ÁùºÏ¿ª½±¼Ç¼

Our challenge: How do we ensure families in India have timely information about childbirth, childcare and family planning, during pregnancy and in the first year of the child's life?

The innovation: High-quality health information and advice to Indian families - particularly in rural areas – through the growing use of basic mobile phones. Our human-centred design mobile health solution has been scaled to 17 states by the Government of India to empower families and frontline health workers to improve child mortality and maternal health.

Kilkari (a baby’s gurgle) is our mobile messaging service designed to reinforce frontline health workers’ counselling by delivering information to families to help healthier choices and lives. Combined with tools and training for frontline health workers – our Mobile Academy training course, and Mobile Kunji tool to support frontline workers in communicating with families - the service is strengthening this ‘last mile’ of the health system, to increase their knowledge, skills and confidence in communicating, and reinforcing their information. Aiding with all of this is the trusted voice of ‘Dr Anita', the fictional narrator across our suite of mHealth services – Mobile Academy, Mobile Kunji and Kilkari – providing health information, guidance and friendship to families across India.

Kilkari’s free, weekly, stage-based audio messages about pregnancy, childbirth, childcare and family planning are delivered directly to families’ phones as one pre-recorded call per week for 72 weeks, linked to the stage of pregnancy or child’s age and timed for the highest-risk periods, between the second trimester of pregnancy until the child is a year old. Available in five languages – Hindi, Bihari, Oriya, Assamese and Bengali – family mobile phones are automatically subscribed as soon as a pregnancy is registered in the government database.

Following two independent evaluations and analyses from Johns Hopkins University and Stanford University, now published in a special supplement of , here are the lessons we learned over a decade of digital development:

1.      Mobiles can provide access to health information at scale using appropriate technology

Kilkari is one of the world’s largest mobile maternal messaging services and has reached 24.6 million subscribers across 17 states. Mobile Academy is the largest mobile-based training programme for health workers in the world and has reached over 235,000 frontline health workers across 16 states in India. Amid low levels of smartphone access and ownership among women in low-income and low-literate settings, both services use IVR (Interactive Voice Response) technology to help overcome these challenges.

2.      Timed and targeted information can improve modern contraceptive use and immunisation

When Dr Anita gave advice on condom use, people listened: Those who listened to Kilkari were associated with a 3.7% higher use of modern reversible contraceptives; the number rose to 7.3% among those who heard 50% or more of Kilkari content, compared to non-listeners – largely driven by increased condom use. Effects were even larger for families with a male child (9.9% increase), in the poorest socioeconomic strata (15.8% increase), and in disadvantaged castes (12.0% increase). The evaluation also found higher rates of immunisation among infants at 10 weeks (2.8%).

3.      A relatively small amount of the relevant content, delivered at the right time, is a cost-effective way of saving lives

Seven Kilkari calls on reversible contraceptive methods, totalling just over 10 minutes and delivered direct to families’ mobile phones, had an effect on those families’ practices. Peer-reviewed analysis of our randomised controlled trial showed that Kilkari has saved nearly 14,000 lives (96% child lives and 4% maternal) and has been declared a highly cost-effective intervention, with the cost per life saved ranging from USD $392 to $953 depending on the intervention year.

4.      Design mHealth solutions with an equity lens to reach the poorest communities with mobile phone access

It’s important to think about how communities are using mobile phones, and when. The poorest subscribers, educated to at least secondary level, appear to have had the biggest equity gains from exposure to Kilkari, thanks to design decisions like the ‘retry’ algorithm – which tried mobile phone numbers at different times of the day, to reach families when they had time to listen.

5.      Subscription-based business models are challenging in low-resource settings

In the initial years, Kilkari subscribers were charged a nominal fee – but this user-fee model failed to cover marketing costs. Kilkari became a toll-free service in 2016 with call costs covered by the Government of India, enabling greater reach and impact.

6.      Digital interventions must be informed by gender intentional design

The gender digital divide in India, and the offline and online norms that create this divide, necessitate a gender-intentional, research-driven approach to designing mHealth interventions. We needed to understand who is left behind by digital interventions - and how to reach and impact those groups through alternate communication channels and platforms.

7.      Digital direct-to-beneficiary communications need to be complemented by a mix of other interventions to shift social norms and change deeply entrenched behaviours.

Despite advice that covered a full range of infant and childcare, Kilkari was not found to have had measurable impact on infant and young child feeding practices. Our evaluators found that practices under ‘normative influence’ – where families do not need to engage with the health system, like complementary feeding - saw more positive associations when communication tools like Mobile Kunji were used, providing opportunity for further discussion.

 --

This article was first written in November 2022 and updated in March 2023.

Kilkari is one of only five mHealth services globally to reach over one million subscribers and won ‘Best mobile innovation for women in emerging markets' at GSMA Global Mobile Awards 2019. Learn more about Kilkari on our website, in the  (third-party site) and at the International SBCC Summit from December 2022. 

Calculations on lives saved and cost effectiveness appear by LeFevre, A.E. et al, ‘Are stage-based, direct-to-beneficiary mobile communication programmes cost-effective in improving reproductive and child health outcomes in India? Results from an individually randomised controlled trial of a national programme.’

We are grateful to Stanford University for analysis of our evaluation, and to Johns Hopkins University for conducting the randomised controlled trial.

Sara Chamberlain is currently on sabbatical as India Digital Director; Radharani Mitra is India Creative Director and Global Creative Advisor; and Anna Godfrey is Head of Evidence at ÁùºÏ¿ª½±¼Ç¼ Media Action.