As low- and middle-income countries transition from paper to digital systems, family planning programs can benefit from unprecedented opportunities to improve services. Investments in digital health tools have expanded exponentially, but information on what works—and what does not— remains limited and scattered. As investments have increased, digital applications and data fragmentation have proliferated, but stakeholders are moving towards more coordinated efforts to scale digital health solutions, support countries’ digital health infrastructure, and share evidence-based learnings.
This Digital Health Compendium enables users to explore case studies across a range of digital health technologies used to enhance family planning programs mainly in sub-Saharan Africa, but also in other regions of the world. Digital health applications in family planning programs can be broadly classified as those affecting demand generation, service delivery, supply chain management, and the policy and enabling environment. In many low- and middle-income countries, digital health innovations were adopted earlier in other health sectors, including HIV/AIDS, maternal and child health, and noncommunicable disease prevention and response. As a result, much of the impact evidence is likewise restricted to those sectors. To advance greater adoption of digital technology in family planning programs, more data and information on the challenges, opportunities, scalability, and results are needed. This compendium aims to consolidate emerging information and data on applications of digital technology in family planning programs to inform adoption and scale-up of successful approaches.
All of the case studies were submitted by the implementing organizations and include a description of the digital health intervention, program context, and, if available, important findings and lessons learned through rigorous evaluations or program data. The compendium facilitates a quick search for case studies based on the target user for digital health intervention, building block for the digital health enabling environment, family planning program classification, and country location. The case studies give policy and program decisionmakers insights on real-world applications of digital health, promising practices, challenges, and other lessons that can be applied to current and future programs.
A digital approach to complement in-person clinical training of family planning providers
Digital Health Adviser
Abt Associates (prime)
Viamo (subcontractor for platform management)
August 2019 – August 2020
Nigeria: Federal Capital Territory, Oyo, Akwa Ibom, Plateau
Health Care Provider, Data Services Provider
There are approximately 35 million women of reproductive age (15 to 49 years) in Nigeria; however, only 12 percent of married women within this age group are using modern family planning (FP) methods (Nigeria Demographic Health Survey 2018). Increased use of modern FP methods could help reduce the high maternal mortality rate in Nigeria. To increase the modern contraceptive prevalence rate (mCPR), the Nigerian government developed a task-shifting, task-sharing policy that allows community extension health workers (CHEWs) to include long-acting and reversible contraceptives in their FP service provision. The U.S. Agency for International Development (USAID) funded Sustaining Health Outcomes through the Private Sector (SHOPS) Plus project supported task-shifting to a lower cadre of clinical providers by offering updated training tailored to CHEWs. SHOPS Plus also offered in-person follow-up to all of its newly trained providers across four supported states in Nigeria (Federal Capital Territory, Oyo, Akwa Ibom, Plateau). However, FP providers requested additional resources that were more accessible than a highly technical, paper-based FP manual.
To complement and extend the existing training and follow-up with newly trained providers, SHOPS Plus developed audio job aids for FP providers that could be accessed through interactive voice response (IVR) messages on-demand and through regularly scheduled biweekly calls.
Through user-centered problem-specification and solution design workshops with FP providers in Nigeria, SHOPS Plus identified two additional channels of training reinforcement: 1) on-demand audio job aids that FP providers could call at any time to select and listen to key technical messages on FP topics of interest, and 2) a schedule of voice-recorded content that SHOPS Plus could routinely push to FP providers to maintain engagement, remind providers about best practices, and monitor knowledge, attitudes, and self-reported practices. These two approaches were selected because they met the needs of CHEWs who could access this information using basic phones— since many did not have smartphones or wifi (rendering mobile apps and websites inaccessible). Further, the on-demand approach was selected because it was sustainable beyond the duration of the SHOPS Plus project.
To implement this intervention, SHOPS Plus partnered with Viamo to leverage the existing 3-2-1 platform with the Airtel network operator. Viamo is a social enterprise that specializes in using IVR, short message service (SMS), Random Digit Dialing, and unstructured supplementary services data (USSD) to support partners with behavior change communications and evidence-gathering via simple mobile phones. The 3-2-1 platform is accessible for free to anyone in Nigeria with an Airtel SIM card and it already offered on-demand voice recordings on health topics, including general FP, for beneficiaries. All informational content on the platform is developed in partnership with local experts, developent organizations and apporopriate government agencies. In Nigeria, on average, the health messages are accessed 35,000 times each month. SHOPS Plus developed and validated FP curriculum-based content with FP providers and posted 38 key messages, which providers can listen to for free by navigating through an interactive menu. The menu topics for FP providers include: counseling, general FP information, safety and documentation, short-acting methods, long-acting methods, and pelvic exam.
In addition to the on-demand component, SHOPS Plus pushed key messages and quizzes to all clinical providers on a weekly basis (one key message and one corresponding quiz per week). Messages were pushed to providers’ primary phone numbers on any network. This gave SHOPS Plus the opportunity to continuously engage with providers and to monior whether clinical providers were retaining the technical knowledge and applying it in practice.
SHOPS Plus posted content to the 3-2-1 on-demand platform and began pushing bi-weekly key messages and quizzes in mid-2019. In total, there are 38 key messages available on 3-2-1 and 34 weeks of push content, which is recycled at the end of the 34 weeks. SHOPS Plus trained 931 providers and assigned Airtel SIM cards through which providers can access 3-2-1 for free. Trained providers were also all added to the schedule of bi-weekly push messages.
As of April of 2020, 62,094 messages and quizzes had been sent to all FP providers and trainers across the four states in Nigeria. On average, 65 percent of providers picked up the call and 41 percent completed the call. Of those picking up the call, approximately 70 percent attempted quizzes, and of those, 92 percent answered correctly. These quizzes helped to identify where providers struggled with technical content but also indicated that providers were generally able to understand the concepts and apply them. Because all providers were pushed content, there was no control group that only received in-person training and therefore it is not possible to measure the impact of the messages.
The on-demand 3-2-1 platform received more than 9,000 calls from Nigerians trying to access technical FP information but only a fraction of these were FP providers with the secret code who could access the content. Among FP providers, counseling topics were most popular, including information on gender bias and gender-based violence. The content describing the steps of a pelvic exam was the least popular. Overall, provider engagement was much stronger with the push content and quizzes than it was with 3-2-1.
In qualitative interviews at the end of the project, FP providers lauded the audio job aids because of their ability to “reawaken memory” and “boost confidence in service provision.” One female community health extension worker said, “3-2-1 wow! A platform whereby I easily have access to any information on family planning methods instantly. I so much like it because the information is straight to the point without delay.” However, usage of the on-demand platform was lower than anticipated, possibly because providers were already receiving biweekly key messages and quizzes pushed to them.
Although SHOPS Plus will discontinue push messages and quizzes when it closes in 2020, the on-demand content will remain available for free to providers indefinitely via the Airtel/Viamo 3-2-1 platform. The technical content that SHOPS Plus developed and recorded will be shared with other implementing partners who will adapt it and push it to their FP providers. In this way, the SHOPS Plus team ensures the sustainability and reusability of the content.