Using behavioural design and theories of change to integrate communication solutions into health systems in India: evolution, evidence and learnings from practice.

Between 2011 and 2019, an integrated communication programme to address reproductive, maternal, neonatal and child health was implemented in the Indian state of Bihar. Along with mass media, community events and listening groups, four mobile health services were co-designed with the government of Bihar. These were Mobile Academy-a training course for frontline health workers (FLHWs) supporting them as the last mile of the health system; Mobile Kunji-a job aid to support FLHWs' interactions with families; Kilkari-a maternal messaging service delivering information directly to families' mobile phones, encouraging families to seek public health services through their FLHWs; and GupShup Potli-mobile audio stimulus used by FLHWs in community events. While Mobile Kunji and GupShup Potli scaled to other states (two and one, respectively), neither was adopted nationally. The Government of India adopted Kilkari and Mobile Academy and scaled to 12 additional states by 2019. In this article, we describe the programme's overarching person-centred theory of change, reflect on how the mHealth services supported integration with the health system and discuss implications for the role of health communication solutions in supporting families to navigate healthcare systems. Evaluations of Kunji, Academy and GupShup Potli were conducted in Bihar between 2013 and 2017. Between 2018-2020, an independent evaluation was conducted involving a randomised controlled trial for Kilkari in Madhya Pradesh; qualitative research on Kilkari and Academy and secondary analyses of call record data. While the findings from these evaluations are described elsewhere, this article collates key findings for all the services and offers implications for the role digital and non-digital communication solutions can play in supporting joined-up healthcare and improving health outcomes.