Anandi
The Sustainable Development Goals (SDG) envision the reduction of Maternal Mortality Ratio (MMR) to less than 70 per 100,000 live births and Neonatal Mortality Rate (NMR) to less than 12 per 1000 live births by 2030. India’s MMR in 2017-19 was 103 (95% CI: 94-113) and NMR in 2020 was 20.2. With renewed focus on the perinatal period, between 1992-93 to 2019-21 the proportion of hospital-based deliveries in India increased from 25% to 89%. However, according to NFHS-5 (National Family Health Survey, 2019-21) in India, only 58.5% of women had at least 4 antenatal visits while just 26% women took Iron and Folic Acid (IFA) for 180 days or more.
Many high-risk factors responsible for maternal and neonatal mortality have their roots in the antenatal period: about 20-30% pregnancies are high risk, and these high risk pregnancies (HRPs) are responsible for 75% of perinatal morbidity and mortality. 25% of maternal mortality occurs in the antenatal period resulting from high risk factors directly linked to pregnancy. The only effective approach to reducing the maternal and neonatal mortality and morbidity resulting from these conditions is identifying high-risk factors early and ensuring timely referral and efficient management through pregnancy before their descent into a critical stage.
Currently, the provision of continuum of care for high-risk pregnancy, which includes early identification of high-risk pregnancy (HRP), its causes and its complications, appropriate referral, treatment and follow-up care including need-based laboratory investigations and follow up after discharge/treatment until safe delivery, is inadequate.
WHO guidelines (2015 and 2017) focus on basic preventive and promotive antenatal care, early assessment for high-risk cases and complications and management of obstetric complications. However, the use of these guidelines at different levels of facilities and referral systems is not well understood. There is often confusion regarding the individual roles to be played by the Auxiliary Nurse Midwife (ANM) at the primary level of public health care system (Health Sub Centre), the Medical Officer (MO) at the secondary level (Primary Health Centre) and the specialists at the tertiary level (Community Health Centre/District hospital) in the management of high-risk pregnancy. Lack of clear protocols leads to a poor referral system, which further leads to increased irrational, delayed and complicated referrals ultimately resulting in overcrowding of tertiary facilities leading to increased maternal and neonatal mortality and morbidity. Hence, there is a pressing need for evidence-based guidelines that clearly delineate the role of each health care provider at every level of the referral chain in the management of high-risk pregnancy with as little ambiguity as possible.
Furthermore, there is a critical need to train and handhold health workers to deliver quality antenatal and childhood care services, especially for high risk factor management, based on these evidence-based protocols. Several studies have identified deficits among ANMs in maternal and newborn-related skills and the urgent need to strengthen skills of ANMs, especially through in-service training. A situational assessment study done by ARMMAN in Telangana revealed that ANMs in Telangana currently only manage anemia. 94% ANMs end up referring all high-risk cases to specialists, bypassing the referral chain. The health care providers at the higher levels of the referral chain, namely MOs and specialists also need training support. As per the situational assessment, 25% of MOs lack clarity in the management of various high-risk conditions, only 60-65% of the specialist obstetricians and gynecologists in the district hospitals have the requisite knowledge to manage various high-risk pregnancies and approximately 23% of MOs expressed lack of clarity regarding referral to first or second referral units in various situations. There is also a need to conduct comprehensive training at each level of the health cadre in these protocols and incorporate the protocols into an intuitive digital algorithmic decision support tool to support the health workers and officers in identification, tracking and end-to-end care management of high-risk pregnancies.
The Mother and Child Tracking System/Reproductive and Child Health (MCTS/RCH) Portal, the live database of mothers and children in India, and other government databases function in their own silos with little interoperability and poor data quality with severe gaps and multiple redundancies. This results in differing estimates of prevalence and coverage leading to confusion and reduced reliability. Thus, there is a lack of actionable health data for not just just tracking of women with antenatal high-risk factors, but also for health systems planning and program management.
Tech-enabled approaches help to create a system linked with the database, leading to early detection, end-to-end tracking and management of high-risk factors during pregnancy by the health workers, leading to a sustained reduction in irrational, delayed or complicated referrals and ultimately reducing maternal and neonatal mortality and morbidity.
ARMMAN has designed an integrated, comprehensive, multi-step, systemic approach for improved identification, tracking and end-to-end management of high risk pregnancies during the antenatal period so that there is sustained reduction in delayed, complicated and irrational high-risk referrals to tertiary facilities resulting in lessening of the burden on them, leading to their improved functioning and overall reduction in maternal and neonatal mortality and morbidity. This intervention is known as "Anandi'' or "Integrated High-Risk Pregnancy Tracking and Management (IHRPTM)".
