Territórios Saudáveis

Prevention and detection of diseases with less social inequality from geo technology and intelligent and instant campaigns for long distances.

Approximately 95 million Brazilians (44% of the total population) suffer from at least one chronic non-communicable disease (CNCD), and the most affected are the most vulnerable: in capitals, premature mortality attributable to CNCDs reaches to be 163% higher in the poor than rich neighborhoods. In Brazil they are about:

• More than 28 million hypertensive people do not measure their blood pressure, and consequently part of the reason behind the 100,000 annual deaths caused by strokes;
• More than 7.6 million diabetics do not monitor glycated hemoglobin and there are currently 10,000 amputations per year caused by untreated diabetes;
• More than 300,000 people die every year from preventable causes, such as heart attacks caused by untreated diabetes or newborns whose mothers didn't have access to prenatal care.

This is despite the country's free and universal healthcare system.

We know that primary care is transforming health: there is an increase in life expectancy and access to preventive health care is improving the health outcomes of patients. So why do the poorest regions in particular still have low health outcomes despite a system rich in professionals?  A large part of the reason is a deficit of access, due to a lack of social analysis of the territory and inefficient use of community health agents, caused by an absence of access to data to create action plans.

The social analysis of the territory is a product and process for the decentralization of health actions, adapting and prioritizing actions and resources to the needs related to the epidemiological profile of each region. Together with the community health agents, it should mainly help to improve:

• Access: There is widespread evidence that utilization of healthcare facilities decreases exponentially with distance from the patient and that utilization of healthcare facilities is uneven – meaning that those who access facilities are the members in the best population situation. Community health workers extend care to underserved communities, where they improve health equity and increase access.
• and Effectiveness: community health agents promote trust and convey health messages more effectively. Community health workers can also help service users avoid traveling to health facilities, which translates into time savings and transportation costs.

Despite the importance of social analysis in the territory, today in Brazil only 6% of the topics in health team meetings are about diagnosis and monitoring of the territory - the least discussed topic among primary care teams. This makes a large number of municipalities have outdated social analyzes of the territory, which directly impacts the population's access to services and the efficiency of the Health System. Among the obstacles are technical difficulties (low computerization, connectivity, and literacy digital) for access to the necessary data and availability of manpower to process these data in concrete improvements of territorialization.

The development of effective action planning for the work of community health agents could help the health system to obtain similar performance results at a lower cost and in a more convenient and culturally appropriate way for the patient.

* Today, all PHC health professionals in Brazil need to register their services in a standardized database and send it to the national Ministry of Health. That allows a simple solution made for a specific municipality to be scalable for all others in Brazil.

Our initiative is divided into 3 main parts:

1. Creation of digital mapping of the individuals of the municipalities- we take advantage of the SQL database of the existing work systems to, through a process of extracting and processing data with python feed our web platform in Next.js that georeferences and makes available, in a visually attractive way, household and individual records with health information, providing a product to qualify meetings and team planning with social analysis of the territory, that can be used by each of 47,786 family health teams.
2. Sending of instant mass health campaigns segmented to the most vulnerable profiles - to achieve health results and bring even distant users closer to the units, we carry out automatic contact via instant messaging service (Whatsapp). Our campaigns are created through the study of neuroeconomics, using “nudges” - ie behavioral approaches that aim to exploit common cognitive biases to influence decision-making. Decreasing the professional's work and having more efficient results. These campaigns, when executed in mass, can use their results to learn, through artificial intelligence, more effective strategies to convince the public to adopt healthier behaviors.
3. Together with the products, we offer remote technical assistance - because even with a good and clear diagnosis, health managers of city halls find it difficult to implement action plans.

Thus, using information that would be discarded, we want to increase equity and comprehensiveness in health, improving access to better quality care and allowing teams to focus on those with the most urgent needs and deepest vulnerabilities.

As the final audience for these improvements, we have the most vulnerable health groups, with priority being given to the following audiences in the poorest regions:

• Pregnant women;
• Women of reproductive age with active sex life;
• Children younger than one year;
• People with non-communicable chronic diseases (diabetes and hypertension) and reduced mobility;

Our solution users are mainly family health team coordinators, community health agents, PHC managers, and local health administration at the municipal or district level. These will be able to receive feedback on the performance of their work and will reduce the time spent in ineffective information systems.

We are well-positioned to serve municipal authorities across Brazil due to 3 main factors:

History and funding of the organization - The NGO where the solution is part - Impulso Gov - is already nationally known for previous health products in various spheres, such as the fight against COVID (https://coronacidades. org/) and Mental Health (http://saudemental.impulsogov.org/). As it is a non-profit institution, this allows us to establish partnerships with municipalities quickly and without bureaucracy. In addition, this form of financing makes us less volatile to political/government transitions.

Diversity and composition of the team - The NGO where the solution is part is composed of professionals of excellence in several areas, such as:

• • Public Health Professionals - professionals who have worked on the front lines of healthcare, such as hospital administrators -, the technology industry, and the government sector, deeply understand the pain and reality of the healthcare facilities in which we serve. Making it easier for our solutions to be the most adequate to their reality.
  • Economics and Public Policy Professionals - professionals who know the reality and contact with the government, as well as institutions to finance our initiatives.
  • Designers and Developers - our entire development process focuses on understanding our users and how our solutions can adapt to their reality. Our technology team actively participates in the discovery and ideation process, ensuring that the newest and most promising technology is used. In addition to having members who have studied behavioral neuroscience.

