ARMMAN

ARMMAN is an India-based NGO that leverages technology to create cost-effective, scalable, non-linear, systemic solutions to improve maternal and child health. Our programs provide pregnant women/mothers with critical preventive information to improve health seeking behaviour and also support health workers and systems with technology-enabled training. We are currently implementing Kilkari and Mobile Academy programs (largest mobile-based maternal messaging program and largest health-worker training program across the world, respectively), in partnership with the Ministry of Health and Family Welfare.  

Winning the Elevate Prize will support our ambitious plans to scale existing interventions pan-India [Kilkari, Mobile Academy and Integrated High-Risk Pregnancy Management Tracking (IHRPM)] and support innovations in multimedia and two-way communication approaches (WhatsApp/Thin App) with incorporation of AI/predictive analytics. It will enable creation of a technology platform with backend data integration with AI across programs for monitoring and tracking high-risk beneficiaries with planned targeted interventions. It will catalyse collaborations with multilateral agencies, support organizational development and provide access to critical funds. Strategic marketing and communication efforts will help accelerate our impact.

The idea of ARMMAN germinated during medical residency, where I witnessed pervasive systemic gaps leading to preventable maternal/child deaths. The scale of India’s problems made it evident that any solution I designed must be scalable and cost-effective. Exponential mobile phone usage in India made mHealth an exciting solution and thus, ARMMAN was born in 2008. 

mMitra and Kilkari are free voice-call services providing pregnant women/mothers with preventive care information to demand timely care. Mobile Academy and IHRPM programs train/support health workers [frontline health workers (ASHAs), Auxiliary Nurse Midwives (ANMs), Medical Officers (MOs)] to provide efficient antenatal/childhood care.  This enables early identification and improved management of high-risk conditions with reduced high-risk referrals to tertiary hospitals, leading to reduced maternal and child mortality/morbidity.

Our programs have reached over 23 million women and 173,000 health workers across 17 states. Kilkari and Mobile Academy will scale pan-India by 2025, reaching 45 million women and training 1 million ASHAs. IHRPM will train 10,000 health workers in 2021, with subsequent scale-up. mMitra will become a sandbox for testing innovations: AI/predictive analytics with Google Research India and increased focus on high-risk factors through two-way communication/multimedia content via WhatsApp/thin app.

In India, a woman dies in childbirth every hour (26,437 annual deaths); two children under-five die each minute (8,24,000 annual deaths). India has 9% of the global maternal mortality burden. Contributing factors include poor access to critical information as overcrowded health systems deprioritise counselling while inadequately trained health workers are unable to detect/manage high-risk conditions in time. Delay in detection and timely management of risk factors leads to referral system failure, delayed care seeking, overburdened tertiary facilities and increased maternal/child mortality and morbidity.

ARMMAN’s supports pregnant women/children and health workers by:

1. Improving preventive information access:

a. mMitra and Kilkari: Free voice-call services providing preventive information during pregnancy/infancy.

b. Increased focus on high-risk factors through two-way communication/multimedia

content via WhatsApp/thin app, call center services and tracking

2. Training and Supporting Health workers 

a. Mobile Academy: mHealth-based refresher training program for ASHAs. 

B. Integrated High-Risk pregnancy management: Tech-enabled training of Auxiliary Nurse Midwives, Medical Officers and Specialist doctors on high-risk pregnancy management (Zoom/learning app incorporating multimedia approaches) with  two-way communication (WhatsApp helpdesk/thin app/call center) 

3. Planned: Integrated technology platform with analytics/AI for tracking, monitoring and planning targeted interventions.

Traditional solutions for spreading health awareness create parallel networks that are resource-heavy, non-standardized and unscalable. Traditional classroom training for health workers is expensive and does not allow for frequent refresher training. ARMMAN’s mHealth solutions (including multiple multimedia approaches and callcenter support) address these systemic gaps.

Our programs are designed for scale without dilution of impact through our innovative ‘tech plus touch’ model i.e. we combine our tech-enabled weekly interface with the beneficiary/health worker with a human interface provided by the call center/field staff. This enables limited human resource requirement inspite of multiple touch points, leading to nonlinear growth at extremely low cost.  It costs 35 cents to send calls to a woman covering pregnancy and infancy through Kilkari. We partner with the national and state governments, 97 hospitals and 41 on-ground NGOs.  We leverage the existing frontline health worker network of the government and partner NGOs without creating parallel structures. mHealth-based programs also have the advantage of program upgradation without additional investment as beneficiaries  automatically upgrade phones. With increased mobile penetration and cheap data, ARMMAN’s mHealth-based interventions promise sustainability. Ongoing pilots on AI/predictive analytics (in partnership with Google Research India) and WhatsApp also promise disruptive impact.

