Family Planning Counselling D-tree International

Community Health Workers (CHWs) are uniquely suited to provide home-based family planning services, especially in rural areas. However, counselling algorithms, such as the Balanced Counseling Strategy Plus, are complex. Mastery requires more training than CHWs typically receive.

This is a classic situation in which decision-support software, running on a mobile device, can make possible what otherwise would not be possible: flawless adherence to the Balanced Counselling Plus advice-giving process.

So we implemented such an app. But we did more: we innovated. We implemented a whole system within which the CHWs use the app and provide the services. Finally, we have been able to monitor success in increasing the provision of quality services to the target population.

Here we explain in a bit more detail.

the problem

Although family planning services in Tanzania are offered free of charge and citizens have a high awareness of contraceptive methods, uptake of family planning in Tanzania remains low.

As of 2010, 24% of married women of reproductive age (MWRA) were using a contraceptive method with a total fertility rate (TFR) of 5.4. The situation is more pronounced in rural Shinyanga region, where only 12.5% of MWRA are using a modern contraceptive method, TFR is 7.1 and 22% of women have an unmet need for family planning.

One factor affecting initiation of contraception and continued use is satisfaction with family planning services, and studies have shown that the most common reason for discontinuation is dissatisfaction with the quality of family planning services.


Initial funding from the Packard Foundation and the Evidence2Action program gave Pathfinder International the chance to try to improve this situation by giving a cadre of 230 Community Health Workers the responsibility of going into the community to provide such services.

Pathfinder chose to work with D-tree International to design and deploy digital technology to enable this cadre to maintain a high level of quality in the services provided.

counselling algorithm

At the heart of the CHWs task was the counselling prescribed by the Balanced Counselling Strategy Plus (BCS+). Using Mangologic, D-tree designed and implemented an interactive dialogue embodying the logic of the BCS+. This hides the complexity of the BCS+ from the CHW - the CHW just has to respond accurately to the questions posed by the dialogue, and the app takes the CHW securely through the counselling process in accordance with best practice.

This formed the core of an app to be used by the CHWs. However, the program had other tasks and other issues to tackle besides the cognitive complexity of the BCS+ ...


High quality counselling doesn't entail just a visit, it entails caring enough about the client to follow-up: to make sure the client's needs are met, and continue to be met over time.

The application developed by D-tree therefore was organised around a complex workflow which manages the steps a CHW needs to take for each individual client, and the time at which those follow-ups are due.

As with the BCS+, once implemented in software, this complexity is hidden from the CHW and yet the app makes it straightforward for the CHW to operate in compliance with the workflow and thereby ensure high quality counselling over time for her/his clients.


Despite the complexities of the counselling algorithm and the workflow, the CHW has only to interact with an attractive app with simple menu options and question-answer dialogues.

Not only do CHWs usually not have the benefit of much training, they also often work isolated and with little supervision.

In such circumstances, it requires specially dedicated individuals to retain the motivation provide a good service.

pay for performance

To address the issue of motivation, D-tree devised a Pay For Performance scheme for the CHWs in this cadre, based on targets whose achievement can be determined entirely through the data produced by the system.

So, for example, a CHW can earn a bonus payment for a month by making a certain percentage of all follow-up visits scheduled for that month.


The app provides counselling logic and helps the CHW to manage her clients. The data also gets synced with the server and this can be very useful from a program management point of view.


D-tree International

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