Table 1 Afya mHealth components and lessons learned

Pharmacy-based monitoring patient visit attendance

Automatically logs patient attendance and allows entry of next visit date

Pharmacists registers patient with biometric ID and inputs medication pickup, next appointment into the system

Robust measure of retention — last stop of clinic visit, made sense for cash to be disbursed here

Track patient medication pickup in nearly real-time (robust measure of retention)

Pharmacists entering data into the mHealth system to document receipt and type of medication given

Overcomes key information gaps that could benefit care

Obtain next visit date for accurate measurement of retention in care

The program needs to have readily available benefits for users that are clear to clinic staff.

Training and engagement with clinic staff as partners will be essential as their buy-in is key to successful implementation.

Biometric ID

Identifies patient using fingerprint, logs appointment attendance for cash eligibility, provides near real-time information about visit attendance

Saves clinic time by efficiently and rigorously monitoring patient visit attendance

Avoids participant misclassification that can arise from lengthy clinic IDs that must be transcribed from paper records to the database

Overall, fingerprint identification was highly acceptable to patients and clinicians and may increase the system’s perceived legitimacy.

iterative improvements were required to overcome fingerprint recognition challenges.

It took a while to get this right.

Financial incentive disbursement integrated with mobile money

Automatically sends cash for visit attendance via the mobile money provider used by the client, seamlessly incorporates any program “rules” without human error

Simplifies the logistics of disbursing cash payments

Increases privacy compared to cash

Auto transfer connected to fingerprint scan bolsters connection between visit attendance and cash

Overall, the mobile money disbursement was highly acceptable

Some concerns about privacy and autonomy in spending.

At scale, automated cash distribution will be essential for feasible implementation of financial incentives in HIV clinics.