ARMMAN domain experts had created algorithmic, color coded, detailed, easy to understand protocols for end-to-end management and referral for each level of the cadre - ANM, MO and specialist - for 35 high-risk conditions when Dr. Aparna Hegde was a part of the antenatal care guidelines committee of the Ministry of Health and Family Welfare in 2019. 18 high risk conditions were prioritized for Telangana based on the analysis of high-risk conditions of the RCH database of Telangana (KCR) and the advice of a state level expert committee.
Anandi/ IHRPTM has been rolled out in Telangana after the state government entered into a five-year memorandum of understanding (MoU) with ARMMAN in 2020. The state of Telangana will serve as a model state following which the intervention can be scaled across the country in a phased manner.
Aspects of Anandi/ IHRPTM program in Telangana:
Shortlisting of 18 high-risk pregnancy conditions and creation of tailor-made protocols: After the 18 high-risk pregnancy conditions were finalized in conjunction with the state government of Telangana, The protocols are translated in the local language (Telugu) for use by ANMs. The color-coded protocols for 18 high-risk pregnancy conditions were accepted as a policy by Government of Telangana and recognized as guidelines for diagnosis and management by public health functionaries through three tiers of public health system in the state.
Blended training of health workers on 18 high risk pregnancy conditions: A blended approach for training with a mix of online and offline training has been initiated in the state in three batches of around 6 modules each. Overall, we aim to train 400 specialists, 1200 medical officers and 9000 ANMS across the state of Telangana.
Learning App: The training method is supported by a “learning app” embedded in the tablets provided by the Telangana government to all the ANMs, MOs and specialists in the state for long-term handholding. The learning app contains multimedia content including live action and animation videos, complemented with simulations, interactive quizzes, and notifications to encourage learning at the learner’s convenience. The content for six modules is ready, and training will begin shortly.
Handholding of the ANMs and MOs: Two-way communication support will be provided through a WhatsApp helpdesk and a call center for remote handholding when they implement the protocols on the ground.
Tracking App: A tracking app with the algorithmic protocols embedded as a decision support tool, will support the ANM and MOs during the care process. It will prompt them to note the relevant signs and symptoms and guide them through the appropriate diagnostic interventions, treatments and referral as needed.
Integration of the tracking app with the KCR platform: The data generated through the tracking app will be integrated with the RCH database of Government of Telangana (KCR portal) to enable improved tracking and end-to-end management and targeted training of health cadres based on the distribution of risk factors in the state.
Creation of a single technology platform that integrates the beneficiary data with high risk factor tracking and health worker data: The integrated tech platform will ensure further linkage of the KCR portal and high-risk data (accrued from the high-risk pregnancy tracking data) with the data obtained from Kilkari and Mobile Academy, the largest mHealth programs of their kind in the world currently being implemented by ARMMAN in collaboration with the MoHFW. Kilkari is a free voice-call service providing critical preventive care information to women directly on their mobile phones during pregnancy and infancy (Reached 26 million women), while Mobile Academy is an mHealth-based refresher training course for frontline health workers/ ASHAs (Trained 248,000 ASHAs). Both are currently present in 18 states with an expansion to Telangana planned in the next few years. Backend data integration across interventions will enable creation of targeted programming and refresher training. For example, if hypertension is identified as a prevalent high-risk condition in an area, information can be sent to women during pregnancy through Kilkari, while ASHAs, ANMs, MOs and Specialists can be trained on hypertension specific to their work and geography.
Dashboards at every level: Dashboards for relevant real time monitoring and reporting at various levels of the health system right from the state level to the block and district levels. They will also provide directions on the need for refresher training.
Scale up to new geographies: In the next five years, we will have completed Telangana and started the program in four more states (Andhra Pradesh, Karnataka, Assam and Odisha), at which point ARMMAN will refine all components and decide whether to adopt a platform approach to a nationwide scale-up.
Anandi/ IHRPTM will ensure that all cadres of health workers in the public health care system are trained in management and referral strategies for high-risk pregnancy conditions, resulting in overall improvement in quality of antenatal care, reduction in delayed, complicated and irrational to tertiary facilities, ultimately leading to a reduction in maternal and newborn morbidity and mortality.
We are training 400 specialists, 1000 medical officers and 9000 ANMs across the state of Telangana, and will be supporting them via the learning app, tracking app and two-way communication. This will benefit approximately 0.75 million pregnant women, 0.65 million newborns and 40 million state population (family members of beneficiaries) in a year. Within four years of interventions, our program will reach a total of 3 million pregnant women and 2.6 million newborns in the state. Through Anandi/ IHRPTM, we are also anticipating a 50% reduction in one or more of the 18 high-risk pregnancy conditions, implying that around 124,000 pregnant women will face a reduced burden in one or more of these conditions each year.
