Ligne Verte Toll-Free Hotline

1. Using cell phones to increase access to family planning information in the Democratic Republic of Congo   "Ligne Verte" Toll-Free Hotline

2. Presentation Outline Introduction to PSI/DRC Country Context Background Information The Ligne Verte: Operations and Calls Call Data Analysis The Research Gap

3. Population Services International PSI is a nonprofit organization which address the health problems of low-income and vulnerable populations through social marketing in more than 60 developing countries Program Areas: Malaria Reproductive Health Child Survival HIV and Tuberculosis

4. Association de Santé Familiale In the Democratic Republic of Congo (DRC), PSI works through it’s local affiliate, Association de Santé Familiale (ASF) PSI/ASF has worked in DRC since 1987 without interruption in spite of civil unrest or war Program areas: Malaria, FP, HIV and Safe Water Product distribution includes: condoms, five modern contraceptives, insecticide-treated mosquito nets, ACT malaria treatment and two point-of-use water treatment products Strong emphasis on information and behavior change communication (BCC)

5. Democratic Republic of Congo Formerly Zaire and often confused with its much smaller neighbor, the Republic of Congo (or Congo-Brazzaville); population aprox 3 millionFormerly Zaire and often confused with its much smaller neighbor, the Republic of Congo (or Congo-Brazzaville); population aprox 3 million

6. DRC: Country Context Population estimated to be 68 million, making it Africa’s fourth most populous country The capital, Kinshasa, is Africa’s third-largest city (est. 9 million) Current annual growth rate: 2.9% a year (or 2 million people a year) UN estimates DRC’s population will be 180-230 million by 2050 DRC’s land mass is comparable to the US East of the Mississippi Less than 3,000 km of paved road; it is virtually impossible to travel from one end to another by any means other than air travel Major regional differences in geography, culture, language and economic wealth DRC is perhaps best referred to as a ‘sub-continent’… Even the U.N. has referred to any statistics coming from DRC as “highly suspect” so all stats and numbers here should be taken with a grain of salt… The geography and transportation system make moving goods and people around the country a Herculean task – and extremely expensive (with a big impact on health programming and budgets)DRC is perhaps best referred to as a ‘sub-continent’… Even the U.N. has referred to any statistics coming from DRC as “highly suspect” so all stats and numbers here should be taken with a grain of salt… The geography and transportation system make moving goods and people around the country a Herculean task – and extremely expensive (with a big impact on health programming and budgets)

7. DRC: Country Context From 1994-2003, DRC was engaged in the deadliest conflict since WWII 5.4 million excess deaths since 1998; 3.4 million displaced (IRC, 2008) Outbreaks of conflict persist in the eastern provinces The conflict decimated the country’s infrastructure Focus now on stabilizing the country, political processes, reconstruction Given these circumstances, and DRC’s size and geography, health and technology situations are vastly different from even most African countries IRC Special report on Congo – January 2008 Congo’s recent history and current situation are particularly relevant for the health and technology situations IRC Special report on Congo – January 2008 Congo’s recent history and current situation are particularly relevant for the health and technology situations

8. Background: Family Planning in the DRC Total Fertility Rate: 6.3 children per woman (DHS 2007) 2007 CPR for modern methods: 5.8 % (DHS 2007) Third-lowest among sub-Saharan African (from DHS surveys since 2000) DRC experienced a 10% decline in CPR since the outbreak of conflict 15% in 1995; 4.4 % in 2002 24% unmet need (40 % including those using traditional method) This translates into nearly 6 million Congolese women with an unmet need for modern contraceptive methods Unmet need: the percentage of women of reproductive age who which to space or limit their births but are not currently using any method of contraception DRC really has an extraordinary FP situation. It is virtually unheard of to see a CPR drop as severe as DRC has experienced Although we are starting near the bottom in terms of CPR, we’re not exactly starting from scratch (considering the previous 15% CPR) and this puts DRC in a different category from other very-low CPR (and pre- demographic transition) countries. At the same time, this ‘advantage’ is countered by the extreme difficulties with transportation in DRCUnmet need: the percentage of women of reproductive age who which to space or limit their births but are not currently using any method of contraception DRC really has an extraordinary FP situation. It is virtually unheard of to see a CPR drop as severe as DRC has experienced Although we are starting near the bottom in terms of CPR, we’re not exactly starting from scratch (considering the previous 15% CPR) and this puts DRC in a different category from other very-low CPR (and pre- demographic transition) countries. At the same time, this ‘advantage’ is countered by the extreme difficulties with transportation in DRC

9. Background Info: PSI’s FP Program USAID-funded FP program since 2003 Implemented in 14 cities in 8 of DRC’s 11 provinces Major activities: Distribution of 5 products under the brand Confiance Confiance partner network: 78 clinics; 277 pharmacies; 113 mobile educators Training of clinicians, pharmacists and gov’t partners Ligne Verte toll-free family planning hotline USAID is currently the only major bi-lateral donor FP programming in DRC; FP/RH are not adequately funded in the DRC, largely due in part to other priority areas and competing funding for other health interventions (namely malaria and HIV)USAID is currently the only major bi-lateral donor FP programming in DRC; FP/RH are not adequately funded in the DRC, largely due in part to other priority areas and competing funding for other health interventions (namely malaria and HIV)

