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.
In Bangladesh, the power of health in every mother’s hand
Bernard Christopher Halsana
Deputy Director Dnet
The information below appeared in the original case study.
Government of Bangladesh
Dr. Ananya Raihan
Client, Health Care Provider, Health System Manager, Data Services Provider
Services and Applications, Infrastructure
This case study was originally published in the mHealth Compendium Special Edition 2016, developed by the African Strategies for Health project, implemented by Management Sciences for Health with support from the U.S. Agency for International Development (USAID). Updates to the original case study, submitted by the implementing organization in March 2021, appear in the final section of this case study.
Aponjon (meaning “dear one(s)” in Bangla) aims to help to substantially reduce maternal and newborn deaths by improving health-seeking behaviors and preventive care among pregnant women, new mothers, and their families.
The Mobile Alliance Maternal Action (MAMA) program launched nationally in December 2012. A Bangladeshi social enterprise, Dnet, implements Aponjon in partnership with the Ministry of Health and Family Welfare (MOHFW) and with support from the US Agency for International Development.
Although under-five child mortality has decreased considerably in Bangladesh, neonatal mortality has decreased at a slower rate, with neonatal deaths a larger share of infant mortality. Greater progress was needed at that stage. Given that newborn survival and health are intrinsically linked with the health of women before conception, during pregnancy, and around the time of birth, and recognizing limitations in human resources for health, Aponjon developed as a mobile-based behavior change communication (BCC) program to increase health-seeking behavior at the household level and use of health facilities to prevent neonatal deaths.
The service is designed for women between 6 and 42 weeks of pregnancy and mothers with a child under one year of age. It features critical health information and reminders based on gestational stage and age of baby in the form of text and voice messages. The messages also address “gatekeepers” such as the women’s partners, mothers, and mothers-in-law. In addition, Aponjon also launched a mobile application “Shogorbha” for pregnant women and redesigned its website as a host of web services.
Globally, Aponjon is a unique mHealth initiative because it functions through all of the country’s telecom operators—six. About 81% of Aponjon users are from rural areas; 60% of women users have their own mobile phones. Technology stakeholders in the program include the telecom operators and value added services platform aggregator.
Aponjon has two major components: content (voice/ text) and call center (counselling). The primary audience (expecting and new mothers) are delivered two messages, either by SMS or interactive voice response (IVR), a week while the secondary audience (partners, in-laws, parents, etc.) receive one, with each message costing about US.03 cents. The voice messages are a mix of direct messages and mini-skit messages, with local actors playing the roles of a doctor, pregnant woman, mother, and mother-in-law. Gatekeepers’ information reinforces messages provided to the mother and encourages family involvement in healthy decision-making around pregnancy, birth, and infant care.
All Aponjon content complies with the government’s BCC guidelines. Content is identified, designed, and adapted based on ethnographic research; semi-structured content surveys; a review of national guidelines and international literature on maternal, newborn, and child health (MNCH); and an expert review by a panel of Bangladeshi physicians, researchers, and communications professionals. Followed by feedback from BabyCenter, the messages are approved by the Information, Education, and Communication (IEC) Committee of the MOHFW. The service is available in Bangla and two local dialects. Aponjon also offers a counseling line to subscribers, serving as a direct channel to communicate with a doctor about health problems. Aponjon partners with the field forces of BRAC, Infolady (Dnet’s program), MaMoni, Social Marketing Company, Smiling Sun, and several local nongovernmental organizations and agencies for customer acquisition. Customers can also register themselves, and provide information to ensure that the messages are in sync with the gestational stage or baby’s age. Users are also able to select a preferred time of day for message delivery so that the message is received when it is most convenient.
Dnet carried out extensive formative research from September 2011 through May 2012 before launching the service nationally. The research included 1,403 subscribers from five divisions, including 349 pregnant women (25%), 575 mothers of children under age one (41%), and 479 other household decision-makers (e.g. husbands, mothers-in-law) (34%). Areas of interest included: gender and mobile phone ownership; effective strategies for enrollment and promoting user awareness; acceptable cost models; user satisfaction of the content and tech platform; influence of content on MNCH-related health-seeking behaviors; and the involvement of family members in the service. Data collection included a pretest focus group, registration forms, deregistration data, payment status data, structured interviews, field observations, and phone surveys. The Johns Hopkins School of Public Health mHealth Initiative jointly produced a report with Dnet that examines and analyzes Dnet’s formative research.
