Family Planning Digital Tools: A Comprehensive Evaluation

Posted Julho 5, 2022
Impact Area Sexual & Reproductive Health

By Eden Demise, Research Associate, Strategy & Insights, PSI; Alexis Coppola, Sr. Program Manager, SRH, PSI; Alexandra Angel, Technical Advisor, SRH, PSI; and Kristen Little, Sr. Research Advisor, Strategy & Insights, PSI

In 2020, for the first time, over half of the world’s population were using mobile internet. Three-quarters of these users lived in low-and middle-income countries. Given the increase in internet connectivity globally, the use of digital technologies is one of several promising High Impact Practices (HIPs) in family planning, providing new opportunities to advance digital self-care, and make headway towards achieving universal health coverage.

The Problem

Currently, there is a growing range of resources available on effective digital interventions, including the HIP brief on Digital Health for Social and Behavioral Change and the HIP enhancement briefs on Digital Health for Systems and Digital Health to Support Family Planning Providers (linked below). However, these resources are limited in helping governments, implementers, and donors identify which family planning and reproductive health tools have high-quality content.

Analyzing the Resources

To fill this evidence gap, FHI 360, under the USAID-funded Research for Scalable Solutions (R4S) project, conducted a digital family planning and reproductive health tools landscape and content analysis to review and identify high-quality tools for adoption, adaptation, and scale-up.

The full analysis – as well as the nine recommended tools, are summarized in this brief (published December 2021), with more details available in this PowerPoint deck.

The recommended tools were highlighted in a webinar at the 2021 Global Digital Health Forum: So Many Tools: Which Ones to Choose? on December 8th, 2021. Register for the 2021 Global Digital Health Forum for free here to watch the webinar. You can also listen to a fire-side chat with some of the recommended tool owners here. These resources are designed for those interested in developing, funding, or implementing client-facing digital interventions and are intended to fill in the evidence gap on high quality family planning and reproductive health digital platforms.

Tools With High Quality Content

Among the nine short-listed digital tools, three were developed by Population Services International (PSI): Adolecent 360 (A360’s)’s 9Ja Girls Love, Life, and Health (LLH) Guidebook, 9Ja Girls Big Sista Chatbot, and Counseling for Choice (C4C) Chatbot. Taking advantage of mobile phone and internet access as an entry point, each of these three tools bring consumers a ‘click’ away from health information curated in a manner that makes it easy for them to access, digest, understand and apply to make informed health choices.

9Ja Girls LLH Guidebook

*Snapshot of 9ja Girls Facebook Messenger*

The LLH guidebook, developed under the A360 Nigeria project, is used to facilitate in-person and virtual classes and conversations via Facebook Messenger and WhatsApp, related to love, relationships, family planning and reproductive health.

This tool scored highest in six areas: complete list of modern methods, method effectiveness, duration of protection, dual method use (i.e., offers protection against HIV and sexually transmitted infections), discreteness, and menstrual health.

The 9ja Girls program currently has 40 LLH WhatsApp groups with 20-40 students in each group, facilitated using the LLH guidebook. The 9ja Girls Facebook Messenger, also facilitated by the LLH guidebook, receives an average of 1,300 messages per month and provided 159 referrals to in-network providers in 2021. The Facebook Messenger provides a safe space for girls to have private and confidential conversations with a provider, receive personalized on-demand family planning and reproductive health information and linkages to quality products and services.

9Ja Girls Big Sista Chatbot

A second A360 Nigeria tool, the Big Sista Chatbot, is an automated menu-based information tool developed via Facebook in 2020.

This tool scored highest in five areas: complete list of modern methods, duration of protection, dual method use (i.e., offers protection against HIV and STIs), discreteness, and menstrual health.

In 2021, the Big Sista Chatbot reached 849 unique users with personalized and actionable family planning and reproductive health information by linking clients to clinics and Facebook Direct Messenger, where clients receive referrals to 9ja Girls Centres.

*Snapshot of 9Ja Girls Big Sista Chatbot*

C4C Chatbot

*C4C places the consumer at the center of care and the experience, from provider-led interactions to conversations a user has with a digital chatbot.*

The C4C chatbot launched in 2020 is an interactive, user-facing tool designed to provide family planning and reproductive health information, including menstrual health to people where and when they want it, privately and securely. The C4C chatbot is a dynamic tool; users respond to questions about their unique preferences and needs in terms of FP, and the tool recommends 2-3 methods that best fit their stated preferences. The tool is accessible to users via Facebook and WhatsApp.

