SPECIAL ARTICLE Mobile Phones for Maternal Health in Rural Bihar Reducing the Access Gap? Marine Al Dahdah, Alok Kumar Health programmes that are using mobile phones to improve maternal health in rural India are examined. Presented by its promoters as a universal, accessible and “smart” empowering technology, how mobile devices transform gender inequalities on the ground is analysed. By using empirical data collected on a global mHealth programme deployed in Bihar, how mHealth devices negate the multifactorial dimension of gender and health inequalities is explained, and also how these devices can reinforce inequalities on the ground is examined. Marine Al Dahdah (marine.aldahdah@gmail.com) is a sociologist at Centre de Recherche, Médecine, Sciences, Santé, Santé Mentale, Société (Cermes3), CNRS – Université Paris Descartes—EHESS, Paris and a research associate at Centre for Social Sciences and Humanities, Delhi. Alok Kumar (aalokkashyap.in@gmail.com) is an independent consultant for the World Bank in Bihar. 50 I n 2016, seven billion people were mobile phone users, thus propelling the mobile phone ahead of other information and communication technologies (ICTs). Whether it be mobile personal health records or confidential clinical data sent via text messaging, these devices are increasingly used to provide “better” health services in a context of reduced health expenditure and increased involvement of patients. Substantial research has been conducted on eHealth—health on the internet—in recent years, mainly regarding the nature and the value of health information on the web (Adams and Berg 2004), the redefinition of the roles of lay and expert in health, and the subsequent transformation of the patient–caregiver relationship (Henwood et al 2003). Yet, very little research has been conducted on the use of the mobile phone and wireless technology within health programmes, called mHealth or mobile health, and especially in the global South, or in development contexts. However, the impact of mobile technologies on healthcare in such contexts raises critical questions that become particularly acute in the context of increased access to mobile phones in India. The recent multiplication of mHealth worldwide illustrates the overall trend towards the globalisation and technologisation of biomedicine. The widespread idea, that digital technologies improve the quality of care, reduce health disparities and optimise health systems, takes shape in a diverse set of technical devices: mHealth, telemedicine, big data, etc. This paper offers a glance at this new field of mHealth through the study of a particular maternal mHealth project deployed in Bihar, based on fieldwork conducted in 2015 in two districts and five blocks, among almost 100 women, 30 community health workers (CHWs) and 20 implementers, all involved in a maternal mobile health project. We propose to focus more specifically on gender inequalities that these sociotechnical devices are revealing and even enhancing on the ground, and how these are entangled with socio-economic and health inequalities. Whereas mobile health is presented by its implementers as a neutral, universal, accessible and “smart” technology to improve health in Bihar, we will analyse how it, in fact, reinforces inequalities on the ground. A ‘Simply Brilliant’ Innovation Using mobile phones to access and relay health information in developing countries is the topic everyone in health and technology is talking about right now. There’s a reason for that, of course. It’s one of those “simply brilliant” innovations that seem to make perfect sense. … Can a cell phone save a life? It’s extremely possible. (Newman 2011) MARCH 17, 2018 vol lIiI no 11 EPW Economic & Political Weekly SPECIAL ARTICLE Access to mobile phones is becoming increasingly common over the globe, and is expanding much faster than access to the internet (ITU 2013). mHealth figures are mainly coming from mobile operators and mobile technology providers. They estimated the global market in 2013 between 23,000 and 1,00,000 apps worldwide, a rather approximate estimation that focuses only on apps that are accessible on the major United States-based app stores (Pew Research Centre 2012). Only smartphones can use those kinds of apps. Thus, most of them are not yet reachable for the majority of the developing countries. Thereby, most of the projects deployed in resource-poor settings are SMS-based or vocal services, which can be used on a basic handset. Mobile health projects and applications emerged at the beginning of the 2000s, and have been popping up in the developing countries for the past five years. Aware of the growing deployments of mobile technology, international health actors have been trying to better characterise this phenomenon. In 2011, the World Health Organization (WHO) described mHealth as the practice of medicine and public health assisted by mobile technologies, such as mobile phones, patient monitors, “personal digital assistants” (PDA s) and other wireless technologies (WHO 2011). The WHO segments mHealth according to a typology of projects that include: communication from individuals to health services (call centres, helplines or hotlines), communication from health services to individuals (appointment or treatment reminders, awareness and mobilisation campaigns on health issues), and communication between health professionals (mobile telemedicine, patient monitoring, aid to diagnosis and decision-making). The innovative and transformative component of mHealth constitutes a central argument to promote its spread. “Mobile phones and wireless internet end isolation, and will therefore prove to be the most transformative technology of economic