Immediate impact: Better informed women will proactively adopt positive health behaviors, exhibit higher alertness to risk signs and proactively seek care. A Randomized Cluster Trial (RCT) evaluating mMitra (p<0.05) showed: 38.4% increase in pregnant women who took IFA tablets for 90 or more days; 22.5% increase in infants who tripled their birth-weight at end of 12 months. Improved training enhances health workers’ knowledge and helps early identification of risk-factors/timely referrals. Mobile Academy’s evaluation found improvement in ASHAs’ knowledge of critical health behaviors and ability to persuade ‘difficult clients’ to adopt healthier behaviors.

Intermediate impact: An efficient primary system with robust referrals and better high-risk tracking decongests the tertiary system, improving overall efficiency. mMitra RCT showed that among women referred for high-blood pressure, 25.32% more women in the intervention group adhered to the advice.

Distal impact: National programs (Kilkari, MA, Integrated HRPM) extract data from live national databases of pregnant women and children. An iterative feedback loop improving this databases’ quality enables entry of hitherto excluded women with access to other economic benefits/welfare schemes. Supporting MCH also improves other SDGs: eliminating under-nutrition in Asia and Africa would increase global GDP by 11 percent.

Currently, our programs are reaching 1.68 million women and children and 47,000 frontline health workers. From April 2021-March 2022, we expect our programs to reach 5.25 million women and children and train between 50,000-70,000 frontline health workers (ASHAs), 9000 Auxiliary Nurse Midwives (ANMs), 1006 Medical Officers (MOs) and 313 Specialist Doctors. 

As part of our COVID-response, from April 2020 onwards, 300,000 women have been sent critical COVID-related information on their mobiles during pregnancy and infancy. Similarly, 800,000 government health workers have been sent COVID-related updates on their mobile phones. 15,600 pregnant women and children accessed our virtual OPD (clinic) for free consultations with obstetricians/gynaecologists and paediatricians while 60,300 pregnant women and children were linked with essential healthcare services and facilities. These COVID-19 interventions continue, and in addition, we will train and support 180,000 ASHAs and 40,000 ANMs in COVID-19 management in the next 3 months.

Overall, programs implemented by ARMMAN have reached over 24 million women and children and trained 187,000 heath workers till date.

By 2025, we will reach 45 million women with preventive care information and train 1 million health workers. Thus, women are empowered to seek care in time while health workers are trained to provide timely management of high-risk conditions. This will reduce late-stage high-risk referrals to tertiary centers from 50% to 25% by 2030, thereby improving maternal and child mortality (Indicators 3.1 and 3.2 under SDG Goal 3). 

We use research studies for outcome/impact evaluation and monitoring dashboards for operational/process efficiencies. 

A Randomized Cluster Trial (RCT) on mMitra showed: 20.3% increase in proportion of women who made 4 or more ANC visits; 48.5% increase in proportion of infants who were exclusively breastfed; 22.5% increase in infants who tripled their birth-weight at end of 12 months. mMitra’s pre-post intervention study showed 96% women sought treatment for complications during pregnancy compared with 72% at baseline. 

Operational indicators for mMitra and Kilkari include Technical Efficiency Index: % calls reaching beneficiaries’ phone; Program Efficiency Index: % women who picked up at least one of four monthly calls; Beneficiary Attentiveness Index: % calls in which at least 50% content was heard. Health workers’ training indicators include training-quality, knowledge and effectiveness in identification/referral/management of high-risk cases.

Health systems’ struggle with COVID-19 has resulted in deprioritization of maternal and child health, which is a fundamental part of primary health care. This has disproportionately affected the already vulnerable population of underprivileged mothers and children. While we continue our Rapid Response to COVID-19 through interventions addressing emerging healthcare gaps and needs, the long-term impact of COVID-19 on IMR and MMR in India will affect our efforts to improve maternal and child health outcomes. 