This tool scored highest in the following four areas: complete list of modern methods, duration of protection, return to fertility, and dual method (i.e., offers protection against HIV and STIs).

Since August 2020, over 10,000 individuals in Cote d’Ivoire have accessed this tool, and nearly 40% of those living in the capital city of Abidjan were referred to a clinic within the PSI network. To further contribute to a growing body of evidence on use of digital tools, R4S is currently conducting a mixed-method study evaluating why people use the chatbot, barriers and facilitators to the use of the chatbot and if users intend to seek family planning and reproductive health methods and services after interacting with the tool. Findings from this study will be used to refine the digital tool and scale-up to other countries.

Leveraging What Works

PSI has successfully utilized mobile technology to provide personalized, actionable information on family planning and reproductive health. Making use of popular messaging platforms such as WhatsApp, Facebook Messenger and microsites is part of PSI’s consumer-powered digital health approach – placing cultural context and accessibility at the forefront. One of our priority areas is to re-position PSI’s in-house learnings and digital solutions, including the A360 tools and C4C chatbot, as global goods to support and encourage all initiatives that bring us closer to universal health coverage.

If you are interested in adapting the A360 tools, contact: [email protected].

If you are interested in adopting the C4C chatbot, contact: Alexandra Angel: [email protected].

Reference here the High Impact Practice Briefs mentioned in this article:

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Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

By: Fana Abay, Marketing and Communications Director, PSI Ethiopia

In rural Ethiopia, women and girls often face significant barriers in accessing healthcare facilities, which can be located hours away. Moreover, there is a prevailing stigma surrounding the use of contraception, with concerns about potential infertility or the perception of promiscuity. To address these challenges, the Smart Start initiative has emerged, linking financial well-being with family planning through clear and relatable messaging that addresses the immediate needs of young couples—planning for the lives and families they envision. Smart Start takes a community-based approach, utilizing a network of dedicated Navigators who engage with women in their localities. These Navigators provide counseling and refer interested clients to Health Extension Workers or healthcare providers within Marie Stopes International-operated clinics for comprehensive contraceptive counseling and services.

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For example, in Mali, access to formal health services remains challenging, with four in ten people living several miles from the nearest health center, all without reliable transportation or access. In 2009, the Ministry of Health adopted a community health strategy to reach this population. The U.S. President’s Malaria Initiative (PMI) Impact Malaria project, funded by USAID and led by PSI, supports the Ministry with CHW training and supervision to localize health services.

In 2022, 328 thousand malaria cases were recorded by CHWs); 6.5 thousand severe malaria cases were referred to health centers, according to the national health information system.

During that time, the PMI Impact Malaria project (IM) designed and supported two rounds of supportive supervision of 123 CHWs in their workplaces in the IM-supported regions of Kayes and Koulikoro. This included developing and digitizing a standardized supervision checklist; and developing a methodology for selecting which CHWs to visit. Once a long list of CHW sites had been determined as accessible to supervisors for a day trip (including security reasons), the supervisors telephoned the CHWs to check when they would be available to receive a visit [as being a CHW is not a full-time job, and certain times of the year they are busy with agricultural work (planting, harvesting) or supporting health campaigns like mosquito net distribution].

Supervisors directly observed how CHWs performed malaria rapid diagnostic tests (RDTs) and administered artemisinin-based combination therapy (ACT). They recorded CHW performance using the digitized checklist, interviewed community members, reviewed records, and provided on-the-spot coaching. They also interviewed the CHWs and tried to resolve challenges they expressed, including with resupply of commodities or equipment immediately or soon afterwards.

Beyond the observed interactions with patients, supervisors heard from community members that they were pleased that CHWs were able to provide essential malaria services in the community. And the data shows the impact.

In IM-supported areas of Mali, 36% of CHWs in the first round were competent in performing the RDT, which rose to 53% in the second. 24% of CHWs in the first round compared to 38% in the second were competent in the treatment of fever cases and pre-referral counseling. Between both rounds, availability of ACT increased from 80 percent to 90 percent.

Supportive supervision with interviews and observations at sites improved the basic competencies of CHWs between the first and second rounds, and additional rounds will help to understand the longer-term programmatic benefits.

Taking a market-based approach to scale sanitation in Ethiopia

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In Ethiopia, PSI leads the implementation of USAID Transform WASH (T/WASH) activity with consortium partners, SNV and IRC WASH. Contrary to traditional models that rely on distribution of free or heavily subsidized sanitation products, T/WASH utilizes a market-based sanitation approach. This approach creates sustainable and affordable solutions, by integrating market forces and supporting businesses to grow, while creating demand at the household level.

