Lentis/Cell Phones in Developing Countries

Introduction
Cell phone ownership in developing countries has increased dramatically. In 2014 cell phone ownership rose to more than 70% in many developing countries, up over 60% compared to 2002. A majority of these phones are cell phones—devices only capable of making calls and sending text messages—not smartphones—devices capable of accessing the internet.

There is no agreed-upon metric for classifying developing countries. The World Bank uses Gross National Income (GNI) to group countries into four income tiers: low, lower-middle, upper-middle, and high. High-income countries are normally considered developed, while all others are considered developing. This chapter focuses on low- and lower-middle income (LMIC) developing countries.

Despite sparse internet connectivity, people in LMIC countries still use cell phones for a variety of tasks. Sending SMS messages and taking photos/videos were the most common uses. Other activities included getting health information and making or receiving mobile payments.

M-Pesa
The popularity of mobile money is increasing in industrialized nations, with applications such as Venmo, and Apple Pay. These services allow users to make cashless transactions using their smartphones. The popularity of mobile money is also rising in the developing world. More than 65% of Kenyans and 50% of Ugandans regularly use M-Pesa to send or receive money. . Cell phones are more prevalent than smartphones in developing nations because of their cost; hence, smartphone apps such as Venmo are not used. In developing countries, users instead opt for mobile money services such as M-Pesa.

M-Pesa (M stands for “mobile”, and pesa means "money" in Swahili) is a mobile money service offered by Vodafone. Launched in 2007, M-Pesa is the largest cashless service in Kenya by transaction value, transaction count, customer count, and merchant count. In 2016, there were 24 million registered M-Pesa users, with over 16 million 30-day active users. The same year, the sum of transactions through M-Pesa amounted to over Shs 5 trillion (50 billion USD). Instead of using an internet connection, M-Pesa takes advantage of SMS text messaging to communicate between users on its network. Such a network requires less advanced infrastructure than that of a developed nation and makes this technology affordable in developing countries.

To register for M-Pesa, customers meet with an agent at an M-Pesa kiosk. The agent links the user’s cell phone to their ID and the user chooses a pin number. The user can add or withdraw cash from their M-Pesa account at these kiosks. To transfer money to another M-Pesa account, the user navigates to their phone carrier menu (Safaricom in Kenya, Vodacom in Tanzania) and selects the M-Pesa menu. The user can then select what kind of transaction they want to make, enter a receiving M-Pesa user's phone number, the amount to transfer, and the user's pin number.

Challenges for M-Pesa in Kenya
Although M-Pesa rose to popularity with citizens in Kenya, not everyone supported mobile banking at first. The Kenyan banking industry opposed M-Pesa and, in an effort to shut it down, lobbied the Kenyan government to audit the service. Since M-Pesa had no backing banking infrastructure, the banks claimed that there was not enough regulation. However, the audit found that M-Pesa was sound. Joseph Kinyua, Permanent Secretary Treasury, stated:

“This audit by the Central Bank on M-Pesa system provides comfort to the Treasury and I would like to assure Kenyans that this innovative idea of money transfer through the mobile telephones is safe and reliable.”

Following the audit, Kenyan banks switched to supporting M-Pesa. Rather than fight the service’s rising popularity, banks integrated key features of M-Pesa with existing services. Additionally, banks are now working with Vodafone to produce services such as | M-Shwari.

mHealth
Cell phones can be used to improve health outcomes in developing countries in a number of ways. Most commonly, they can be used for:
 * Data gathering, which can help countries keep more accurate information about the health of their population, including mortality rates and the prevalence of particular diseases or conditions
 * Training community health workers and providing a more direct communication link between these workers and experts in clinics and city centers
 * Providing health information directly to patients, by enabling internet-based information queries, or though setting up phone numbers for patients to call to receive health information and advice directly

Cell phone-based health tools are often referred to as “mobile health”, or “mHealth” interventions. mHealth has been applied to both industrialized and developing countries.

Experts often refer to the “iron triangle” of health care; the belief that the cost, access, and quality of care are inexorably linked, and one cannot be changed without adversely affecting the others. Many stakeholders are enthusiastic about mHealth in part because they believe mHealth interventions can break the iron triangle by both reducing the cost and increasing the access to health care all over the world without compromising quality.

mHealth in India
While future expansions of this chapter could enumerate on examples of mHealth initiatives in a variety of developing countries, this initial investigation will focus on efforts in India. India is an ideal mHealth case study because there have been documented efforts from both external organizations and India’s own Ministry of Health and Family Welfare. Additionally, as a large and diverse nation India has a considerable set of challenges to address if mHealth initiatives are to be successful. In January of 2016, the Government of India officially launched a mobile health initiative aimed at reducing maternal and infant mortality by training community health workers and directly delivering health information to new and expectant mothers. India’s Ministry of Health and Family Welfare is working with the Grameen foundation, a non-profit organization which develops mobile technology for developing countries.