10. Background: Cell Phones in Africa Cell phone market in Africa has grown at twice the rate of the global market Despite recent rapid growth in DRC, the cell phone is still a very new technology By 2007, 10% of Congolese had cell phones and 50% of the country lived in an area where cell phone service is available 4 major cell phone providers with regional variation on market share but no available data Market share can impact the volume of calls from different regions - Market growth : Ewing, J. 2007. Upwardly mobile in Africa. Business Week, September 13 2007. Available at http://www. businessweek.com/ globalbiz/content/sep2007/gb20070913_705733.htm. - DRC cell phone data: International Telecommunications Union, External Affairs and Corporate Communications Division. 2008. ICTs in Africa: Digital divide to digital opportunity. Available at http://www.itu.int/ newsroom/features/ict_africa.html. http://www.itu.int/ITU-D/icteye/Reporting/ShowReportFrame.aspx?ReportName=/WTI/BasicIndicatorsPublic&RP_intYear=2007&RP_intLanguageID=1- Market growth : Ewing, J. 2007. Upwardly mobile in Africa. Business Week, September 13 2007. Available at http://www. businessweek.com/ globalbiz/content/sep2007/gb20070913_705733.htm. - DRC cell phone data: International Telecommunications Union, External Affairs and Corporate Communications Division. 2008. ICTs in Africa: Digital divide to digital opportunity. Available at http://www.itu.int/ newsroom/features/ict_africa.html. http://www.itu.int/ITU-D/icteye/Reporting/ShowReportFrame.aspx?ReportName=/WTI/BasicIndicatorsPublic&RP_intYear=2007&RP_intLanguageID=1

11. Why a toll-free FP hotline? Family Planning program staff noticed low levels of knowledge about FP in general and a high level of rumors surrounding FP and contraception The toll-free hotline, combined with growing cell phone use, could offer a unique opportunity to offer Congolese free, confidential information on FP Thus, the Ligne Verte was designed: as a pilot to see if a cell phone FP hotline could be successful to provide confidential, accurate FP information to refer potential users to Confiance network clinics provide accurate information to people beyond PSI’s program reach respond quickly to detailed questions about FP and contraception Respond to rumors and prevent the spread of false information on contraceptives provide accurate information to people beyond PSI’s program reach respond quickly to detailed questions about FP and contraception Respond to rumors and prevent the spread of false information on contraceptives

12. Launching the Ligne Verte In 2005, PSI approached the two main cell providers about setting up a toll-free hotline - the first demand of its kind in the DRC Only Vodacom was able to establish a toll free hotline – but only for calls from Vodacom cell phones Each call costs PSI $.36 and is limited to 2 minutes PSI advances $1,500 per quarter and reimburses charges over this amount; annual costs for the hotline around $8,000 Technical difficulties caused the hotline to be shut down for a 3-month period in 2006, after which it was re-opened Since then, other toll-free hotlines have since been established in DRC, including the CDC’s HIV hotline Technical difficulties caused the hotline to be shut down for a 3-month period in 2006, after which it was re-opened Since then, other toll-free hotlines have since been established in DRC, including the CDC’s HIV hotline

13. Ligne Verte - Operations One fixed phone line in the PSI Kinshasa office Trained FP Mobile Educators who answer calls Two 4-hour shifts each day Trained for specific questions from callers and have a list of all Confiance partner sites for referrals Hours: Monday–Friday: 8 a.m. to 4:30 pm (Kinshasa time) Call information is written into the hotline’s log book Financed with program income funds from sales of Confiance commodities from the USAID-funded FP project

14. The hotline operates out of a room in the Kinshasa office; call information is recorded by hand in the log book

15. Promoting the Ligne Verte Hotline is promoted through: FP IEC events: open houses, community events, household visits Inclusion in product packaging and communication materials Mass media Through radio and television spots Through FP theme television broadcasts Ligne Verte pocket calendars distribution: By Mobile Educators Distributed at Confiance partner sites Word of mouth

16. The Ligne Verte number is even included on partner clinic signs and pocket calendars

17. Calling the Ligne Verte All calls are confidential Calls are answered in French/Lingala/Swahili Each caller is asked his or her: Location Gender Age Marital Status If necessary, caller is referred to a Confiance clinic or local health center (where Confiance clinics are not available) - Lingala and Swahili are DRC’s two most widely spoken indigenous languages- Lingala and Swahili are DRC’s two most widely spoken indigenous languages

18. 2008 Call Data•Although originally designed to reach WRA, data from the Ligne Verte shows that men call the hotline far more often than women; however the proportion ranges from 70% in Kinshasa to 90% in Katanga.