Through our program we are also anticipating a 20% reduction in maternal and neonatal mortalities in Telangana. Thus, a total of 3 million pregnant women will be satisfied with the improved quality of ANC services provided by three tiers of public health facilities, leading to renewed faith in the public health care system and increase in demand for antenatal care services from public health facilities.
As a practicing urogynaecologist and through my work at ARMMAN, and several field visits across the country, I realized the obvious absence of comprehensive guidelines for end-to-end management of high-risk pregnancies and brought it to the notice of the Ministry of Health and Family Welfare, which then constituted a committee to review and improve the country’s antenatal guidelines. I put together a committee of doctors to develop 35 comprehensive, evidence-based, color-coded, simplified algorithmic guidelines for end-to-end management of high-risk pregnancies, of which protocols for end-to-end management of 18 high-risk conditions were adapted for Telangana and accepted as policy by the state.
We have a highly capable team with strengths across various verticals. Dr. Karishma Thariani has helped in developing the protocols and creating content, and also conducts training for the senior gynecologists (specialists) and medical officers of Telangana. She has trained and worked at various premiere medical institutions in the country and comes with immense experience in the field. Our content specialist has completed her training from Stanford and has in-depth expertise in developing and overseeing content strategy with experience across organizations such as BBC Media Action, United Nations Development Programme and Centre for Equity Studies. Dr. Chetan CP leads the IHRPTM program and has two decades of experience in public health and has worked with WHO and Columbia Global Centres on systems strengthening. Since all our interventions are tech-enabled, we have a robust technology team. The CEO, Ramesh Padmanabhan, has over 25 years of experience in the information technology and non-profit sectors. Suresh Chaudhury, the Senior IT Consultant in charge of technology at ARMMAN, has 27 years of experience in process design, application design, development and implementation.
ARMMAN is currently using an in-house created mobile-based application for health workers in its Arogya Sakhi Home-based Antenatal and Infancy Care program in severely underserved tribal districts like Palghar in Maharashtra which trains local women health leaders (Arogya Sakhis) to 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 for diagnostic tests and supported by a mobile application encoded on a tablet that acts as an intuitive job-aid with a decision-support algorithm that takes her through the care process. The app provides guidance on the symptoms and signs to be noted and the investigations to be performed identify women and children with high risk factors early, and gives alerts regarding high risk factors, the required treatment and need for referral. The Sakhis can also access training videos on the mobile tablet for self-learning.
In the case of Anandi/ IHRPTM, ARMMAN and the state have entered into a tripartite agreement with Argusoft for developing, deploying, and providing support for the learning app and the tracking app, which will be powered by Argusoft’s MEDPlat platform. MEDPlat has been deployed successfully in other states in India and other countries. One of the large implementations of the program is in Gujarat where over 65 million beneficiaries are digitized in the system and is used by all the ANMs in the state for providing all RMNCH services. The learning and tracking apps for Anandi will be layered on top of this existing app.
ARMMAN also has strong experience in training health workers; apart from the Arogya Sakhi program, we are currently implementing Mobile Academy, the world’s largest mobile-based refresher training course for frontline health workers (ASHAs) in partnership with the Ministry of Health and Family Welfare. Over 248,000 ASHAs have been trained across 20 states of India so far, with a planned pan-India expansion by 2025-26.
- Leverage existing systems, networks, and workflows to streamline the collection and interpretation of data to support meaningful use of primary health care data
- Provide actionable, accountable, and accessible insights for health care providers, administrators, and/or funders that can be used to optimize the performance of primary health care
- Balance the opportunity for frontline health workers to participate in performance improvement efforts with their primary responsibility as care providers
- Pilot
Our technical partner Argusoft already manages an application for ANMs in Gujarat which provides for maintaining a longitudinal health record of the woman, keeping track of the details of services provided at the community level. Our tracking app will be layered on top of the existing application, extending its scope to include end-to-end management of high-risk conditions during pregnancy and making it easily scalable to other parts of the country.
The backend integration of the tracking app with the national database will enable creation of targeted programming and refresher training, allowing the state to proactively allocate resources to a particular district which is performing badly in a particular high-risk condition. Furthermore, Integration of AI and predictive analytics from the very outset will help in creating targeted programming. The long-term goal is that AI will eventually help to predict high-risk factors in the individual woman and help the state to proactively allocate resources based on need and trends as predicted by AI.
