Family Planning Digital Tools: A Comprehensive Evaluation

By Eden Demise, Research Associate, Strategy & Insights, PSI; Alexis Coppola, Sr. Program Manager, SRH, PSI; Alexandra Angel, Technical Advisor, SRH, PSI; and Kristen Little, Sr. Research Advisor, Strategy & Insights, PSI

In 2020, for the first time, over half of the world’s population were using mobile internet. Three-quarters of these users lived in low-and middle-income countries. Given the increase in internet connectivity globally, the use of digital technologies is one of several promising High Impact Practices (HIPs) in family planning, providing new opportunities to advance digital self-care, and make headway towards achieving universal health coverage.

The Problem

Currently, there is a growing range of resources available on effective digital interventions, including the HIP brief on Digital Health for Social and Behavioral Change and the HIP enhancement briefs on Digital Health for Systems and Digital Health to Support Family Planning Providers (linked below). However, these resources are limited in helping governments, implementers, and donors identify which family planning and reproductive health tools have high-quality content.

Analyzing the Resources

To fill this evidence gap, FHI 360, under the USAID-funded Research for Scalable Solutions (R4S) project, conducted a digital family planning and reproductive health  tools landscape and content analysis to review and identify high-quality tools for adoption, adaptation, and scale-up.

The full analysis – as well as the nine recommended tools, are summarized in this brief (published December 2021), with more details available in this PowerPoint deck.

The recommended tools were highlighted in a webinar at the 2021 Global Digital Health Forum: So Many Tools: Which Ones to Choose? on December 8th, 2021. Register for the 2021 Global Digital Health Forum for free here to watch the webinar. You can also listen to a fire-side chat with some of the recommended tool owners here. These resources are designed for those interested in developing, funding, or implementing client-facing digital interventions and are intended to fill in the evidence gap on high quality family planning and reproductive health digital platforms.

Tools With High Quality Content

Among the nine short-listed digital tools, three were developed by Population Services International (PSI): Adolecent 360 (A360’s)’s 9Ja Girls Love, Life, and Health (LLH) Guidebook, 9Ja Girls Big Sista Chatbot, and Counseling for Choice (C4C) Chatbot. Taking advantage of mobile phone and internet access as an entry point, each of these three tools bring consumers a ‘click’ away from health information curated in a manner that makes it easy for them to access, digest, understand and apply to make informed health choices.

9Ja Girls LLH Guidebook

Snapshot of 9ja Girls Facebook Messenger

The LLH guidebook, developed under the A360 Nigeria project, is used to facilitate in-person and virtual classes and conversations via Facebook Messenger and WhatsApp, related to love, relationships, family planning and reproductive health.

This tool scored highest in six areas: complete list of modern methods, method effectiveness, duration of protection, dual method use (i.e., offers protection against HIV and sexually transmitted infections), discreteness, and menstrual health.
 
The 9ja Girls program currently has 40 LLH WhatsApp groups with 20-40 students in each group, facilitated using the LLH guidebook. The 9ja Girls Facebook Messenger, also facilitated by the LLH guidebook, receives an average of 1,300 messages per month and provided 159 referrals to in-network providers in 2021. The Facebook Messenger provides a safe space for girls to have private and confidential conversations with a provider, receive personalized on-demand  family planning and reproductive health  information and linkages to quality products and services.

9Ja Girls Big Sista Chatbot

A second A360 Nigeria tool, the Big Sista Chatbot, is an automated menu-based information tool developed via Facebook in 2020.

This tool scored highest in five areas: complete list of modern methods, duration of protection, dual method use (i.e., offers protection against HIV and STIs), discreteness, and menstrual health.

In 2021, the Big Sista Chatbot reached 849 unique users with personalized and actionable family planning and reproductive health information by linking clients to clinics and Facebook Direct Messenger, where clients receive referrals to 9ja Girls Centres. 

Snapshot of 9Ja Girls Big Sista Chatbot

C4C Chatbot
C4C places the consumer at the center of care and the experience, from provider-led interactions to conversations a user has with a digital chatbot​.

The C4C chatbot launched in 2020 is an interactive, user-facing tool designed to provide family planning and reproductive health information, including menstrual health to people where and when they want it, privately and securely. The C4C chatbot is a dynamic tool; users respond to questions about their unique preferences and needs in terms of FP, and the tool recommends 2-3 methods that best fit their stated preferences. The tool is accessible to users via Facebook and WhatsApp.

This tool scored highest in the following four areas: complete list of modern methods, duration of protection, return to fertility, and dual method (i.e., offers protection against HIV and STIs).

