CHIP: Family Planning, SRHR in India

India, home to 1.4 billion people, is the center of significant population growth, with projections indicating it will exceed 1.58 billion by 2035. This looming demographic surge places immense strain on an already overburdened healthcare system. The picture is far from uniform across the nation. 

In 2016, the Mission Parivar Vikas (MPV) campaign identified 146 districts across seven states, home to 44% of the population, as high-fertility regions. These districts were the focal point of a comprehensive family planning intervention facilitated by community health workers. While commendable improvements have been observed, 11.4% of reproductive-age women in these districts still reported unmet family planning needs in 2021, in contrast to 9.5% in other districts nationwide. This glaring divide underscores the urgency of the challenge.

A pivotal aspect of this challenge lies in the persistently low modern contraceptive use among adolescents and young women. National Family Health Surveys (NFHS) data paints a disconcerting picture. Despite modest improvements between NFHS-4 and NFHS-5, with modern contraceptive use among married adolescents increasing from 7% to 19% and among young women from 26% to 32%, these figures remain worryingly low. Rajasthan, India's largest state, epitomizes this challenge with a startling statistic: one in five reproductive-age women in the state is not using contraception, and less than 5% have engaged in family planning discussions with community health workers over the past three months.

Community Health Integrated Platform (CHIP) is a groundbreaking solution that empowers young female community health workers to efficiently manage integrated health services in their respective villages through a unified digital platform. This platform is designed to streamline the delivery of critical health services and over 12 primary healthcare verticals. Through longitudinal tracking of healthcare programs, CHIP seamlessly integrates data across each vertical using a health systems strengthening approach. Here's a simple explanation of what CHIP is, what it does, and how it works:

What is CHIP?

CHIP is a user-friendly digital platform accessible via smartphones. It is specifically designed for three essential health workers in the Indian public health system: ASHA (Accredited Social Health Activist), ANM (Auxiliary Nurse Midwife), and Medical Officers. These community health workers are crucial in delivering primary healthcare services at the last mile. 

What Does CHIP Do?

CHIP is a comprehensive toolkit for community health workers, enabling them to effectively engage with beneficiaries and provide vital family planning services. Here's how CHIP works to address various aspects of family planning and SRHR:

1. Beneficiary Tracking: The platform allows community health workers to track beneficiaries who have availed family planning services. This ensures that beneficiaries receive timely support and follow-up care.

2. Identifying Beneficiaries: CHIP helps health workers identify eligible couples needing family planning services and provides counseling on safe and effective contraceptive methods.

3. Dropout Prevention: The platform equips health workers with tools and resources to prevent dropout rates among beneficiaries. They can offer personalized support and information to engage beneficiaries in family planning services.

4. Key Focus Areas: CHIP empowers community health workers to address critical focus areas in family planning, including reducing multiparity, promoting birth spacing, providing information on long-acting contraception, ensuring safe sterilization procedures, reducing teen pregnancies, facilitating early pregnancy registration, offering postpartum contraception guidance, and providing information on safe abortions when needed.

How Does CHIP Work?

Community health workers use CHIP on their smartphones to access and input data, track beneficiaries, and provide essential information. The platform operates online and offline, ensuring that health workers can use it even in areas with limited connectivity. It allows for longitudinal tracking of beneficiaries, making it easier to provide consistent support and monitor their progress.

By empowering community health workers with this digital platform, CHIP significantly enhances their capacity to effectively deliver family planning and SRHR services. It bridges the gap between healthcare providers and beneficiaries, particularly in remote or underserved areas, ultimately increasing awareness, access, and utilization of family planning methods.

CHIP is a data-driven solution that improves the quality of healthcare services and contributes to addressing the global challenge of unmet family planning needs. It offers a scalable and practical model that can be adapted in different regions, potentially impacting millions of women and families worldwide.

Health officials use CHIP to understand disparities in health care delivery and allocate data-driven interventions.

In conclusion, the Community Health Integrated Platform (CHIP) is a transformative solution that empowers community health workers by ensuring they are skilled, supervised, supplied, upskilled, and salaried to leverage technology at the last mile to deliver primary care at scale.