The IHRPTM program aims to build upon and strengthen the existing health systems with ripple effects on other health programs or schemes. It tries to do so by addressing the main blocks contributing to inefficiencies by improving systems relating to knowledge dissemination, empowering real-world application of knowledge and continuous data flow through the state portals for inbuilt analytics, oversight, informed decisions, and targeted budgeting. All this will improve the way high-risk pregnancies are managed through a sustainable intervention. As a ripple effect, the data collected could be used to direct state sponsored benefits to the health beneficiaries without risk of duplication.
Currently Anandi/ IHRPTM is supported by organizational funds, and not by a specific anchor donor. The monetary support from MIT Solve will bring financial stability to the program, and reduce our dependency on unrestricted funds for program implementation.
Anandi/ IHRPTM has been designed to be embedded in the public health system, thereby enabling an enormous reach across the state in which it is being implemented. The solution also has an inbuilt sustainability model as we are building it without creating parallel structures which are human and finance resource intensive. In Telangana, it is a co-invested public private partnership (PPP) model between the state and ARMMAN. The entire program is embedded within the health system with the protocols created as part of the program already released as state policy. Also, ARMMAN has signed a five-year memorandum of understanding (MoU) with the state government to implement the program in Telangana.
Our innovative ‘tech plus touch model’ i.e., leveraging the existing frontline health worker network of the government and partner developmental organizations like UNICEF, academic networks in India like Federation of Obstetric and Gynaecological Societies of India (FOGSI), National Neonatology Forum (NNF), Indian Pediatric Association (IPA), etc., create for multiple touchpoints to share our program findings, enables our programs to scale cost-effectively. This provides a non-linear growth at extremely low cost.
Digital India is a flagship program of the Government of India with a vision to transform India into a digitally empowered society. Through the learning and tracking app all the public health functionaries of the state are transforming the quality of ANC care in the state using digital solutions without any extra cost, as all these health functionaries are already provided with tablets. The learning and tracking apps are being created under a tripartite agreement between the state government, ARMMAN and the tech vendor Argusoft. All the directives necessary for the program are sent to the health cadre from the state government. The face-to-face training of the health care providers is done by state master trainers (who have been trained by ARMMAN) with online support from ARMMAN. The protocols have been created keeping in consideration the resources, equipment, supplies and staffing available and hence the state will not incur any untoward costs in ensuring that the policy is followed at every level of the referral system. All the ANMs and medical officers in Telangana already have access to tablets. Once the health care providers are trained and the new normal is created in terms of high-risk pregnancy management, the program will be further entrenched within the system.
Our Impact goals for the next one year in Telangana include:
25% improvement in knowledge of ANMs, MOs and Specialists on how to manage 18 high-risk pregnancy conditions
Full-fledged learning app on 18 high-risk pregnancy conditions becomes operational and health functionaries will start using the app
Our impact goals for the next five years in Telangana and other geographies include:
20% reduction in maternal and neonatal mortality
50% reduction in any one or more of 18 high-risk pregnancy conditions
25% reduction in number of irrational, late-stage and complicated referrals
25% increase in pregnant women who receive quality antenatal care (ANC) in the primary health system and referral chain
Reach 50 million women and their newborns, and train 47,400 ANMs, 7300 MOs and 1290 specialists from five states of India
The implementation of Anandi/ IHRPTM incorporates a step-wedge approach which includes:
Finalization of technical and programmatic guidelines for 18 prioritized high-risk conditions specific to Telangana and prevention of perineal trauma at the time of delivery
Training of every health cadre in the high-risk protocols through a hybrid model including remote online training.
Creation of a learning app to be embedded in the tablet of the ANMs, MOs and specialists using multimedia-based approaches (live-action videos, simulations, interactive quizzes, and notifications)
Call center and WhatsApp helpdesk support for long-term handholding when the ANMs and MOs implement the protocols on the ground
Integration of the protocols into an intuitive decision support tool (tracking app) to handhold the various levels of the health cadre through the care process
Integration of the backend data of the tracking app with the KCR portal for better tracking
Creation of a dashboard for multiple levels of the state health system for real-time monitoring
Development of a continuous quality improvement cycle and integration of AI and predictive analytics.
Training of MOs and Specialists on the first 12 modules (out of 18) is complete and the ANM training on the first six modules will begin soon. Pre-post tests were conducted prior to training on each module, as well as post training to assess technical knowledge, perception and practices towards high-risk pregnancy management
The first six modules are ready to be deployed on the learning app embedded on the tablets of the ANMs and MOs. ARMMAN’s content team has created a mix of live and animation multimedia, complemented by simulations, interactive quizzes, and notifications to encourage learning at the learner’s convenience. Going ahead, we will introduce one multimedia-enabled protocol on the learning app every 15 days/1 month, to allow for complete understanding of each topic and enable revision. Over the 15 days/1 month dedicated to each topic, the trainee will be sent simulations and notifications at regular intervals in addition to the multimedia content to facilitate in-depth training. An interactive quiz will be sent to the trainees on each topic at the end of the initial training. Another quiz will be sent three months later to determine long-term recall and refresher training will be conducted as necessary. A release of new content every 15 days-1 month will allow for the interest levels to remain high.