development of our time,” as Jeffrey Sachs had already advocated in 2008 (World Bank 2012: 1). This call for technological change—its future and promises—is structuring the field of mHealth, its organisation and actors. Actually, innovation studies identified those dynamics as characteristic of innovative devices. In line with the work of Joly et al (2013) on the economy of technoscientific promises, or Flichy (2003) on imaginaries of innovation, or Rajan (2012) on promise as a symptom of technoscientific capitalism, our corpus analysis1 brings out a clear “promising communication” at stake in mHealth discourses. All these promises come together to promote the mobile phone as a “simply brilliant” innovation for health. Some of these promises—unrelated to health—are fed by the general hopes and hypes related to the mobile phone. Its ubiquity and accessibility allow everybody to be easily connected with anybody, anywhere, and at anytime, making this technology omnipotent and universal at the same time. Mobile phones are key to the economic growth of developing countries. “Studies have suggested that increased mobile ownership is linked to higher economic growth. It is also likely to have twice as large an impact on economic growth in developing countries as in Economic & Political Weekly EPW MARCH 17, 2018 vol lIiI no 11 developed ones because the starting point of infrastructure in poorer countries is so much lower in terms of landlines and broadband access” (UNDP 2012: 10). These devices serve as substitutes for a whole bunch of useful tools that you could hardly find in the poorest countries: “In developing countries mobile phones not only complement other technologies but also substitute for them—for example, as cameras, debit cards, or voice recorders” (World Bank 2012: 4). In addition to these “mobile promises,” promises linked to the health sector are expanding the whole promising tendency of these discourses: “The use of mobile and wireless technologies to support the achievement of health objectives (mHealth) has the potential to transform the face of health service delivery across the globe” (WHO 2011: 9). More Than Just Healthcare? Three major promises—effectiveness, cost efficiency and empowerment—are constantly used to promote mHealth: “Mobile applications can lower costs and improve the quality of healthcare as well as shift behaviour to strengthen prevention, all of which can improve health outcomes over the long term” (Qiang et al 2012: 9). These three promises are at the foundation of mHealth. While these provide content and credit to this new field, these also raise expectations that might not be fulfilled. Effectiveness of healthcare and health workers has improved thanks to mobile and digital health data. Instantly updated data, collected on-site, facilitate emergency and crisis management (Callaway et al 2012). Mobile apps can improve the quality and accuracy of diagnosis by compiling “good practices,” international protocols, analysis of personal health records, and offering personalised treatments in accordance with these indicators (Alepis and Lambrinidis 2013). mHealth can reach patients wherever they are, even if there are no health facilities around. In developed countries, isolated patients can call and exchange health data directly with health professionals through mobile apps (Sankaranarayanan and Sallach 2014). This new connectivity can emerge even without mobile phones, through CHWs sent to the isolated communities to collect health data via the mobile phone, evaluate the needs and connect these populations instantly with health facilities (Källander et al 2013). Meanwhile, mHealth is also presented as a low-cost mean of health expenses rationalisation and even a way of downsizing health expenditure. By optimising medical time, by avoiding unnecessary hospitalisations, redundant exams or superfluous medicines, by preventing missed appointments or interruption of treatment, mHealth reduces health costs. Moreover, mHealth combined with mBanking will ensure secure out-of-pocket payments even if patients do not have any bank accounts, and will allow uninsured patients to apply for micro-insurance schemes to cover their health expenses (World Bank 2012). Finally, the promise of “empowerment” is crucial as it is the only “human” or “patient-centred” justification for these devices, the only one involving citizens and not only the optimisation of healthcare services (Qiang et al 2012: 39). Far from its original meaning—a grass-roots acquisition of power 51 SPECIAL ARTICLE or reinforcement of power—empowerment, in the case of mHealth, is mainly reduced to a relative autonomy or a limited accountability of patients. This promise echoes the individualistic and liberal vision of empowerment adopted by international aid agencies in early 2000 and described by several scholars. Initially, the term was most commonly associated with alternative approaches to development, with their concern for local, grassroots community-based movements and initiatives, and their growing disenchantment with mainstream, top-down approaches to development. More recently, empowerment has been adopted by mainstream development agencies as well, albeit more to improve productivity within the status quo than to foster social transformation. Empowerment has thus become a ‘motherhood’ term, comfortable and unquestionable, something very different institutions and practices seem to be able to agree on. (Parpart et al 2003: 24) The empowering effect of mHealth is seen in the idea of an increased degree of autonomy for patients from the healthcare system and also the vision of shared accountability. Thus, health cannot fully be delegated to