A multi-faceted personality, published researcher, and philanthropist Dr. Aparna Hegde, is also a TED fellow. With her commitment to improving maternal and child healthcare in India, she started her non-profit organisation ARMMAN (Advancing Reduction in Mortality and Morbidity of Mothers, Children and Neonates). Presently, she is building the Department of Urogynaecology at the Cama Hospital, Mumbai, India's first comprehensive Centre of Excellence in the field, which will offer world-class treatment for women completely free of cost. Her vision is a world where every mother is empowered and every child is healthy.
You moved back to India a few years ago from the United States following stints at Stanford University and the Cleveland Clinic. What led to
ARMMAN? What has been its focus and biggest achievement?
The idea of ARMMAN germinated during my medical residency, where every day I would witness pervasive systemic gaps leading to preventable maternal and child deaths and morbidity. Women reached the hospital in a critical condition, often at a late stage. The only way things could improve was when efforts were concentrated at the level of the community. Given the magnitude of the problem, it was apparent that the solutions had to be designed for scale at the outset in such a manner that the impact was never diluted. Exponential mobile phone usage in India made mHealth an exciting solution and thus, ARMMAN was born in 2008.
I created ARMMAN to address systemic problems affecting maternal and child health by leveraging technology and existing health infrastructure to create scalable, cost-effective, and evidence-based solutions. We provide critical preventive care information to women during pregnancy and infancy, thus enabling them to seek and demand better health care for themselves and their children, along with training and supporting health workers to detect and manage high-risk conditions in time.
Today, programmes implemented by ARMMAN have reached over 41 million pregnant women, new mothers and their children, and trained more than 3,24,000 frontline health workers in 20 states in India.
In the past few decades, we have seen a significant growth of NGOs which are translating the concepts of equity, social justice, community participation, and integrated development, within the primary health care realm. What sets ARMMAN apart from other NGOs that work in this field?
Traditional solutions for spreading health awareness involve the creation of a parallel health worker network, which is resource-heavy, inconsistent, expensive, and not scalable. ARMMAN's unique blended 'tech plus touch' approach leverages technology and the health worker network and existing health infrastructure of the government and NGO partners, to achieve scale at low cost.
Our technology is simple and resource-light and has the advantage of regular iteration without additional investment as women and health workers automatically upgrade their phones. Technology also enables the creation of deeper and more nuanced programming. Our 'fit-for-purpose' approach tailors programmes based on technology access, risk factors, and equity parameters to ensure significant impact on the most disadvantaged populations. Our access to a huge database enables us to deploy data analytics, including predictive analytics and AI, to improve programme efficiency.
Our programmes are housed within the Government of India and tackle systemic issues to enable sustainability. The sheer scale achieved by ARMMAN's interventions has not been earlier realised in India or elsewhere. Kilkari and Mobile Academy, implemented in partnership with the Government of India, are the largest mHealth programmes of their kind in the world. ARMMAN is proactively embracing equity-based and gender-transformative approaches, seamlessly integrating these principles through innovations in our programmes.
Can you tell us more about how technology has been instrumental in the success of your programmes?
The idea for scalable technology solutions came to me in 2008 when I was a student at Stanford. Everyone thought I was crazy but it has worked out well. Our 'tech plus touch' enables us to reach women and health workers more often than is possible with traditional models, thus providing non-linear growth, while still providing human touch points for enrolment, accessing feedback, and answering questions as every technological solution is incomplete without a tangible aspect.
Via programmes like the mMitra and Kilkari, ARMMAN has been making inroads in reducing mother and child mortality. How do these programmes achieve your objectives?
Both programmes address delays in seeking care by working directly with pregnant women and new mothers to improve access to preventive care information. These weekly voice-calling services provide culturally sensitive information directly to the woman, through pregnancy and infancy, using dialect, diction and content that she can understand. mMitra was started by ARMMAN in 2013 and scaled to nine states of India. ARMMAN's demonstrated success with mMitra led to the partnership with the Ministry of Health and Family Welfare in January 2019 for the implementation of their Kilkari programme.
One of your collaborations is with Google as part of their 'AI for Good' initiative. What has been the role of AI in your programmes?
