A number of drivers enable a project’s sustainability, many of which are discussed in the Scale-up section of this Guide. These might include working closely with MOH and private sector partners from the beginning of the process to build buy-in from those who can provide financial, human, and technological resources in the long term.
In addition, tracking up-front and ongoing program costs and estimating scale-up costs is essential for both demonstrating potential cost savings and for securing government and private sector investments in mHealth. Understand total cost of ownership (TCO) of the project—all of the direct and indirect costs, including social cost and opportunity cost, of the mHealth application. A solid understanding of TCO can inform decisions about partnerships, subsidization, and other financing options. Dimagi has developed a helpful TCO Model, included in this Guide, for use by CommCare users. It can be adapted for use by other mHealth programs as well.
Seemingly obvious decisions made early on—like which mobile device is used—have an enormous impact on the program’s uptake, cost structure, and continued success. These are examples of potential drivers of mHealth’s scalability and sustainability that are established early on in the project:
- Is texting more expensive than the Internet in the program setting?
- Do users have reliable mobile phone reception?
- Is there a local “help desk” or support system in place for troubleshooting and maintenance of software and hardware, and how do the costs for operating this help desk change with user volume?
- Would nurturing local technology partners lead to long-term stability by fostering local ownership and capacity to monitor and maintain the technology over time?
- Is operating an open source platform, a purchased platform, a licensed proprietary platform, or a customized platform more cost effective in the long term?
Other drivers that enhance sustainability include the ability to be honest about what does not work, the capacity to learn from these failures, and the flexibility to adapt the mHealth program accordingly. A strong monitoring and evaluation (M&E) system will not only facilitate documentation of the successes and failures of the process, but it will also help the implementing team articulate the value and benefits of the program to a range of stakeholders. If the mHealth program is shown to be cost-effective and to have a positive impact on health and other outcomes, the case will be made for continued funding and scale-up.