Brief Overview of CHIP

Beneficiaries: reproductive age women belonging to predominantly rural underserved communities (2/3), about 400,000 of whom earn <$1/day. 1/10 of these women do not have access to desired family planning services. 1/15 of these women do not have access to community health workers to provide quality family planning services. These beneficiaries receive suboptimal services due to a combination of sociocultural, gender, awareness, and access related challenges to primary health care at large. For example for every 15 reproductive age women who undergo a hysterectomy, only 1 man undergoes a vasectomy. 

Our solution aims to empower beneficiaries through data-driven communication to follow-up on timely receipt and continuation of family planning services, antenatal care messages, and longitudinal RMNCH awareness engagements, along with our partners ARMMAN.

Change agents: community health workers are locally elected "daughters-in-laws" of their respective villages charged with overseeing the primary health care mobilization of 1000 people in their village. They enroll beneficiaries in family planning services, distribute contraception at the doorstep, engage in early pregnancy identification activities, accompany women to delivery centers, improve awareness of birth spacing and long-term contraception. These CHWs, known as ASHAs, in India are burdened by delayed renumeration (of up to 3 months), they also earn less than a daily wage laborer, face a mix of paper and digital systems with redundant data entry, and have challenges with coordinating longitudinal care with their colleagues - Auxilairy Nurse Midwives and Medical Officers at the Primary Health Center.

Our solution streamlines follow-up of primary health care services, longitudinal care coordination, incentive estimation, automates reporting (saving up to 20 hours per month) and soon will link service delivery to automated payments with the support of our government partners. Our platform is digitally, clinically, and financially empowering these CHWs to take charge of family planning, SRH services in their communities.

Khushi Baby is driven by a team of dedicated professionals comprising over 65 members, each equipped with core skill sets in public health, medicine, technology, design, data science, field implementation, management, and public policy. Driven by a decolonizing global health approach, our team's talent is hired from the communities they serve. 

Our journey towards creating the Community Health Integrated Platform (CHIP) has been marked by active collaboration with community health workers, who are the flagbearers of our innovative solution and champions for change on the ground. We have spent over 200,000 hours using a human-centric approach to design CHIP to ensure increased uptake and adherence for the highest possible impact. 

Over the past six years, we have deployed digital health solutions directly at the village level, immersing ourselves in the realities and challenges faced by beneficiaries and healthcare providers.

In the last three years, we've proudly served as the Technical Support Partner to the Department of Health of Rajasthan. This partnership has been instrumental in our journey, enabling us to scale the platform to cover 35,000 villages, reaching over 30 Million people. Through this experience, we've cultivated a comprehensive understanding of the macroscopic and microscopic perspectives on healthcare priorities affecting beneficiaries, community health workers, and health officials alike.

Our engagement with the community extends beyond technology development. We have executed every facet of the pipeline required to take CHIP to the field, from policy requirement gathering and budgetary planning to advocacy, design, development, and deployment. We've conducted virtual training of trainers and in-person capacity-building sessions, actively participating in over 480 community health worker WhatsApp groups.

Our commitment to meaningful engagement and collaboration with the community is reflected in our ability to incorporate recommendations from esteemed organizations such as WHO, GAVI, JHPIEGO, UNFPA, and UNICEF into the unified platform adopted by the State Department of Health. This trust is further demonstrated by the Department of Health's 3-year legal agreement with us, validating our expertise and commitment.

What sets us apart is our ability to deliver solutions and services that operate at one-tenth of the cost of similar digital health platforms in other low- and middle-income countries (LMICs). Our focus on efficiency and effectiveness ensures that the resources entrusted to us are maximized to make a meaningful impact on the ground.

Additionally, we are committed to being data-driven and impact-oriented. With over 80 Key Performance Indicators (KPIs) for impact and performance, our approach is deeply rooted in measuring the real-world effects of our interventions. Moreover, our commitment to evidence-based practices is underscored by a rigorous Randomized Controlled Trial (RCT) conducted in partnership with 3ie, further validating the effectiveness of our approach.

In essence, our team's unique qualifications, experiences, and unwavering dedication have positioned us as leaders in digital health solutions. We are not just creators of technology; we are active partners and advocates for the communities we serve, driving positive change and health equity at the grassroots level.

300,000 beneficiaries for family planning and SRHR services

Offline-First Unified Healthcare: CHIP introduces an innovative, offline-first solution for unified primary healthcare. It streamlines the tasks of health workers while eliminating redundancy, making it particularly effective in areas with limited connectivity. Unlike many other platforms, CHIP offers a unified interface for primary healthcare tracking across 12 vertical programs and for three levels of health workers: community health workers, nurses, and medical officers.

