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 mobile job aid for community health workers in Tanzania to support family planning programs
Tanzania Ministry of Health and Social Welfare
January to July 2013
Health Care Provider, Data Services Provider
Services and Applications, Workforce
Family planning use protects the health of women and their children by spacing births, preventing unwanted or high-risk pregnancies, reducing the need for abortions, and preventing mother-to-child transmission of HIV/AIDS, ultimately leading to a reduction in maternal and child deaths. One critical determinant of adoption and continuation of contraceptives is overall client satisfaction with family planning programs. Therefore, provision of good-quality contraceptive services is vital to reducing unmet need for family planning.
In Tanzania, current contraceptive use is low; 34.4 percent of women of reproductive age use any form of contraception, and only 27.4 percent use modern contraceptive methods. Further, over a quarter of women report unmet need for family planning.
To address these low levels of contraceptive use, a pilot intervention using a mobile job aid was developed to guide community health workers (CHWs) to deliver integrated counseling on family planning, HIV, and other sexually transmitted infections (STIs).
Beginning in June 2011, FHI 360, Pathfinder International, and D-tree International developed the family planning algorithm in partnership with the Tanzania Ministry of Health and Social Welfare based on a combination of evidence-based tools, such as the Balanced Counseling Strategy Plus Toolkit. The job aid was developed to help CHWs counsel, screen, provide and refer clients for family planning, HIV, and other STIs. The pilot intervention and study were implemented with 25 CHWs in three wards in Ilala district in Dar es Salaam between January and July 2013, registering a total of 710 family planning users (455 continuing users and 255 new users) and counseling them on how to use the mobile job aid over the six-month intervention period.
All users were screened for current pregnancy, questioned on partner support for contraceptive use, counseled on a range of contraceptives, and screened for HIV/STI risk. Most new and continuing family planning users chose pills and male condoms (59 percent and 73 percent, respectively). Pills and condoms were provided by the CHWs at the community level. Referrals were made to the health facility for pregnancy confirmation, injectable contraceptives, long-acting reversible contraceptives, and HIV/STI testing. Follow-up visits with clients were planned to confirm completion of the health facility referral.
Since the initial pilot project was implemented, the system was rebuilt using the Logiak software platform and enhanced to include a more comprehensive workflow, supervisory system, citizen feedback reporting, and a pay-for-performance system. This updated system has been used by more than 400 CHWs in Tanzania with technical support from D-tree International, implemented by Pathfinder International and Shirati KMT Hospital.
Routine data collection and analysis was performed throughout the intervention, evaluating the performance of the program using the data collected to execute it. The key findings were:
Scale of Initiative
Over the six-month implementation period, 710 clients were registered and received family planning counseling using the mobile job aid: 455 clients (64 percent) who were already using some form of contraception (continuing users) and 255 (36 percent) who were not using any contraceptives (new users).
Some 455 clients who were already using contraception received a total of 1,044 follow-up visits from the CHWs over a period of six months. At the time of the first visit by the CHW, nearly 35 percent of the continuing users were using condoms and 38 percent were using oral contraceptive pills. Some 255 new clients received a total of 269 follow-up visits from the CHWs. The majority (n = 232) of clients stated they were planning to have a baby in the near future and were educated on short-acting contraceptive methods. The remaining clients were educated on long-acting contraceptives and permanent methods.
HIV Counseling and Services
All 710 clients received education, risk assessment, and pretest counseling for HIV and other STIs. The majority of both the continuing users (73 percent) and the new users (58 percent) said they had been recently tested for HIV. Among those who were willing to share their test results, 57 percent of the 276 continuing users and 54 percent of the 138 new users tested HIV-positive. The high percentage of individuals with HIV in the study is due to the fact that the mobile job aid intervention was piloted as part of Pathfinder’s community home-based care for people living with HIV/AIDS program.
Clients were referred to the health facility for services that could not be directly provided by the CHW at the community level. For example, 21 percent of new family planning users and 28 percent of continuing family planning users were referred for HIV testing/STI services. Of the clients who received referrals and follow-up by the CHWs, nearly 50 percent completed their referrals.
The use of mobile job aids for delivery of integrated family planning programs holds great promise. However, in order to scale effective programs, a critical appraisal and open discussion of the challenges and solutions is necessary. Implementing organizations must understand that mobile tools support the work of CHWs who still need proper and consistent training to be able to do their jobs well. These applications can serve as guides, encouragement, and reminders to follow up with their clients. In this pilot implementation, 25 CHWs were able to serve more than 700 clients with the appropriate family planning support, improving contraceptive usage and testing rates. Because of their success, these services were extended to a much wider population by upwards of 250 CHWs. The services available through the job aid were expanded to include free direct communication between clients and CHWs, as well as SMS reminders and a supervisory application and dashboard.