health professionals; patients have to shoulder their share of responsibility, too. For mHealth promoters, mobile phones play a key role in this empowerment through the optimisation of prevention and treatments: (i) Easy access to health information via mobile phones will lead to sound health behaviour. By improving the understanding of preventive actions, risky behaviour will be avoided. These “positive health-seeking behaviours” will improve the health of entire populations in the long run. (ii) A better understanding of treatments will help patients follow medical instructions and prescriptions. Studies have been already conducted on treatment adherence for chronic diseases in Western countries to show that alerts, reminders and followups through the mobile phone help patients follow instructions and treatments, thus the “empowered chronic patient” does not have to go to the health facility too often and is more in charge of their own health. Closer to a liberal than a liberating vision of empowerment, the technological empowerment of mHealth maximises individual interest and thus will ensure the efficiency of healthcare. Maternal mHealth projects deployed in the developing world constitute fascinating illustrations of this techno-liberal vision of empowerment. We shall now introduce the project we selected to do an in-depth study of mHealth. The ‘Most Promising mHealth Project’ Sub-Saharan Africa and South Asia have in common the highest mobile phone and mobile internet growth rate worldwide (+40% in 2013, twice the rate of the rest of the world). However, these regions also have the shortest life expectancy at birth, the highest infant and maternal mortality rates worldwide, and the worst indicators related to the different development goals fixed by the United Nations. The idea that the growing phenomenon of the mobile phone could lead to a better health situation for Africans and South Asians rose and took shape in more and more mHealth projects in these regions. To better understand this phenomenon, we did fieldwork in Ghana and India in 2014 and 2015 to study several 52 mHealth projects,2 and among them Mobile Technology for Community Health (Motech), the “most promising mHealth project.” The most promising mHealth project that I have seen, called Motech, focuses on maternal and child health in Ghana. Community health workers with phones visit villages and submit digital forms with vital information about newly pregnant women. The system then sends health messages to the expectant mothers, such as weekly reminders about good pre-natal care. The system also sends data to the health ministry, giving policymakers an accurate and detailed picture of health conditions in the country. Those working on AIDS, tuberculosis, malaria, family planning, nutrition, and other global health issues can use the same platform, so that all parts of a country’s health system are sharing information and responding appropriately in real-time. This is the dream, but it works only if frontline workers are inputting data, health ministries are acting on it, and patients are using the information that they receive on their phones. (Gates 2012) The Motech project was launched in 2010 in Ghana by the Grameen Foundation with the financial support of the Bill and Melinda Gates Foundation. The goal of Motech is to improve maternal, newborn and child health outcomes in rural developing contexts. Its aim is to support women during their pregnancy and until a year after birth. This project combines modules of health information for women and health professionals, identification and tracking of patients, collection and processing of health data, SMS alerts and voice messages. The aim for Motech is to become a global platform used worldwide for different health issues, to sustain and increase the quality and accessibility of health information and care. The Motech project was then launched in India (in Bihar) in 2012 based on the Ghanaian experience. In this paper, we are presenting a part of our analysis on the Bihar experiment of the “direct to consumer” application of Motech called Kilkari. Kilkari was launched in Bihar in 2013 as a part of a bigger project that encloses three mHealth applications. It was first launched in eight “innovative” districts and extended to 20 districts afterwards. Kilkari is the only application directly targeting pregnant women. It is a vocal messaging system that provides maternal health information to pregnant women and mothers with children younger than 12 months. The weekly messages on pregnancy address context-specific factors like nutritional advice, and encourage women to seek antenatal and postnatal care by sending alerts and reminders for clinical care and visits. It is a fee-based mobile phone service, that for `1 sends one voice message in “rural Hindi.” We went to two of the eight pilot districts where the subscriptions rates to Kilkari were the highest in the state. We selected five blocks among those with the highest subscription rates to organise the fieldwork. We met implementers of Kilkari in Delhi and the selected districts, and the managers of the primary health centres of the blocks that connected us with the facilitators (accredited social health activist [ASHA] facilitators) of the cWhs. We then organised focus groups with community health workers involved in Kilkari and, thanks to them, organised focus groups with women in 13 villages. All the interviews were conducted by Marine Al Dahdah and Alok Kumar, and were fully transcribed in English and imported in nVivo software along with the field notes to conduct a qualitative MARCH 17, 2018 vol lIiI no 11 EPW Economic & Political Weekly SPECIAL ARTICLE analysis. This