ARMMAN has partnered with Google Research India (AI for Social Good); CRCS, Harvard University; and IIT Chennai to use Artificial Intelligence to predict the risk of expectant mothers dropping out of our mMitra programme along with creating targeted interventions to improve positive healthcare outcomes. This collaboration has led to the creation of a prediction model for low listeners, which is now integrated into mMitra. A Randomized Controlled Trial conducted between November 2022 and February 2023 showed that women selected by the AI model to receive a service call had listened to more mMitra call content in comparison to the controls. We are now developing a similar AI model for Kilkari in partnership with Google Research India.
This is just one of the examples of how ARMMAN has adopted AI to strengthen its data and evidence-based insights, which will help our programmes to cater to the changing needs of women, children, and health workers.
India has one of the highest maternal and child mortality rates in the world. How will the Arogya Sakhi programme make a difference? What are its salient features?
In severely underserved tribal districts where there is a lack of or non-existent primary care system, frontline health workers (ASHAs) are trained to become Arogya Sakhis who provide home-based preventive care, perform diagnostic tests, screen for high-risk factors, and ensure early referral, during the antenatal period and infancy. Arogya Sakhis are equipped with medical kits and trained to perform basic diagnostic tests including haemoglobin, blood sugar, urine, blood pressure, foetal doppler, and anthropometric measurements. They are also supported by a mobile application that guides them through the care process, helps identify high-risk signs and symptoms, and gives alerts regarding the need for referral.
You have said that almost 90% of maternal deaths in India are avoidable if women receive the right kind of intervention. What are the most acute problems in our maternal healthcare system?
The three-delays model explains why a mother or child dies. The first delay is in the decision to seek care due to a lack of access to preventive care information. The second delay is in reaching care due to long distances, poor roads, poor availability of cost-effective transportation and basically not knowing where to go and the third delay is in receiving adequate health care due to lack of facilities, equipment and trained staff at the hospital they go to.
What are the steps that need to be taken to rectify this and ensure quality care for mother and child?
Quality primary health care is almost non-existent in both rural and urban India. It is imperative that both pregnant women and children have access to quality primary health care so that risk factors are picked up and they are referred in time to higher levels of care before it is too late. This will also ensure that the tertiary centres are not overcrowded. In almost all countries in the world which have good models of health care delivery like Spain and the U.K. in the developed world and Thailand, Brazil and Mexico in the developing world, primary care forms the anchor around which a well-defined referral system is built. Task shifting needs to be done, meaning the midwives, etc., should be provided training in performing specialist tasks in areas where there is a chronic shortage of health professionals. There needs to be an overhauling of public health infrastructure to ensure all health centres have the appropriate facilities, equipment, supplies and staffing necessary to provide care appropriate for their level.
Our on-ground experience of 15 years has also brought to light the impact of equity and gender disparity on the success of mHealth programmes in maternal and child health. ARMMAN is actively adopting strategies that prioritise equity and promote gender transformation. We are weaving these principles into our programmes through innovative approaches.
Evidence shows that giving birth in a health facility with a skilled attendant is not sufficient to reduce maternal and newborn deaths and severe morbidity. Why does this happen?
Improved hospital-based care during delivery and obstetric emergencies are effective measures for reducing maternal and infant mortality. Hence, the present health policy has had a single-minded focus on institutionalising delivery: the proportion of hospital-based delivery increased from 25% in 1992-93 to over 88% in 2019-21. However, this has not been supported by a concomitant focus on preventive/promotive health services within the primary health care system.
Only 31% of women receive the full range of antenatal services in India and studies show that lack of awareness of high-risk factors and complications among women and their family members is one of the major causes underlying 35-60% of maternal deaths. Even when there is uptake of antenatal or childhood care, the quality of information provided is poor. Simultaneously, there is a critical need to train health workers to deliver quality antenatal and childhood care services including high-risk factor management.
With CSR a major component and initiative of many corporates, how can a corporate come forward to help in this field?
ARMMAN's interventions are supported by many corporates across multiple geographies. Through CSR initiatives, companies can fund our programmes in specific areas, thereby leading to better maternal and child health indicators in that particular geography. Corporates can also come forward to share their expertise in multiple areas such as fundraising, research, communication, human resources, etc., which would help ARMMAN in organisational strengthening as we set about to achieve our vision of reaching 70 million women and their children and training 850,000 health workers across India by 2030.