This document discusses how mobile phones can help achieve the Millennium Development Goals (MDGs) by reaching remote, "last mile" communities. It notes that 50 countries are not on track to meet the MDGs, especially in Africa. The author believes current strategies have limitations and that rethinking assumptions is needed. Mobile phones can play several roles, including substituting for transportation, providing on-demand advice and education, cutting delays in information sharing, and enabling citizen monitoring and accountability. The author outlines a birth registration partnership in Uganda between the government and a mobile carrier that leverages phones to scale up registration at low cost. He poses questions for private sector actors on how they can further support development goals through technology and partnerships

1. Keeping the Promise of Achieving MDGs– Reaching the Last Mile
Dr Sharad Sapra, Unicef, June 6th 2011
Based on current progress, it is estimated that almost 50 countries of the world will not achieve the
MDGs by 2015. Most of them are in the area of child and maternal mortality; and most of them are
in Africa. Sadly it could be another target left unachieved and another promise broken. But that
need not be so.
The science available to us today is sufficient to help us achieve the targets. The political will is
expressed repeatedly. Delivery systems have been put in place and yet after the initial rapid pace of
progress, movement towards the last mile is slow. I believe that the strategies that have been put in
place have brought us to the point where we are today – very close to being successful but not yet
all the way there.. However, I also believe that these strategies have delivered the results that they
could and doing more of the same will not take us towards achieving the targets.
I believe some of the basic assumptions on which we based our programme strategies have changed
and therefore need to be revisited. For example – in the water sector, we worked on the assumption
that safe water is not available. We invested in drilling bore holes, putting in place piped water
schemes as close to the population as possible. While in Urban and peri urban areas in many cases
we were able to put the water point right into the house, in many areas people still have to walk
some distance to collect water. Even when 95% of water sources provide clean drinking water, over
90% of the water at the consumption point (household) is contaminated. As a result, the simplest of
all diseases – diarrhoea, is still rampant and diarrhoeal deaths are still one of the top 3 or 4 killers of
children in Africa. The question then is should the focus not also be to put at water transportation
and storage and purification at the point of consumption, regardless of the source.
I also believe that the last mile challenges we face today are not the challenges that can be
addressed by the sectors that face the challenges. The answers lie in other sectors. For instance, in
the case of immunization, the challenge is not really the vaccine or the technique of injecting or
administering the dose of the vaccine or effectiveness of the vaccine per se. The challenge is usually
that of getting the vaccine to the right place at the right time – a logistics issue. The medical
profession as we all know are trained in medical sciences, logistics not being one of the subjects. But
private sector companies, courier companies, transport companies, Coke and Pepsi, the Walmarts,
game, pick and pay and Woolworths of this world are experts in logistics and distribution systems.
Unfortunately they are not a part of or linked to the Health Ministry.
Many efficiency gains within the current system can be achieved that can bring us much closer to
achieving the MDGs by just focussing on removing the bottlenecks and delays in the delivery
systems.
That brings me to this wonderful industry sector of communication – the Mobile Phones and the role
that they can play in helping Africa reach its development objectives.
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2. With over 500 million cell phone subscribers by September 2010 and a possible 850 million
subscribers by 2015, Africa is the fastest growing cell phone market in the world. In fact Africa today
has more cell phone subscriptions than US and Canada put together. In Uganda, 70-90% of volunteer
community health care workers already own basic mobile phones. Powerful tools are already in the
hands of those best suited to address last mile challenges.
People often see a cell phone as a talking device. I see it in many different ways –
1. As a substitute for transport – many things can be done over the phone that earlier required
the use of transport e.g. cash transfers
2. As a personal advisor/ educator – with appropriate services, a cell phone can become a tool
where people can get advice, information and guidance in total privacy and on demand –
already people are getting reminders for their next medical check up or taking their next
dose of medicine and even getting private on demand English language courses. Also
imagine a health worker in a remote area entering signs and symptom information about
cases and immediately getting feedback on possible diagnosis, treatment and referral.
3. As a digital bridge between those who have fibre optic and other cable based internet
connections and those who don’t – so we do not wait for the cables to reach before people
have access to information and who know maybe the technology will advance in a way that
no cables would be needed in the future in many of our African countries;
4. As key tools that can cut down delays between the time the information is acquired and
acted upon. Significant investments have been made by countries in designing management
information systems. To me these systems focus too much on managing information. Often
they are data heavy and replicate the sequential process of moving data as was done with
paper from one level to the next. As a result breakdowns are common and the system is only
as strong as the weakest link. With cell phones, I believe we can work in developing systems
that are not designed around Managing Information but systems that provide Information
for Management. With cell phones the 4 or 5 bits of actionable and critical information can
be sent to the server from where all the processing is done and feedback and aggregated
data for action sent via sms or ussd to all levels almost instantly. Drug stock outs, teacher
and student absenteeism are some examples. Birth registration, registration of vulnerable
children and households and direct cash transfers are some of the examples that illustrate
the point.
5. I also see the power of the cell phones in accountability, transparency and citizenship.
Imagine an SMS being sent to hundreds and thousands of pre-enrolled subscribers asking if
the water point in their village is working or not, or if the teacher is there in the classroom or
not, or if the health center has a particular marker drug or not and getting instant feedback
that gives the picture of the whole country in a very short time and at a very low cost. By
doing this you are making the community aware of their entitlement, engaging them in
monitoring their entitlements and giving them feedback as to what action can they take to
address the problem. The aggregated information can also be shared with local leadership at
various levels and a national public discourse can be undertaken to act on the problem.
