Case Study - Kilkari: A Maternal and Child Health Service in India - Lessons Learned and Best Practices for Deployment at Scale

"In order to persuade people to think and do things differently, you need to get inside their heads to understand the barriers to behavioral change, and the triggers that might empower people to break these barriers. This is why behavioral change communication content needs to be localized - because unless it is culturally specific and relevant, it won't resonate."

In January 2016, the Government of India launched a nation-wide mobile health programme designed by BBC Media Action. The service, Kilkari, is designed to benefit nearly 10 million new and expecting mothers by providing audio based maternal and child health messages on a weekly basis. The objective is to improve family health - including family planning, reproductive, maternal, neonatal and child health, nutrition, sanitation and hygiene - by generating demand for healthy practices. This case study from The GSMA Association describes the evolution, learnings, and best practices of the service, which initially began as part of the Ananya programme in Bihar.

In the state of Bihar, the maternal mortality rate at MMR 219 is much higher than the national average at MMR 178. "There is an urgent need to increase uptake of antenatal services, attended delivery, essential new born care and post-natal care practices in order to decrease infant and maternal mortality rates. In order to achieve this, it is critical to influence both the drivers of and barriers to the adoption of positive reproductive, maternal, neonatal and child health behaviours by families and communities, shift negative social norms and improve risk perceptions to persuade families to adopt healthy reproductive, maternal, neonatal and child health behaviours more effectively."

Kilkari (a baby's gurgle in Hindi) delivers free, weekly, time-appropriate audio messages about pregnancy, child birth and child care via Interactive Voice Response (IVR). Messaging begins in the second trimester of pregnancy and continues until the child is one year old. The health-messaging framework for Kilkari was developed in partnership with nationals and international public health experts, who provided input and reviewed all of BBC Media Action's final scripts to ensure that they complied with local government priorities and conditions in the state. The Kilkari content is presented in the voice of a female doctor character, called Dr Anita. Meant to be "[a]uthoritative yet sympathetic and engaging, Dr Anita is a friend, philosopher and guide to both community health workers and families."

Kilkari complements Mobile Academy (a free reproductive, maternal, neonatal, and child health audio training course designed by BBC Media Action for community health workers (CHWs) in India) by reinforcing the messages communicated by CHWs, who are communicating directly with new and expecting mothers and their families, to increase the uptake of healthier behaviours.

BBC Media Action uses an iterative human-centred design (HCD) approach whereby the content and usability of the service are repeatedly user-tested with beneficiaries to ensure accessibility, engagement, and impact. BBC Media Action spent six months, including four rounds of user-testing to get the content for Kilkari Bihar right. This required BBC Media Action to put together a dictionary of health vocabulary and phrases that rural women could understand. The national version of the Kilkari content was also user-tested with new and expecting mothers and their families in four Hindi-speaking states. An Oriya version of the content for the state of Odisha was also produced and tested. Two tribal versions of the language have subsequently been produced, with the support of the Barr Foundation, for the majority tribal populations in the state of Jharkhand. And content production in Assamese is currently underway for the state of Assam.

Since men control access to the majority of phones in rural Bihar and are responsible for making financial decisions and buying credit and services for the phone, BBC Media Action decided to reach out to fathers primarily in the marketing and promotion of the service. Standard VAS marketing channels, such as top-up shop promotions, would not have been effective when promoting a mHealth service for rural women in India, because these points of retail are not conducive to conversations around maternal health, and the majority of rural women do not visit them. Thus, BBC Media Action's strategy to market Kilkari focused on a range of below-the-line (BTL) marketing initiatives, such as: rural activation via agents at street theatre performances; incentivising CHWs to act as promoters; and targeted digital marketing via SMS (text messaging) and outbound dialing (OBD) by MNOs. BBC Media Action used Kilkari-branded vans to create awareness. They were equipped with audio-visual aids and a Kilkari song that was played out aloud in the villages they visited. There were other branding initiatives, such as wall paintings, stencilling, tin plates, posters, and stickers in the villages.

BBC Media Action learned a number of lessons through this process, which led the organisation to change its marketing approach. An incentive programme was devised where every CHW who helps a family become a loyal Kilkari subscriber receives talk time credit on her mobile phone. This marketing approach was much more effective, generating 130,000 loyal subscribers, where 70% listened to nearly 100% of every Kilkari message. Another specific lesson learned: Partnerships with local and national governments can be powerfully leveraged to deliver immediate scale with very little investment in marketing by using data in government Health Management Information Systems.

According to the 2011 Census of India, only 53% of women in Bihar are literate. Kilkari, as an audio rather than text-based service, overcomes this challenge. Furthermore, Kilkari, which can make outbound pre-recorded phone calls to any mobile handset in India using any SIM card, is seen as a compelling solution for the majority of the population, who cannot take advantage of smartphone apps or the mobile internet (they use brick or basic feature phones). Since its first inception, the service has evolved from being a traditional cross operator service, with a standard value added service (VAS) revenue share business model, to a toll-free service, with call costs covered by the Government of India.

With regard to the business model, it was found that a business-to-business (B2B) enterprise agreement with a single mobile network operator (MNO), where call costs are covered by government, is more financially rewarding for a MNO than a VAS priced for the base of the pyramid. Standard VAS business models, based on revenue share, do not generate sufficient income to make preventative health education services sustainable for the base of the pyramid. To reach rural women at the base of the pyramid with preventative maternal and child health education, services need to be free as cost is a significant barrier to uptake.

In terms of technology, Kilkari developers learned that mobile technology solution providers and/or aggregators that offer fully managed solutions as a core business proposition are well placed to support mHealth services at scale when compared to large multinational software and hardware vendors that make the majority of their revenue on license sales. In addition, they found that open source software can be challenging to develop and support at scale, but reduces the total cost of ownership and makes procurement less of a barrier to government adoption.

Looking ahead, in 2018, Kilkari will begin to scale across the rest of the country. With support from the United States Agency for International Development (USAID), BBC Media Action is analysing the call data records generated on a daily basis by Kilkari to provide weekly and monthly reports on the uptake and usage of the service. With support from the Gates Foundation, and strategic direction provided by government, BBC Media Action is also in the process of carrying out a call centre survey of Kilkari subscribers. Finally, BBC Media Action is working with independent evaluators to design robust impact-evaluation studies and a financial analysis of Kilkari.