Aparna Hegde

Aparna Hegde is using an innovative Tech plus Touch model to strengthen the existing healthcare system in India to deliver timely care and information for pregnant women and children. In doing so, she is creating a future where the experience of pregnancy and childbirth is one of hope and courage as opposed to fear and trauma.

Aparna Hegde is addressing the systemic gaps in pregnancy healthcare in India and in doing so reducing the high mortality rates which exist among mothers and children. Using an innovative ‘Tech plus Touch’ model, Aparna is leveraging technology as an equalizing force to strengthen the existing healthcare system so that lifesaving care and information can be provided during pregnancy, childbirth, and the critical months and years after birth. Aparna’s approach is anchored in the belief that technology cannot be mutually exclusive from human-centric care when it comes to addressing maternal care. Her approach marries the twin opportunities of penetration of technology and an established frontline health worker model (ASHAs) to the systemic gaps which exist, thus ensuring the wellbeing of all mothers and then their children in the early years of their lives.

Through her organization ARMMAN (Advancing Reduction in Mortality and Morbidity of Mothers, Children, and Neonates), Aparna is using technology to strengthen the capacity of frontline government health workers while also developing interventions that provide timely information and data to both patients and medical professionals on nutrition, adherence and other key areas related to maternal and child health. The ubiquity of mobile phone technology makes interventions easy to scale up cost-effectively. For example, through partnerships with local NGOs and state governments, Aparna launched the mMitra program, which is a free mobile voice call service that sends preventative care information regularly to mothers during infancy and pregnancy in a vernacular language. Aparna’s approach is to always work with the system as opposed to reinventing an entirely new one, thus drawing in ownership from the government. mMitra is jointly managed through Kilkari, the Indian Governments largest mobile health education platform. Similarly, Aparna trains ASHA workers on life-saving preventative health behaviors, how to better connect and engage with mothers during maternity, and provides other useful training to build their capacity. In doing so, she is ensuring that both the efficacy and effectiveness of interventions can be improved and ultimately health seeking behavior is leveraged. So far 23 million women have benefited from interventions undertaken by ARMMAN while 170,000 frontline workers have been trained.

Aparna has made deep headway towards creating an India where pregnant women and mothers are equipped with the best health information available, where high-risk pregnancies are identified at an early stage and thus correctly cared for. Her interventions have already seen significant reductions in child and maternal mortality rates in India, especially among rural communities.

A moment of incredible joy is when a newborn is placed in the arms of the mother for the first time – a delight that every mother should have the right to experience. For many pregnant women in India, this memory never materializes and instead, childbirth is associated with fear and trauma. In India 67,385 babies are born every day, equivalent to one-sixth of all childbirths globally. For many children who make it through childbirth, the milestone is only temporary, with two children under the age of 5 years of age losing their lives every minute and many suffering from chronic undernutrition and stunting, which has lifelong consequences. In addition to this, HIV transmission from mother to baby also contributes significantly to child mortality. Of all HIV infections in India, 39% or 816,000 are attributed to women. In the absence of effective intervention, the risk of transmission of HIV to a newborn child is around 20-45%.

In India, 46% of all maternal deaths and 40% of all neonatal deaths happen during labor or the first 24 hours after birth. Pre-maturity, neonatal infections, birth asphyxia, and congenital malformations are among the major causes of newborn deaths. Most of these deaths are among women between the ages of 15-29, most of whom are at the prime of their reproductive lives. While there exist correlations between the income, level of educational attainment, and rural-urban divide, and these deaths, the major factors that are of influence include a lack of access to prenatal care and care in the postpartum period, the mother's access to proper nutrition during pregnancy, sanitation, and hygiene, and finally, timely access to other medical care.

The Government of India has put a major spotlight on trying to address these issues and as a result, improve maternal health indicators. In November 2016, the government launched the Pradhan Mantri Surakshit Matritva Abhiyan, or the Prime Minister’s Safe Pregnancy Scheme, which provides free and comprehensive care on the ninth day of every month during pregnancy. Pregnant women are provided free antenatal checks in their second or third trimester at government health care facilities. Despite the state initiative, getting these services to pregnant women has proven to be difficult, especially among those in Tier 2 and 3 towns. This is due to the opportunity cost of receiving this care, which often means that a woman and her partner must travel long distances and forgo earning income for a day. Hence the majority of women decide to not take on this support or resort to informal settings run by non-medically trained individuals. In Bihar, a mere 3.3% of all pregnant women reported getting the full antenatal care, despite it being free.

