This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.
Mobile health (mHealth) approaches offer potentially affordable ways to support the care of HIV-infected patients in overstretched health care systems. However, only few studies have analyzed the costs associated with mHealth solutions for HIV care.
The aim of this study was to estimate the total incremental costs and incremental cost per beneficiary of an interactive SMS text messaging support intervention within a clinical trial.
The Mobile WAChX trial (NCT02400671) evaluates an interactive semiautomated SMS text messaging intervention to improve adherence to antiretroviral therapy and retention in care among peripartum women infected with HIV in Kenya to reduce the mother-to-child transmission of HIV. Women were randomized to receive one-way versus two-way SMS text messages. Messages were sent weekly, and these messages included motivational and educational content and visit reminders; two-way messaging enabled prompt consultation with the nurse as needed. Microcosting methods were used to collect resource-use data related to implementing the Mobile WAChX SMS text messaging intervention. At 2 sites (Nairobi and Western Kenya), we conducted semistructured interviews with health personnel to identify startup and recurrent activities by obtaining information on the personnel, supplies, and equipment. Data on expenditures and prices from project expense reports, administrative records, and published government salary data were included to estimate the total incremental costs. Using a public provider perspective, we estimated incremental unit costs per beneficiary and per contact during 2017.
The weighted average annual incremental costs for the two-way SMS text messaging group were US $3725 per facility, US $62 per beneficiary, and US $0.85 per contact to reach 115 beneficiaries. For the one-way SMS text messaging group, the weighted average annual incremental costs were US $2542 per facility, US $41 per beneficiary, and US $0.66 per contact to reach 117 beneficiaries. The largest cost shares were for the personnel: 48.2% (US $1794/US $3725) in two-way and 32.4% (US $825/US $2542) in one-way SMS text messaging groups. Costs associated with software development and communication accounted for 29.9% (US $1872/US $6267) of the costs in both intervention arms (US $1042 vs US $830, respectively).
Cost information for budgeting and financial planning is relevant for implementing mHealth interventions in national health plans. Given the proportion of costs related to systems development, it is likely that costs per beneficiary will decline with the scale-up of the interventions.
In 2017, an estimated 180,000 children became infected with HIV [
Use of SMS text messaging communication is a promising approach for improving ART adherence in peripartum women. Several studies and meta-analyses have shown that regularly delivered SMS text messages can improve ART adherence and retention in care outside of pregnancy [
While SMS text messaging interventions are supported by policymakers to improve ART adherence, little is known about the value for money of such technologies. In a global survey conducted by the World Health Organization, lack of evidence on economic evaluation was identified as a major barrier to implementation of mHealth solutions in resource-constrained settings [
The Mobile WAChX trial (NCT02400671) evaluates one-way versus two-way communication versions of a semiautomated SMS text messaging intervention to improve ART adherence and retention in care in peripartum women at 6 facilities in Nairobi and Western Kenya. One-way SMS text messaging consisted of weekly automated motivational and educational SMS text messages and clinic visit reminders. Participants randomized to the two-way SMS text messaging arm additionally had the capability of communicating with a nurse through the SMS text messaging system. Participants randomized to the control arm received no SMS text messages (standard of care).
The study procedures for the randomized controlled trial are described in detail in a previous paper [
We used an activity-based ingredients approach to identify all activities undertaken to deliver the Mobile WAChX project. Activities included intervention planning, project partner sensitization, staff training, system development, and delivery of SMS text messages. After identifying all intervention-related activities, we quantified the resources used and valued these by using the best available data on salaries and commodity prices. We used a combination of data collection methods to collect primary resource-use and cost data, including obtaining prices from project expense reports, administrative records, and published government salaries, and conducting semistructured interviews with facility-based health workers and project administrators. Time-motion studies were conducted in both facilities to record staff time spent on intervention activities (eg, recruiting, screening, and registering participants, sending SMS text messages to users). Data collection was conducted between October 2017 and January 2018.
We organized cost data into one-time fixed costs and variable costs (
Activity and input cost categories and description.