Advanced Data Collection and Analysis: CHIP leverages advanced technology to collect comprehensive data on over 800 health indicators. This data-driven approach provides a holistic view of health in the region, enabling health workers to make informed decisions and track critical healthcare outcomes. Machine-learning models within CHIP predict key healthcare outcomes, enhancing disease tracking and flexibility while making it scalable to address diverse health challenges.

Scale and Financial Backing: CHIP's substantial $13.6 million investment from the Ministry of Health and Family Welfare demonstrates a strong commitment to its expansion and impact. As the 5th largest community health worker platform in India and the largest operating outside the central Ministry of Health and Family Welfare, CHIP has the scale to catalyze broader positive impacts in the healthcare sector.

User-Centric Design: CHIP places a strong emphasis on enhancing the user experience for community health workers. It introduces several user-friendly features, including Optical Character Recognition (OCR)-based beneficiary registration, integrated work-plans, real-time decision support during checkups, visual hint cards, and a learning management system. These features streamline the work of health workers and improve the quality of care provided to beneficiaries.

Interoperability and Ecosystem Integration: CHIP goes beyond just being a standalone platform. It integrates into a broader healthcare ecosystem, linking with software for intrapartum health tracking and facilitating interoperability with Internet of Things (IoT) devices and decision-support algorithms. This holistic approach ensures that CHIP is not isolated but connected to other critical components of the healthcare infrastructure.

Advanced Geospatial Analytics and Automation: The CHIP dashboard incorporates advanced geospatial analytics, automated community outreach features, and forthcoming capabilities for automated impact evaluation. This empowers health workers and policymakers with valuable insights and data-driven decision-making tools.

Powered by Khushi AI: At the core of CHIP's innovation is Khushi AI, housing machine-learning models for predicting critical healthcare outcomes, such as antenatal care drop-out, c-section, low-birth-weight, and severe-underweight infant outcomes. This infusion of AI-driven insights enhances the platform's ability to address complex healthcare challenges.

Next Year (2024):

1. Scale Deployment: In the following year, Khushi Baby aims to significantly scale the deployment of CHIP in Rajasthan, covering primary health and sub-health centers across the state. This expansion will directly impact millions more reproductive age women for family planning and SRHR services

2. Interoperability: Achieve Ayushman Bharat Digital Mission (ABDM) certification, a milestone representing a new digital health framework for India. This certification will enable CHIP to seamlessly integrate with other healthcare systems, ensuring that beneficiaries can access their longitudinal records, regardless of their location or healthcare provider, nationwide. 

3. Partnership Expansion: Continue to build strategic partnerships with government entities and research and delivery organizations such as PATH and the Government of Maharashtra for piloting CHIP in new regions, Audere for incorporating AI for STI/RTI automated test interpretations on the smartphone and ARMMAN for automated community outreach for family planning and SRHR services. These partnerships will be instrumental in extending the reach and impact of the platform.

Next Five Years (2028):

1. National Integration: While we scale CHIP to other states across India, By 2028, the goal is to make CHIP an integral part of India's national digital health strategy. This ambitious objective aims to empower over 1.3 million community health workers, who will collectively reach over 1 billion underserved individuals. This nationwide deployment will contribute to achieving several SDGs, including Goal 3 (Good Health and Well-being).

2. Research and Impact Evaluation: Conduct rigorous research and impact evaluations to measure the effectiveness of CHIP in improving healthcare outcomes and reducing health disparities. The findings will inform continuous improvements and contribute to evidence-based practices in healthcare delivery, supporting Goal 17.

Inputs:

• Khushi Baby's CHIP, including the KB mobile app, KB dashboard, and KB voice calls.
• Dedicated team members with expertise in public health, technology, data science, and field implementation.
• Data synchronization capabilities.
• Training and supervision resources for frontline health workers and IT staff.
• Monitoring and evaluation mechanisms.