A 2016 survey conducted in India found that women in a household who witness a maternal death in their families are more reluctant to seek help from a hospital setting, choosing instead to see traditional birth attendants. Many of these traditional healthcare settings are unhygienic, not run by medical professionals, and carry with them higher risks of serious infection or death. This trend also highlights the sociological reality that exists in the country, where death is highly stigmatized and hence health episodes and concerns are dealt with behind closed doors. This risk tolerance is further exacerbated because of a lack of timely and credible information about maternity, pregnancy, and nutrition.

While the Indian government and civil society organizations have started to take strides to address these issues, life-saving health interventions remain low due to systemic problems such as gaps in knowledge and resource constraints. India’s maternal and child health programs have historically been dependent on expensive pilot programs that are too resource-dependent, particularly on human capital. This has made it often too difficult for them to scale up and reach those who need it the most. Furthermore, interventions have been designed in reaction to the most extreme problem at hand, the high number of mortalities. By taking a reactionary approach to the problem, interventions have often focused on surface-level interventions, such as access to infrastructure. While these problems are real and need investment, they cannot be expected to work without a contextual understanding of social and cultural factors as well. Furthermore, the care required for a mother spans a period, including antenatal care during pregnancy, skilled care during childbirth, and support in the weeks and months after birth. Recognizing this and seeing the equalizer that technology can be to address this problem, Aparna Hegde launched ARMMAN to address these systemic gaps.

Aparna has always been moved by the fact that so many mothers and children die due to preventable maternal and newborn deaths in India. Regardless of where the medical profession took her in the country, it was a problem that stood out. Aparna spent a significant amount of time post-2005 understanding the problem at hand and thinking of potential solutions. She realized early on in her apprenticeship journey that India was going through digital acceleration where technology in the form of mobile phones was becoming cheaper and accessible to all types of people. Aparna started thinking about how this could potentially be a lever to strengthen the care that mothers could receive during their prenatal journey, at childbirth, and in the early years of a child’s life. Her vision was to move towards zero preventable maternal and newborn deaths in the country. She also understood the need to humanize relations and intentions.

In 2008, Aparna established ARMMAN Foundation and focused her first intervention on establishing an interoperable platform that could provide real-time information on the availability of intensive care unit (ICU) beds and blood types in hospitals and blood banks across India. Aparna witnessed women enduring blood loss during labor as they were being shuffled from hospital to hospital with the hopes of finding empty ICU beds and the right blood types. The Project HERO (Helpline for Emergency Relief Operations) was a culmination of a helpline, website, SMS, and mobile application, and played a pivotal role in directing doctors and patients towards vital information and services across Mumbai and Pune.

Aparna realized that a core systemic problem that existed and needed to be addressed was a lack of access to preventative care information during pregnancy and infancy. Furthermore, where information existed, a lack of contextualization and know-how to interpret this information meant that it was seldom useful. Aparna initially piloted an SMS-based service that could cover this void, but she soon realized that it was too one-dimensional. The questions which needed to be answered were things like - would the women, many of whom are illiterate, be comfortable reading and interacting with text messages?

Aparna recognized, while technology was an equalizer, it would only be effective if interventions were created via evidence-based research and through the input of the stakeholders who would interact with the solution. She spent a considerable amount of time in Dharavi, Asia’s largest and most industrious slum area where the problem of maternal and infant mortality is pertinent. It was through detailed studies and interaction with the communities here that she launched mMitra, a voice-based communication system to bridge the information gap. Based on an automated call system, pregnant women and new mothers would receive agreed-upon periodic calls that would provide information on what to do and prevent during pregnancy and after a child has been born. When the woman answers the phone, she is greeted by another woman’s voice, which is warm and inviting; she speaks in the same language and most often in the same regional dialect. As it is like having a friend on the line and not a medical professional, women are more likely to positively interact, and fear is overcome. The system has been designed in a way that it caters to the different social dynamics within a family, where a woman might not always have access to a phone, or network issues may prevent a call from going through. If this is the case, the woman can make a missed call at any time, and she will receive a phone call back with the information for that week. In total, women receive 145 calls that are between 1.5 to 2 minutes in duration throughout their pregnancy and during the child’s first year of birth. By 2016, the program enrolled 610,000 women in the program across 8 different states in India through partnerships with state governments and local NGOs, and the team measured a 25% increase in women who took Iron and Folic Acid (IFA) tablets for 90 days or more, along with a 17% increase in infants who tripled their birth weight at the end of one year. In launching mMitra, Aparna was the pioneer of the first mobile-based maternal health information program in the world.

