Is Fee-for-Service Better Than Free for Global Health and Development?

Mhealth innovator and Sproxil.com's CEO Ashifi Gogo has asserted that even in low income countries, people will pay for value. As evidence he points to countries such as Nigeria where it is common for people to have not just one cell phone, but several: One for each carrier so they can juggle their device depending on which carrier has the best service in their location. Phones aren't free, but even folks living on tiny incomes pay for them because the technology provides value that is meaningful to their lives.

Speaking with Ashifi during a presentation at Dartmouth College, the idea soon emerged that when end users pay for services, the service provider is accountable to those users. If, on the other hand, the WHO or other funder is paying an NGO to provide services to a population, accountability for performance is likely to be based on artificial metrics dreamed up by payers who are not receiving the service. A fee-for-service model based on users paying for a service also enhances financial sustainability for service providers as well, who are now reliant on market forces rather than grant-funding cycles.

Now Datadyne has made a slide deck available that makes this case much more eloquently. It is also from the proverbial horses mouth, since it comes from experts in the field, and not writers such as this one expounding from their desks. The slide below is part of a much larger deck expounding on the strengths of mhealth, and the Datadyne approach, available here.

Is Big and Free Better?

If, on the other hand, you believe that services should be free to users, then a compelling case could be made for philanthropic efforts by high tech for-profits with deep pockets such as Google. The New York Times provides an interesting perspective this morning on Google's failure to have the impact on philanthropy that the gurus of search had hoped for. Specifically the story is about Google.org (referred to simply as DotOrg), the philanthropic arm of everyone's favorite search megalith that was supposed to reinvent philanthropy. Some good works definitely emerged, such as InSTEDD. But overall, the story asserts, DotOrg has not lived up to its promise.

This is an instructive case study that may be applicable to other efforts. According to the NYT story, Google was primarily interested in good works that could be performed using complex technological solutions. They eschewed the world of text-messaging, for example, because it was just too simple. Not sufficient a challenge for Google's superior engineering prowess. Unfortunately for Google, organizations like Datadyne are showing us that often the most effective solutions are precisely these relatively low tech, high value communication tools. Solutions that are web-based, multiplatform, require little training, highly reliable and scalable are far easier to implement than more complex solutions.

Further, it appears that Google had technology and went searching for an application. The more prudent approach is precisely the opposite: Find a compelling problem that you understand, explore solutions, then see what tools, high-tech or not, that can help you reach your objective in the real world context that the problem exists in.

Is this an argument for the superiority of smaller niche organizations that are mission driven? Isn't it more important to really "own" your problem, work with end users and effected populations to understand their context, then seek out technological or other solutions?

Is the world of the do-gooder giants such as Google, WHO, USAID, etc. the model of the past, while the future will provide an "app-store" approach: Smaller specialized units that do one thing very well, allowing end users to choose which tools or partners are best suited for their specific environment and challenges?