analysis revealed the various power issues and inequalities at stake. We will focus first on gender inequalities. Kilkari: A Gendered Technology? From the beginning, the project perfectly integrated gender issues and tried to encompass it by talking only to men: When you see our promotion around Kilkari, you see a man on the theme, who says if you are the best father of the village you should subscribe to Kilkari. it’s a service that was targeted to men, since they hold the money and the service need to be bought, the service was targeted to men. All the promotion that happened was targeted to males.3 However, those campaigns did not work at all and the implementers had to turn towards a more efficient way to reach the women through the CWHs: ASHAs and anganwadi workers (AWWs). We met 99 women in Bihar, 90 young women between 18 years and 30 years of age and nine mothers-in-law and mothers who subscribed to Kilkari for their daughters-inlaw or daughters. Even in our sample that was structured to find Kilkari users, more than one quarter of our interviewees never subscribed to the service. And among the one that subscribed to it, less than half of them listened to more than four messages. Less than 10% of the 99 interviewed women listened to the messages for more than six months, which is too short a period to provide a follow up of women during pregnancy and until the the infant turns one year old. So, why do they not subscribe to or why do they drop out of the system so quickly? There are a lot of reasons for the non-adherence to Kilkari, but we will only evoke the ones that are related to gender. The first one is access to a mobile phone: “I did not subscribe because my husband carries mobile for his work, how would I listen to it if I subscribe.”4 The second one is the fee issue, the fact that the service costs `1 is a major cause of disruption: “Deduction of `1 is expensive for me.” And, the third major issue is related to serious technical problems that lead to the discontinuity of the service even if the client paid for it: “Calls stopped coming even when there was credit in the mobile account.”5 The service is creating conflicts between men and women on these three major points: “My husband said that it’s not necessary to listen to it and money gets deducted. He wasn’t ready to understand when I tried to convince him.” “My brother told that lot of money gets deducted, so he deactivated it. He said he would not give me the mobile anymore.” “My husband disconnects the calls anyway. Since money gets deducted. He would deactivate it.”6 This can tell us that the service is not working well, but it also tells us how gender inequalities are accentuated by this technical device. Several science and technology studies scholars have clearly shown that access to ICTs is harder for women, because they do not have free access to hardware—computers or mobile phones are owned by the husband—but also because those technologies are conceptualised, developed and deployed by men (Henwood and Wyatt 2000). Among ICTs, mobile phones are particularly interesting, because gender inequalities are accentuated less than with using computers or accessing the internet. Because, mobile phones are cheaper Economic & Political Weekly EPW MARCH 17, 2018 vol lIiI no 11 and easier to use than computers or the internet, they seem to be a more “egalitarian” technology, but a woman is still 14% less likely to own a mobile phone than a man in the Global South. This figure increases to 38% if she lives in South Asia, and goes even higher in rural and poor areas (GSMA 2013). Almost half of the women we met in Bihar had their own phone, but these women are over-represented in our study as compared to the general population because they were the ones targeted to subscribe to Kilkari. In rural India, accessing mobile phones is still an important issue for women. Women still rely a lot on men to access this technology. Half of the women we met in Bihar were relying on men (husband, or brothers or fathers-in-law) to access mobile phones: “There when I was with my husband, he kept the mobile with him, here at my mother’s home, my brother keeps it.”7 “Their husbands or in-laws may have mobiles but they (women) would not be able to use it.”8 We found that 70% of the women who own a mobile are married to men who work outside Bihar and are not at home. So, women whose husbands work and live outside Bihar are more likely to own a phone. Ownership of the mobile is not the only gendered issue. Its uses are also very interesting to study and provide insight on the failure of Kilkari. Gendered Mobile Use During the interviews, we asked about what a mobile can do. Perceptions of this are different from the real use of this object. These perceptions show only the possibilities of the object: “Mobile has made our lives much more convenient. If something happens, one can communicate using it right away. In case of an emergency, mobile can be used to transmit information.”9 “Earlier it took lot of time to communicate; now it is faster. In case of emergency, one can make a call. It can be used to call people at distant places or to use internet and know new things. News can be read on mobiles.” However, when you ask about what they can do with the mobile, you realise that mobile services are not so accessible to these women: “The benefit of mobile is not much because call rates is not affordable.”10 “Sometimes for two months, there is no credit in the mobile. Only if there is an emergency and someone is going to the market, I will ask the person to get it recharged.”11 Women are facing multiple difficulties in accessing and using mobile phones in Bihar. First, access to mobile phones is