Still, Aparna witnessed that many women don’t sign up to the platform or engage in care during their pregnancy, even if they live in urban areas. These women tend to be those who live in dwellings that are slums or similar. Normally, the way ARMANN would reach women in remote areas is by placing trained health workers in the antenatal clinics of government hospitals; they introduce the program to women who come for their first visit and enroll them on mMitra. However, many women do not visit a government hospital until late in their pregnancy. To address this gap, Aparna has partnered with community NGOs to develop women leaders (called Sakhis, or “friends”) in each locality. These women reach out to other women and enroll them in the program before their crucial second trimester. They have established a network of health workers in 77 government hospitals, partnered with more than 43 community NGOs, and deployed more than 5,853 Sakhis across urban slums in India. Aparna sees community ownership as being critical in generating new demand for health-seeking behavior and this has been a critical factor in the success of her innovations. ARMAAN has innovated several such mobile-based solutions, some catered to specific categories of stakeholders. For example, their Moderately Underweight Children (MUW) program trains nutrition counselors to provide advice on nutrition, sanitation, and hygiene. These calls are scheduled weekly and last for 10-15 minutes for the first 8 weeks and then reduced to once per fortnight for the last 2 months. Supplementing the live counseling service is a 24/7 helpline and weekly voice calls that packed together ensure women can get the correct information they need promptly. The ecosystem approach that ARMAAN uses with all its innovations aims to build confidence in women and their families that they are not alone on their journey.

Similarly, for HIV-positive and high-risk mothers, Aparna launched another specific program. This program is supported by Johnson & Johnson and their ‘Connect for Life’ technology platform. The program consists of a total of 351 voice messages (offered in Hindi and Marathi), empowering the women with critical information that focuses on fetal development, counseling, medication reminders, the importance of adhering to ART (antiretroviral therapy), positive living, the right nutrition, breastfeeding, investigative tests, and other important guidance. Besides these automated voice messages, the program also offers automated visit reminder calls and follow-up by the dedicated call center staff, thus hand-holding them through the care process to prevent transmission of HIV/AIDS to the infant. In parts of the country where some public health infrastructure exists – for example, in Nandurbar in Maharashtra and parts of Rajasthan – ARMAAN also supports the work of government health workers with the help of a tablet and mobile phone encoded apps that digitally coordinate the activities of these health workers, guide them through their activities, and provide intuitive and real-time situational medical instructions on the care needed and referral required.

There was still one major challenge to be addressed – providing health care to women in rural India, where facilities are sparse, and transportation is cumbersome and untimely. These women are daily wage earners, and they need a chaperone or spouse to go with them, even if the clinic is nearby. The opportunity cost of losing a day’s wages is too high so many prefer to go to ‘local doctors’ who often have little or no formal training in medicine. To defer women from falling prey to bad medical advice, Aparna developed and tested a home care system called Arogya Sakhi. To deliver this service, she trained women from the community to become health entrepreneurs, providing home-based antenatal and infancy care, including basic diagnostic and treatment interventions for a nominal fee. They are supported by a mobile app that guides them through the entire care process, helps identity high-risk symptoms, and gives them alerts if the patient needs a referral or more specialized consultancy. In addition to helping the women, the program has a major ancillary benefit: they’ve trained 253 women health entrepreneurs who can now supplement their family income. Each Arogya Sakhi earns between INR 1500 to 3000 rupees per month ($25 to $50).

Technology has enabled Aparna to bring down the cost of the mMitra service from INR 350 ($5) to INR 24 (less than $1) for each woman over the course of a pregnancy and her infant’s first year. That includes the cost of technology, voice calls, and a staff of more than 85 people to coordinate the programs. Aparna’s strategy has been to always institutionalize her innovations through partners with outreach potential and leverage such as the government.

Over the last twelve years, Aparna has concluded that technology is not the innovation. Rather, innovation lies in how technology is deployed. For example, ARMMAN’s demonstrated success with mMitra led the Ministry of Health and Family Welfare (MoHFW) to partner with Dr. Aparna to jointly manage a similar platform run by the government, Kilkari (the world’s largest government mobile health information platform), that had delivered care information weekly to 10 million subscribers. With the partnership with ARMMAN, Kilkari has now reached 23 million women and their children across 16 states and Union Territories of India and currently has 2.5 million active users. Kilkari is also now available in five languages. The partnership with the government also includes a mobile learning platform, Mobile Academy, that trains government frontline health workers, reinforcing and refreshing their knowledge of life-saving preventative health behaviors and improving the quality of their engagement with pregnant women, mothers, and children. They are rigorously monitored and evaluated for constant quality improvement. The Mobile Academy has reached 150,000 frontline health workers. Kilkari and Mobile Academy were launched by the MoHFW in 2015 and were managed in partnership with BBC Media Action until 2018; ARMMAN began its partnership with the Ministry to manage these two programs in 2019.