Aponjon conducts widespread bi-annual phone surveys. Apart from tracking health-seeking knowledge and practice indicators, the surveys query users if the service benefitted them and what could have been done better in terms of content and design of service delivery.
Aponjon received support from the Access to Information Program II (A2I-II) hosted by the Prime Minister’s Office, which facilitated coordination among various government agencies for the program. Aponjon actively participates in the district health information system initiative of the Directorate General of Health Services-Management Information Services office and has already streamlined its system data landscape.
Another important public sector contribution comes from the Bangladesh Telecommunications Regulatory Commission (BTRC), which helped secure approvals for differential charging and approved the short code and Aponjon counselling line. Aponjon’s partners in the private sector have also included Johnson & Johnson, Agora, Lal Teer, and Beximco which contributed through corporate social responsibility (CSR) funds and sponsorships and helped in brand propagation. Telecom operators also complied with the mode of differential charging and made it possible for Aponjon to reach people across the socioeconomic spectrum.
On the technical side, SSD-Tech provides the technical platform for service delivery with “MT charging,” meaning clients are charged when messages are received. Synesis IT serves as the call center service provider that developed a customer relationship management system and a separate system for the counseling line.
After the national launch, Aponjon acquired 100,000 subscribers by July 2013. The subscriber base hit 750,000 in August 2014, 1 million in September 2014 and 1.5 million in December 2015. In addition to standard SMS and IVR, the service has made content available through a mobile application, “Shogorbha”, for pregnant women. Aponjon aims to reach 2 million subscribers by September 2016 and launch newer products.
During its pilot phase, Aponjon served 1,403 subscribers in a few urban and rural areas across five divisions of Bangladesh. A core research team had evaluated various aspects of the service before national roll-out. Community health workers from BRAC and USAID’s MaMoni project assisted in enrolling most of the initial subscribers. Popular campaign strategies were executed in select urban locations and their contribution in the overall growth of subscription was reviewed. Using local leaders and spokespeople to increase awareness of Aponjon while also forging greater trust in the brand, building partnerships with more community-based organizations, including more detailed messages on nutrition, arranging for refresher trainings for call center agents and initiating a ticketing system for better management of service issues by vendors are some major pilot phase outcomes that paved the way to a large-scale implementation.
Dnet uses innovative financing models, leveraging CSR funding at local and global levels, and providing the service for the poorest subscribers free of charge while charging the better-off users the full price. Dnet also uses advertising and sponsorship donations. Aponjon is financed primarily though support from development agencies (88%), namely USAID. The next largest portion of Aponjon’s funding comes from local CSR (7%), followed by the Sponsor-a-Ma campaign (4%). Together, user fees and fees charged to companies interested in using the messaging for advertising make up slightly less than 1% of Aponjon’s funding.
Aponjon has faced some vital challenges in the process of scaling up its operations. Lack of funding for above-the-line campaigns crippled the program’s ability to sustain its brand communication efforts. In spite of co-branding efforts with products of high rural market penetration, the program never overcame the need for launching above-the-line campaigns as the rate of self-registration was persistently low. Also, mostly due to the former, Aponjon had to heavily rely on customer acquisition led by community-based agencies that had to be paid more than some leading nongovernmental organizations.
Aponjon conducts periodic surveys to understand the impact of the intervention and to gather feedback for further modification of the service. Annual sample surveys have been conducted since 2013 to understand how the service impacted users both in knowledge and practice, if at all. Reasons behind non-compliance with content instructions and the process of and barriers to behavioral changes are explored. Two sample surveys have been done so far, reaching 799 expecting and new mothers. These surveys revealed that about half (54%) of Aponjon users are first-time mothers, while 66% of them reported having been actively using some form of family planning. About 14% of users reported to have spaced previous births by at least 3 years. When users were asked about their level of satisfaction with Aponjon services, 91% indicated they were “satisfied” and 35% gave the services the highest possible rating.
Aponjon also conducted a content survey in 2013 to better understand user acceptability and comprehensibility of messages received. A total of 335 women and 88 gatekeepers were interviewed. User feedback and preferences on message length, content type, message frequency, and usability were translated into actionable recommendations. Some of the major actions based on findings included the introduction of content in two major local dialects, incorporation of content specific to the rural version, and advanced messages on pregnancy care and home remedies.
