Digital financial services (DFS) refer to the delivery of traditional financial services through digital devices such as phones, laptops, and tablets, for instance, mobile money payments. Evidence suggests that DFS has the potential to make financial services accessible to the underserved population (Gartner, 2022). Health development partners like WHO, USAID, and GAVI are promoting digital payment solutions as a substitute for traditional payment systems to leverage these advantages. More recently digital payment solutions have been proposed as the preferred mode of payments to frontline health workers engaged in mass vaccination campaigns. Mobile money can help the 1.7 billion people who lack a bank account to access financial services.” (Angela Wipperman, 2022).
From March 2022 to July 2023, community health workers (CHWs) in Malawi were unequivocally supported in the five rounds of nationwide polio vaccination campaigns using mobile money payments for their allowances and field work funds. The Digital Health Payment Initiative and Research in Africa (DHPI-R) conducted in-depth interviews with CHWs who participated in the polio campaign in seven Malawian districts between Aug 2022 and July 2023 to comprehensively assess the effect of mobile money payments on their work output and morale.
The CHWs expressed both advantages and disadvantages associated with mobile money payment systems. CHWs’ perceptions varied depending on their places of residence (urban, peri-urban, and rural / hard-to-reach). In this article, we present some of these perceptions. More specifically, we focus on CHWs' perceptions in rural hard-to-reach settings.
Generally, all CHWs (including those in hard-reach-areas) believe that mobile money payments facilitate convenient and easy access to funds, as cited by participants at a focus group discussion in Mchinji district in Malawi: “Receiving money through the phone is easy and good, it has been so easy for us during this campaign because we received our money through Airtel money, and we can withdraw the money at any time here at the village. We don't walk a long distance to withdraw the money.”
CHWs also said that mobile money payments saved them time. They no longer had to spend time traveling to banks or other financial institutions to withdraw their allowances, and they could also use mobile money to make payments to others, such as for transportation or food.
The net effect of these advantages, that is, convenience, ease of access and further remittance of funds, and time saved, has generally contributed to efficiency in executing daily duties. They can spend less time on administrative tasks and more time on their work, which can help to improve the quality of care they provide.
However, we noted from the research that perceptions of mobile money payments by CHWs in rural hard-to-reach settlements were relatively different.
Mobile money agents serving rural hard-to-reach settlements are few and not always easily accessible. CHWs in hard-to-reach settlements said they travel long distances to access mobile money agents, with some travelling 50-60 km to cash-out points: “We struggle to withdraw the given allowances because in rural areas you have to travel long distances to find the agent to withdraw the money. There are few agents and some areas do not have agents at all,”a CHW in Chiwamba, a rural settlement in Malawi narrated.
Mobile money agents serving rural hard-to-reach settlements are not always liquid. After travelling long distances to access a mobile money agent, CHWs noted that mobile money agents cannot always cash out funds to them. They are not always liquid, as cited by CHWs in Salima district “When we go to withdraw our allowances from agents, most of them say they do not have cash; so, we fail to access the money. Sometimes we withdraw part of the allowances, and it takes days for us to withdraw the balance from the same agent, sometimes compelling us to go to other trading centers to withdraw the money. As a result, we lose a lot of money in transport, because these trading centers are not close to our residences.”
Accessing mobile money in rural hard-to-reach settlements comes with higher transaction costs in the form of transport and time lost. CHWs incur extra costs and lose time in travelling long distances to access mobile money agents. These transaction costs are not always factored into funds disbursed to CHWs to compensate for the loss.
Generally, digital payment systems improve convenience and even productivity. However, there are underlying infrastructural aspects that play a fundamental role such as the transport network, availability of mobile money agents, and liquidity by mobile money agents. CHWs in urban and peri-urban settlements, unlike their counterparts in hard-to-reach settlements, find mobile money payment systems favorable; partly because they do not have to travel long distances to access their money, mobile money agents are easily accessible, and they are mostly liquid i.e., able to cash out funds.
Good network coverage is a strong facilitator of digital payment systems. CHWs acknowledged that a good network is key to the successful use of mobile money payment systems, as it helps them know promptly that funds have been reflected in their account. As cited by a key informant in Lilongwe, the capital of Malawi: “Digital payment is good, but it relies much on network availability. For example, health workers situated in areas with good network coverage easily know and access their money; but those who are in rural areas where there is no network coverage have difficulties in withdrawing the allowances or knowing that the money is in, as the transaction messages come late because of network coverage challenges; sometimes they stay without network coverage.”
Given the above experiences, key stakeholders in the health sector who are proponents of digital payment solutions should consider the following:
There is no one-size-fits-all. The use of mobile money payment should be considered on a case-by-case basis. Some settlements are more ready for this solution than others. For obvious reasons, CHWs in urban and peri-urban settings are generally more receptive to digital payment solutions than CHWs in rural settlements.
Factor in transaction costs. When disbursing funds to CHWs using mobile payment systems, consider factoring in transaction costs, especially the cost of transport to disbursement points.
Be conscious of the availability, accessibility, and liquidity of mobile money agents. Before activating mobile money as a payment system, establish the number of agents, how accessible they are by target settlements, and how liquid they are. Where possible, ensure to disburse funds to mobile money agents ahead of cash-out by CHWs.
Take TELCO network coverage into consideration. Areas without sufficient network coverage may not be receptive to mobile money payment systems, because they may not know that funds have reached their accounts. Furthermore, mobile money agents in such areas may not be able to cash out funds to CHWs.
A hybrid approach to payments to CHWs is probably inevitable. Key stakeholders may want to consider a hybrid approach i.e., a combination of traditional (cash-based) payment system alongside the mobile money system. The above factors i.e., accessibility and availability of mobile money agents, liquidity of mobile money agents, and network coverage, could be considered critical success factors to a go / no-go decision to roll out digital payment solutions to specific settlements.
We do hope that these perceptions and the recommendations coming along with them will inform digital payment policy in the health sector in rural settings in sub-Saharan Africa and other similar settings going forward.
The Digital Health Payment Initiative and Research in Africa (DHPI-R) Project, funded by the Bill and Melinda Gates Foundation, is based at Makerere University in collaboration with the University of Dakar in Senegal. Additionally, Compelling Works and Kamuzu University of Health Sciences are collaborating with DHPI-R to implement the project in Malawi.
Authors: Dr. Simon Ndira - Founder & CEO Compelling Works, Angelica Kiwummulo - Deputy Country Director Compelling Works Uganda, Patricia Khomani - Senior Manager Compelling Works Malawi, Julie Aweko DHPI-R Senior Project coordinator Makerere University and , Judith Grace Amoit, DHPI-R Communication Officer Makerere.