Since August 2020, over 10,000 individuals in Cote d’Ivoire have accessed this tool, and nearly 40% of those living in the capital city of Abidjan were referred to a clinic within the PSI network. To further contribute to a growing body of evidence on use of digital tools, R4S is currently conducting a mixed-method study evaluating why people use the chatbot, barriers and facilitators to the use of the chatbot and if users intend to seek family planning and reproductive health methods and services after interacting with the tool. Findings from this study will be used to refine the digital tool and scale-up to other countries.

Leveraging What Works

PSI has successfully utilized mobile technology to provide personalized, actionable information on family planning and reproductive health. Making use of popular messaging platforms such as WhatsApp, Facebook Messenger and microsites is part of PSI’s consumer-powered digital health approach – placing cultural context and accessibility at the forefront. One of our priority areas is to re-position PSI’s in-house learnings and digital solutions, including the A360 tools and C4C chatbot, as global goods to support and encourage all initiatives that bring us closer to universal health coverage.

If you are interested in adapting the A360 tools, contact: [email protected].  

If you are interested in adopting the C4C chatbot, contact: Alexandra Angel: [email protected].

Reference here the High Impact Practice Briefs mentioned in this article: 

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For over 50 years, PSI’s social businesses have worked globally to generate demand, design health solutions with our consumers, and work with local partners to bring quality and affordable healthcare products and services to the market. Now consolidating under VIYA, PSI’s first sexual health and wellness brand and social business, our portfolio represents the evolution from traditionally donorfunded projects towards a stronger focus on sustainability for health impact over the long term. Across 26 countries, the VIYA model takes a locally rooted, globally connected approach. We have local staff, partners and providers with a deep understanding of the markets we work in. In 2022, we partnered with over 47,000 pharmacies and 10,000 providers to reach 11 million consumers with products and services, delivering 137 million products. VIYA delivers lasting health impact across the reproductive health continuum, from menstruation to menopause. Consumer insights drive our work from start to finish. Their voices, from product exploration to design, launch, and sales, ensure that products not only meet consumers’ needs but exceed their expectations. The consumer is our CEO. 

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Digitalizing contraceptive counseling to reach rural women and girls in Ethiopia

By: Fana Abay, Marketing and Communications Director, PSI Ethiopia 

In rural Ethiopia, women and girls often face significant barriers in accessing healthcare facilities, which can be located hours away. Moreover, there is a prevailing stigma surrounding the use of contraception, with concerns about potential infertility or the perception of promiscuity. To address these challenges, the Smart Start initiative has emerged, linking financial well-being with family planning through clear and relatable messaging that addresses the immediate needs of young couples—planning for the lives and families they envision. Smart Start takes a community-based approach, utilizing a network of dedicated Navigators who engage with women in their localities. These Navigators provide counseling and refer interested clients to Health Extension Workers or healthcare providers within Marie Stopes International-operated clinics for comprehensive contraceptive counseling and services.  

In a significant development, PSI Ethiopia has digitized the proven counseling messaging of Smart Start, expanding its reach to more adolescent girls, young women, and couples. This approach aligns with the priorities set by the Ethiopian Ministry of Health (MOH) and is made possible through funding from Global Affairs Canada. The interactive and engaging digital messaging has revolutionized counseling services, enabling clients to make informed and confident decisions regarding both their finances and contraceptive choices. 

Clients who received counseling with the digital Smart Start tool reported a higher understanding of their options and were more likely to choose contraception (74 percent) compared to those counseled with the manual version of Smart Start (64 percent). Navigators also found the digital tool more effective in connecting with clients, leading to higher ratings for the quality of their counseling. 

By December 2023, PSI Ethiopia, working in close collaboration with the MOH, aims to reach over 50 thousand new clients by leveraging the digital counseling tool offered by Smart Start. This innovative approach allows for greater accessibility and effectiveness in providing sexual and reproductive health services, contributing to improved reproductive health outcomes for women and couples across the country. 

Building community health worker capacity to deliver malaria care

By: Christopher Lourenço, Deputy Director, Malaria, PSI Global 

Community health workers (CHWs) are critical lifelines in their communities. Ensuring they have the training, support, and equipment they need is essential to keep their communities safe from malaria, especially in the hardest to reach contexts. 

For example, in Mali, access to formal health services remains challenging, with four in ten people living several miles from the nearest health center, all without reliable transportation or access. In 2009, the Ministry of Health adopted a community health strategy to reach this population. The U.S. President’s Malaria Initiative (PMI) Impact Malaria project, funded by USAID and led by PSI, supports the Ministry with CHW training and supervision to localize health services.  

