Introduction
Digital health encompasses the subsectors of health information technology, mobile health (mHealth), electronic health, telehealth and telemedicine. Evidence gathering on the effectiveness of digital health solutions is a growing field.1 Mobile phones are becoming ubiquitous and, increasingly, an important tool in global health programmes.2–4 Mobile phones have the potential to connect clients with healthcare providers, optimise data collection, provide new avenues of delivering information and facilitate healthcare worker training and communication.4–8 Their increasing use as a channel for the delivery of health information content has shown some promise in bolstering health behaviours and demand for timely and appropriate health services in a range of settings.9 10
Kilkari (the Hindi word for a baby’s gurgle) is an outbound service that delivers weekly, gestational age appropriate interactive voice response audio messages about pregnancy, childbirth and childcare directly to families on their mobile phones, starting from the second trimester of pregnancy until the child is 1 year old.11 Established by BBC Media Action and the Indian Ministry of Health and Family Welfare in 2013, Kilkari has scaled to over 13 states and is estimated to have over 10 million subscribers. The programme draws information on mobile phone numbers and gestational age or the baby’s date of birth from government electronic tracking registries. Depending on timing of enrolment during pregnancy or following childbirth, subscribers may receive up to 72 weekly audio messages. Additional details on the programme are available elsewhere.11
Evidence on the impact of Kilkari is emerging,12 along with details on subscribers’ perceptions of content13 and exposure.10 14 However, little is known about the programme’s eligibility, reach and retention at scale across 13 states. Kilkari’s subscriber base is drawn from data in government tracking registries captured by frontline health workers (FLHWs) including Accredited Social Health Activists and Auxiliary Nurse Midwives. Data recorded in print registers are uploaded into electronic records, and ultimately, ingested into the Kilkari programme’s platform called MOTECH. The quality of registry data helps to determine the proportion of women at population level eligible for the programme (coverage), and the programme’s reach defined in terms of the gestational timing of first call and alignment of those calls with the target schedule. Retention is defined by the proportion of beneficiaries that remain in the programme through completion (1-year post partum) and is assessed by exploring deactivation trends.
Improved understanding of Kilkari’s eligibility, reach and retention aims to shed light on differences in programme performance across geographical areas. As programmes scale, they may undergo a ‘voltage drop’ in reach and impact attributed in part to the changes in the programme design and implementation required to scale, including strategies to recruit patients, promote the programme and update beneficiary information (eg, phone numbers, date of birth) to ensure continuity in access to messages.15 16 Understanding of the users’ journey from eligibility and entry into the programme, through to completion, will help to identify key inflection points where programmatic strategies can be developed to intervene, bolster programme performance and beneficiary engagement and ultimately, improve impact.
In this analysis article, we draw from system generated data on subscribers across 13 states who entered the Kilkari programme in 2018 to explore eligibility for subscription, reach and retention (figure 1). To determine eligibility for subscription, we start by estimating the proportion of pregnant women contained within the government tracking registries which drives Kilkari’s coverage at a population level. We next explore the timing of when subscribers are first called during pregnancy or postpartum; a factor which establishes the window of exposure to Kilkari calls. Among subscribers who answer at least one call (and thus are ‘reached’) during pregnancy, we determine the frequency of date of birth updates which serve to ensure that calls are aligned with women’s gestational/postpartum age. We conclude by assessing retention in the programme and ascertaining the reasons for deactivation. Overall findings from this analysis aim to illustrate the subscriber’s journey from entry in the programme and the timing of the first call to completion at 12 months post partum. By mapping drop-offs at each point along this journey, we aim to catalyse discourse on how to maximise future coverage, reach and retention.