This is not the first time mHealth has been used to improve infant and maternal mortality in India. Vodafone, a telecommunications company based the UK, has been utilizing mobile technology to disseminate a series of videos designed to educate Indian citizens about good nutritional practices.

Challenges for mHealth in India
India has a high linguistic diversity; there are 22 official languages and over 1000 other native languages. Thus the work required to make health information accessible to people in India - particularly to people in rural areas who tend to have less health care access to begin with and thus stand to benefit significantly from mHealth - is higher than usual. Additionally, health information should be presented in visual and auditory formats when the intended audience has less than 100% literacy.

There are also examples in India of women having restricted access to mobile phones. Some villages in the state of Gujarat have banned unmarried women and girls from owning cell phones, on the grounds that it would be a harmful distraction, and that if they do need to use a phone they can borrow their father’s. Even when women are not explicitly banned from using mobile phones, if a family has only one cell phone it may be primarily controlled by the male head of the family. This greatly limits the usefulness of mHealth applications that seek to deliver information about health and nutrition directly to women.

In acknowledgement of these barriers, and of other gender norms that may be at play, Vodafone has taken a unique approach by targeting their information about maternal and child health to men as well as women. Their videos depict a man taking over some of the household chores when his wife is pregnant to ensure she gets enough rest. When other men mock him for “disgracing his family name” by acting like a “henpicked man”, he stands up to them, arguing that he is upholding his family name by making sure his wife and child will be healthy. While it is still not clear from the data whether or not this approach has been effective, it does illustrate that different approaches will be needed for different cultural contexts.

Conclusion
Countries can skip developmental stages and directly implement new technologies. This skipping process, called leapfrogging, allows developing countries to quickly narrow the gap between themselves and developed countries. However, this advancement does not occur in a social vacuum. The path through which society introduces a technology has great impact on its social interface. Two social groups may view identical technologies in different contexts based on the altered path created by leapfrogging.

The overall introduction of cell phones in developing countries demonstrates leapfrogging. Many African countries do not have landline infrastructure. Instead of using resources to develop landlines, they can skip that stage in communications development and advance directly to cellular networks. Cell phone adoption patterns in Africa demonstrate this effect: fewer than 6% of people have landlines, while over 70% own cell phones.

Conventional health system development involves creating clinics before collecting health data. mHealth reverses this process since cell phones can distribute health information and collect data without health clinics. Health workers can then use this data to identify areas that need health clinics, ensuring that clinics are built in the most effective areas. Because mHealth in developing countries skips the initial health clinic stage, designers must adapt the system. mHealth exists in both developed and developing countries, but citizens of each country interpret the systems differently. The challenges associated with mHealth in India show these differences in social interface.

Standard development dictates that banks must be built before mobile banking can take root. M-Pesa skips the process of constructing brick-and-mortar banks and ATMs and proceeds directly to mobile banking. Ben Lyon, co-founder of a Nairobi-based mobile payment company, described the leapfrogging process well:

"“By leveraging third party retail outlets and making the phone the primary means of exchange, mobile money bypassed the need to distribute ATMs and POS Terminals.”"

Leapfrogging exists in other contexts as well. In the 1980s and 1990s, Hyundai Motors’ engine development had fallen behind that of competitors. Rather than invest heavily in carburetor-based engines, the standard at the time, Hyundai invested in injection-based engines. By skipping much of the carburetor-based engine research and development (R&D) stage, Hyundai saved time and money. These savings helped Hyundai catch up to their foreign competitors.

While leapfrogging boosts development, not all technologies and societies can skip stages. Social and developmental factors impede the Chinese automobile industry from leapfrogging to clean energy technologies. The nuances of these factors are too intricate to be fully discussed here, so further work is needed to investigate them in detail.

Cell phones in developing countries change much more than banking and health. Future authors could expand upon the social effects of sending text messages and taking photos/videos. The chapters about compulsive connectivity and the sociology of texting provide supporting analyses of the effects of increased connectivity.