Further, in case the third wave strikes India, there will again be limited access to the communities and health facilities. While our tech-enabled interventions successfully circumvent the physical and social constraints of COVID-19, enrolling new beneficiaries may be impacted. We are working with our on-ground partners to pilot remote enrollments. Elevate Prize will facilitate conversations and cross-learnings with other organizations across the world facing similar challenges.

Lastly, a majority of the funds are getting diverted towards immediate COVID-19 relief efforts. While that is critical, it is creating fund scarcity in areas such as maternal and child health. ARMMAN is constantly engaging with its current donors and reaching out to new ones for program delivery and financial sustainability. Funds from the Elevate Prize will provide much-needed support.

ARMMAN is at an inflection point in its journey where brand recognition and media visibility can play a catalytic role. We have demonstrated success with managing the largest mobile-health programs of their kind across the world, through a strong partnership with the national and state governments, and have ambitious scale-up and program augmentation plans. As an Elevate Prize winner with support from a global network of experts, ARMMAN would have the opportunity to catalyse collaborations with multilateral agencies, improve access to strategic advice/support for organizational development while scaling, and raise critical funds.

The recognition from the Elevate Prize would also enable a dialogue with other international non-profits working in maternal and child health and/or who use technology to deliver their programs at scale, to exchange best practices, explore areas for cross-learning and potential collaboration. 

The brand visibility would also enable us to attract the right kind of partnerships and new talent as we augment our programs through targeted content for high-risk conditions, two-way communication, predictive analytics and AI and multimedia content. It would also aid us in building a deeper engagement with the government to influence systemic changes and focus on advocacy for creating long-term sustainability.

ARMMAN demonstrates commitment to gender equity, diversity and inclusion at the organizational level and through our interventions.   

ARMMAN has a female founder; 71% women in key positions including 60% in senior leadership; and women comprise 82% of employees. ARMMAN’s board of trustees is predominantly female (5 out of 9 members) and comprises professionals from diverse backgrounds who are leaders in their individual fields. 

Since ARMMAN works in the maternal and child space, the team is predominantly female at the frontline (including hospital supervisors and call centre staff); and this frontline team comprises 45% of total team strength (of 130) and members belong to a similar socio-economic status as the women we work with. Similarly, mMitra’s network of 7000 incentivized health workers (through partnerships with on-ground NGOs) comprise women from within the communities they serve.

While gender is already an important part of our work, our goal is to further improve our understanding of various cross-sectionalities of equity. We are also trying to refine our understanding of the interplay between technology and equity, especially among the most under-served. We also plan to design appropriate tools to track and measure how our interventions impact empowerment.

My knowledge comes from an immersive experience of 10.5 years as a medical student, resident doctor and an Associate Professor at an over-crowded government hospital. During this time, I also helped design a program on primary health care and referrals in Mumbai. Through these hospital and community experiences, I witnessed systemic gaps leading to inequities. They informed my approach while creating foundational principles for  ARMMAN’s programs. Thus, our interventions are designed to be cost-effective, scalable and use the “tech plus touch” model, without creating parallel structures. My alternate life as a Urogynaecologist providing free care daily to women in a government  hospital is an extension of ARMMAN’s work, as Urogynaecology treats what ARMMAN tries to prevent. Further, my research work laid the ground for ARMMAN’s evidence-based approach. 

ARMMAN has a capable leadership team and is governed by a qualified Board/Steering Committee. CEO Ramesh Padmanabhan has technology and general management expertise. His earlier roles included CTO at Piramal Foundation and CEO/MD at NSE.IT. 

Our female frontline team constitutes 45% of our team and belongs to a similar socio-economic status as our beneficiaries. Further, mMitra’s network of 7000 health workers comprises women from within the communities they serve.

In 2018, MoHFW invited ARMMAN to take over Kilkari and Mobile Academy implementation from BBC Media Action. While this was an incredible opportunity, it was also challenging. Firstly, while ARMMAN had demonstrated success with mMitra, the scale of Kilkari and Mobile Academy was significantly higher with a steep fundraising requirement. There was also a question-mark around mMitra’s relevance if ARMMAN started implementing a similar program (Kilkari). As a founder, I felt that this opportunity, though intimidating, would help ARMMAN over the long-term as it provided exponential scale through the government collaboration and would lead to sustainable change. Thus, my first priority was to create internal buy-in for the decision. Next, we quickly enhanced organizational capabilities in financial planning, technology, program management and navigating complex government relationships by upskilling and recruiting. We hit a bottleneck when a funder who had committed 50% funds backed out unexpectedly and it took intensive fundraising efforts to bridge the gap. Today, taking this bold decision has been proven correct. We are now in the third year of a successful government partnership and are planning Kilkari and Mobile Academy versions 2.0. mMitra has successfully transitioned as a sandbox to test pilots for scaling-up through Kilkari.