In 2022, 328 thousand malaria cases were recorded by CHWs); 6.5 thousand severe malaria cases were referred to health centers, according to the national health information system. 

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Beyond the observed interactions with patients, supervisors heard from community members that they were pleased that CHWs were able to provide essential malaria services in the community. And the data shows the impact. 

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Taking a market-based approach to scale sanitation in Ethiopia

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In Ethiopia, PSI leads the implementation of USAID Transform WASH (T/WASH) activity with consortium partners, SNV and IRC WASH. Contrary to traditional models that rely on distribution of free or heavily subsidized sanitation products, T/WASH utilizes a market-based sanitation approach. This approach creates sustainable and affordable solutions, by integrating market forces and supporting businesses to grow, while creating demand at the household level. 

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To share the journey to market-based sanitation, representatives of the Ethiopian Ministry of Health and the USAID Transform WASH team took to the stage at the UN Water Conference in 2023.

“Rather than relying on traditional aid models that often distribute free or heavily subsidized sanitation products, market-based sanitation creates sustainable and affordable solutions, integrating market forces and supporting businesses to grow.”  

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Promoting self-managed care like Self-testing and Self-Sampling

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Building upon the success and insights gained from our work with HIV self-testing (HIVST), PSI is actively applying this approach to better integrate self-care, more broadly, in the health system beginning with Hepatitis C and COVID-19. Self-testing has emerged as a powerful tool to increase access to integrated, differentiated, and decentralized health services, accelerating prevention, care, and treatment for various diseases, while also increasing health system resilience against COVID-19.

Here’s how we got there.

Seven years ago, the landscape of HIV self-testing lacked global guidelines, and only the U.S., the UK and France had policies in place that allowed for HIV self-testing. High disease burdened countries in low-and-middle-income-countries (LMICs) lacked evidence and guidance for HIVST despite major gaps in HIV diagnosis.

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Babylon’s AI symptom checker and PSI’s health provider locator tool captures real-time, quality data that supports health systems to plan, monitor and respond to consumer and provider needs. But for this data to be effective and useable, it needs to be available across the health system. Fast Healthcare Interoperability Resources (FHIR) standard provides a common, open standard that enables this data exchange.
PSI’s first consumer-facing implementation of FHIR was launched in September 2022 as part of the Babylon Symptom Checker project in Vietnam, enabling rapid alignment between PSI and Babylon’s FHIR-enabled client records systems. PSI already has several other consumer health FHIR implementations under active development in 2023, including PSI’s collaboration with the Kenya MOH to launch a FHIR-enabled WhatsApp national health line for COVID-19 health information. PSI will also look to adopt and scale health workforce-facing FHIR-enabled tools, such as OpenSRP2, which will be piloted in an SRH-HIV prevention project in eSwatini in partnership with Ona by the end of 2023.

— Martin Dale, Director, Digital Health and Monitoring, PSI

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By: Dr. Zayar Kyaw, Head of Health Security & Innovation, PSI Myanmar

Under a three-year investment from the Indo-Pacific Center for Health Security under Australia’s Department for Foreign Affairs and Trade (DFAT), PSI is enhancing disease outbreak surveillance and public health emergency preparedness and response capacities in Myanmar, Cambodia, Laos, and Vietnam. When PSI conducted a review of existing disease surveillance systems in Myanmar, it identified several gaps: although the Ministry of Health had systems in place for HIV, tuberculosis, malaria and other communicable diseases, they were fragmented, with different reporting formats and reliance on paper-based reporting. In addition, private sector case surveillance data were not routinely captured, yet private clinics and pharmacies are the dominant health service delivery channel in the country. This hindered effective disease prevention and control efforts.

Building on our extensive private sector malaria surveillance work under the BMGF-funded GEMS project in the Greater Mekong Subregion, PSI implemented a case-based disease notification system using social media channels to overcome the limitations of paper-based and custom-built mobile reporting tools. These chatbots, accessible through popular social media platforms like Facebook Messenger and Viber, proved to be user-friendly and required minimal training, maintenance, and troubleshooting. The system was implemented in more than 550 clinics of the Sun Quality Health social franchise network as well as nearly 470 pharmacies. The captured information flows to a DHIS2 database used for real-time monitoring and analysis, enabling rapid detection of potential outbreaks. Local health authorities receive instant automated SMS notifications, enabling them to promptly perform case investigation and outbreak response.

In 2022, private clinics reported 1,440 malaria cases through the social media chatbots, while community mobilizers working with 475 private providers and community-based malaria volunteers reported more than 5,500 cases, leading to the detection of two local malaria outbreaks. Local health authorities were instantly notified, allowing them to take action to contain these surges in malaria transmission. During the same time, pharmacies referred 1,630 presumptive tuberculosis cases for confirmatory testing – a third of which were diagnosed as tuberculosis and enrolled into treatment programs.