19. 2008 Calls by province• No clear links between target population size and proportion of calls• Over 1,500 calls (8%) were from the three provinces where PSI does not implement family planning activities - Again, population numbers are ‘highly suspect’ and are, at best, a loose estimation- Again, population numbers are ‘highly suspect’ and are, at best, a loose estimation

20. Most commonly asked questions: What is FP/birth spacing? Location of Confiance partner sites General information about contraceptives and/or the line of Confiance products Side effects of contraceptives Questions about rumors/false information Requests from health personnel to partner with the Confiance network

21. Not all questions are related to FP Some are pertinent to PSI’s other programs and health in general: How do I avoid getting HIV? Where are the Prudence (condoms) available? Others are not so pertinent… Can you give me phone credit? Can I have some money? In general, over 80% of calls are related to FP

22. Challenges The hotline often experiences technical problems; generally fixed within a day Free calls currently limited to one carrier CDC’s HIV hotline operates with all major carriers Accessibility is limited to French, Lingala or Swahili 2 minutes is often insufficient to adequately respond to questions Callers often get a busy signal Many calls come from areas outside PSI’s FP program reach Callers are referred to their closest health center but there is no guarantee of FP service availability

23. Ligne Verte data collection The Ligne Verte was not designed as a research tool but data has provided us with much useful information on caller profiles and common FP questions/preoccupations Basic data provided by Ligne Verte could also be used to evaluate program activities and/or FP needs in the DRC, including: tracking program reach (esp. outside of intervention zones) better analysis of questions may indicate the most pressing FP knowledge gaps are we reaching our target groups?

24. In-house Research To evaluate call levels outside of current hours of operation, during a two-week period in Dec. 2008 calls were answered in the evenings and on Saturdays Findings: There is a high level of calls on Saturdays and until 6:30 in the evenings Men call in a higher proportion (91%) on Saturdays Women call in a higher proportion (30%) in the evenings The expanded hours increased December’s call volume by 20% The Ligne Verte sim card was transferred to a cell phone Vodacom does not operate its hotline on Sunday, so calls could not be taken then The Ligne Verte sim card was transferred to a cell phone Vodacom does not operate its hotline on Sunday, so calls could not be taken then

25. Call Data Analysis – what we know What we know from our data analysis: Majority of calls are from men Women call in a higher proportion from Kinshasa than from any other province Call volume is not determined by target population size or number of FP sites per province Women make proportionally more calls in the evenings Expanding the hours of operation would increase overall call levels

26. Call Data Analysis: what we want to know Why more men than women call the hotline Better access to cell phones? More exposure to messaging (esp. through mass media) on the hotline? Do men have a greater unmet need for FP information? Why proportionally more women call from Kinshasa Relatively higher economic levels (i.e. higher cell phone ownership)? Do women have better access to information in the capital? What determines the volume of calls Higher market share for Vodacom in certain regions? Better advertising of the hotline in some provinces? How callers heard about the Ligne Verte Would aid in targeting promotion of the hotline and measuring effectiveness of program communication activities Why more men than women call – are we missing our target group or is a hotline simply a more effective means for reaching MEN? Research could help us determine whether the L.V. should put more emphasis on reaching women or whether other means of IEC are more effective for reaching WRA in DRCWhy more men than women call – are we missing our target group or is a hotline simply a more effective means for reaching MEN? Research could help us determine whether the L.V. should put more emphasis on reaching women or whether other means of IEC are more effective for reaching WRA in DRC

27. Need for a Research Agenda Although illuminating, the Ligne Verte data collection and analysis is limited By amount of data collected per call By time and personnel constraints The hotline is an additive activity and has no research funding or component PSI/DRC has realized the potential of the hotline’s data to provide base information on FP needs

28. How to adapt the LV as a research tool without compromising the hotline? More info gathering questions could increase data base Questions could be asked to find out: How callers learned of the hotline Exact call locations to analyze call patterns (urban/rural; proximity to bordering countries, other FP sites, etc.) Attitudes towards FP However, the integrity of the hotline must not be compromised Confidentiality must be maintained The goal is to respond to caller’s questions

29. The Need for a Research in the DRC There is an outstanding need for basic research in DRC Inadequate research on all sectors in DRC since 1990s Lack of comprehensive information on health, demographics, economics and technology in the DRC means a lot of guess work Although indirect research methods may be used, for evidence-based programming we need more concrete data on DRC on which to build program-specific research Cell phones are still a new technology in DRC and more research is needed on the emerging telecommunications market to determine how best to exploit this technology for health messaging For a country of its size, there is shockingly little comprehensive research on most aspects of lives in the DRC; research from neighboring countries can be helpful but its relevancy is often limited to a region or provinceFor a country of its size, there is shockingly little comprehensive research on most aspects of lives in the DRC; research from neighboring countries can be helpful but its relevancy is often limited to a region or province

30. What next? At the country level: look for more opportunities for formative research on health and telecommunications and other sectors At the program level: design research needed to guide hotline priorities Expand the number of lines? Hours? Cell phone providers? Languages? Do we need to reach out more to women with the hotline or is it a particularly effective means of reaching men? How can we design the Ligne Verte to better collect data and evaluate program activities?

31. For more information on PSI/DRC’s FP hotline: http://www.psi.org/resources/pubs/USAIDCaseStudyDRC.pdf Contact: Jamaica Corker: jcorker@psicongo.org