Tabitha Hrynick
Linda Waldman
Publication Date
July 1, 2017

“Information and communication technologies (ICTs) and mHealth innovations hold great potential to improve health systems and health outcomes while at the same time enhancing citizen engagement and accountability. Yet there has been little assessment of the impact of mHealth innovations on the ground.”

This paper reviews the experiences of seven mHealth initiatives funded by the Making All Voices Count programme, which took place in Indonesia, Nigeria, South Africa, and Tanzania. The paper discusses how these mHealth initiatives were able to support citizen engagement and accountable governance for health services in diverse contexts, and highlights some of the challenges that arose in the course of these projects. As explained in the paper, “[T]he widespread availability of ICTs and their potential for amplifying citizen voice, facilitating multi-directional communications, and real-time, large-scale data collection has generated considerable enthusiasm for ICT-enabled accountability....Despite this burgeoning field, the work on ICTs and health system accountability remains in its infancy, and it is here that this paper makes its contribution.”

The mHealth projects discussed in this paper address a range of health issues such as sexual and reproductive health (SRH), maternal health, and HIV/AIDS. The projects included are: OurHealth, eThekwini Ward AIDS Committees (WACs) and Thuthuzela Voices (all in South Africa), Mobile Mapping for Women’s Health (Tanzania), Text2Speak (Nigeria), SMS Gateway (Indonesia), and Citizen Journalism for Quality Governance of Universal Health Insurance Scheme (Indonesia). The paper draws on semi-structured interviews conducted with representatives of the seven projects, as well as project documentation held by the Making All Voices Count programme. This included proposals, progress and final reports, and, in one case, research papers produced by project personnel.

The paper presents a brief discussion of accountability in the literature, which is followed by a discussion of the projects, exploring how they understood and sought to enhance accountability through mHealth. The paper also looks at the role of technology in each project, with particular attention to the challenges related to its development, and whether/how it promoted accountable governance. It also explores what forms of citizen engagement were used by the initiatives and how this affected their scope to enhance accountable governance. As explained in the report summary, “All seven projects worked on the underlying assumption that citizen engagement and voice are central to strengthening accountability. Information gathering was seen as a prerequisite for advocating for service improvements; hence all seven projects used mobile phones or tablets to capture information on local service provision as a way of augmenting citizen voice. Five of the seven used technology to solicit people’s feedback on their experiences of service delivery, their needs and/or concerns, and then shared this information with government actors. While ICTs succeeded in providing quicker and easier ways of collecting and analysing information, they were not without their challenges. Developing apps or other technology often proved a slow process during project design, which was exacerbated by the relatively short period of funding from Making All Voices Count. Changes in government staffing (locally or nationally) also meant that some projects lost the crucial link with sympathetic and influential individuals who were willing to listen to and amplify citizen voices within government and policy circles, and take action when necessary.”

In particular, the paper explores the projects’ relationships with state actors, highlighting the importance of taking political considerations seriously. Discussions look at to what extent the social, economic, political, and power relations were considered in project design and implementation and how this shaped the ability of the seven mHealth initiatives to facilitate citizen voice and accountable governance. In summary, “Some projects had already built good working relationships with key stakeholders, including local communities, local-level officials and national-level decision-makers, and it was these projects that felt they were reasonably successful in reaching their accountability goals. Where projects lacked these linkages and relationships, it was much harder to achieve their goals."

Based on the findings, the report concludes that “there are limits to what technology can deliver in terms of augmenting citizen voice and enhancing accountability, particularly in the absence of other offline activities such as engaging citizens in meaningful ways and building good relationships with key government actors and departments.” It offers the following as key themes or lessons learned:

  • Engaging existing community-level groups or forums is more likely to lead to success in uptake of ICTs for improving health services and strengthening accountability.
  • Other stakeholders (e.g., health workers) must be involved to maximise impact and sustainability and to allay any fears about consequences of negative feedback.
  • Unless those in positions of power to change things (locally and/or nationally) are allies in the process, efforts are unlikely to meet with success.
  • Offline spaces can strongly complement online innovations to leverage individual citizens’ feedback and translate that feedback into action to improve services.

Click here [PDF] for the related Institute for Development Studies (IDS) Working Paper - “Accountability in Health Systems and the Potential of mHealth”.