Impact Evaluation of Triggerise's Tiko Platform

Triggerise designed web and phone based Tiko platform to connect young girls and women to the health products, services and information. The platform uses principles of behaviour economics to motivate positive choices-including rewards, promotions, discounts, coupons, reminders, alerts etc. The platform was implemented in several cities from seven states of India to provide Sexual Reproductive Health (SRH) and maternal and child health (MCH) products and services. The consumers (called Rafikis) use Tiko card to get discounts and to earn 'Tiko miles' rewards at Tiko franchised healthcare providers and pharmacies. Tiko miles are redeemable towards lifestyle products or services (e.g., beauty salons). The local Tiko health promoter (celled Pro agent) can also buy health and hygiene products at bulk discounts and sell them at profit. Triggerise appointed Network for Engineering, Economics Research and Management (NEERMAN) to conduct an independent impact assessment of the Tiko platform with multiple research objectives include health impact evaluation at the Rafiki level. NEERMAN used an ex-post observational design to compare usage of SRH and MCH services and family planning (FP), antenatal care (ANC) and postnatal care (PNC) practices by comparing Users and Non-Users of Tiko platform, and accounting for the selection bias statistically. The structured questionnaire collected data on knowledge, practices, barriers, enablers for SRH and MCH services, exposure o Tiko platform, and how it helped or did not help. The survey participants were approx. 1200 users and 600 non-users being served by approx. 350 pro-agents in their respective operations area. The association between use of Tiko platform and various outcomes were identified using a generalized linear model with fixed effects at pro-agent level and including a set of covariates. To evaluate the effect modification by type of pro agent - government community health worker (CHW) versus others - an interaction model was used. The standard errors were automatically clustered at pro-agent level due to fixed effects. Primary outcomes are proportion of married Rafikis currently using any contraceptives, currently using modern short-term contraceptives, proportion of Rafikis who delivered a child post Jan 2019 and received at least 4 ANC check-ups, consumed at least 100 iron folic acid (IFA( during pregnancy, and received a PNC check-up within 6 weeks of birth.

mHealth, Social Franchising, Social Marketing, Impact Evaluation, Market-Driven, Family Planning, Antenatal Care, Community Health Workers

The study compares family planning, antenatal care and postnatal care related outcomes (multiple) for women who had registered on Tiko Platform between those who used the platform and those who did not access any services on the platform. The comparison is done ex-post with a single cross sectional survey in March-April 2021. Model uses fixed effects at Pro-Agent level who is a local health promoter of a small geographical area and recruits and serves women in that area so that confounders at agent and levels beyond are controlled. For women/household level confounder control, a few socio-economic and demographic variables at the woman level were included in the model, and sensitivity of the results with and without adjusting for these control variables was investigated.

By nature of the intervention, the implementers or pro agents knew who the users and non-users are, and this was critical even in sampling. The data collectors did not know who were the users and non-users but a smart data collector / outcome assessor could figure out who were the users based on type of questions that were asked and answered. Investigators also knew who were users and non users as it was essential for analysis and setting up the data.

These participants accessed various services on Tiko platform such as buying contraceptives, visiting doctors for ANC etc. They earned Tiko Miles/Points for such health seeking behaviours which they could then redeem at network of grocery shops, pharmacies, beauty salon etc. Tiko card also enabled them to get discounts at pharmacies and at health care providers. These participants were free to access any other government or private health care facility as free economic agents. Users of Tiko platform were identified by the backend system that recorded all health seeking behaviours / actions, reward point accumulation, and use of those reward points.

These participants registered on Tiko platform on basis of recruitment drive and pitch by Pro agents, but they did not access any service and became dormant. However, These participants were free to access any other government or private health care facility and could access fame family planning and ANC products and services. They could even access Tiko network doctors and pharmacies but they would not get any Tiko Miles/Points or discounts without the use of Tiko card. Non Users were identified as those registered women who did not have any record of using services using Tiko card as per the backend system

Tiko platform is a mix of social franchising and social marketing concepts to promote health behaviours through rewards to health promoters (pro agents), healthcare providers (doctors and pharmacies), Beneficiaries (women needing FP and/or ANC services), and shop keepers and life-style service providers where beneficiaries, providers and promoters could use their rewards points. The health promoters could purchase from wholesale retailers products such as sanitary napkins, condoms and then resale these at profit. Beneficiaries were given discounts and their rewards points can be used as cash to avail certain lifestyle services at participating locations, and so did the health care providers. Pro agents also got incentives for recruiting the beneficiaries and after beneficiaries reached certain service access/use milestones. All this was integrated on a mHealth platform using smart phones and smart cards (for those without access to Tiko card).

Non-Users of Tiko did not use Tiko platform but they could access any health care provider or pharmacy to avail same services related to Family planning, antenatal care, postnatal care

Whether a woman used any contraceptive - traditional or modern methods, and permanent or temporary methods

Whether the study participant recalled consuming 100 or more IFA tablets when pregnant with youngest child born after 1 January 2019

Whether the study participant recalled receiving 4 or more ANC check-ups from any health care provider when pregnant with youngest child born after 1 January 2019

Proportion of women who received a postnatal check-up within 6 week of the delivery from a healthcare provider

Whether the study participant recalled receiving at least one postnatal health check up within 6 weeks of the youngest child's birth

Out of pocket expenditure on antenatal care, iron folic acid tablets, delivery, and postnatal check-ups

Reported expenditure in Indian Rupees for antenatal care, iron folic acid tablets, delivery, and postnatal check-ups associated with the youngest child born after 1 January 2019

Proportion of women receiving Antenatal check-ups at (a) Tiko franchisee doctors, (b) other private doctors, or (c) government healthcare provider

Separate proportions are estimated for each of the three locations of antenatal check-ups when pregnant with youngest child born after 1 January 2019

Proportion of women receiving postnatal check-ups at (a) Tiko franchisee doctors, (b) other private doctors, or (c) government healthcare provider

Separate proportions are estimated for each of the three locations of postnatal check-ups within 6 weeks after delivery of the youngest child born after 1 January 2019

Inclusion Criteria: Women who are registered on Tiko Platform with Pro-agents active in 2020-21 Age 18-50 Address and contacts details are found with help of Pro-agent Exclusion Criteria: Does not consent to participation Does not agree or confirm registering on Tiko Platform If a woman is never married, she is excluded from survey on family planning but surveyed for use of Tiko platform If a married woman does not have a child born on/after 1 January 2019, then she is excluded from the survey on antenatal care, delivery and postnatal care but surveyed for use of Tiko platform

While NEERMAN holds data use and publication rights from Triggerise, the data ownership rests with Triggerise so data access to de-identify observations and variables used in pit is unclear published papers can be made available under certain conditions