What does reach of mobile phones and internet mean for public health in India? Kruti Dalal of ARMMAN, which works to provide pregnant women access to medical services and information, talks about how technology can impact maternal and child health.
ARMMAN: An informed and empowered woman will adopt better health behaviours, understand danger signs and seek timely care. She will proactively take 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 delayed and complicated referrals. This will reduce the burden on overstretched tertiary care facilities, and result in reduced mortality and morbidity and improved functioning of health systems overall.
ARMMAN: Mobile health solutions have emerged as a viable route to reach every last woman directly in her home, and also train health workers. The advantages of scale, agility and cost-effectiveness offered by technology-enabled interventions have come into sharper focus over the past few years as health systems struggle to cope with the pandemic.
The high mobile penetration in India positions voice calls as an excellent mechanism for reaching women and families. According to the Telecom Regulatory Authority of India (TRAI), there are over 1.16 billion wireless subscribers in the country and more households have mobile phones than toilets in India.
For behaviour change communication to be effective, it must be consistent, timed and targeted to reach the right people at the right time. Mobile phones are just the right tools to make it possible.
Technology like the one used by ARMMAN (Advancing Reduction in Mortality and Morbidity of Mothers, Children and Neonates) is simple and resource-light. With increased mobile penetration and cheap data, tech-based interventions promise sustainability. Technology also enables us to create deeper, nuanced programming based on the degree of risk, inequity and gender disparity experienced by the woman and child.
ARMMAN: During the expansive outreach of mHealth we realised that technology alone is not enough. Of course technology allows us to reach more women and health workers when compared to the traditional methods, but it is also important to have human touch. So we pioneered our ‘tech plus touch’ model.
This approach uses the existing frontline health worker network and partner NGOs along with the mobile phones for maximum reach without duplicating efforts. This sustainable, non-linear, evidence-based, scalable and cost-effective model enables us to reach women and health workers on a regular basis. It costs under Rs 750 to send calls to a woman covering pregnancy and infancy through Kilkari and train a health worker through Mobile Academy. We partner with the government, 97 hospitals and 41 on-ground NGOs.
ARMMAN: As a medical resident at one of the biggest tertiary hospitals in Mumbai, Dr. Aparna Hegde, ARMMAN’s founder, saw the systemic gaps which led to preventable maternal and child deaths on a daily basis. Women reached the hospital in a critical condition, often at a late stage. The only way things could improve was when effort was concentrated at the level of the community. The traditional solutions for spreading health awareness and training are often resource-heavy, inconsistent and not scalable. This informed Dr. Hegde’s approach while creating ARMMAN’s foundational principles. India’s exponential mobile phone usage made mHealth an exciting solution and thus ARMMAN was born in 2008.
ARMMAN: ARMMAN addresses issues affecting maternal and child health by utilising technology and the existing health infrastructure. First, we address delay in seeking care by improving access to preventive care information. This is done through free weekly voice-calling services for pregnant women and mothers of children under the age of one. Through mMitra and Kilkari interventions we have reached 2.9 million and 32.9 million women, respectively. Second, health workers are trained for early identification and management of high-risk conditions via Mobile Academy, an mHealth-based training course for frontline health workers and ASHAs (Accredited Social Health Activists). Mobile academy has reached 3,00,000 ASHAs.
We have also used the Integrated High-Risk Pregnancy Tracking and Management Program (IHRPTM) for Auxiliary Nurse Midwives (ANMs), medical officers and specialist doctors. We are currently training 9,000 ANMs, 1,000 medical officers and 300 specialists in Telangana.
Kilkari and Mobile Academy, implemented in partnership with the government of India, are the largest mHealth programmes of their kind in the world.
Our programmes have sent preventative care information to over 35 million women and trained 3,00,000 health workers in 20 states till date. By 2030, we will reach 70 million women and their children and train 8,50,000 health workers across India.
ARMMAN: India accounts for nine percent of the global maternal mortality burden, with over 26,000 women dying from pregnancy and childbirth-related complications every year. For every woman who dies, 20 more suffer debilitating morbidity. India has the second highest number of under five deaths in the world.
About 32 percent of children under five are malnourished and 35 percent are stunted, leading to complications that prevent them from realising their full potential as adults. Male gender preference and favoured treatment of boys has led to a higher infant and under-five mortality and increased stunting in girls.
Poor maternal and reproductive health and malnutrition are not just physical problems but socio-cultural phenomena rooted in gender discrimination. It is adversely impacted by several interlinked factors underlying inequality (including gender, class, race, caste and migrant status).
The lack of focus on primary care leads to lack of access to preventive care information and poor understanding of complications and risk factors amongst pregnant women and mothers. Even when there is uptake of care, the quality of information given is inferior.
Early identification of risk factors, appropriate referral and treatment is also poor as health workers are inadequately trained, overworked, demotivated and lack knowledge. This results in a poor referral system resulting in overcrowding in tertiary care facilities and increased maternal and child mortality and morbidity.
In the lead image, a mother listening to critical preventive care information (Photo by ARMMAN)
Kruti Dalal is the Deputy Director (Resource Mobilization and Communication) at ARMMAN.