Cost categories, subcategories | Description | |||
|
||||
|
Planning/microplanning | Planning activities for project implementation during the start-up period. | ||
|
System development | Resources and inputs to design the Mobile WAChX system and activities to collaborate with a local mobile technology company to obtain SMS text messaging packages for participants. | ||
|
Initial training | Expenses for conducting 2 training workshops during the start-up period for all project staff, including development of relevant training materials. | ||
|
Sensitization | Stakeholder workshops and activities at facility level. | ||
|
||||
|
|
Value of personnel time | ||
|
|
Service delivery | Activities for delivering the Mobile WAChX intervention, such as recruiting participants, screening and registering participants, and sending SMS text messages to users. | |
|
|
Personnel supervision and coordination | Meetings to supervise staff and coordinate and monitor implementation of activities at all sites. | |
|
Communication | Resources and inputs to deliver SMS text messages to participants, including data bundles for internet, an online platform for hosting the Mobile WAChX system, airtime cost for phone calls, and SMS text messaging cost. | ||
|
Equipment | Investments that last longer than 1 year, including mobile phones, laptops, and furniture. | ||
|
Overhead | Clinic collaboration fee and indirect costs. |
We developed an Excel-based model (Microsoft Excel version 15.28, Redmond) to estimate total incremental costs and incremental unit costs. The sum of all the activity cost categories reflects all the resources required to deliver the Mobile WAChX intervention. All activities were mutually exclusive, thereby avoiding double counting. We used project output data on the number of beneficiaries per month per facility and number of messages sent by the system and nurses per month. These data were collected as part of the Mobile WAChX monitoring and evaluation strategy. We first estimated the total incremental cost for each facility to deliver the Mobile WAChX intervention and divided this by the number of women receiving the intervention to determine the cost per beneficiary. We also estimated the cost per contact, defined as the total cost divided by the total number of messages sent to participants during 2017, for each facility. We analyzed the costs of one-way and two-way SMS text messaging interventions separately. We also estimated the average weighted costs for both facilities by using project output data on the number of beneficiaries per facility.
In addition to estimating intervention costs, we estimated 3 scenarios. The first scenario was to estimate the cost when the two-way Mobile WAChX intervention was implemented in all 6 facilities in this project. In this scenario, the same intervention and personnel were applied to every facility where they shared most start-up costs from system development, cost of system-hosting platform, as well as personnel supervision and coordination costs. The number of participants was the total number of participants receiving intervention in all 6 sites. The second scenario was to estimate a more typical scenario where the MOH of Kenya supports these activities after the pilot phase. We applied the MOH salary scale to service delivery health workers in the current project. Finally, we calculated the incremental cost effectiveness ratios (ICERs) of comparing two-way SMS text messages to no intervention in the 2 facilities. Due to unavailable efficacy data in the Mobile WAChX trial, we used clinical outcome results from a similar randomized controlled trial, which assessed whether two-way SMS text messaging interventions improved plasma HIV-1 viral RNA load suppression at 12 months in 3 clinics in Kenya [
Among the 152 HIV-infected women in facility A who received the Mobile WAChX intervention, 76 (50.0%) were randomized to the two-way SMS text messaging group and the other 76 (50.0%) were randomized to the one-way SMS text messaging group. A total of 80 women participated in facility B, of whom 39 were randomized to the two-way SMS text messaging intervention group and 41 were randomized to the one-way SMS text messaging intervention group (
Summary of the beneficiaries and the total points of contact by health facility in 2017.
Health facility | Two-way SMS text messaging intervention | One-way SMS text messaging intervention | ||||
Beneficiaries, n=115, n (%) | Total automated SMS text messages, n=6924, n (%) | Total nurse SMS text messages, n=1386, n (%) | Beneficiaries, n=117, n (%) | Total automated SMS text messages, n=7318, n (%) | Total nurse SMS text messages, n=0, n (%) | |
Facility A (Urban health center) | 76 (66.1) | 4425 (63.9) | 993 (71.6) | 76 (65.0) | 4604 (62.9) | 0 (0) |
Facility B (Rural subcounty hospital) | 39 (33.9) | 2499 (36.1) | 393 (28.4) | 41 (35.0) | 2714 (37.1) | 0 (0) |
Weighted average total annual incremental costs and unit costs for beneficiaries.
Intervention group | Total costs and unit costs (USD) | ||
Total annual cost | Cost per beneficiary | Cost per contact | |
Two-way SMS text messaging | $3725 | $62 | $0.85 |
One-way SMS text messaging | $2542 | $41 | $0.66 |
Total annual incremental costs by fixed and variable costs.
Cost per beneficiary by fixed and variable costs.
Cost per contact by fixed and variable costs.
Cost shares by input categories for all costs.
Cost shares for variable input categories only.