still a male prerogative: “I do not touch the mobile. He (husband) says that I don’t know how to operate it, I may spoil it and it may stop working.”12 Women who own a mobile phone often get old ones that are not functional, with broken screens that freeze or shut down and cannot be charged: “I have my own mobile but it does not work since last 15 days. (Another woman, reacting) I also have a mobile which is not functional, it doesn’t get charged. It has to be repaired.”13 Women who do have functional mobile phones, most of them are using it for incoming calls and emergency calls. They do not have smartphones (most of the rural Bihari men too do not). But, they do not even have phones with basic functionalities like a music player or basic access to 2G internet, which we can find frequently on the men’s phones. Almost none of them have ever sent 53 SPECIAL ARTICLE a text message, mostly because of literacy issues in the most illiterate state of India where 50% of the women are illiterate. Also, the basic phones they use cannot support the Devanagari script, the only script that they know, if they know, how to read and write. None of them have ever accessed the internet via their mobile phone or used any mobile banking service. For women who own a mobile phone, men are still controlling their usage through phone credit. Nearly all the women we met are depending on men to recharge their phone: “I give a missed call to his number using another mobile and then he calls me back. Sometimes it takes 10 days, sometimes even one month to get it recharged. What to do, I am helpless.”14 None of the women we met regularly recharge their mobile credit by themselves. It is most of the time their husbands or the men in their household (brothers, fathers-in-law) who take care of it. They can be called, but never have enough credit to place calls on a regular basis. This woman, like many others, explained to us that her husband wants to know why and who she wants to call: “He tells me, why do you always need to have credit in it when I get it recharged whenever you want to make a call.”15 Thus, studying the use of mobile phones among these women shows important gender inequalities, in terms of access to phones, credit and functionalities of the phone. Financial inequalities are also very wide in terms of credit expenses. When a woman owns a phone, she will spend 20 times less credit than her husband in one month: “In my husband’s mobile, the expenditure is always much more, `300– `400 per month, but in my mobile, I get it recharged only by `10– `20 per month.”16 These inequalities are reflecting the current gender inequalities of Indian society and more specifically of rural Bihar, where only 10% of the women are getting any job or salary for their farm work. They have little control over the household expenditure.17 These uses of mobile phones also highlight mobility inequalities that seem antithetical to the promises of mobile phones: “We are women. Some family allow women to go out, others do not.”18 “I am not allowed outside because I am daughter-n-law.”19 Women are not allowed to go outside the house or to roam around unnecessarily. It is also the reason why they cannot recharge the phone by themselves: “Here the recharge is not available in shops. One has to go to ‘B’ for this (2–3 km away). How will the ladies go there?”20 And, mobile phones reinforce this confinement in the house since women can be contacted from afar without their going out. By studying this programme in Bihar, we realised that mobile phones are a new way to limit women’s mobility and also to exert a new form of control from afar for husbands who are around or not staying in the village at all. Our Bihar fieldwork shows how mobile phone can objectify male domination (Bourdieu 2002). Uses of mobile phones are different for a woman and a man in Bihar. Mobile phones can reinforce male authority on women, and embody the existing male domination that is well-rooted in rural Bihar. This fieldwork highlights how a technical object can enhance men’s power over women and limit women’s autonomy further more. We would like to bring this analysis to a more complex level by putting gender 54 at the intersection of other inequalities, thanks to the concept on intersectionality (Crenshaw 1989; Yuval-Davis 2015). Indeed, if mobile phones can constitute an instrument of male domination, the varying degrees of determination of the device are set by broader socio-economic and political factors. mHealth and Intersecting Inequalities Used as a dominant analytical frame, gender reveals inequalities between men and women, and male domination at stake in the studied technological artefacts. However, gender, to be relevant, has to be envisioned as consubstantial with other forms of inequalities, which will play a fundamental role in the way mHealth is shifting and transforming unequal relationships of power. The concept of situated intersectionality analyses intersecting inequalities and forms of power at stake in specific contexts and the offsetting mechanisms that technological devices can generate: Situated intersectionality analysis, therefore, in all its facets, is highly sensitive to the geographical, social and temporal locations of the particular individual or collective social actors examined by it, contested, shifting and multiple as they usually are. (Yuval-Davis 2015: 95) From micro to macro, from the individual to the political level, we examine the different domains where technological inequalities are revealed and generated by Motech. This study paper is not exhaustive; it draws attention to some of the major inequalities and forms of domination we identified on the ground, and their