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3. Suddenly, with minor investments, the voice of the people is influencing national action and
policy letting people know that their participation and their VOICE Matters.
6. As a major nano enterprise where hundreds of unemployed young people can be engaged in
reporting, data entry, charging cell phones, working in small groups as cash transfer centres
etc.
I can go on and on and these are not dreams or just flights of imagination but are currently being
rolled out in many countries in the region.
In Uganda, we are working with the Government, and partners like WHO, Find Diagnostics, and
MVP, to roll out a complete mHealth package that spans the continuum of care. For UNICEF, the
focus is not on the technology or the hardware – which is the easiest part to address - but on
building the capacity and skills of the people who will be asked to use these new tools and respond
to new types of information.
The health package being developed in Uganda covers everything from creating demand for services
and providing people with information so they can make informed choices, empowering community
health workers with tools that allow them to send reports – such as disease outbreaks at point of
contact, and providing District Health Teams and Health Facilities - with information to better
manage their resources. Separately, we only get a small part of the picture – for example we might
know we have an increase in community outbreaks of malaria, but have no idea if they can access
drugs at their local community. But when the entire continuum of care is addressed, we can pinpoint
exactly where in the chain the breakdowns are occurring and immediately address them.
However, one of the challenges we are seeing is a growing fragmentation of the health sector as
more and more development actors pilot ICT initiatives. In Uganda, there are over 60+ separate
projects by last count. Many of them duplicate existing efforts, some of them do not follow general
best practices or rely on expensive, unscalable hardware, and a large number of them fail to ensure
their data is actually integrated into the existing government health information systems. Most of
these initiatives operate outside the knowledge of the Ministry of Health. This is posing a serious
challenge to designing national systems meant to scale. There is a desperate need for national
standards, consensus on platforms and technology, and collaboration between agencies and
development actors.
That brings me to the final point of this conversation – the role of Private Sector and the cell phone
service and hardware providers. Many of you are involved in Philanthropy, and that is good.
However, I am more interested in seeing how business models can be worked out where corporate
social responsibility and core business models of the cell phone industry can come together. Because
that is what is needed to have a strong and long-term sustainable relationship between national
development objectives and the core business objectives. Also investing in poor makes good
business sense as they are the largest proportion of the population and their well being is good for
your business.
I want to mention an exciting birth registration initiative in Uganda that has paired Uganda
Telecoms, one of the biggest mobile phone operators in the country, with the Ugandan Registration
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4. Services Bureau. Early on in the process, UNICEF gathered all the key stakeholders – including
government, NGO and academia, working on similar initiatives – to get broad consensus and buy-in,
and avoid duplication.
Uganda Telecoms then developed, at an estimated cost of $50,000 in programming time, a simple
USSD and online / off-line application to enable duty bearers to register new births. Certificates are
printed and available in real-time, and the national offices can access up-to-the-second records from
anywhere in the country.
Now, what is important here is understanding why Uganda Telecom is engaging in this initiative.
From the beginning, UNICEF was not interested in a Corporate Social Responsibility project. We
wanted this system to make good business sense for the Uganda Telecom.
Recent market surveys show that the telecoms are no longer looking at voice as their primary source
of revenue. They are instead using voice to direct consumers to their main money making areas:
SMS and Value Added Services. The most strategic objective for operators currently is on network
expansion, improving market share and driving customer loyalty.
Knowing this, we were able to make a good case for Uganda Telecom to work with UNICEF and
government counterparts on this initiative. Uganda Telecom significantly subsidizes the hosting and
data transfer costs for the birth registration system, making it possible to conduct an entire birth
“transaction” for less than 1 cent. With costs this low, we have a scalable solution that the
Government of Uganda can afford.
In return, Uganda Telecom sees an opportunity to expand their network of users to at least one
“birth registration focal point” in every village. Uganda Telecom envisions this person, who will be
actively engaging with countless households as part of the birth registration work, also acting as
their mobile money operator. Additionally, while the core service of birth registration is offered at
nearly no cost, Uganda Telecom will be providing premium value added services such as an easy way
to notify your family and friends of the birth.
In light of this, I would pose the following questions to those engaged in this field:
1. Can the private sector assign a proportion of their programmer’s time to work with
various Government Ministries pro bono to understand their major communication,
logistics and data movement constraints and design solutions that are not tied to one
specific service provider and that can work for them;
2. Can the private sector assign some time of their technical staff to build capacity of the
young in various universities and vocational schools to build national capacity in this
area;
3. You already offer many free services on your carriers, can some of these be for public
good and crowd sourcing vital development information;
4. Can each of your retail outlets act as data and voice gathering centres so that the
observations and voices of the ordinary and the marginalized can be heard in the highest
levels of the government;
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5. 5. Can each of your retail outlets be a learning point for the young with a combination of
free and chargeable services for public good;
6. Can you all work together on certain public good initiatives so that the programmes of
one can work on the platforms of others as well
7. Can we all have a common portal where we share within the country and in the region,
perhaps even globally what we are working on so that we can harvest the energies and
resources already invested by others in addressing the same challenge and not duplicate
each other’s efforts but benefit from them. Can we all also agree on certain standards
which all of will abide by so the solutions are robust, scalable, easily shared and
replicated.
I know that many of you are already doing a lot of this but there is room for more and this critical
juncture where we have only few years left to achieve MDGs, you all can be a critical player.
Thank You
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