With the completion of these key activities, deployment of learning and tracking apps, introduction of dashboards at block/district/state, integration of backend data with KCR portal and by scaling-up of Anandi/ IHRPTM program to four new states, we are confident of achieving our set goals over the next five years.
We have a 4-E (Efficacy, Effectiveness, Equity & Empowerment) Framework for Monitoring, Learning and Evaluation. Earlier we only measured efficacy and effectiveness: Efficacy is measured via monthly program dashboards using data analytics (including predictive analytics/AI). Effectiveness includes regular assessment of programs via CATI surveys, rapid assessments, small cross-sectional studies and long-term studies such as randomized controlled trials (RCTs), quasi-experimental studies, pre-post intervention, cross-sectional studies, and qualitative research.
We are expanding the framework to include equity and empowerment. We will monitor the efficacy and effectiveness by disaggregating data based on equity parameters, and on the basis of gender for children under 5. We are developing an empowerment tool which will enable an understanding of empowerment among health workers.
The impact of the program will mainly be evaluated using the following three study designs:
Community based study: A quasi-experimental before and after study of recently delivered women (who delivered in the past three months to one year) will be conducted to measure changes in high-risk morbidities from the community perspective and satisfaction with the management strategies followed by health facilities and its staff.
Referral tracking survey: By covering 4-6 health facilities from two-three randomly selected blocks, and by prospectively following pregnant women with one or more of the 18 diagnosed high-risk morbidities, we want to understand referral pathways followed for each of these high-risk pregnancy conditions by these facilities and its staff.
Randomized Control Trial (RCT): An RCT is planned in selected districts of Telangana with learning and tracking apps, and without these apps, to measure impact of the apps on the prevalence of morbidities, changes in quality of management and changes appropriate referrals made.
List of monitoring & evaluation indicators in Anandi/ IHRPTM include
20% reduction in maternal and neonatal mortality
50% reduction in any one or more of 18 high-risk pregnancy conditions (in Telangana)
25% reduction in number of irrational, late-stage and complicated referrals
25% increase in pregnant women who receive quality antenatal care (ANC) in the primary health system and referral chain
Train over 47,400 ANMs, 7300 MOs and 1290 specialists from five states of India (including Telangana)
Reach 50 million women and their newborns
The indicators under provision of care include:
At least 25% improvement in HRP related knowledge & management in ANMs, MOs and Specialists as compared to baseline
At least 85% of specialists, MOs, ANMs and Supervisory cadres trained on 18 modules (in Telangana)
At least 70% sessions held optimal quality
At least 25% improvement in correct responses between pre and post-session scores
Training session quality done for at least 85% sessions
At least 85% of ANMs, MOs and SPLs are using Learning app
At least 85% of complete learning app courses, at least 70% attempt quizzes, at least 50% have correct responses to quizzes
All 100% users receive prompts via notifications sent by app
Number/proportion of pregnant women diagnosed with one or more of the HRPs
At least 25% reduction in irrational, late stage and complicated referrals.
At least 90% confidence in the app use with 100% concordance of the app outputs clinically.
At least 10% reduction in the elective LSCS from current data year 1, with subsequent reduction of 5% per year
At least 25% reduction in irrational, late stage and complicated referrals.
Variations in program coverage by equity parameters
Variations in HRPs by equity parameters
The indicators under experience of care include:
At least 25% improvement in HRP related knowledge & management in ANMs, MOs and Specialists as compared to baseline
At least 20% improvement in confidence of health functionaries to manage HRP as per the protocols
At 25% improvement in satisfaction of pregnant mothers with the quality of ANC services in the facilities
At least 50% improvement in satisfaction of HRP mothers with the diagnosis & management of HRPs
At least 15% improvement in use of public health facilities for management of HRPs
Equitable coverage of program irrespective of caste, difficult area
Equity in level of satisfaction with management of HRP by different equity parameters
The Theory of Change of Anandi/ IHRPTM program is that health workers at every level of the health system are trained, supported and handheld through protocols for high risk conditions, enabling timely detection, management and tracking of these factors via tablet-encoded decision support tools, resulting in the creation of an electronic medical record and dashboard at every level of the health system, leading to a reduction in delayed, irrational and complicated referrals and lower burden on tertiary facilities, ultimately leading to a reduction in maternal and neonatal mortality and morbidity.
The logical framework below links program activities to immediate outputs and longer-term outcomes for the different cadres of health workers.
