Informal mhealth at scale in Africa: Opportunities and challenges.

The extraordinary global growth of digital connectivity has generated optimism that mobile technologies can help overcome infrastructural barriers to development, with 'mobile health' (mhealth) being a key component of this. However, while 'formal' (top-down) mhealth programmes continue to face challenges of scalability and sustainability, we know relatively little about how health-workers are using their own mobile phones informally in their work. Using data from Ghana, Ethiopia and Malawi, we document the reach, nature and perceived impacts of community health-workers' (CHWs') 'informal mhealth' practices, and ask how equitably these are distributed. We implemented a mixed-methods study, combining surveys of CHWs across the three countries, using multi-stage proportional-to-size sampling (N = 2197 total), with qualitative research (interviews and focus groups with CHWs, clients and higher-level stake-holders). Survey data were weighted to produce nationally- or regionally-representative samples for multivariate analysis; comparative thematic analysis was used for qualitative data. Our findings confirm the limited reach of 'formal' compared with 'informal' mhealth: while only 15% of CHWs surveyed were using formal mhealth applications, over 97% reported regularly using a personal mobile phone for work-related purposes in a range of innovative ways. CHWs and clients expressed unequivocally enthusiastic views about the perceived impacts of this 'informal health' usage. However, they also identified very real practical challenges, financial burdens and other threats to personal wellbeing; these appear to be borne disproportionately by the lowest-paid cadre of health-workers, especially those serving rural areas. Unlike previous small-scale, qualitative studies, our work has shown that informal mhealth is already happening at scale, far outstripping its formal equivalent. Policy-makers need to engage seriously with this emergent health system, and to work closely with those on the ground to address sources of inequity, without undermining existing good practice.

CONTEXT MATTERS: FOSTERING, ORPHANHOOD AND SCHOOLING IN SUB-SAHARAN AFRICA.

A growing body of research suggests that orphanhood and fostering might be (independently) associated with educational disadvantage in sub-Saharan Africa. However, literature on the impacts of orphanhood and fostering on school enrolment, attendance and progress produces equivocal, and often conflicting, results. This paper reports on quantitative and qualitative data from sixteen field-sites in Ghana and Malawi, highlighting the importance of historical and social context in shaping schooling outcomes for fostered and orphaned children. In Malawi, which has been particularly badly affected by AIDS, orphans were less likely to be enrolled in and attending school than other children. By contrast, in Ghana, with its long tradition of 'kinship fostering', orphans were not significantly educationally disadvantaged; instead, non-orphaned, purposively fostered children had lower school enrolment and attendance than their peers. Understanding the context of orphanhood and fostering in relation to schooling is crucial in achieving 'Education for All'.

Formalising 'informal' mHealth in Ghana: Opportunities and challenges for Universal Health Coverage (UHC).

While mobile phones promise to be an important tool for bridging the healthcare gaps in resource-poor areas in developing countries, scalability and sustainability of mobile phones for health (mhealth) interventions still remain a major challenge. Meanwhile, health workers are already using their own mobile phones (referred to as 'informal mhealth') to facilitate healthcare delivery in diverse ways. Therefore, this paper explores some strategies for integrating 'informal mHealth' in the healthcare delivery of Ghana, by highlighting some opportunities and challenges. The study mainly employed a combination of literature review, focus group discussions and key informant interviews with community health nurses (CHNs) and other stakeholders, who were purposively selected from the three ecological zones in Ghana. The study found that, while scale-up of 'formal mhealth' remains challenging in Ghana, almost all CHNs in our study are using their personal mobile phones 'informally' to bridge healthcare gaps, thereby promoting universal health coverage. This provides opportunities for promoting (or formalising) 'informal' mhealth in Ghana, in spite of some practical challenges in the use of personal mobile phones that need to be addressed to ensure sustainable healthcare delivery in the country.

Mobile phone use and the welfare of community health nurses in Ghana: An analysis of unintended costs.