articulation with gender. Interpersonal level: Subscription to Motech is always done by the intermediary, that is, the CWHs. Yet, the patient–caregiver relationship has already been analysed as very unequal and a source of symbolic, and sometimes physical violence, especially in developing contexts (d’Oliveira et al 2002). This interpersonal relation is going to play an important role in the enrolment of women in the Motech project. In Bihar, where Motech is a fee-based service, CHWs are key actors. Mostly, it is because they have been convinced or pushed by health workers that women will subscribe to it. In Bihar, women have a trust-based, but also subordinate, relationship with CHWs. ASHA s and AWWs might be the only interlocutors in the village on health issues, and the majority of our interviewees declared that the CHW of their village is a reference person for them and that CHWs were really supportive during their pregnancies: “We believe and do what ASHA tells us. ASHA gives us the right information.”21 Thus, women subscribe to Kilkari because the CHW they know asked them to do so. They do it on a voluntary basis, but most of the time they trust the CHW, they do not know exactly what the service is about, and in some cases that they have to pay for it: “AWW and ASHA, whatever they say, I trust it.”22 “I asked her (the ASHA) why is she asking me to give her my mobile. She told me that she would subscribe me to Kilkari and Dr Anita would call me and I would receive calls related to care during pregnancy and every week `1 will be deducted for this service.”23 “I was not told that money would get deducted for the calls.”24 MARCH 17, 2018 vol lIiI no 11 EPW Economic & Political Weekly SPECIAL ARTICLE From the beginning, the relationship between women and CHWs is not egalitarian, like any other patient–caregiver relationship, but financial inequalities are a major issue in the context of Kilkari. The CHWs are receiving a salary (for AWWs) or incentives (for ASHAs) for the community work they are doing. Thanks to this, they can have greater financial autonomy than the other women of the community and Kilkari can widen this difference further. Indeed, Kilkari offers phone credit incentives for CHWs who subscribe women to the service. Women are paying `1 per message, and the CHW that subscribed them gets `10 of phone credit per subscription after four weeks and `20 after eight weeks of continuous subscription. This incentive system, the fact that women have to pay per message, and that CHWs are getting phone credit for that, generates frictions that both women and CHWs reported during the fieldwork: “One woman told me: credit gets deducted from my account and goes to your mobile account.”25 The phone balance credited as incentive to CHWs is low and many times they do not receive it because the subscriptions do not last long enough, but this system still creates a visible financial imbalance. Thus, Motech is in fact making more apparent and aggravates the inequalities between women and CHWs. Community level: Community constitutes another nexus of inequalities revealed by Motech. Community can take a variety of forms depending on the social structure of the studied group of people. But, for our Bihar study, we will focus on family and caste, on their impact on Motech and vice versa. In Bihar, access to mobile phones and to Kilkari is easier for women who live or went back to their mother’s family during their pregnancy and for delivering the baby. Their mother’s family might be more liberal and attentive to their daughters’ well being than the in-laws’ family, and ready to pay for a service that can help their daughters during their pregnancy. Almost one quarter of the Motech subscribers we met were effectively staying at their mother’s house. Going back to their own family is a favourable factor for women to access Kilkari and can temporarily offset the in-laws’ domination over daughters-in-law. At a meso level, the caste system also plays an important role to access mobile phones and Kilkari. Far from being representative of caste diversity, our sample does not give us the possibility to study in detail the inequalities linked to the extremely complex caste stratification. Here, we just give a broad view on the caste–gender intersection in accessing mobile technologies and mHealth because this intersection was brought many times by our interviewees on the ground. Thus, caste apparently played a role in the inclusion or exclusion of women in the Kilkari project. The Scheduled Castes (SCs) and Scheduled Tribes (STs) still represent the majority of poor people and face tremendous discriminations everyday (Jaffrelot 2002). As we have seen in the villages of Bihar, caste is still a structure-giving authority in rural India. Thus, women as well as CHWs state that access to mobile phones and Kilkari is more Economic & Political Weekly EPW MARCH 17, 2018 vol lIiI no 11 difficult for women from the SC community: “Out of a population of 2,500 individuals, not even a single woman subscribed to Kilkari. Here, most of the people belong to SC and do not have access to mobile phones.”26 Women from these communities would then be almost systematically excluded from a programme like Motech, either because they really do not have access to mobile phones and would be excluded like any other women, or because CHWs are less inclined to working these communities and to convince lower-caste women to subscribe to Kilkari. Economic level: The financial accessibility of Motech is multiform and implies different kinds of economic inequalities. Financial resources are first necessary to acquire a mobile phone, then to make it functional, by bearing the regular costs of