The indicators pertaining to outcomes will mainly be generated through ‘impact evaluations’ conducted at the beginning and end of the interventions. Majority of the output indicators and few of the outcome indicators will be generated through ‘longitudinal cohort studies’ conducted with a select set of public health systems and respective functionaries of these health systems, at periodic intervals of time, during the implementation phase of the program. The activities will mainly be generated through concurrent program ‘monitoring checklists’ and the findings from the ’need-based/dipstick’ studies conducted at different points of time of the implementation phase to identify the domains that need particular focus by the program team.
To achieve the objectives of the IHRPTM Program, leveraging technology is crucial. The approach to tech constitutes the following:
1. A learning app for training of ANMs, MOs and specialists which include live action videos, interactive quizzes, notifications and such other features necessary to enable learning for the health workers at their convenience.
2. Handholding of the ANMs and MOs through two-way communication via call center/WhatsApp Helpdesk to support them when they implement the protocols on the ground.
3. A tracking app with the algorithmic protocols embedded as a decision support tool, will support the ANM and MOs during the care process. It will prompt them to note the relevant signs and symptoms and guide them through the appropriate diagnostic interventions, treatments and referral as needed.
4. Integration with the state database (KCR platform) to enable better end to end tracking, training and targeted focus based on distribution of high risks.
5. Dashboards for relevant real time monitoring and reporting at various levels of the health system right from the state level to the district and block levels.
The integration of the data from the tracking app with the national database/ Reproductive Child Health (RCH) portal, a live database of all the pregnant women, mothers and infants in the country, bolstered by AI analytics will enable us to improve program efficiency by predicting risk factors at the individual level as well as the population-level based on geographical distribution of the factors, thereby helping states to prioritize their scarce resources in an appropriate manner.
ARMMAN and the state of Telangana have entered into a tripartite agreement with Argusoft for developing, deploying, and providing support for the learning app and the tracking app, which will be powered by Argusoft’s MEDPlat platform.
MEDplat, a comprehensive low-code Public Health Management application that has a 360-degree approach to address the challenges that are present today in most public health initiatives viz public health delivery, tracking, learning and monitoring platform is the result of Argusoft’s over twelve years of experience in designing and developing health care applications and watching the dynamics in the domain very keenly, especially the changing policies, emerging evidence-based protocols, rapid policy changes, reporting requirements and most importantly the challenges faced at the field and the gaps between policy and ground implementation. From an India perspective, this platform aligns to the tenets of the National Digital Health Blueprint and the National Digital Health Mission.
MEDplat will be able to deliver all the desired features/functionalities that are expected for this project and provide for end-to-end tracking and management of all RCH and other public health initiatives of the state including integration with the National RCH portal and other national level digital health interventions from a data interchange and creation of unique health identifier perspectives.
The MEDplat platform has been implemented by the Govt of Gujarat pan-state under the name of “TECHO+” and the state-wide roll-out was launched in October 2017 for Family Health Survey (population enumeration) and RCH services and was further enhanced to include Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) services, Facility Interfaces, Non Communicable Diseases and many other features and currently is the system of records in the state of Gujarat.
- A new application of an existing technology
- Big Data
- 3. Good Health and Well-being
- 5. Gender Equality
- 10. Reduced Inequalities
- 17. Partnerships for the Goals
- India
- India
The primary health care data for the solution is collected by the various cadres of health workers in the public health system as it is designed to be embedded in the system rather than creating parallel networks. As the data is entered on the tablets, the traditional method of paper-based collection will be phased out. The solution will also ease the process of developing monthly reports, and remove subjectivity in decision-making as it supports all multiple cadres of health workers with a decision-making tool.
This intervention will therefore support health workers in functioning more efficiently, thereby reducing their workload and freeing up their bandwidth, which acts as an incentive for them to collect data for the solution.
- Nonprofit
In Anandi/ IHRPTM, the ANMs play a crucial role in implementing the program on ground. However, ANMs' lower position within the official hierarchy allows managers and doctors to exercise “power over” them, severely curtailing their expression of all other forms of power. Disempowerment of ANMs occurs at multiple levels in interlinked and interdependent ways reflecting their lack of representation in policy making positions, a virtual absence of gender-sensitive policies, and ultimately organizational power structures embedded in patriarchy. The IHRPTM team is contingent on these issues, and in our program we will treat ANMs with dignity and involve their participation in different decisions of the program implementation.
