Kilkari: A mHealth Audio Service tailor-made for Rural Indian Mothers

Kilkari is an innovative initiative launched by BBC Media Action with over 12 million subscribers.The tool is bringing about a positive change in the health of rural Indian women and their infants.

A pregnant woman in rural Bihar is doing her household chores when her mobile phone rings and she hears a recorded voice message from someone called Dr. Anita. The voice of Anita gives her maternal and pregnancy tips, and reminds her that colostrum, first milk from the breast, is very important for the baby and should not be discarded. This is one of the many messages delivered by Kilkari, a mobile health education service designed to help new and expecting mothers make healthier choices. An initiative by BBC Media Action, Kilkari has worked wonders for maternal and infant health in rural India and was finally adopted by the Government of India. It has now managed to reach over 12 million subscribers across the country.

Collaborating for Change

What began as just a collaboration to tackle the sorry state of maternal and child health in Bihar, evolved into a nation-wide program to help the same cause.

A decade ago, Bihar had some of the worst maternal, neonatal and infant mortality rates in the country, with the maternal mortality ratio at 294 per 100,000 births, the neonatal mortality rate at 34 per 1,000 live births and infant mortality rate at 50 per 1,000 live births. To improve the dire situation, the State government stepped in 2011 and collaborated with Bill and Melinda Gates Foundation. They launched a program called Ananya to improve key health and nutrition indicators in Bihar.

“The Bill and Melinda Gates Foundation lent support essentially for innovations and brought in BBC Media Action to work on one specific part of Ananya. It was centered around generating demand for public health services so that more pregnant women take iron supplements, more mothers get their children vaccinated, more families adopt modern methods of contraception, and related maternal care essentials. We targeted behavior change to increase family’s knowledge of health practices that would save bring down IMR and MMR. We were looking at a 1000-day window from pregnancy to when the child is 2 years of age.”

Deciding on the Medium for Health Promotion

The plan was to reach out through television, but its penetration was quite low; just 27 percent of the population regularly watched TV, and radio was even lower at 12 percent. Their research found that mobile phones were the most widespread medium in use in these areas; 80 percent of households as well as 90 percent ASHA and Anganwadi health workers had access to a mobile phone.

“That’s when we really began to think about how to leverage digital technology, specifically mobile phones for training health workers to provide information to family. We devised a theory of change— use mobiles to train frontline health workers. We had an IVR-based training course called Mobile Academy. Interactive Voice Response or IVR is the technology where you call and hear a pre-recorded voice. It had also won the Global System For Mobile Communications) award among others. At first, we developed the IVR-based training and then adapted it to create an audio training course for frontline health workers, such that it could be incorporated in the most basic phone and could by applied to low literates as well. 2,50,000 workers till date have completed the course.

“Along with training, we had to equip them with job aids; we created a counselling tool for workers which combines the phone with a laminated deck of informative health cards (Kunji). We created another IVR service where the worker dials a number and plays audio content to the woman she is counselling. Since the workers are local village women, people may not always believe them, hence job aids were required to support them – that’s when mobile Kunji came in. This was scaled to several states and won a lot of awards. It was a highly impactful service and the MIT innovations journal published it too,” reveals Sara.

Kilkari: The Last Piece in the Puzzle

BBC Media Action stumbled upon another problem; women often forget about their maternal and child health needs which needed a strategic method of reminding. This is when Kilkari came into the picture. “Kilkari creates a schedule of audio information for each woman based on the due date of her child, from the second trimester of pregnancy all the way till the child is 2 years old. Every week, she gets a pre-recorded call with information about her pregnancy and child’s needs,” adds Sara.

Promoting the Health Promotion Tool

Numerous trials were employed to figure out an appropriate awareness strategy. Household ownership of a mobile phone did not necessarily mean that woman could have access it. Sara points out what women’s access to mobile phones in rural areas varies dramatically; Himachal and Kerala having the highest access and Punjab and Andhra Pradesh having the worst access. It was challenging start as the men mostly buy the talk time and make financial decisions about the phone. Kilkari was launched in Bihar as a paid service to cover the cost of calls. “People were paying one rupee per week for 72 weeks, so we targeted men and did a whole partnership with Vodafone and Airtel through top ups,” adds Sara.

A Successful PPP

But the campaign wasn’t successful as men weren’t the right target group. That’s when they did an expensive on-the-ground promotional campaign and simultaneously promoting the service through frontline health workers. This worked. “Soon, we got contacted by the Ministry of Health. They had been sending SMS texts to their database without much success. They wanted to try Kilkari. We collaborated with them for a year and a half and redeveloped Kilkari as a free service for the entire country. We started with the Hindi-speaking belt. We integrated the Kilkari database with the MoH database which registers all pregnancies, births etc. All numbers were, flowed into the Kilkari system and they automatically subscribed to Kilkari— this changed everything,” beams Sara.

BBC Media Action exited the plan in March 2019 and handed it over fully to the Government who are still running Mobile Academy and Kilkari.

While a plethora of mhealth services fail to make an impact, BBC Media Action’s Kilkari and Mobile Academy are exceptions. Kilkari, which is live in 13 states in five languages has 12.2 million subscribers. Mobile academy, on the other hand, has been launched in 13 states and 2,66,968 workers having started the course (as of March 2019).

As Sara puts it: To change social norms about health practices takes a long time. Change takes time, but this is the first step towards it.