During the last six years, T/WASH has worked alongside the private sector and government (Ethiopia’s Ministry of Health, Ministry of Water and Energy, and Ministry of Labor and Skills), among other stakeholders, to increase household access to affordable, quality sanitation products and services. For example, more than 158 thousand households have invested in upgraded sanitation solutions with rapid expansion to come as the initiative scales and market growth accelerates.

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To share the journey to market-based sanitation, representatives of the Ethiopian Ministry of Health and the USAID Transform WASH team took to the stage at the UN Water Conference in 2023.

“Rather than relying on traditional aid models that often distribute free or heavily subsidized sanitation products, market-based sanitation creates sustainable and affordable solutions, integrating market forces and supporting businesses to grow.”

— Michael Negash, Deputy Chief Party of T/WASH

Promoting self-managed care like Self-testing and Self-Sampling

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Here’s how we got there.

Seven years ago, the landscape of HIV self-testing lacked global guidelines, and only the U.S., the UK and France had policies in place that allowed for HIV self-testing. High disease burdened countries in low-and-middle-income-countries (LMICs) lacked evidence and guidance for HIVST despite major gaps in HIV diagnosis.

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In 2022, private clinics reported 1,440 malaria cases through the social media chatbots, while community mobilizers working with 475 private providers and community-based malaria volunteers reported more than 5,500 cases, leading to the detection of two local malaria outbreaks. Local health authorities were instantly notified, allowing them to take action to contain these surges in malaria transmission. During the same time, pharmacies referred 1,630 presumptive tuberculosis cases for confirmatory testing – a third of which were diagnosed as tuberculosis and enrolled into treatment programs.

Training health workers in Angola

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The shortage of skilled health workers is widely acknowledged as a significant barrier to achieving Universal Health Coverage. To address this challenge, PSI supported ministries of health to develop a digital ecosystem that brings together stewardship, learning, and performance management (SLPM). The ecosystem enhances training, data-driven decision-making, and the efficiency of healthcare delivery.

Here’s what it looks like in practice.

In July 2020, PSI Angola, alongside the Angolan digital innovation company Appy People, launched Kassai, an eLearning platform that targets public sector health workers in Angola. Through funding from USAID and the President’s Malaria Initiatve (PMI), Kassai features 16 courses in malaria, family planning, and maternal and child health – with plans to expand learning topic areas through funding from ExxonMobil Foundation and private sector companies. A partnership with UNITEL, the largest telecommunication provider in Angola, provides all public health providers in Angola free internet access to use Kassai.

Kassai’s analytics system to follow learners’ success rate and to adjust the course content to learners’ performance and needs. Kassai analytics are integrated with DHIS2 – the Health Management Information System (HMIS) of Angolan MOH, to be able to link learners’ knowledge and performance with the health outcomes in the health facilities. The analytics track learners’ performance by course and gives visibility by health provider, health facility, municipality, and province. Each course has pre-and post-evaluation tests to track progress of learning, too.

By the end of 2022, there were 6,600 unique users on the Kassai platform and 31,000 course enrollments. PSI Angola’s partnership with UNITEL, the largest telecommunication provider in Angola, allows for free internet access to learn on the Kassai for all public health providers in Angola. Building on its success for malaria training, Kassai now also provides courses in family planning, COVID-19, and maternal and child health. This reduces training silos and provides cross-cutting benefits beyond a single disease.

Implementing the SLPM digital ecosystem brings numerous benefits to health systems. It allows for more strategic and efficient workforce training and performance management, enabling ministries of health to track changes in health workers’ knowledge, quality of care, service utilization, and health outcomes in real time. The ecosystem also supports better stewardship of mixed health systems by facilitating engagement with the private sector, aligning training programs and standards of care, and integrating private sector data into national HMIS. Furthermore, it enables the integration of community health workers into the broader health system, maximizing their impact and contribution to improving health outcomes and strengthening primary healthcare.

Family Planning Digital Tools: A Comprehensive Evaluation

The Problem

Analyzing the Resources

Tools With High Quality Content

9Ja Girls LLH Guidebook

9Ja Girls Big Sista Chatbot

C4C Chatbot

Leveraging What Works

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The Consumer as CEO

Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

Building community health worker capacity to deliver malaria care

Taking a market-based approach to scale sanitation in Ethiopia

Promoting self-managed care like Self-testing and Self-Sampling

Using peer coaches to counter HIV stigma in South Africa

simplifying consumers’ journey to care in Vietnam

Engaging the private sector for disease surveillance in Myanmar

Training health workers in Angola

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