We also recognize that the impact of our programs could be tempered by overt and covert factors resulting from the social and economic context in which our programs are based. The social inequities undergirding the power asymmetries including gender, caste, religion, tribal status, migrant status, etc. and the intersectionality between them, add another layer of vulnerability and variability. We intend to use a design process and make agile iterative programmatic changes that will enable us to rigorously respond and adapt to these realities, to improve the effectiveness and sustainability of our programs. This is doubly necessary because we intend to shift the discourse, power structures and incentive structures back to the bottom of the pyramid, both in terms of the women and ANMs we train (who are at the bottom of the health hierarchy). This could potentially disturb the status quo leading to unforeseen negative consequences that we need to anticipate and pre-empt.
As an organization, ARMMAN is committed to making a transition to equity-based and gender transformative approaches. ARMMAN will do a thorough audit of our programs and organization by experts in equity and gender to determine changes in program design, implementation processes, organization structure, etc., needed to ensure equity-based service delivery and incorporation of gender-transformative approaches. We will develop lateral approaches to the most marginalized women through special efforts in four of the tribal districts of Telangana. As far as possible program data and outcomes will be disaggregated based on parameters of inequity. An inhouse gender consultant will be appointed to guide our transformation from gender accommodating to gender transformative approaches. Content will be created using equity-based and gender transformative approaches. ARMMAN has developed an empowerment tool to assess empowerment engendered in women by mhealth based information services which will be modified and used in rapid surveys/formal studies of IHRPTM. We intend to do the same for health workers. All formal research studies will include indices to measure equity, gender transformation and empowerment.
As part of our equity-based approach, our expanded 4-E M&E (Monitoring and Evaluation) framework will include indices to measure efficacy, effectiveness, equity, and empowerment. Efficacy and some effectiveness indicators will be gleaned monthly from program dashboards. Need-based projects will be done by either the M&E team within the programs or research team as required to clarify the factors underlying program efficacy and effectiveness metrics. Long-term impact will be determined through randomized controlled trials, quasi-experimental studies, pre-post intervention, cross-sectional studies, and qualitative research. Rapid assessments, small cross-sectional studies etc. will be done at quarterly/half yearly/yearly intervals to measure effectiveness at regular intervals. Empowerment tools will be used to determine empowerment engendered in the subscribers and health workers by our programs.
We will try to assess the progress of work on gender and equity transformative approaches using the following outcome indicator:
There will be 25% improvement in gender-related indices measuring gender transformation among the pregnant women and health workers we serve
ARMMAN leverages mHealth technology to create scalable, cost-effective, gender transformative, equity-sensitive, non-linear, systemic solutions to reduce maternal and child mortality/morbidity. We create at-scale programs with proven impact by partnering with national/state governments, partner NGOs and health facilities to create a unique “tech plus touch” model.
ARMMAN adopts two primary approaches:
1. Addressing delay in seeking care by improving access to preventive care information via free weekly voice-calling services for pregnant women & mothers of children under age one [mMitra and Kilkari (Reach: 2.6 million and 27 million respectively)].
Kilkari (in collaboration with the Government of India) will scale pan-India by 2025-26. The next version (2.0) will adopt a ‘fit-for-purpose’ approach whereby low risk women and children will have access to nuanced voice calls and/or multimedia content with 2-way communication using WhatsApp, based on their access to technology. Those with high-risk conditions and/or equity-encumbrance will be supported via targeted content, 2-way communication, long-term handholding (call centre/WhatsApp support) and lateral approaches through women self-help groups SHGs in tribal areas where the health infrastructure is rudimentary [Swabhimaan 2.0]. Through Swabhimaan 2.0, we will build the capacity of Community Resource Persons (CRPs) from village self-help groups to increase enrollment in Kilkari and provide integrated counseling for nutrition, reproductive health and mental health using gender transformative approaches via content/apps embedded on their tablets/phones that can be accessed even in offline mode.
2. Training health workers for early identification & management of high-risk conditions via Mobile Academy [mHealth-based training course for frontline health workers/ASHAs (Reach: 244,000)] and Integrated High-Risk Pregnancy Tracking and Management Program [IHRPTM] for Auxiliary Nurse Midwives/Medical Officers/Specialist Doctors (Reach: 9000 ANMs, 1000 MOs, 300 specialists in Telangana via hybrid training method).
Mobile Academy will spread pan-India by 2025-26. Mobile Academy 2.0 and IHRPTM will include multimedia content (including live action films, quizzes & notifications), and long-term holding and 2-way communication via Whatsapp & call-center support. IHRPTM will be supported by a learning app with multimedia-based approaches and by a tablet-encoded decision supported tool linked to the live mother and child database of Telangana, enabling end-to-end tracking of high-risk conditions & creation of integrated dashboards at every level.