The use of mobile phones is fast transforming the healthcare delivery landscape in Ghana. A substantial number of health facilities are now dependent on mobile phones to facilitate their work. Evidence of the use of mobile phones in Ghana's healthcare is however limited. In order to contribute to the evidence of the value of using mobile phones to promote healthcare, we interrogated and highlighted unexpected costs imposed on community health nurses who use their personal mobile phones for healthcare delivery in the country. Data for the study were derived from 598 completed questionnaires and extracts from focus group discussions with community health nurses who were sampled from three regions across the three main ecological zones of Ghana. The results show that over 90% of nurses bear the cost of paying for airtime, bundles and chargers used for work-related activities, yet less than 10% of them receive direct compensation. This costly burden has the potential to demotivate the nurses and threaten the country's progress towards the achievement of universal health coverage. More significantly, the data strongly suggest that physical distance, regional location and gender are the main factors triggering extra costs incurred by the nurses. We conclude that the use of personal mobile phones for healthcare delivery imposed huge financial burden on community health workers in Ghana. A suggested intervention to forestall negative consequences on performance is to offer incentive packages to nurses as a compensation for the financial and non-physical costs of using personal mobile phones for work-related activities.

Children as research collaborators: issues and reflections from a mobility study in sub-Saharan Africa.

This paper reflects on issues raised by work with children in an ongoing child mobility study in three sub-Saharan African countries: Ghana, Malawi and South Africa. There are now 70 school pupils of varying ages involved in the project, but the paper is particularly concerned with the participation of those children 14 years and under. We examine the significant ethical issues associated with working with younger child researchers, and linked questions concerning the spaces open to them in African contexts where local cultural constructions of childhood and associated economic imperatives (which commonly drive family and household endeavour) help shape the attitudes of adults to children's rights and responsibilities and inter-generational power relations.

Who bears the cost of 'informal mhealth'? Health-workers' mobile phone practices and associated political-moral economies of care in Ghana and Malawi.

Africa's recent communications 'revolution' has generated optimism that using mobile phones for health (mhealth) can help bridge healthcare gaps, particularly for rural, hard-to-reach populations. However, while scale-up of mhealth pilots remains limited, health-workers across the continent possess mobile phones. This article draws on interviews from Ghana and Malawi to ask whether/how health-workers are using their phones informally and with what consequences. Health-workers were found to use personal mobile phones for a wide range of purposes: obtaining help in emergencies; communicating with patients/colleagues; facilitating community-based care, patient monitoring and medication adherence; obtaining clinical advice/information and managing logistics. However, the costs were being borne by the health-workers themselves, particularly by those at the lower echelons, in rural communities, often on minimal stipends/salaries, who are required to 'care' even at substantial personal cost. Although there is significant potential for 'informal mhealth' to improve (rural) healthcare, there is a risk that the associated moral and political economies of care will reinforce existing socioeconomic and geographic inequalities.

Informal m-health: How are young people using mobile phones to bridge healthcare gaps in Sub-Saharan Africa?

The African communications 'revolution' has generated optimism that mobile phones might help overcome infrastructural barriers to healthcare provision in resource-poor contexts. However, while formal m-health programmes remain limited in coverage and scope, young people are using mobile phones creatively and strategically in an attempt to secure effective healthcare. Drawing on qualitative and quantitative data collected in 2012-2014 from over 4500 young people (aged 8-25 y) in Ghana, Malawi and South Africa, this paper documents these practices and the new therapeutic opportunities they create, alongside the constraints, contingencies and risks. We argue that young people are endeavouring to lay claim to a digitally-mediated form of therapeutic citizenship, but that a lack of appropriate resources, social networks and skills ('digital capital'), combined with ongoing shortcomings in healthcare delivery, can compromise their ability to do this effectively. The paper concludes by offering tentative suggestions for remedying this situation.

Youth reproductive health services in Bulawayo, Zimbabwe.

This study examines young people's access to reproductive healthcare services via an urban youth advisory centre in Bulawayo, Zimbabwe. The aim is to explain why teenagers do not always use existing health services. Data from exit questionnaires with users and focus groups with non-users are analysed to evaluate service accessibility. Analysis suggests that even where clinics are spatially accessible, barriers to access include temporal factors, lack of factual knowledge and stigmatisation. The paper concludes that spatial accessibility is not the only factor necessary to ensure equal access to health services. Recommendations are made towards tackling young people's unmet needs for reproductive healthcare services.