Aponjon performs regular bi-annual phone surveys to track the status of 11 health milestone indicators, including antenatal and postnatal care visits, exclusive breastfeeding, and BCG (TB) vaccination, and to gauge customer satisfaction and loyalty through net promoter scores. The outcomes of these health indicators are then compared to national level values (see Figure 2 below).
A third-party mixed methods evaluation of the program was conducted by the USAID-funded TRAction project. Results indicated that respondents who had used Aponjon for a minimum of six months, received at least three messages per month and carefully listened to most of the messages showed both increased knowledge and practice of maternal and newborn health care. Study recommendations included that the program should emphasis continued use of services for a longer duration, and to explore reasons for not receiving or carefully listening to all messages (Chowdhury, 2015). Other findings indicated that some non-eligible clients were registered by agents, and also that users demanded another service on early childhood development. Based on this research, Aponjon formed an in-house quality control unit and content for early childhood development is being developed.
One of the main challenges Aponjon faced was to gather all mobile network operators under one umbrella. Given that Grameen Phone was the only operator during the pilot, areas such as Chittagong—which had low Grameen Phone coverage—had much fewer subscribers. After a lengthy process of negotiation and technological integration with each operator, four operators were added before the national launch.
Receiving the right and disaggregated service delivery metrics from the technology platform vendor SSD-Tech posed another challenge for the program. Aponjon needed to be able to track message acceptability by content area and monitor fluctuations of deregistration by exposure to content.
Over the last two years, revenue from local CSR funds has decreased alarmingly as local companies are increasingly channeling their CSR funds through in-house charity foundations. This tendency has limited the program’s ability to extend the service to ultra-poor families for free.
Aponjon devised a workaround, where possible, to each of the abovementioned obstacles. Soon after the pilot, the team built on the partnership with the BTRC and brought all six of the country’s telecom operators (including the state-owned Teletalk) aboard. Dnet redesigned service metrics and ensured routine tracking of service delivery based on disaggregated measures. Lastly, the decline in CSR funding from local companies has been tackled with increased sponsorship and fundraising efforts globally. Prior to its dissolution in December 2015, MAMA helped Aponjon broker instrumental partnerships with international donors and corporations such as Johnson & Johnson. Johnson & Johnson offered sponsorships covering the entire service package for over 5,000 mothers in fiscal year 2015-16.
Although the initial program delivery commitment was for 500,000 expecting women and pregnant mothers, Aponjon went on to cater to over 1.6 million subscribers to date. This is not only due to support from USAID but also because of partnerships across the public and private sectors that Aponjon has forged over the years. Furthermore, some major outgrowths from the initial structure of project deliverables are as follows:
Aponjon, based on a tested sustainability model approved by USAID, will transform into a for-profit business called Lifechord. All organizational formalities and legal paperwork have been completed. Initial capital for Lifechord includes program income from non-USAID funds, CSR funds, and Dnet’s own investment. Lifechord will be able to explore radical cost-cutting and income-generation options beginning with the launch of Dnet’s own technology platform in March 2016. This marks an important transition in the program; running the service from its own technology platform means greater control over service delivery metrics, stronger negotiation with mobile network operators as a content provider, as well as opportunities for generating revenue from diverse service innovations. This systemic changeover will translate into efficiency gains, broader developmental leeway, and fewer challenges to exploring new market segments and replicating in different contexts.
However, as an initially donor-funded program, one major roadblock to working out the current transition and sustainability plans is the limited opportunity to attract angel and impact investors, as investments arising from such initiatives cannot be declared as assets for LifeChord going forward. Therefore, Aponjon has been busy crafting its service portfolio with new developments paving a way to diverse revenue-generating activities.
Activities recently launched or in development include:
Aponjon (meaning “dear one(s)” in Bangla) aims to help substantially reduce maternal and newborn deaths by improving health-seeking behaviors and preventive care among pregnant women, new mothers, and their families. Aponjon, established under the Mobile Alliance Maternal Action (MAMA) program, launched nationally in December 2012. A Bangladeshi social enterprise, Dnet, implements Aponjon in partnership with the Ministry of Health and Family Welfare (MOHFW) and with support from the U.S. Agency for International Development (USAID).
Project updates include the following:
A. Completed project phase/funding phase: MAMA Bangladesh, widely known as Aponjon, was funded by USAID. The funding phase was completed in August 2018, and Aponjon now runs on its own income, with no further USAID funding. From the very beginning, Aponjon mHealth (SMS/IVR) service was designed to be connected to all the telecom operators in Bangladesh. Service is integrated with the operator with a revenue-sharing model in which revenue is generated from content delivery (regular service). For regular service, client registration is free, and a charge of $0.03/content is applicable only when the client receives content. Aponjon is able to maintain this price model for clients with subsidies.