Our Theory of Change is that an informed and empowered woman will adopt better health behaviors, decipher danger signs, and seek timely care, proactively taking decisions to improve her health and nutrition and that of her child. Adequately skilled, trained and empowered frontline health workers will support the women by diagnosing high risk factors in time leading to a reduction in irrational/delayed/complicated referrals and timely management of such cases. This will reduce the burden on overstretched tertiary care facilities, leading to reduced mortality and morbidity and improved functioning of health systems overall.
- Individual consumers or stakeholders (B2C)
ARMMAN’s programs are designed for scale without dilution of impact. Our unique ‘tech plus touch’ model leverages technology and the health worker network and existing health infrastructure of the government/NGO partners without creating a parallel network to achieve scale at low-cost: it costs 15 cents to send Kilkari calls to a woman and USD 8 to train a health worker through Mobile Academy.
Both Kilkari and Mobile Academy are implemented through a co-invested PPP model: The government pays for the enrollment, RCH database, technology infrastructure upgradation, software, maintenance cost, data center, and call costs while ARMMAN takes care of its personnel, content, and software enhancement costs. Similarly, Anandi/ IHRPTM is a co-invested PPP model between the state of Telangana and ARMMAN. The learning and tracking apps are being created under a tripartite agreement between the state government, ARMMAN and the tech vendor Argusoft. The protocols have been created keeping in consideration the resources, equipment, supplies and staffing available and hence the state will not incur any untoward costs in ensuring that the policy is followed at every level of the referral system. All the ANMs and medical officers in Telangana already have access to tablets. Once the health care providers are trained and the new normal is created in terms of high-risk pregnancy management, the program will be further entrenched within the system, making it even more financially sustainable.
ARMMAN adheres to a strong financial framework with strict processes in place for governance, compliance and internal audits. We have a 4-member strong department to manage fundraising which is responsible for supporting the organization’s interventions by building and maintaining a diversified network of donors. Channels of fundraising currently include direct outreach to corporates and HNIs, referrals from current donors and grant applications. As the organizational budget increases steadily over the next five years, we will look at ensuring financial stability and sustainability via the following:
1. Increased Focus on Corporate Social Responsibility (CSR)
Through an increased focus on Corporate Social Responsibility (CSR) via direct outreach and references, we plan to increase the CSR contribution in ARMMAN from about 27% at present to at least 30% over the next five years. By establishing strong multi-year partnerships with prominent corporates, we can tap into the CSR pool and also build robust connections with the companies via employee payroll giving and more volunteering opportunities.
2. Increasing Contribution of HNIs and Family Foundations
High Net-worth Individuals (HNIs) and their family offices are important contributors to the social sector with family philanthropy in India expected to grow at a robust 13% per year until FY2026. They have a greater degree of flexibility compared to companies who have to navigate their own internal policies vis-à-vis the CSR regime. Currently individual philanthropists and family foundations contribute only 7% of the total funding raised by ARMMAN. Over the next 5 years, we aim to increase that two-fold to 15% by tapping into references from existing HNI donors and board members, establishing an outreach channel for international HNIs.
3. Establishing A System of Reference
As we build on a handful of key anchor donors for long-term funding support, we will request introductions and references to other potential donors, especially HNIs and foundations. ARMMAN’s Board of Trustees comprises experts across a variety of disciplines with a large and diverse network and we will work closely with them to establish a regular system of references, especially for corporate and CSR donors and individual philanthropists/ HNIs. The contacts of HNIs who are currently supporting us will also be leveraged to reach out to more potential donors within the community.
4. Networking and Fundraising Events
As the COVID-19 situation eases across the world, we will look at organizing on-ground events such as annual fundraisers and galas to attract more contributions from individual donors. We will also collaborate with our existing donors (especially international foundations) for smaller salon sessions with a selected group of representatives from other foundations and family offices in order to create networking opportunities.
At present, ARMMAN’s donor segmentation is well-balanced between Multilateral Foundations (46% of total funds raised) and Corporates (47%), with a small percentage of HNIs (7%). Over the years, we have created a largely balanced donor base with key anchor donors for multi-year support (Eg. Johnson & Johnson, LGT VP, Rippleworks, Dovetail Impact Foundation, Netri Foundation). These international donors have supported us with largely unrestricted repeat funding, giving us the flexibility to utilize the funds where they are most needed. In FY 21-22, over 83% of our funding came from repeat donors.
We received the Skoll Award for Social Entrepreneurship in 2020 and the Elevate Prize powered by MIT in 2021 which came along with some prize money to be used as unrestricted funds. We have recently applied for TED’s Audacious Project for long-term funding and the Maternal and Infant Health Award which awards USD 10 million to an organization implementing transformative community-led solutions. We are also in the last stage of Co-Impact’s Systems Change Initiative Grant; we have submitted the prospectus document describing our goals and strategy for our 5-year systems change initiative and expect to receive official intimation about the status very soon.