battery charging and phone credit (two additional and unavoidable costs), and finally to pay for it messages every week. In addition to that, Kilkari messages are encouraging women to attend health facilities, which incurs substantial costs for women. Indeed, to be fully efficient, it is supposed to change women’s behaviour and to bring them to health facilities. However, health facilities are not financially or geographically accessible for the women we met in Bihar. For instance, women in the study related the dire financial situations arising from institutional deliveries: “Transport to the hospital is through a jeep and it charges `500– `600 to take us to the hospital. Ambulance never comes here.”27 “I had to spend money on each and everything, medicines, injections, food. The nurse also demanded money saying that I gave birth to a boy. Even when a girl is born, she demands money but more money is demanded if a boy is born.”28 The cost of healthcare constitutes for many a central problem to accessing health facilities and delivery there. These healthcare and mobile costs are adding up. Kilkari provides messages that speak of free access to maternity services at the facility level, even if women will in fact pay for these informally. Any health programme that encourages women to attend health facilities should put equal emphasis on improving quality of care and its financial accessibility before advertising for it. In rural India, men would be automatically involved to meet these financial needs, since most of the women in rural Bihar have no financial autonomy. And, even if these women are among the 10% of Bihari women who earn money for their work and can cover mobile expenses by themselves, the money needed for healthcare is too much and remains dependent on the men of the household. These gendered inequalities in accessing healthcare have been identified by many scholars (Kuhlmann and Annandale 2010) and have led to specific policies to make up for the inaccessibility that women face. These compensatory policies invite us to move to the last nexus of inequalities we want to analyse here: the political. Political level: Healthcare structural reforms in the 1990s have led to a wider “commodification” of health, through fee-based health services and increased out-of-pocket expenses 55 SPECIAL ARTICLE (Kuhlmann and Annandale 2010). In India, like in many other emerging countries, the government has experienced a diminishing role in the health sector by subcontracting many health activities to private stakeholders (Shewade and Kumar Aggarwal 2012). These structural reforms have been clearly identified as disproportionately placing women at a disadvantage (Sen and Östlin 2010). Because women are heavily dependent on public primary health centres (PHCs) that are providing maternal and infant care, healthcare reforms that are affecting public structures strike them harder than males and lead to a significant increase in maternal mortality (Ekwempu et al 1990). India recently put in place specific maternal entitlement policies to make up for the financial difficulties pregnant women face in accessing health facilities. The Janani Suraksha Yojana (JSY) launched in 2005 is a national programme to promote institutional delivery. It targets specifically the 10 states of India where institutional deliveries are the lowest (low-performing states), Bihar among them, where financial entitlements are twice as much as those of other states (high-performing states). To benefit from the JSY, women have to be registered and gave birth at a PHC or public hospital. Women will need a bank account, a birth certificate, and proof of delivery in a public facility. In Bihar, she will then get `1,400 if she lives in a rural area and `1,000 in an urban area. Women in our sample think that accessing this scheme is too complicated and expensive because of the mandatory requirement of a bank account and formalities that entail bribes: “For the registration of the birth we have to give `200, normally this is supposed to be almost free.”29 “To receive the maternity benefit of `1,400, I have to have a bank account. If I need a bank account, I will have to maintain a minimum balance of `500 in it, only then they open the bank account. Also for a bank account to be opened, I would need identity documents (ID proofs). To get these documents, I will have to pay bribes everywhere.”30 And, even if they fulfil these eligibility criteria, women do not get the money on time. Sometimes it even takes eight–nine months after delivery to reach them because the district itself receives funds very late to transfer money to the beneficiaries: “We have not received maternity benefit. They said that it would take two–three months because there are no funds available now.”31 Further, women state that the scheme does not even cover the costs of delivery, and certainly not antenatal and postnatal care costs. They describe point-by-point the different expenses that an institutional delivery entails. From transportation to birth certificate, to multiple bribes, food and medicines, they have to pay, each and everything and each and every person to deliver at a public facility. In all, they will spend between `1,500 and `2,000 to deliver at the PHC: “There is no fixed amount, sometimes for delivery in total one would spend `1,000 and sometimes it is `2,000. But the minimum is `1,000 to `1,200. The amount that we get under maternity scheme is not of much use.”32 “We spend more than the `1,400 of the maternity benefit scheme on informal payments made to nurse, transport and medicine.”33 56 According to the National Family Health Survey (NFHS)-4 data, the average out-of-pocket expenditure per