How Do We Cure mHealth Pilotitis? Critical Lessons in Reaching Scale

Successful pilots are in abundance, but most of the sector has been slow to reach scale. This series of posts offers nine different perspectives from leaders in mHealth.

mHealth has the potential to transform healthcare, particularly for the hardest-to-reach women and children around the world. The debate about exactly how, when, and in what form is alive and well. Successful pilots are in abundance, but most of the sector has been slow to reach scale. In short, the sector has a case of mHealth Pilotitis. In the first debate of a series on mobile health, the Skoll World Forum on Social Entrepreneurship partnered with Johnson & Johnson and Stanford Social Innovation Review to surface important lessons and learning from some of the world’s leading organizations who have taken mHealth services to scale. This debate will also set the stage for a larger discussion on mobile for development at this year’s Skoll World Forum in Oxford, UK.

Our country, South Africa, has a split personality. There is a tug-of-war constantly raging between good and evil.

The “evil twin” is responsible for a continuous surge of the HIV pandemic. South Africa is still the country with the largest HIV-positive population in the world: More than 5.4 million people are infected with HIV, with the overall prevalence for adults aged 15-49 years sitting at between 17-18 percent. In some of the worst affected provinces, more than 40 percent of all pregnant women accessing antenatal clinics are HIV-positive. In 2010, it was estimated that 1,783,000 people (including children) were in need of antiretroviral drugs.

But let’s not forget the “good twin.” The country is experiencing unprecedented levels of mobile penetration: 90 percent of South Africans have access to a mobile phone and 10 percent have access to more than one. More and more people are also accessing the Internet exclusively via their mobile phones, and a World Wide Worx report in 2011 estimated that 6 million South Africans have mobile Internet access. This brings an amazing opportunity to reach people with mobile content that is far more engaging and entertaining than one-way SMS.

In 2009, Praekelt Foundation decided that something needed to be done to bring together the good and the evil—a product that would leverage the opportunity that mobile penetration, and mobile Internet penetration in particular, brings.

Lesson 1: Start with what is there, and try and harness that instead of reinventing the wheel.

We started by looking at two of the most popular existing mobile Internet sites in the country, where we knew the country’s youth was already very active. These platforms happened to be the free-for-customer service that the two major network operators in South Africa had: Vodafone Live is the Vodacom-version, and MTN Play is the MTN version. Collectively, these two platforms reached more than 10 million unique users per month, delivering content such as sports news, celebrity gossip, and special offers on ringtones. We thought, “If this is where sexually active youth hang out on mobile, surely these leading network operators will have some form of relevant sexual and reproductive health info for users to consume?” We were wrong. When searching for the words “HIV” or “AIDS” on these two giant mobile social networks, the results that came back were shocking: zero, nil, nothing…

This sparked an idea that something should be done to harness this existing audience—in a space where they were comfortable but where there wasn’t information addressing the sexual and reproductive health issues they faced. And so, YoungAfricaLive was born: a mobile social network around love, sex, and relationships in the time of HIV/AIDS.

Lesson 2: Plan and build your solution for scale from the start.

We sold the idea—and the fact that we would fund all development, maintenance, moderation, and ongoing content management costs for a year—to leading operator Vodacom South Africa. As excited as we were (and as glamorous as it would sound to claim that we knew from the start that this platform would “fly”), we did not really think it was going to do as well as it did. We built the technology with the modest target of reaching 10,000 people in year one. When a year passed and we had 250,000 unique users, we (and the technology) were in trouble. Our disbelief in the potential of our idea ultimately lead to many engineering-tears, as we had to rebuild much of the original technical infrastructure.

Lesson 3: One-directional messaging by itself will never create behavior change.

So what made this site different? Why has it grown to close to 1.4 million unique users and scaled to two additional countries, Tanzania and Kenya? Well, once we fixed the technology, we kept reminding ourselves of the vision: to deliver engaging, entertaining, and provocative content, not to take the traditional top-down, preachy approach to health care and behavior change communication that starts with “do’s and don'ts” and never asks “why.” Granted, we are very lucky in South Africa—we have a mature and intelligent mobile user base, but this trend is expanding very quickly to the rest of the continent, and the days of spamming people with unsolicited texts that say, “Stop having multiple concurrent partnerships, you can get AIDS,” is long gone.

In summary, solutions that are 1) hardware-dependant, 2) do not analyze existing user behavior, and 3) do not engage the user in a two-way conversation, will fail—and they will continue the vicious cycle of pilotitis, in mHealth.