Effect of COVID-19 lockdown on mobile payments for maternal health: a regression discontinuity analysis of 819,840 person-days of health wallet use data (Preprint)

BACKGROUND The COVID-19 pandemic has resulted in an unprecedented popularity of digital financial services, for contactless payments and government cash transfer programs to mitigate the economic effect of COVID-19. The effect of the pandemic on the use of digital financial services for health in low-and middle-income countries, however, is poorly understood. OBJECTIVE To study the effect of the first COVID-19 lockdown on the use of a Mobile Maternal Health Wallet (MMHW) in Antananarivo, Madagascar, and draw conclusions on the effect of lockdown measures on the use of digital health services. METHODS We analysed MMHW data from 3,416 women at 25 public-sector primary care facilities and four hospitals from January 1 to August 27, 2020. We collected data on savings, payments, and voucher use initiated at the point-of-care. To estimate effects of the first COVID-19 lockdown in Madagascar, we used regression discontinuity analysis with modified Poisson regression for binary variables to estimate risk ratios. RESULTS Over the 819,840 person-days of observation, we recorded 3,719 savings, 1,572 payments, and use of 3,144 electronic vouchers. The first COVID-19 lockdown in Madagascar reduced mobile money savings by 58.5% (P<.0001), payments by 45.8% (P<.001), and voucher use by 49.6% (P<.001). The recovery duration after the lockdown differed by age group: Women aged 30 and older recovered substantially faster than younger women. Results remained robust in sensitivity analyses using ±20 days of the optimal bandwidth. CONCLUSIONS COVID-19 lockdown strongly reduced the use of mobile money in the health sector, affecting savings, payments, and voucher use. Reduced savings imply that the lockdown diminished women's expectations of future healthcare use, while declines in payment and voucher use indicate decreased actual healthcare utilization. These effects are crucial since many maternal and child healthcare services cannot be delayed for long, as the potential benefits will be lost or diminish if women do not receive the services within a narrow time window. CLINICALTRIAL This was an ancillary study using data from the 4MOTHERS trial, a randomised hybrid effectiveness implementation trial quantifying the effect of a mobile health wallet intervention on maternal health outcomes in Antananarivo (German Clinical Trials Register, DRKS-ID: DRKS00014928). The study was approved by the institutional review board of the University of Heidelberg on February 3, 2020 (reference number: S-428/2019).