title: Sustainable Cost Models for mHealth at Scale: Modeling Program Data from m4RH Tanzania.
abstract: BACKGROUND
  There is increasing evidence that mobile phone health interventions ("mHealth") can improve health behaviors and outcomes and are critically important in low-resource, low-access settings. However, the majority of mHealth programs in developing countries fail to reach scale. One reason may be the challenge of developing financially sustainable programs. The goal of this paper is to explore strategies for mHealth program sustainability and develop cost-recovery models for program implementers using 2014 operational program data from Mobile for Reproductive Health (m4RH), a national text-message (SMS) based health communication service in Tanzania.
  
  
  METHODS
  We delineated 2014 m4RH program costs and considered three strategies for cost-recovery for the m4RH program: user pay-for-service, SMS cost reduction, and strategic partnerships. These inputs were used to develop four different cost-recovery scenarios. The four scenarios leveraged strategic partnerships to reduce per-SMS program costs and create per-SMS program revenue and varied the structure for user financial contribution. Finally, we conducted break-even and uncertainty analyses to evaluate the costs and revenues of these models at the 2014 user volume (125,320) and at any possible break-even volume.
  
  
  RESULTS
  In three of four scenarios, costs exceeded revenue by $94,596, $34,443, and $84,571 at the 2014 user volume. However, these costs represented large reductions (54%, 83%, and 58%, respectively) from the 2014 program cost of $203,475. Scenario four, in which the lowest per-SMS rate ($0.01 per SMS) was negotiated and users paid for all m4RH SMS sent or received, achieved a $5,660 profit at the 2014 user volume. A Monte Carlo uncertainty analysis demonstrated that break-even points were driven by user volume rather than variations in program costs.
  
  
  CONCLUSIONS
  These results reveal that breaking even was only probable when all SMS costs were transferred to users and the lowest per-SMS cost was negotiated with telecom partners. While this strategy was sustainable for the implementer, a central concern is that health information may not reach those who are too poor to pay, limiting the program's reach and impact. Incorporating strategies presented here may make mHealth programs more appealing to funders and investors but need further consideration to balance sustainability, scale, and impact.
authors.affiliation: FHI 360, Durham, North Carolina, United States of America.|Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Emily R
authors.initials: ER
authors.lastname: Mangone
authors.affiliation: FHI 360, Durham, North Carolina, United States of America.|Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Smisha
authors.initials: S
authors.lastname: Agarwal
authors.affiliation: FHI 360, Durham, North Carolina, United States of America.|School of Nursing and Health Professions, University of San Francisco, San Francisco, California, United States of America.
authors.forename: Kelly
authors.initials: K
authors.lastname: L'Engle
authors.affiliation: FHI 360, Durham, North Carolina, United States of America.|Kenan-Flagler School of Business, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America.
authors.forename: Christine
authors.initials: C
authors.lastname: Lasway
authors.affiliation: FHI 360, Durham, North Carolina, United States of America.
authors.forename: Trinity
authors.initials: T
authors.lastname: Zan
authors.affiliation: Text to Change, Amsterdam, The Netherlands.
authors.forename: Hajo
authors.initials: H
authors.lastname: van Beijma
authors.affiliation: Johns Hopkins Center for Communication Programs, Baltimore, Maryland, United States of America.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Orkis
authors.affiliation: Johns Hopkins Center for Communication Programs, Baltimore, Maryland, United States of America.
authors.forename: Robert
authors.initials: R
authors.lastname: Karam
mesh_terms: D000328:Adult; D017280:Condoms / Q000706:statistics & numerical data; D003268:Contraception Behavior / Q000523:psychology; D003270:Contraceptive Agents / Q000600:supply & distribution; D003362:Cost-Benefit Analysis; D005193:Family Planning Services / Q000379:methods* / Q000458:organization & administration; D005260:Female; D006801:Humans; D008297:Male; D018803:Models, Economic; D009010:Monte Carlo Method; D013636:Tanzania; D017216:Telemedicine / Q000191:economics* / Q000706:statistics & numerical data; D060145:Text Messaging / Q000191:economics* / Q000706:statistics & numerical data
chemical_list: D003270:Contraceptive Agents
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