Activities:

1. Deployment of CHIP: Khushi Baby deploys its digital health platform, CHIP, in partnership with community health workers across underserved areas.
2. Data Collection and Decentralization: CHIP facilitates real-time, granular data collection, with an emphasis on decentralizing data management.
3. In-field Decision Making Support: Health workers use CHIP for in-field decision-making support, particularly in family planning and sexual reproductive health (SRH) protocols.
4. Standardization of Family Planning Protocols: CHIP ensures standardized family planning protocols are followed, enhancing consistency in healthcare delivery.
5. Resource Management: The platform empowers health workers by providing resources and tools for efficient resource management, optimizing the use of family planning methods and supplies.
6. Community Engagement: CHIP promotes community engagement by enabling health workers to interact with beneficiaries, providing education and information on family planning and SRH.
7. Frontline-Mother Interaction and Education: Health workers use CHIP to facilitate interactions between mothers and healthcare providers, offering education and guidance on family planning.
8. Remote Education and Reminders: CHIP includes features for remote education and reminders, ensuring that beneficiaries receive timely information and family planning services.

Outputs:

• Real-time, granular data related to family planning and SRH.
• Increased communication between health providers and beneficiaries on family planning and SRH.
• Increased communication between beneficiaries on family planning and SRH.
• Digitized, searchable information system for family planning and SRH.

Intermediate Outcomes:

• Increased awareness and knowledge of family planning and SRH methods and benefits.
• Improved communication and open discussions about family planning within couples.
• Greater access to family planning information and services, particularly in remote or underserved areas.
• Shift in societal perceptions towards family planning and SRH.
• Development of positive attitudes and intentions regarding the use of contraception.

Ultimate Outcomes:

• Increased contraceptive use, including long-acting reversible contraception (LARC) and male sterilization.
• Reduced unintended pregnancies, including teenage pregnancies.
• Improved family planning outcomes and sexual reproductive health among the target population.

Impacts:

• Enhanced family planning services leading to healthier reproductive choices.
• Empowered communities with access to quality family planning and sexual reproductive health care services.

Assumptions/External Determinants:

• Technical factors, such as data syncing and cell signal coverage, are reliable.
• Organizational factors, including training, supervision, and workforce turnover management, are effectively addressed.

Why We Expect Our Solution to Have an Impact:

Khushi Baby's CHIP is designed to address critical barriers in family planning and sexual reproductive health care services. By leveraging technology and empowering community health workers, CHIP overcomes barriers such as lack of information, privacy concerns, low risk perception, and hostile social environments related to family planning and SRH. Through data-driven decision-making, improved communication, and community engagement, CHIP aims to bring about positive changes in awareness, access, and attitudes specifically in the field of family planning and SRH.

The deployment of CHIP leads to real-time data collection, which, in turn, improves communication and resource management specifically in the context of family planning and SRH. These intermediate outcomes contribute to the ultimate outcomes of increased contraceptive use, reduced unintended pregnancies, and improved family planning and SRH services. By addressing the complex interplay of factors affecting family planning and SRH, CHIP's holistic approach aligns with the United Nations Sustainable Development Goals and has the potential to catalyze positive impacts in these specific areas of healthcare.

65

9 years

We have an interdisciplinary team of 65 full time members, including public health practitioners, designers, communication experts, field monitors, data engineers, data scientists, android developers, backend developers, testers, and health care providers.

99% of the team members live in the LMIC / country where the solution is deployed and are people of color. We are working to improve gender balance within our team which is currently at 70:30 M:F.

We have spent over 200Khours co-creating our solutions with community health worker partners in the field. 

We raise funds from iNGOs, family foundations, CSRs, and awards. These funds support the services we provide to governments free-of-cost. The government then leverages our services and adopts our solution to create impact at scale. Our donors ask us to report the impact and essentially fund for impact created. 

We also engage in contract based work with development partners, who look to leverage customized versions of our solutions in geographies where our teams have a mutual presence and government alignment. 

1. Improve scalability and interoperability of CHIP platform by alignment with DIIG principles and ABDM certification to expand access to Digital Square donor base and further government-funded RFPs in India.

2. Build in-house resource mobilization unit and expand in-house monitoring and evaluation team for identification and donor relationship as well as improved impact reporting 

3. Raise funds from multi-year, catalytic grants from iNGOs / family foundations in the Data Science for Good and Digital Health spaces

4. Raise at least 20% of revenue from contract-based work with development partners such as JHPIEGO, JSI, PATH, WHO, UNICEF, UNFPA, etc.

5. Develop pipeline for research-based funding through creation of synthetic public health research databank, whereby research efforts could be cross-applied to original data without exposure of original data