delivery in a public health facility is `1,724. Few studies that have evaluated the scheme show that the JSY is troublesome, and generates new inequalities between districts and even among women from the same district (Centre for Equity Studies 2015). But, still, as the latest figures released by NFHS-4 show, the scheme has had an impact, with institutional deliveries in public facilities having risen to 47.7 % in Bihar from NFHS-3 (2005–06), when it was a meagre 3.5%. However, this scheme, compared to universal coverage or free access to healthcare for pregnant women, deals with healthcare accessibility in a very narrow and partial way. It does not take into account the multiple costs implied by antenatal and postnatal follow-ups. According to NFHS-4, less than 4% of women in Bihar had a full antenatal check-up as recommended by the WHO; around 58% of mothers never had any postnatal contact in the 48 hours after delivery as recommended by the WHO (MoHFW 2015–16). Though the recent implementation of the JSY increased institutional delivery, it will not solve on its own the issue of maternal mortality on the long run since it does not take into account the full process of maternity follow-ups from antenatal to postnatal care. In the long run, the quality of healthcare provided at PHCs and the experience of women there is still going to be an issue, if it does not improve: The expense on delivery exceeds the amount we get under the maternity benefit scheme. It is just that people go to the PHC thinking that there are facilities there, which are better than delivering at home. But in fact, there is no benefit from delivering at hospital, and it is too expensive.34 Conclusions Using situated intersectionality and examining the nexus of inequalities, we have offered a nuanced and complex analysis of unequal situations at stake in mHealth. Through the study of several particular intersections, from individuals to public health policies, we highlighted the complex inclusion of a technical device in a situated context. Thus, we pointed out the inequalities sometimes reinforced and sometimes offset by the technical artefact. This paper shows how the implementation of a technology is context-dependent, and implies different degrees of interactions and determinations. Envisioning that the reception of an automated vocal message once a week can make up for such varied and entangled inequalities enmeshed in Motech seems nothing but wishful thinking. However, the Government of India is now investing in these new technologies to improve health, and in 2017 the Ministry of Health and Family Welfare extended Kilkari to Madhya Pradesh, Rajasthan, Jharkhand and Uttarakhand (Chamberlain 2014). The modalities of implementation at a national level have to be further studied, but the numerous difficulties encountered on the field in Bihar should be taken into account to avoid the failure of Kilkari and the potential increase in health inequalities through this mechanism. MARCH 17, 2018 vol lIiI no 11 EPW Economic & Political Weekly SPECIAL ARTICLE Notes 1 Qualitative corpus analysis of four corpuses: (i) Worldwide general press: Factiva (English and French), “Mobile and Health,” 446 articles (2011–13). (ii) Techno and Health specialised press: Factiva, for the four most evoked regions in the general press (Africa, India, UK and US), 581 articles (2011–13). (iii) Scientific press: PubMed, “Mobile and Health,” 213 articles (January 2010–14). (iv) International reports: 20 reports (United Nations, European Union, World Bank, World Health Organization, United Nations Development Programme, Internationla Telecommunication Union, UNICEF, Organisation for Economic Co-operation and Development, United States Food and Drug Administration, Indian government, Institute for Healthcare Informatics) published during 2010–14 on ICT4D (information and communication technologies for development) or on “mHealth,” 50 reports from GSM Association on ICT4D and 20 reports from mHealth Alliance. 2 This research was part of Marine Al Dahdah’s PhD dissertation. Broader results of this doctoral research have been recently published in Gender, Technology and Development (Al Dahdah 2017). 3 Interview with K, employee at BBC Media Action, Delhi, 2015. 4 Focus group discussion (FGD) with woman n°2, District A, 2015. 5 FGD with woman n°3, District A, 2015. 6 FGD with woman n°1, District A, 2015. 7 FGD with woman n°1, District A, 2015. 8 FGD with community health worker n°2, District A, 2015. 9 FGD with woman n°1, District A, 2015. 10 FGD with woman n°9, District B, 2015. 11 FGD with woman n°3, District A, 2015. 12 FGD with woman n°7, District B, 2015. 13 FGD with woman n°9, District B, 2015. 14 FGD with woman n°13, District B, 2015. 15 FGD with woman n°12, District B, 2015. 16 FGD with woman n°3, District A, 2015. 17 World Bank Data, India, viewed on 14 September 2015, http://data.worldbank.org/country/ india. 18 FGD with woman n°12, District B, 2015. 19 FGD with woman n°7, District B, 2015. 20 FGD with woman n°1, District A, 2015. 21 FGD with woman n°3, District A, 2015. 22 FGD with woman n°11, District B, 2015. 23 FGD with woman n°12, District B, 2015. 24 FGD with woman n°11, District B, 2015. 25 FGD with community health worker n°2, District A, 2015. 26 FGD with community health worker n°2, District A, 2015. 27 FGD with woman n°10, District B, 2015. 28 FGD with woman n°7, District B, 2015. 29 FGD with woman n°10, District B, 2015. 30 FGD with woman n°8, District B, 2015. 31 FGD with woman n°9, District B, 2015. 32 FGD with woman n°12, District B, 2015. 33 FGD with woman n°3, District A, 2015. 34 FGD with woman n°10, District B, 2015. 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