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.
An award-winning, automated, interactive, and on-demand short message service (SMS or text message) system that provides simple, accurate, and globally relevant information on reproductive health
Associate Director, Research Utilization
This was developed by FHI 360 but has since been shared with multiple organizations via license agreements.
2009 - 2010
m4RH was originally piloted in Kenya and Tanzania. It was adapted in Rwanda, though it was ultimately integrated into a separate digital intervention. It is available in Tanzania as part of the government system, as well as within Viamo’s 3-2-1 service in Tanzania, Uganda, and Afghanistan. It is also available in Malawi.
Services and Applications
One of the biggest barriers to the use of contraception and other family planning methods continues to be lack of adequate, accessible information. Misinformation and lack of information often leave concerns about side effects and opposition to contraception unaddressed. People may also want to be discreet when asking questions about contraception. As mobile phone ownership and use continue to rise globally, disseminating family planning information through mobile phones presented itself as a promising solution to the unaddressed needs. Mobile for Reproductive Health (m4RH) was developed to provide easily accessible information on family planning methods and to connect people to nearby family planning counseling and services.
m4RH is an SMS, or text message-based, health information service that began in two countries over a period of seven years, and has been adapted and scaled to new population groups and new countries. m4RH was originally developed as a free text message-based service that describes the benefits, common family planning method misconceptions and barriers, and side effects of nine family planning methods. In some instances, it also provided a searchable database of clinics that offer family planning counseling and services as well as role model stories or story installments modeling positive health attitudes, norms, and behaviors. FHI 360 designed and developed m4RH content in 2009–2010 using best practices for health communication by engaging country-specific target audiences; identifying their attitudes, needs, and practices related to contraception; and creating and testing targeted messages to meet those needs based on global and country-level family planning guidance documents, such as the World Health Organization Family Planning Handbook. m4RH consumers are only sent content that they request, which also raises the level of interest and engagement with the individual receiving the content. FHI360 originally partnered with the technology non-profit, Text to Change, to build the technological system, and with ministries of health and multiple public health partners to promote the service.
One of the first mobile phone interventions for reproductive health, m4RH was developed in 2009 as part of a pilot study in Kenya and Tanzania. The pilot originally provided only the most basic and essential information about family planning as well as information on the location of clinics. The content has since been adapted for young people aged 10 to 24 in Rwanda, Tanzania, and Uganda with additional topics, including puberty, sex, pregnancy, healthy choices, gender-based violence, and dual protection. m4RH has also partnered to integrate the content into other health information platforms, such as via interactive voice response in Afghanistan and Malawi. FHI 360 has made the m4Rh content available for free via a simple license agreement to half a dozen interested organizations operating around the world.
Initial m4RH feasibility and acceptability studies demonstrated that m4RH engages men and women of all ages, though more young people used the service. Through qualitative phone interviews, users reported finding the service helpful and trustworthy; they appreciated the on-demand nature of the service and its anonymity; some users reported changes in behavior, such as initiating a contraceptive method or talking with a partner about contraception. (L’Engle et al., 2013; Vahdat et al., 2013).
A total of 13,629 new m4RH users were enrolled in a randomized controlled trial (RCT) conducted in Kenya by Abt Associates in partnership with FHI 360, with funding from the United States Agency for International Development, between September 2013 and May 2014. m4RH consumers were sorted into a full-access group or a limited-access group, which was considered random assignment due to the high volume of consumers and large variations in SMS delivery times, considering the differences in network speed and coverage throughout the country. The full-access group received all content and services m4RH offered described above, and the limited-access group had access to the clinic locator and general motivational messages. Outcomes of interest included family planning knowledge gains, use of contraception by the participant or participant’s partner, any discussion of family planning with their partner, and any recent visits by the participant to a clinic for family planning consultations.
The average age of study participants was 25. About two-thirds (68.4 percent) were women and one-third (31.6 percent) were men. The study was conducted entirely through text message. Surveys were sent to each participant at three intervals: after 24 hours, after six days, and three months post-enrollment.
The RCT demonstrated a 13 percent improvement in family planning knowledge among m4RH users after three months, compared to a control group (Johnson, 2016). Participants reported better understanding of the correct use of various contraceptive methods and new understanding about side effects and dual protection. The program’s effects on behavior, such as using contraception or communicating with a partner about contraception, were minimal, which suggests that text messages alone may not be enough to propel a change within the complicated cultural and political environment of family planning.
m4RH has witnessed successful vertical, horizontal, and global scale-up due to its acceptability, potential for impact, and relative ease to understand and adapt. Data showed that important but hard-to-engage target audiences were reached by m4RH messaging with a positive effect on reproductive health knowledge. Although m4RH was designed at the height of the “age of SMS,” its evidence-based messages remain relevant and valuable and are now being integrated into interactive voice response and chat. Any organization wishing to access the content can contact FHI 360 to obtain the license agreement.