Besides regular service, Aponjon uses innovative financing models, leveraging Corporate Social Responsibility/philanthropic funding at local and global levels. Service is provided free of charge for the poorest subscribers while charging the better-off users the full price sponsoring a mother at $0.05/content on an average. In 2016, Aponjon provided pregnancy-related health content to rural, marginalized pregnant women with the support of BACHAO, a US-based nonprofit organization. From 2017 to 2020, Aponjon provided health content service to Nobo Jatra Beneficiaries, a project of World Vision Bangladesh. In 2020, Aponjon provided COVID-19 awareness content to project beneficiaries and stakeholders. In 2017 and 2019, in partnership with Selfless, a registered charity organization in England and Wales, Aponjon provided pregnancy content in Sylhetti dialect. From 2018 to 2020, Aponjon provided nutrition-focused health content to beneficiaries of Strengthening Multisectoral Nutrition Programming (MSNP) through Implementation Science, a project of FHI360.
B. Aponjon Shoishob service launched: Aponjon Shoishob service launched in September 2019. It is an IVR/voice OBD (outbound dialing) and SMS-based mHealth service that provides important weekly health messages to parents of children ages 1 to 5 years. It aims to disseminate vital lifesaving and health-related behavioral change communication (BCC) messages for improving child health and safety.
For each child, the subscriber receives two BCC messages per week, for a period of four years maximum (from age 1 up to age 5). The messages are aligned to children’s age-specific needs, aiding users in making informed decisions about their children’s health and well-being. BCC messages focus on common childhood diseases, nutrition, growth and development, child’s social orientation, accidents and abuse, and good parenting practices. In addition, the service also features a 24/7 doctor’s line for immediate, expert medical advice on demand on child health issues.
The Contents Category:
Service Delivery Flow:
After the project period, no marketing and promotional activities were done yet, as of March, 2021, the currently active clients of the Shoishob service number more than 10,000.
C. Aponjon Koishor mobile App: Launched in April 2016, Aponjon Koishor is a mobile app in Bangla, designed for adolescents. The app contains topic-specific information on physical and mental changes adolescents commonly experience, their interests and curiosities, how to deal with relationships with friends and family and other social issues, reproductive system, sexually transmitted diseases, HIV, thoughts before and after marriage, family planning, pregnancy, issues during pregnancy and after the birth of the baby, and many more.
Target Groups: (1) Adolescent boys and girls (ages 10-19) and (2) Parents of the adolescent.
Feature of the mobile app
D. Aponjon Shogorbha mobile app versioning: An upgraded version of the mobile app for pregnant women released in July 2019. The modification includes the following:
E. Contribute to the MNCSP project:
After completion of the MAMA Bangladesh project, Dnet got the opportunity to serve as the technology partner for MaMoni—Maternal Newborn Care Strengthening Project (MaMoni MNCSP) of Save the Children Bangladesh with the support of USAID. Under this project, Dnet is providing prenatal and antenatal care reminder SMS to the beneficiary of MNCP project at Madhobpur Upazila in Habiganj District using the SMS delivery platform. This SMS-based reminder service started in June 2019 and had an internal survey in December 2019 to gain insight into the effectiveness of the intervention. In 2021, the service will be expanded to the whole Habiganj District and in one upazila in the Noakhali District. Upon the success of these pilots there is opportunity to scale up in other districts in the coming years.
Original Case Study
2. Bangladesh Demographic and Health Surveys 2014 http://www.niport.gov.bd/wp-content/uploads/publication/1432536472-BDHS%202014%20KIR.pdf
3. Health Workforce Crisis in Bangladesh https://everyone.savethechildren.net/articles/health-workforce-crisis-bangladesh
4. MAMA Bangladesh: Lessons Learned on the Way to 500,000 Subscribers. http://mobilemamaalliance.org/sites/default/files/BangladeshCaseStudy2014.pdf
5. Chowdhury, Mahbub Elahi. Key Findings Presentation: Evaluating accessibility, acceptability and effectiveness of Aponjon mobile health messaging for improved maternal and newborn health behaviors and practices in Bangladesh. September 2015. http://www.tractionproject.org/resources/keyfindings-mama-study-traction-supprted-study-conducted-international-center-diarrheal