Aparna is also working with the Maharashtra government to create and scale up the protocols for the management of high-risk pregnancies by health care providers. This is supported by Mother & Child Tracking System (MCTS), which is a comprehensive mobile-based tool for the Auxiliary Nurse Midwife (ANM), a frontline healthcare worker in the public health system. The mKhushali app, launched in collaboration with Tata Trusts, increases work efficiency, reduces paperwork, and ensures that mothers and children with high-risk factors are identified in time and referred to the relevant healthcare facility. ANMs cater to a population of 3000-5000 each and they are responsible for providing primary healthcare services undernutrition, immunization, family planning, and maternal and child health programs. An important part of an ANM’s work is collecting health-related data. They capture around 200 key indicators of different health parameters. As the ANMs focus on providing healthcare services beyond just maternity and childcare, Aparna sees this platform being expanded to transform the complete capability of the country’s frontline workers. By 2018, the pilot had covered 114 villages from Taloda and 27 villages in Dhadgaon, Maharashtra, training 37 ANMs from 6 primary healthcare centers.

She is also partnering with the Telangana government to train the medical officers to pick up risk factors early before it's too late. To improve high-risk pregnancy management and outcomes, she built a protocol with the Government of India, composed of 36 conditions which has become a policy in Telangana. Now, ANMs, medical officers, and specialists will have color coded algorithmic sections for the better perception of their roles and responsibilities.

Aparna also realized that meaningful scale could be achieved only with the use of technology. It would help create programs that were lean in terms of resources needed yet find the right balance between depth of impact and scale. Her programs have impacted the lives of over 23 million pregnant women, new mothers, and their families in 16 states of India. In the next five years, she wants to reach 45 million women and children through Kilkari and to train 1 million healthcare workers by scaling up Mobile Academy throughout India. Aparna has also joined hands with Google and Howard University to build artificial intelligence tools for data analytics and storage. This would also integrate all her programs into a single platform. Further, Aparna is working on building version two of the applications which will use smartphones, have better multimedia content, and more two-way communication tools. By using the existing infrastructures of government, she creates tremendous impact across India. Inevitably, Aparna’s work also involves a lot of data collection, and it is important to note here that Aparna has not and does not plan on commercializing this data and strongly believes all the user data should remain private and protected.

Aparna grew up in a lower-middle-class Brahmin family in Mumbai, India. Despite her family needing to work hard to make ends meet, Aparna recognized her own privileges. She internalized that the lottery of life presented her with an upper-caste identity and the opportunity to pursue her dreams in an urban setting. As a result of this, Aparna constantly made a conscious effort to see the world from the perspectives of others around her. Aparna’s youth years were pledged to contributing to issues she felt strongly about, such as animal safety and rights, where she spent a significant amount of time ensuring the welfare of stray dogs in Mumbai. She also worked closely with Akanksha Foundation, helping develop small clusters of model schools to support the Foundation’s advocacy efforts to replicate these schools across the entire education system.

Aparna’s early exposure to heterogeneous communities shaped a personal ambition of hers, to follow a career based on the pillars of science, service, and research. She had a dream of doing this to address either one of two problems, access to quality education or healthcare, which she felt were the most fundamental rights of all citizens in India. It was during her time with Ashoka Fellow, Armida Fernandez, and her organization SNEHA that Aparna realized the true potential that technology could play in strengthening public health and safety systems. Aparna worked closely with Armida to develop SNEHA’s first program.

Deciding to pursue a full-time career in health and medicine, Aparna saw quick career progression and success, with an International Fellowship in Urogynecology and Pelvic Reconstruction Surgery while holding a master's degree from Stanford University. Aparna intended to become a Urogynecologist and a technocrat to use her knowledge and skills to support those who are most often deprived of access to specialist care, in particular women and children from lower socio-economic backgrounds. It was during her time in residency at the Sion Hospital in Mumbai that Aparna realized she needed to do much more with her life to contribute to fixing a broken healthcare system. She was particularly moved by the problems she was witnessing related to maternal and neonatal mortality as well as child nutrition. It was then that she decided to launch ARMMAN, with the vision of transforming the existing healthcare systems and ensuring all mothers and children can get through maternity and childbirth healthily and safely. She invariably proves her leadership skills at every level of progression.

Aparna is also simultaneously building an academic center and department of Urogynecology, which will host India’s first universally recognized Fellowship Program, which will also be a treatment center for patients to get access to dignified care at no cost. For her remarkable contributions to the sector, Aparna has received many accolades, including the prestigious National Institute of Health Grant in the US, and more recently being awarded the Skoll Award for Social Entrepreneurship.