Salud en tus Manos (Health in Your Hands)

Bolivia is the second poorest country in the western hemisphere, after Haiti. Almost 40% of the population lives below the poverty line and has increased poor health for millions of vulnerable people each year. Evidence shows that poverty and poor health are linked – usually due to social and economic inequalities. In Bolivia, the most vulnerable populations are deprived of positive health outcomes due to lack of information, money or access to health services – many of which help them prevent or treat diseases. One of the biggest obstacles for many Bolivians, especially informal workers, who make up close to 85% of population employed, is sacrificing their health because they cannot afford other basic services and needs such as food or housing. Additionally, many Indigenous groups face cultural and social barriers impeding them from using health services causing serious consequences and thus perpetuating their disproportionate levels of poverty, and Bolivia has the largest proportion of indigenous people in Latin America, with 62% of its total population considering themselves to be of indigenous descent. 

 Worldwide, the deadliest non-communicable diseases (NCDs) are almost always preventable. It is estimated that 64% of all deaths in Bolivia can be attributed to NCDs such as cardiovascular diseases and diabetes – usually related to poor nutrition. We have seen this become a huge issue in Bolivia as the pandemic reaches its third year and health inequalities are exacerbated, particularly for women. Chronic patients are most affected as they are more probable to become severely ill while managing their daily activities, diet, exercise, and regular follow-ups regardless of lockdown and the stressed healthcare systems.  Research suggests that Community Healthcare Worker programs that provide appropriate follow-up can positively impact NCD control and care, particularly in lower and mid-income countries like Bolivia.  

To make healthcare and follow-up more accessible to underserved groups in Bolivia, “Salud en tus Manos” leverages upon its existing Community Healthcare Workers (CHWs) program with 300 trained volunteers and adds an innovative telemedicine program, offering remote care at affordable prices as well as easy, accessible follow-up services through chatbots via the most commonly used digital tools in the country – WhatsApp and Facebook. The program connects people from underserved communities (where healthcare services and information are limited) to healthcare providers and members of their own communities who are professionally trained to provide doctors remoteassistance in their diagnoses. Patients are then added to an automated follow-up service which becomes their personal assistant in health and well-being. The chatbot guides them in using familiar tools and tips to help them build and sustain healthy habits – thus reducing health inequalities, financial burdens associated with NCDs while promoting preventative measures within the population. 

This solution targets the most vulnerable populations living below the poverty line in bothrural and semi-urban communities where healthcare centers and specialized professional providers are limited or unavailable. Since over 80% of the Bolivian work force is part of the informal sector, they do not have access to public healthcare systems. Our solution addresses several factors associated with health outcomes by increasing access to health services and professional care through CHWs, telemedicine, and chatbots. Many social determinants of health are perpetuated by economic and social influences. Underserved populations and those living below the poverty line are more likely to have poor health outcomes due to unhealthy learned behaviors because of limited resources, environmental influences contributing to poor air quality, and other social factors.  

By connecting underserved communities to trustworthy CHWs and providing them digital tools we are increasing access to information and fostering the creation of healthy and sustainable habits. First, communities are connected with a CHW from their own community knowledgeable in health, next they can easily access telemedicine through their leader who is connected to our network of reliable doctors and finally receive any follow-up through the chatbot available via Facebook and/or WhatsApp, the most commonly used social media apps in Bolivia. This solution provides an innovative and holistic approach to increasing access to basic health services using a sustainable model at a reliable cost.  

Pro Mujer engages the most vulnerable communities, whose access to healthcare, skilling opportunities and financial services is often the most tenuous. Starting in Bolivia, Pro Mujer (PM) has provided comprehensive solutions at both individual and collective levels to facilitate women’s empowerment in Latin America for over 30 years. Pro Mujer now has presence in Argentina, Bolivia, Guatemala, Mexico, Nicaragua and Peru. Pro Mujer proactively creates spaces for women to re-define what is possible for them to be and do and provides holistic tools for women to achieve full agency to make decisions on matters which are important in their lives.  

“Salud en tus Manos” program addresses the obstacles women face in accessing adequate and affordable healthcare. Active community leaders join the program as Community Healthcare Workers (CHWs) who provide guidance to people with NCD such as diabetes and hypertension. CHWs are volunteers who have strong bonds with their communities and many of which speak Aymara, the most common Indigenous language, providing more confidence and access to the most important information needed for a medical consultation or health intervention. The CHWs program started in 2020 with 120 volunteers and carried out more than 26,000 preventive screenings as well as 23,000 counseling sessions. This program has expanded Pro Mujer’s visibility in rural areas by creating safety nets for women experiencing health issues as well as connecting them to medical professionals in emergency situations. For 2022, the program seeks to expand to 300 CHWs and strengthen referrals and follow-up processes to become more accessible to underserved populations through telemedicine and chatbots.  

This project is in a transformation stage, during which valuable tools are added to expand the scope and equitable access of healthcare. The most pressing challenge is how to advance our technological approach, by transforming the chatbot from an educational focus into a more robust application that uses widespread technology to foster healthy habits among the target communities, and that can be customized to fit individual patient needs.

The project seeks to incorporate technology into field work to provide communities with equitable, accessible and affordable alternatives for their healthcare. Our approach is aligned with the third sustainable development goal, focusing on broadening access to healthcare.  It allows for specialized care at a fraction of the regular price by cutting transportation costs altogether and ensures adhesion to treatment through regular follow-ups by our CHWs as well as support in the creation of healthy habits with the constant use of our chatbot. This program can be scaled and replicated across the country and strengthened by the inclusion of local governments and an ample network of healthcare providers. Additionally, this program can be expanded into other countries in which Pro Mujer operates or currently has CHWs.  

