SafeMom – Poketran’ny Reny Tomady (Maternal Mobile Health Wallet – MMHW)

In Madagascar, 80% of the population live on less than $2.15 a day  and 70% are at risk of medical impoverishment [1]. Despite the goal of universal health coverage (UHC) by 2030, out-of-pocket payments remain the main source of healthcare financing, pushing 500,000 Malagasy people into extreme poverty each year and depriving many others of essential care [2] According to the most recent district health survey conducted in Madagascar, 97% of respondents were not covered by any type of health insurance [3].

The consequences are particularly severe for pregnant women: the maternal mortality rate reaches 335 deaths per 100,000 live births, while 11% of women receive no prenatal care and only 46% of deliveries are assisted by skilled personnel [4, 5, 6].

Between 2016 and 2020, mobile money transactions more than doubled, reaching USD 639 million, and mobile money accounts now outnumber traditional bank accounts.

These figures highlight the urgent need to reduce financial barriers and improve access to care for pregnant women.

[1] Madagascar Risk of Catastrophic Expenditure for Surgical Care Percent of People at Risk. World Bank. 2018. Accessed November 18, 2019. https://data.worldbank.org/indicator/SH.SGR.CRSK.ZS?locations=MG.

[2] Global Monitoring Report on Financial Protection in Health. World Health, World Bank Organization. 2019. Accessed November 18, 2019. https://www.who.int/healthinfo/universal_health_coverage/report/fp_gmr_2019.pdf?ua=1Get

[3] Institut National de la Statistique (INSTAT) and ICF. 2022. Madagascar Demographic and Health Survey, 2021. Antananarivo, Madagascar and Rockville, Maryland, USA: INSTAT and ICF.

[4] The World Bank Group. Maternal mortality ratio (modeled estimate, per 100,000 live births). 2017. Available at https://data.worldbank.org/indicator/SH.STA.MMRT?locations=MG, accessed on August 16th 2022.

[4] The World Bank Group. Pregnant women receiving prenatal care (%). 2021. Available at  The World Bank Group. Pregnant women receiving prenatal care (%). 2018. Available at https://data.worldbank.org/indicator/SH.STA.ANVC.ZS?locations=MG.

[6] Births attended by skilled health staff (% of total). Available at: https://data.worldbank.org/indicator/SH.STA.BRTC.ZS?locations=MG.

The problem: Less than half of births are assisted by skilled health professionals, and 15% of pregnant women receive no prenatal care. In public health centers, consultations are free, but everything else must be paid out of pocket. This is not only due to low revenue, but also to the lack of a reliable, accessible way to save money, receive co-financing for health care, and ensure funds are available when needed.

Approach: This lack led us to create the Maternal Mobile Health Wallet (MMHW) – a digital wallet designed to help women reduce maternal care costs and be financially prepared for childbirth with a professional in a health facility. With this wallet, they can save any amount at any time, receive vouchers for free medicines, ultrasounds, and emergency ambulance services, as well as subsidies from donor health programs or contributions from individuals and businesses.

Funds in the wallet can only be used for health expenses.

But innovating is not enough; the solution must also reach and be adopted by the target populations in order to have a real impact.

The approach also includes actively collecting and integrating feedback from communities (local staff, patients, health center staff, and community agents) to co-develop the intervention and technology. We also rely on scientific evidence through partnerships with a research consortium. References are listed in the “Remarks” section.

Location: This initiative is based in the Analamanga region of Madagascar, which includes the capital Antananarivo as well as peri-urban and rural areas, with a poverty rate of 45% (at $1.25/day, in purchasing power parity for 2000, 2012).

Activities:

• The mTOMADY outreach team (5), community agents (86), and midwives in health centers raise awareness among pregnant women on how to prepare financially for delivery and newborn health (up to 28 days) by depositing money for health services in the mobile wallet.
• The initiative also reinforces awareness around maternal and neonatal health (educational materials, ongoing training for community agents).
• The initiative reduces the financial burdens on families by making ANC drugs free  (iron, etc.), offering 2 free mobile ultrasounds conducted by mTOMADY midwives, and vouchers for ambulance services if needed. The ultrasound results also help guide women on how much to save (simple or complicated delivery).
• The initiative pays up to 33% of care costs, proportionate to the amount saved.
• The health centers (21) are trained to use the platform and provide care. The quality of maternal care at partner providers is assessed, followed by training and provision of equipment. This is in collaboration with the EMAD (Mobile District Support Team) of the Ministry of Health, which is also a member of the initiative’s oversight committee.
• Climate x Health:  In partnership with the Ministry of Health, TOMADY designed questionnaires (01/2025) and will conduct interviews (starting 03/2025) to assess the knowledge, attitudes, and behavior of pregnant women, health workers, and community agents regarding the link between climate and maternal health. The results will help us adapt the solution and technology to integrate climate issues into maternal health care. So, starting in February 2025, awareness and monitoring activities for pregnant women will include themes related to respiratory infections, hypertension, and waterborne diseases – conditions influenced by climate change.

Technology: The platform was developed on Ruby on Rails, building on existing mobile-technology infrastructure. Each stakeholder uses a specifically-designed interface adapted to their needs and constraints:

• Pregnant women interact with the mobile health wallet (MMHW) via a USSD menu. Anyone who doesn’t have a personal phone only needs a SIM card, that can be inserted into a device at participating healthcare providers.
• Healthcare providers use an offline-first tablet interface to validate patient records, if needed, and submit reimbursement claims. Submissions undergo semi-automated fraud detection before reimbursement, ensuring faster processing.
• Healthcare funders use a web interface to track use of the mobile health wallet and vouchers, and validate health center reimbursement claims. Added to this is a dashboard (Power BI) to monitor the use of care and wallet performance.
•  Community agents can connect to mTOMADY using any mobile phone to access their own “commission” wallet, and to submit and track their performance-based payments.

We are always seeking to innovate, and in January will launch a mobile version of the provider interface and research into AI and OCR to digitalize handwritten medical records and improve the billing system.

Sustainability: This second iteration differs from the first by adding the goal of establishing a sustainable funding pipeline for the MMHW, specifically targeting corporate donations, while continuing to pursue partnerships with organizations who might need and be willing to pay for technology adaptation. The corporate outreach strategy has been finalized and pilot-tested (mainly managed from Berlin).

The program also explores non-monetary motivation strategies, such as enhancing the tool’s added value for users.

To reduce operating costs and align with the local market/needs strategy, the organization will transfer all its technical capacity to Madagascar starting in January 2025, after several months of capacity-building led by the Berlin technical team. This transition will lower operational costs while strengthening local skills and increasing proximity to local opportunities, particularly with the government, NGOs, and other key stakeholders in the area of health.

Compliance with national regulations: mTOMADY has authorization from the Ministry of Public Health to operate its technology tools within the health system. This includes compliance with data security and protection standards, as well as continued work on interoperability with the Ministry’s information system.

• There are no tools specifically designed for health savings and accessible to unbanked populations. Moreover, this solution targets pregnant women directly and includes actions to encourage its use.Some initiatives use mobile and digital technologies to improve access to healthcare financing, generally through two approaches: electronic healthcare payments and large-scale health insurance management. For example, CarePay offers a savings wallet for middle-income groups, and OpenIMIS focuses on managing public health insurance.Our technology integrates easily with existing programs (public and private) or can operate independently.Thus, it provides added value by:
  • Filling financial gaps: mobilizing resources through individual savings and donor-funded vouchers for essential services such as medicines or ultrasounds.
  • Providing flexibility:
    • It can be adapted for other purposes, for example, in Uganda we drew on our experience to digitalize an existing community initiative by developing a mobile wallet allowing cardiovascular patients to save and automatically contribute to a bulk drug-purchase fund at the hospital level.
    • Geographic and service expansion in Madagascar: The health wallet is reaching areas beyond the capital. In Fénérive-Est, a rural area in the Analanjirofo region, the wallet now operates in 7 health centers with GSM coverage, enabling the deployment of electronic payments. This initiative covers 50% of healthcare and medicine costs for pregnant women  and children under 5 (becoming the health wallet for mothers and children).
    • Internationalization: The technical feasibility of the wallet was successfully tested in Bukavu, Democratic Republic of Congo (DRC), between August and December 2024. Initially planned only for pregnant women, the tool was opened to all users. This pilot program demonstrated the potential for expansion in other regions with similar contexts. An evaluation is underway to serve as a guide for continuation and scaling.