Cost estimates in the 2 scenarios compared to the baseline scenario estimates reflected in
The ICERs of comparing two-way SMS text messaging versus no intervention in the 2 facilities and the input parameters are summarized in
This is the first study to estimate the costs of an mHealth intervention to promote prevention of MTCT (PMTCT)-ART adherence among peripartum women. Previous studies have shown that SMS text messaging interventions have a positive impact on ART adherence and maternal and neonatal health outcomes in low-and-middle income settings [
Only a few studies have provided the cost estimates of mHealth interventions, including SMS text messaging interventions, in low-income countries. The MAMA program was initiated in 2012 in South Africa to enhance the utilization of MCH services among pregnant and postpartum women by sending registered users SMS text messages twice per week. The estimated program costs over 5 years was US $1.2 million, 17% of which was incurred by costs on program development and 31% on SMS text message delivery costs [
Personnel costs accounted for the largest share of the total costs in our project (US $1794/US $3725, 48.2% in two-way and US $825/US $2542, 32.4% in one-way SMS text messaging intervention groups), followed by software development of the SMS text messaging management system and communication costs. Our results are consistent with findings from previous studies that labor costs for delivering other SMS text messaging interventions were the main drivers of the total program costs, followed by SMS text messaging program development [
Our findings provide important costing information for budgeting and financial planning for implementing mHealth interventions to achieve UHC in Kenya. mHealth interventions, as a part of the broader eHealth interventions, may become transformational strategies in addressing public health challenges and striving toward UHC in Kenya. This need has also been reaffirmed by the Kenya’s Health Policy (2014-2030), National eHealth Policy (2016-2030), Information Technology Master Plan, and the Health Bill [
To our knowledge, this is the first study to estimate the costs of an mHealth intervention targeting PMTCT and MCH in Kenya. Our study has limitations. First, we did not include the labor costs of international collaborators who contributed to the program design and installation and other start-up activities such as work planning meetings. Second, we had to make assumptions about the allocation of communication costs to research and implementation activities, which may influence the total implementation costs. Third, we did not allocate equipment costs to research activities, which may lead to overestimation of the total implementation costs. Equipment such as laptops and phones were mainly used for service delivery, and we do not have detailed information on how much equipment was used to support the research-related activities. Therefore, the evidence should be used with the consideration that after taking into account the equipment costs allocated to research activities, the total incremental cost of implementing SMS text messaging interventions would be lower than the estimates in this study.
In conclusion, this study fills the knowledge gap on the costs of mHealth approaches for improving PMTCT-ART adherence among pregnant women in Kenya. When operating at scale, there may be opportunities to reduce the costs per beneficiary. As the Mobile WAChX intervention is scaled up, further research is needed to understand the economic impact from different perspectives, including cost-utility analyses to assess the value for money compared with alternative approaches to improve women’s clinical outcomes and adherence to HIV treatment as part of PMTCT services.
Annual incremental costs and cost per beneficiary by activity at facility A.
Annual incremental costs and cost per beneficiary by activity at facility B.
Weighted average annual incremental costs and cost per beneficiary by activity at facility A and facility B.
Sensitivity and scenario analysis: total annual costs and unit costs for beneficiaries.
Incremental cost-effectiveness ratios of two-way SMS versus no intervention in viral load suppression and adherence.
Input parameters for incremental cost-effectiveness ratios of two-way SMS versus no intervention in viral load suppression and adherence.
antiretroviral therapy
Chipatala cha pa foni
incremental cost effectiveness ratio
maternal and child health
mobile health
Ministry of Health
mother-to-child transmission
prevention of mother-to-child transmission
Reducing Maternal and Newborn Deaths
universal health coverage
We would like to acknowledge the project staff and health care workers who participated in the data collection and supported us during this activity. This research received administrative support and mentorship from the Global Center for Integrated Health of Women, Adolescents and Children (Global WACh), which is jointly supported by the Departments of Global Health, Pediatrics, and Obstetrics and Gynecology. This study was supported by the following grants: National Institute of Allergy and Infectious Diseases (P30AI027757; Principal Investigator: Dr. Jared Baeten and K01AI116298; Principal Investigator: Dr. Alison Drake). Support was also received from the National Institute of Child Health and Human Development (R01HD080460; Principal Investigator: Dr. Grace John-Stewart and K24HD054314; Principal Investigator: Dr. Grace John-Stewart).
YC, CL, GJS, KR, and JU contributed to the study design. YC conducted primary data collection and data analyses. JK and DM coordinated data collection in the field. YC, CL, and KR wrote and revised the initial drafts of the manuscript. All authors contributed to manuscript revisions and interpretation of study results.
None declared.