Learning from Ebola: How Mobile Money Can Prevent Health Crises

By Jonathan Kourgialis, Program Officer

mSTAR/Liberia ended activities in May 2018 after enrolling 4,870 civil servants across Liberia into mobile salary payments and successfully handing the mobile salary payment program over to the government. This post is part of a summer blog series on mSTAR/Liberia: what went well and why, how we overcame challenges, and lessons for the future. We’re writing from a management angle, monitoring and evaluation angle, a communications angle and a digital financial services angle. 

The Ebola outbreak hit Liberia hard. From 2014 to 2016, there were 10,678 cases and 4,810 lives claimed. Weakened from a protracted civil war, Liberia’s healthcare system struggled to keep up with the epidemic. Failures in the health system created severe consequences on the ground. One of those failures, with dire ramifications, revolved around payments.

As the Ebola outbreak raged, the Government of Liberia and partners introduced new financial incentives to compensate frontline health workers for the severe risks encountered when combatting the disease. However, the government and its partners were not able to transfer these new payments reliably to frontline staff, who were often placed in remote areas with limited access to banks. The government and its partners relied on cash, which was disbursed throughout Liberia by “pay teams,” who drove cash to rural towns. A pile of factors including quarantines, poor road and banking infrastructure amidst the ongoing crisis, low liquidity, and fear of the disease made pay teams inefficient and slow. Delays in the disbursement of payments contributed to health worker strikes, further crippling response efforts. The difficulties in making payments and the ensuing health workers’ discontent highlighted the critical role that efficient payment processes play in mobilizing health workers during a health emergency.

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A clinic in Lofa County, Liberia, one of the first counties in Liberia hit with Ebola.

To avoid the recurrence of a payment breakdown like this, mSTAR worked with the Government of Liberia’s Ministry of Health (MOH) to build a set of standard operating procedures (SOPs) for payments to health workers through mobile money. When working efficiently and smoothly, mobile money has proven to make a significant impact on health crisis outcomes. At the height of the Ebola crisis in Sierra Leone, for example, the digitization of salary payments is estimated to have saved 2,000 lives in Sierra Leone by eliminating strikes by unpaid response workers. This is estimated to have saved almost $11 million in security and other costs related to moving cash. The SOPs mSTAR created for the MOH ensure the MOH’s payment functions will be strong enough that if a future emergency occurred, whether it was Ebola or another epidemic, health workers at the frontline would be compensated for their contributions and willing to stay on the job.

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Navigating rural Liberia’s roads.

To create the SOPs, mSTAR first mapped MOH’s complicated payment types, systems, and streams. This included salaries paid to MOH employees through traditional government payment systems, incentive payments to contract workers paid directly by the MOH, and allowances to health workers paid directly by the MOH, each differentiated by funding stream. MOH staff are paid through funds from the GOL and funds from donors, so systems and streams are unconnected and not interoperable. Taking this into account, and utilizing mSTAR’s data systems, interoperability and mobile money expertise, mSTAR and the MOH came up with the three key tasks for the MOH to complete in the case of a health emergency:

  1. Coordinate data exchanges of staff and payment information between the MOH’s unconnected databases;
  2. Register health workers for mobile money payments within GOL systems and with the mobile money service providers (if necessary); and
  3. Disburse mobile money payments across the various payment streams.

The SOPs outline how to accomplish these tasks and graphical flows and steps breaking down each. This included recommendations on how mHero, a two-way mobile phone-based communication system, can efficiently register staff for mobile money payments and alert the MOH to mobile payment issues.

mSTAR built in recommended safeguards for the success of the SOPs such as the creation of a mobile money payments emergency committee to oversee the implementation of the SOPs during an emergency and the establishment of mobile money payment accounts specifically for MOH payment streams prior to an emergency.

While theses SOPs are tailored to the Liberian MOH’s systems, the collaborative effort to develop SOPs for the scaling of mobile money payments for health workers, or any type of emergency responder, is replicable in other contexts. It is a necessary endeavor for governments of any country vulnerable to health or natural disaster emergencies. As was seen in Liberia during Ebola, making sure that those risking their lives to save others are compensated in a timely and efficient manner is vitally important to overall emergency response efforts and is worth investing in prior to an emergency. While we hope that the Liberian MOH does not have to use these SOPs in the future, they are now prepared to pay frontline staff if the need arises again. We recommend that other governments prepare themselves in a similar manner where possible.

Jonathan Kourgialis is a Program Officer at FHI 360. He has focused on mSTAR’s work in Liberia, building and strengthening the Government of Liberia’s mobile money salary payment systems. Jonathan currently works on civil society and peace building projects.

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