may not live up to the expectation with some telcos).

    Long term, I’m excited to continue conversations about working with individual telcos and the GSMA ‘union’ to make available the services that will be most useful to us. Based on the broad issues we’re discussing here I think there is a profit incentive for telcos to offer these services. Eduardo offered some useful insight on how to go about making the pitch to various telcos.

The ICT4CHW list has a new discussion about once a week, you are welcome to join us.

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