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.
Bridging the gap between family planning knowledge and behavior
Senior Program Officer
Institute for Reproductive Health, Georgetown University
The information below appeared in the original case study.
Georgetown University’s Institute for Reproductive Health leads a team that includes:
Indian Society of Healthcare Professionals
Fertility Awareness for Community Transformation project
Institute for Reproductive Health
Client, Data Services Provider
Services and Applications
This case study was originally published in the mHealth Compendium Volume 5, 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.
Does fertility awareness and family planning information impact attitudes and behaviors around family planning? Could knowledge increase the likelihood of family planning method uptake? Georgetown University’s Institute for Reproductive Health (IRH) has developed a two-part service to answer this question. The first service, CycleTel Family Advice, is a series of 65 educational short message service (SMS) texts on fertility, family planning, couples communication, and related topics. Messages are written as conversational stories and targeted by age, sex, and marital status. CycleTel Family Advice users can also access the second service, CycleTel Humsafar, a family planning method directly on their phone. Based on the Standard Days Method® (SDM), CycleTel Humsafar helps a woman identify which days during her menstrual cycle she is most likely to become pregnant and alerts her on fertile days.
IRH, in partnership with others, has followed a step-wise, systematic approach to CycleTel Humsafar development and pilot testing since 2010. Under the US Agency for International Development-funded FACT Project (2013-18), IRH and partners were able to design and develop the CycleTel Family Advice Service, and offer it at scale in India through a private sector partnership. Both services were made available to users starting in early 2015 and will be evaluated for behavioral outcomes.
IRH has partnered with Life Tools in India, a pre-installed application available on over 25 million phones in India. Integrating with the Life Tools application, CycleTel Family Advice Service and the CycleTel Humsafar services are now available in 12 local Indian languages and able to reach users at scale. CycleTel Family Advice will reach 350,000 users over 18 months and provide users with 15 weeks of content (users receive messages four times a week). These messages will contain stories that illustrate common situations in family planning and provide information on fertility and family planning topics. These stories have been pretested to ensure that they are culturally appropriate and engaging.
Content is delivered entirely through the Life Tools platform and at no cost to users. Users are also given access to a CycleTel Helpline so that they can access additional information. For the CycleTel Humsafar service, over 11 million Life Tools users have the opportunity to enroll in the CycleTel Humsafar service. CycleTel Humsafar first determines if a woman is eligible to use SDM by asking a series of screening questions. If eligible, she enters the date of her last period and the service informs her of her fertile days during the cycle. She receives alerts on her “unsafe days” throughout the month. To continue using the service, the user must enter her period date every month and complete the billing process to pay 10 INR. Additionally, through the Helpline number, trained counselors are available for one-on-one consultation over the phone.
CycleTel Family Advice was piloted with over 25,000 users in four languages in April 2014. Over 90 percent of users indicated that they learned something, and demographic questions indicated that over 50 percent of users were men, suggesting that this service is an effective way of engaging men in family planning. IRH has done extensive research on CycleTel Humsafar previously. Over 95 percent of users interviewed at exit reported that they received messages at an appropriate time and in an appropriate quantity, indicating that the technology worked as designed. When asked what they liked most about CycleTel, more than 80 percent of users reported appreciating its ease-of-use and the timely reminders. Nearly 90 percent of women and 80 percent of men interviewed said that they would recommend this service to others.
In 2015 and 2016, IRH will conduct extensive research on the two services at scale through phone surveys with new, continuing, and discontinued users and answer the following questions: Does CycleTel Family Advice improve knowledge and attitudes related to fertility awareness and family planning? Does it lead to adoption of family planning, including CycleTel Humsafar? How long do CycleTel Humsafar users continue SDM use? Do they use SDM correctly? Does it lead to uptake of other family planning methods? Answers to these questions and related system-generated data on conversion rates and continuation rates will drive product improvements in the future.
The complementary CycleTel services—CycleTel Family Advice and CycleTel Humsafar—are well positioned to increase access to both information on fertility and family planning and a direct-to-consumer family planning method. IRH’s partnership with Life Tools and its consumer pay model will test sustainable expansion of the service in 12 Indian languages and offer lessons for the mHealth field. For an mHealth service to be taken to scale, continuous iteration, investment, and partnership development is required for a sustainable service and strong user base.
The CYCLETEL Family Advice and CYCLETEL Humsafar projects have been complete since 2018. The projects’ life cycles only extended until 2017, with funding from USAID’s Development Innovation Ventures (DIV) office. The projects were testing a market approach for development solutions, and without substantial evidence that they could survive alone in the market, no additional funding was secured.
Overarching lessons learned from the project include the following:
Anticipate Changes in the Technological Landscape
Based on the expressed willingness of customers to pay for the service in formative research, IRH expected the service to be self-sustaining by 2017. The model would shift from a single-sided market relying on donors, to a double-sided market relying on donors and users, and finally to a single-sided market relying on users alone. However, over the years of implementation, the telecommunications sector changed dramatically. Unlike earlier stages of the mobile revolution, cell phone users no longer expect to pay for app-based services. They had become accustomed to using mobile services for free. For example, new users preferred to not pay to send a text to register for the service (a cost of 4 rupees), but rather, registered with the call center because calling the toll-free number is free. This led IRH to explore alternative partnerships, as was explained in sections above. In addition, smartphones began and continued to grow in India, particularly at the higher end of the market, which includes users who are most able to pay. As such, IRH began exploring user acquisition strategies and opportunities for market integration and scaling up the CycleBeads app under this project. The lessons learned, shared above, speak to the growth of the mHealth market in this direction.
Find the Right Partners
IRH also faced challenges in finding appropriate partners to reach customers. As mentioned above, in 2014, it partnered with the Indian telecommunications company HCL, which had developed an mHealth platform called Nokia Life, later rebranded as Life Tools. The platform was already sending health- and agriculture-related information to 50 million Indian mobile users. CycleTel had worked with HCL to add both educational messages related to fertility and family planning and CycleTel to HCL’s suite of apps. The partnership involved the use of the Nokia Life payment platform and a revenue sharing agreement. It was a sustainable model until the business relationship between HCL and Nokia shifted rapidly, influenced by an external partner. Some things are out of one’s control in program implementation, and in development venture projects, things can shift in ways development organizations cannot easily adapt to. Partner selection and thoroughness in understanding the systems that will be integrated together are important considerations to the success of a project.
“CycleTelTM: Expanding Access to Family Planning Via Mobile Phones”. (Washington, DC: Institute for Reproductive Health, Georgetown University for the U.S. Agency for International Development [USAID], August 2017),