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Fertility Awareness Methods [Global mHealth Initiative] CycleTel™: Bringing a market-based mindset to mHealth
[Originally posted as a Global mHealth Initiative Blog Post here]
CycleTel™ is an innovative mHealth product: a fertility awareness-based family planning method delivered to users in India via SMS. I recently spoke with Alexis Ettinger and Nicki Ashcroft from the Georgetown University’s Institute for Reproductive Health (IRH) to learn more about this USAID-funded program.
What is CycleTel?
CycleTel is an mHealth service that uses text messaging to facilitate the use of the Standard Days Method® (SDM), a knowledge-based family planning method. The service was initially conceptualized and piloted in 2009 and has been expanding in India through extensive formative and market research with over 1500 women users of the service. CycleTel was designed and is being implemented by a team of entrepreneurs, researchers, technologists and family planning experts based in India and Washington, D.C.
Why go mobile?
CycleTel is based on SDM, a modern, easy-to-use and scientifically-proven fertility awareness-based family planning method developed and tested by IRH in 2001. IRH developed CycleBeads®, a color-coded string of beads, to help women track the days of her menstrual cycle to identify her fertile window and see which days she is likely to get pregnant. IRH found its ability to scale-up this family planning method was often subject to countries’ varying political dynamics, health system and supply chain capacities to get CycleBeads into the hands of women and couples. These factors potentially limited women’s choice to use an appropriate family planning method for their needs, such as SDM.
Mobile technology allows CycleTel to become a direct-to-consumer product, expanding the family planning method mix and leveraging the large penetration of mobile phones to bypass health system challenges in making this family planning method as widely available as possible. CycleTel may not eliminate the need for a physical family planning commodity for some women in some country contexts, but it presents an exciting opportunity to be the first family planning method delivered directly to women, in their pockets.
CycleTel Growth
How has CycleTel evolved?
CycleTel has benefited from extensive formative research to refine the product and its business model. The concept was piloted in 2009 among 100 users, initially using a Frontline SMS platform before IRH decided to build its own platform. Since then, IRH has conducted seven phases of formative research testing with over 1000 women, including focus group discussions and cognitive interviews, two rounds of manual testing, automated testing, business analysis and market validation. The formative research guided user-centered design of the service, assessed feasibility and acceptability of the product, adherence to the service and explored how to bring this new product to market. Research on development of the business model is particularly novel, as this market-based mindset has made sustainability of the service a priority goal from the outset of the service.
“How do you bring a new product to market – that’s really the positioning we are taking with [CycleTel]. It is a SMS service – a mobile service – but it’s a family planning product. So like other products and new methods entering the market we have to overcome demand generation, user education, knowledge – everything that it requires to go from a non-user or maybe infrequent user of family planning to someone who understands the value [in family planning]. This tool is a direct to consumer product, so everything that goes into acquiring a customer for other products is true for this project.” – Alexis Ettinger, IRH
In 2012, IRH worked with the Boston Consulting Group (BCG) to build a series of financial models and a business model for CycleTel. Informed by research participants’ willingness to pay for CycleTel, as well as India’s robust Value Added Service (VAS) market, IRH and BCG identified a pricing scheme that they believed would be acceptable to users and financially sustainable at scale. This research included identification of target segments and potential market share, an analysis of the mHealth industry and determination of potential stakeholders.
To test some of the assumptions put forth in the business model, CycleTel conducted market validation research in 2013. This research assessed the viability of the CycleTel model in the market, with actual customers, under real-world conditions. It explored how CycleTel can identify, acquire, and retain customers, and how to operationalize monetizing a product. One of the major takeaways IRH has had from their market validation research is that testing of business models and pricing structures is a huge, untapped area of study in the field.
“The next step beyond willingness to pay is to see if your business model assumptions stand in the real world. In an ever-changing mobile market, it’s not enough to have your product validated in research, but you need to ensure that it’s validated in the market — and adapt ever so quickly if it isn’t. You also need to consider how to operationalize payments: when do you charge users, how do you get the money from users to you? In India that’s not a trivial consideration…there are different models. You could work with a MNO [mobile network operator] for auto-billing; you could look towards micropayments using a mobile intermediary processor. For market validation testing we didn’t have a payment partner so we actually did cash collection. The actual cost of cash collection was more expensive that the revenue we generated from the service. So we would never do cash collection at scale, but it was an interesting anecdote for comparing costs to monetize versus the revenue generate from a user-fee model.” – Alexis Ettinger, IRH
CycleTel Future
How will CycleTel approach scale-up?
In India, IRH will approach scale-up by understanding four fundamental issues to success of a mHealth service: technical performance, partnership models, usability of the service and development of a customer base. Technically, the system needs to be very robust, so that it will be able to support an expanding customer base. Relationships with NGO partners and other intermediary partners will be required in order to assist in acquiring new users and to support complementary education and interpersonal communication activities. As the service expands, CycleTel usability will need to consider adding additional language options to ensure broader reach. And finally, CycleTel must ensure that they reach – and retain – a broad consumer audience.
Recently CycleTel formed a partnership in India with Nokia Life Tools, a pre-installed application on select Nokia phones, to include CycleTel as one of the services featured in their healthcare suite of applications. Nokia Life Tools has been included on phones in India since 2009 and is available to 50 million mobile phone users.
“Pre-installed applications make the customer discovery process a lot more seamless. Customers have already built a trust with these applications. So, we’re really excited that we will have the CycleTel product and information about fertility and family planning embedded into that system so users can find us.” – Alexis Ettinger, IRH
CycleTel also plans to expand to new countries. Kenya is poised as the next country to be introduced to mobile and digital products for family planning, under a new project with The Bill and Melinda Gates Foundation. In Kenya IRH will test CycleTel SMS communications against other modalities for expanding access to SDM family planning, such as a smart phone application, CycleBeads®, that visually represents the CycleBeads product and an online web application, CycleBeads Online, within the CycleTechnologies family of products. IRH is interested in understanding how women if different socio-economic groups interact with the three products, as the organization does not want to restrict itself to one modality at the risk of being outpaced by consumer demand.
“Being market-based has allowed us to realistically assess the challenge of bringing a mobile product to market. Rather than thinking ‘mobile is great – we will reach everybody!’ we have become aware of why that might be challenging and [we have started to] think about how we can push past those challenges. [Our work in Kenya] reflects how fast the mobile industry is changing and how fast we need to adapt to that changing environment…our expansion to Kenya will be about partnerships and all about the country ecosystem. This is about an open market and users. IRH must explore different modalities for different markets as the mobile industry changes.” – Nicki Ashcroft, IRH
What’s next for CycleTel?
IRH looks forward to continued operations research. In India this will include testing the impact of partnership with Nokia Life Tools on users’ basic knowledge about fertility and attitudes about family planning, as well as uptake of CycleTel. The team will also continue to comparison test various go-to-market strategies for the service. In Kenya IRH will begin with formative research to assess acceptability of mobile and digital products for family planning, and will launch a comparison test of various modalities, including CycleTel, for communicating about fertility awareness and the SDM method of family planning.
“The hype and potential of mobile is amazing. We wouldn’t be here without the [mHealth] community and the funders. But [mobile] is not a silver bullet. Earlier on we thought ‘great, we’ve built it an now we’ve done the hard part.’ But that’s just the start. Reaching customers and making the product relevant to their lives is still to be done.” – Nicki Ashcroft, IRH
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