• TED Talk: https://www.ted.com/talks/aparna_hegde_maternal_and_child_health_is_a_human_right 

• Skoll Video: https://www.youtube.com/watch?v=kopJV9Y5eQk&t=247s 

• Interview with Barkha Dutt: https://www.youtube.com/watch?v=cMwSYLU5U2I 

• Interview with Faye D’souza (Inside Cama Hospital): https://www.youtube.com/watch?v=jE9w6IH2X1I&t 

• Interview with Shereen Bhan on CNBC-TV18: https://www.cnbctv18.com/videos/healthcare/priority-should-be-to-vaccinate-the-vulnerable-population-says-icmrs-samiran-panda-9471311.htm 

• FinTech TimesNOW Show: https://fintech.tv/times-now-affordable-healthcare-access-in-india/ 

• TEDxGateway Webinar hosted by Faye D’souza: https://www.youtube.com/watch?v=Nanz5euE9ts 

• Panel at Devex’s Prescription 4 Progress in San Francisco: https://www.youtube.com/watch?v=cYDwkxGnuLw 

• Talk at Godrej India Culture Lab: https://www.youtube.com/watch?v=CKOz7eOozoc 

• TEDxGateway Talk: https://www.youtube.com/watch?v=JEM902F0tNo 

Winning the Elevate Prize will support our ambitious pan-India scale-up plans. By 2025, Kilkari and Mobile Academy will reach 45 million women and train 1 million ASHAs, respectively, while Integrated High-Risk Pregnancy Tracking and Management (IHRPTM) will train 26,500 ANMs and 8,640 MOs in the next 5 years. 

It will also support our COVID-19 interventions. While the current COVID-19 interventions continue, we will also train and support 180,000 ASHAs and 40,000 ANMs in COVID-19 management in 15 states with potential for pan-India scale-up. The integrated intervention includes addition of a COVID-19 specific chapter to the existing Mobile Academy program; creating and dissemination of COVID-19 focussed video and multimedia-based content; conducting online trainings via Zoom; establishing a call-center for query resolution by trained Medical Officers and Counsellors. 

The funding will also support innovations in multimedia and two-way communication approaches (WhatsApp/Thin App) with incorporation of AI/predictive analytics, and the creation of 2.0 versions of Kilkari, mMitra and Mobile Academy. We are currently revisiting our 5 to 10 year strategy and creating a blueprint roadmap for ARMMAN, and the support from Elevate will help us to firm up these plans. 

Our partnership-model engages the government, private sector, multilateral organisations and community NGOs. Our partnerships include:

• Ministry of Health And Family Welfare (MoHFW) for Kilkari and Mobile Academy programs and development of technical guidelines for high-risk pregnancy management for ANMs, MOs and Specialist doctors

• State government of Telangana for implementation of the Integrated High-Risk Pregnancy Tracking and Management project

• Partner NGOs: ARMMAN has partnerships with 40 NGOs with a network of 7000 female health workers  for enrolling women in our programs. 

• Health Facilities: Partnerships with 87 government/private hospitals for enrollments 

• AI for Social Good, Google Research India; CRCS, Harvard University; and IIT Madras for using predictive data analytics/AI in mMitra 

• IIM Ahmedabad for studies including cost-effectiveness analyses and data analytics 

• Technical Bodies: Partnerships with national bodies such as The Federation of Obstetric and Gynaecological Societies of India and National Neonatology Forum 

• Technology Partners: ARMMAN has partnered with Inscripts, Beehyv and Knowlarity to provide external support to our technology team enabling seamless delivery of tech-enabled programs.

• Dasra: It provides strategic inputs with support in organizational development, capacity building and fundraising.

• Content Partner: mMitra voice messages were jointly created by ARMMAN and Babycenter through rigorous community-needs assessment.