The ultimate goal is to prevent the development of non-communicable diseases and their risk factors, specifically hypertension, obesity and diabetes, amongst underserved communities in Bolivia. To do so, our work focuses on equitable access to health services such as timely diagnoses and preventive treatment and additional follow-up care led by community leaders. An additional prevention component is fostering the creation of healthy habits that impact not only the person receiving the telemedicine consult and individual chatbot counseling but also, their families. In Bolivia alone and within the next five years, this program has the potential to reach close to 100,000 individuals and improve health outcomes in these populations significantly. 

A differentiating factor of our program is that our health campaigns are carried out in the most-visited spaces for our target population. Our CHWs visit markets, bus stations, vaccination centers, schools, they seek out the people that do not have the time or resources to get the medical care they need. Community-based operations like these include preventive risk-assessment screenings, counseling sessions and referrals to specialized care.

This project aims to directly reach 5,000 people in NCD preventive screening, referral and telemedicine consult, follow-up by CHWs and creation of healthy habits through the chatbot in one year. Additionally, to continue sensitizing the broader community, at least 15,000 preventive risk-assessment screenings should be carried out, with 40% of these referred to follow-up care programs. 

The overall impact of this project will be measured by 1) percentage of people diagnosed with NCDs in relation to their overall behavioral risks; 2) number of people who access health services (CHWs and Telemedicine) after confirmed NCD diagnosis; 3) percentage of people who adhere to preventative strategies and treatment recommended by telemedicine consultations and CHWs;4) percentage of overall patients reporting a positive change in behavior after counseling session and chatbot use. In order to adequately measure changes in attitude and behaviors, Pro Mujer will establish baseline data that includes a poll regarding the beneficiaries' current habits while intersecting their responses with health input like weight and BMI. The follow up program will insure that this data is updated every three months to track progress.

Currently, 37% of people screened are overweight while only 1 % of people screened are underweight, additionally 20% of people screened are at risk of suffering hypertension. 

If technology is used to provide equitable healthcare services in remote, underserved communities, then people will have access to better care, tools and follow-up increasing treatment adhesion and creating healthy behaviors thus reducing the incidence of NCD in Bolivia.  

There are three main technological components to our program:

1. Telemedicine used to connect our specialized health professionals to patients with support of our CHWs doing field work.  

2. Click Medix, an electronic health record app that has been tailored to fit the needs of our field operations, allowing CHWs to register all the necessary information of patients and their care. 

3. Botmaker, a chatbot creation software that has allowed us to design several educational campaigns in the most used social media apps across Latin America.  

Pro Mujer believes that gender equity is a human right and that all people should have equal access to society, public spheres, decision-making and to equal protection. We strongly believe that woman can be formidable agents of positive change when barriers to opportunity are eliminated. It recognizes that women’s identities are complex and non-exclusive, and that each woman may have different priorities based on their circumstances. Pro Mujer’s gender-sensitive strategy follows feminist values of solidarity and collaboration, creating a tight-knit network of women that support each other.   

Pro Mujer seeks to constantly innovate and adapt its practices, both internal and external, to best support women in their life journey. Furthermore, as a though leader in women’s equality and inclusion in Latin America, it encourages other organizations to adopt a gender-lens framework to offer a wide array of opportunities for the future. Pro Mujer will contribute to closing opportunity gaps in Latin America by elaborating on past success to add value and greater impact.   

Pro Mujer’s institutional knowledge is an asset that can be codified, transformed into intellectual capital and shared with civil society, businesses and governments in order to foster new solutions, services, products and public policies that empower women in Latin America. Pro Mujer is uniquely positioned to fill critical gender data gaps in Latin America and by doing so, help society to equip decision makers with more timely and clearer evidence about programs and interventions that are working to accelerate economic progress, equality, and security. 

"Salud en tus Manos" is a program that benefits underserved communities, providing equitable health services at low costs, seeking to improve the quality of life of beneficiaries by reducing the incidence of NCD in Bolivia.  

The service begins with a health screening carried out by Pro Mujer’s CHWs to establish NCD risk factors. Based on this screening, the beneficiary is provided with a medical consultation through telemedicine and treatment or control recommendations to avoid further development of the disease.  

Upon receiving consultations and recommendations, beneficiaries are provided further follow-up through periodic monitoring by CHWs as well as reminders and tips provided by a personalized chatbot. 

In case of diagnosis of an NCD, the beneficiary will be referred to a medical partner, who can confirm the diagnosis and establish an affordable treatment plan that includes additional support and follow-up from established CHWs. 

Pro Mujer’s CHW program in Bolivia was originally funded through grants and donations to initially train the first generation of CHWs. Since then, over 300 CHWs have been trained in basic health services and can provide health workshops to local businesses.  As the project grows there is potential for it to become more financially sustainable through fees acquired from health workshops and as CHWs connect underserved populations to necessary health services and NCD treatments, they will charge a commission to medical partners. In addition to program operating costs, these fees will cover CHW per-diem, travel, food and cell phone data used for the training. This sustainable financial model is expected to generate a revenue of $50,000 in 2022.   

The original CHW program is thanks to generous donors such as Horizon Therapeutics, Eurofins, Procosi and International Foundation totaling USD $225,000 and has allowed Pro Mujer to operate the program successfully during these two years. Since creation, Pro Mujer has been piloting a business model to understand the areas of revenue possible for the program. For 2022, Pro Mujer projects that the CHW program will generate a revenue of $50,000 and grow as more CHWs are trained and provide workshops.