Training health workers in Angola

By: Anya Fedorova, Country Representative, PSI Angola  

The shortage of skilled health workers is widely acknowledged as a significant barrier to achieving Universal Health Coverage. To address this challenge, PSI supported ministries of health to develop a digital ecosystem that brings together stewardship, learning, and performance management (SLPM). The ecosystem enhances training, data-driven decision-making, and the efficiency of healthcare delivery.

Here’s what it looks like in practice.

In July 2020, PSI Angola, alongside the Angolan digital innovation company Appy People, launched Kassai, an eLearning platform that targets public sector health workers in Angola. Through funding from USAID and the President’s Malaria Initiatve (PMI), Kassai features 16 courses in malaria, family planning, and maternal and child health – with plans to expand learning topic areas through funding from ExxonMobil Foundation and private sector companies. A partnership with UNITEL, the largest telecommunication provider in Angola, provides all public health providers in Angola free internet access to use Kassai.

Kassai’s analytics system to follow learners’ success rate and to adjust the course content to learners’ performance and needs. Kassai analytics are integrated with DHIS2 – the Health Management Information System (HMIS) of Angolan MOH, to be able to link learners’ knowledge and performance with the health outcomes in the health facilities.  The analytics track learners’ performance by course and gives visibility by health provider, health facility, municipality, and province. Each course has pre-and post-evaluation tests to track progress of learning, too.

By the end of 2022, there were 6,600 unique users on the Kassai platform and 31,000 course enrollments. PSI Angola’s partnership with UNITEL, the largest telecommunication provider in Angola, allows for free internet access to learn on the Kassai for all public health providers in Angola. Building on its success for malaria training, Kassai now also provides courses in family planning, COVID-19, and maternal and child health. This reduces training silos and provides cross-cutting benefits beyond a single disease.

Implementing the SLPM digital ecosystem brings numerous benefits to health systems. It allows for more strategic and efficient workforce training and performance management, enabling ministries of health to track changes in health workers’ knowledge, quality of care, service utilization, and health outcomes in real time. The ecosystem also supports better stewardship of mixed health systems by facilitating engagement with the private sector, aligning training programs and standards of care, and integrating private sector data into national HMIS. Furthermore, it enables the integration of community health workers into the broader health system, maximizing their impact and contribution to improving health outcomes and strengthening primary healthcare.

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The health of PSI’s consumers is inextricably linked to the health of our planet. That’s why we’ve joined the Climate Accountability in Development as part of our commitment to reducing our greenhouse gas emissions by 30 percent by 2030. Read about our commitment to environmental sustainability.

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Zero Tolerance for Discrimination and Harassment

PSI is committed to establishing and maintaining a work environment that fosters harmonious, productive working relationships and encourages mutual respect among team members. Read our policy against discrimination and harassment here.

PSI is committed to serving all health consumers with respect, and strives for the highest standards of ethical behavior. PSI is dedicated to complying with the letter and spirit of all laws, regulations and contractual obligations to which it is subject, and to ensuring that all funds with which it is entrusted are used to achieve maximum impact on its programs. PSI provides exceptionally strong financial, operational and program management systems to ensure rigorous internal controls are in place to prevent and detect fraud, waste and abuse and ensure compliance with the highest standards. Essential to this commitment is protecting the safety and well-being of our program consumers, including the most vulnerable, such as women and children. PSI maintains zero tolerance for child abuse, sexual abuse, or exploitative acts or threats by our employees, consultants, volunteers or anyone associated with the delivery of our programs and services, and takes seriously all complaints of misconduct brought to our attention.

OUR FOCUS

Diversity and Inclusion

PSI affirms its commitment to diversity and believes that when people feel respected and included they can be more honest, collaborative and successful. We believe that everyone deserves respect and equal treatment regardless of gender, race, ethnicity, age, disability, sexual orientation, gender identity, cultural background or religious beliefs. Read our commitment to diversity and inclusion here. Plus, we’ve signed the CREED Pledge for Racial and Ethnic Equity. Learn more.

OUR COMMITMENTS

Gender Equality

PSI affirms gender equality is a universal human right and the achievement of it is essential to PSI’s mission. Read about our commitment to gender equality here.

Cover

01 #PeoplePowered

02 Breaking Taboos

03 Moving Care Closer to Consumers

04 Innovating on Investments

ICFP Q&A:
Let's Talk About Sex

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