Recurring and close contact with members of public health -

• • Direct contact with family care team members - we have been working closely with municipal managers, offering virtual technical assistance to more than 50 municipalities in the use of data and technology to solve problems in primary health care. In addition, we have a direct connection with a group of 280 local health secretaries (out of a total of 5,570 in the country) through instant messages (WhatsApp) in which we constantly send updates.
  • City level - NGO Board of Directors conduct multi-day field trips along with other rotating staff members to ensure they are up-to-date on challenges faced by staff on the ground.
  • National sphere - Partnerships we have with major bodies in the area of public health, such as the Ministry of Health, the National Council of Health Secretaries (Conass), and the National Council of Municipal Health Secretaries (Conasems). This allows us (i) to make contact with people who work directly in the development of public health policies (ii) to increase the number of civil servants and municipal governments with whom we have contact, (iii) to increase credibility due to the visibility given by these large organizations.

As creator and leader of the initiative, Gabrielle Arruda also stands out for her strong and passionate leadership in the area of Social Impact. She has a degree in science and technology and a Bachelor's in Neurosciences, winner of national Olympic medals in mathematics, and had undergraduate scholarships from the Semear Institute, the Institute of Pure and Applied Mathematics, and Fundação Estudar.

She was also a semifinalist for the Crossroads Emerging Leaders Program at Harvard University, which rewards talent from low-income and first-generation families at the university.

Has participated in several Social Impact networks - such as the CHOICE movement - and organized sessions at the Latino Internet Issues Conference (YouthLACIGF), and the first sessions of the Brazil Conference in Brazil. She was an ambassador and was selected to represent Brazil at the 3rd International Youth Summit in Lahore, Pakistan.

She also did scientific outreach by participating in an exhibition of women in mathematics and with articles published in the magazine of the Malala foundation.

Despite being young, she was the first technical leader in technology at Impulso Gov's NGO and is currently responsible for the area.

Over all these months that we have been working on the territorial project within the organization Impulso Gov, we have carried out: 

• Conversations with several health experts on the subject; 
• Interviews with users - There were more than 50 interviews with users including nurses, doctors, community health agents, and PHC managers; 
• Field visits; 
• Understanding and testing in different municipalities - Different products were built and tested in about 8 municipalities. As a result, the references for the creation of the platform came from cities with different characteristics and challenges, so the final product is not biased in terms of demography, size, technological development, and geographic location of the city.

Ease and effectiveness. We facilitate the use of data and show in the most intuitive way where are the regions where teams and patients are not going, and intervention is most needed. It is not necessary to know how to program or analyze the data, everything is easy and fast for the user. Our interventions are also easily accessible.

Efficiency. We use the most innovative behavioral research along with data processing to have the best segmentation for campaigns. Reducing the expenditure of time and increasing the results of health interventions.

For the next year, we have three main objectives, with the respective action plans and their results below:

• (i) Cost-benefit analysis of the product in the municipality of Igarassu - Pernambuco:
• Testing the effectiveness of using the product in relation to registrations;
• Testing the effectiveness of using the product in relation to campaigns for indicators;

(a) Plan: We will carry out a separation of the teams that will have access to our product and control only with the consultancy, in addition to an additional control with the municipality that is not part of our program. We will measure the results in registrations and attendance of: women with completed cytology exams; children with poliomyelitis or Pentavalent vaccine; hypertensive with blood pressure measurement; diabetics requesting/receiving glycated hemoglobin and pregnant women.

(b) Expected results: We, therefore, intend to analyze and quantify the impact of our initiative.

(ii) Implementation of the initiative in the other 10 municipalities that we currently partner with;

(a) Plan: We will offer free consultations to the managers of all partner municipalities where we will implement our initiative;

(b) Expected results: We have all municipalities using our tool.

(iii) Product test in environmental surveillance in the municipality of Tapirai, São Paulo;

(a) Plan: Test, through joint construction of an action plan with the environmental department of the municipality of Tapirai, the use of the solution for the environmental surveillance aspect.

(b) Expected results: Lessons learned from using the tool for health surveillance;

Conditional to funding we also have 4 possible secondary objectives:

• Optimization and other various advances on the map;
• Enabling testing via messaging at scale;
• Advances in the intelligence of campaigns sent by messaging;
• Increased initiative for our other partner municipalities.

For the next year, we have three main objectives, with the respective action plans and their results below:

• Cost-benefit analysis of the product in the municipality of Igarassu - Pernambuco:
  • Testing the effectiveness of using the product in relation to registrations;
  • Testing the effectiveness of using the product in relation to campaigns for indicators;

(a) Plan: We will carry out a separation of the teams that will have access to our product and control only with the consultancy, in addition to an additional control with the municipality that is not part of our program. We will measure the results in registrations and attendance of: women with completed cytology exams; children with poliomyelitis or Pentavalent vaccine; hypertensive with blood pressure measurement; diabetics requesting/receiving glycated hemoglobin and pregnant women.

(b) Expected results: We, therefore, intend to analyze and quantify the impact of our initiative.

• Implementation of the initiative in the other 10 municipalities that we currently partner with;

(a) Plan: We will offer free consultations to the managers of all partner municipalities where we will implement our initiative;

(b) Expected results: We have all municipalities using our tool.

• Product test in environmental surveillance in the municipality of Tapirai, São Paulo;

(a) Plan: Test, through joint construction of an action plan with the environmental department of the municipality of Tapirai, the use of the solution for the environmental surveillance aspect.

(b) Expected results: Lessons learned from using the tool for health surveillance.

Conditional to funding we also have 4 possible secondary objectives:

• Optimization and other various advances on the map;
• Enabling testing via messaging at scale;
• Advances in the intelligence of campaigns sent by messaging;
• Increased initiative for our other partner municipalities.

We've been to several municipalities, but, we are currently in 2 municipalities, impacting 40 health teams and 126,000 residents.

For the next year (2023), we intend to expand to the entire portfolio of partner municipalities, reaching 10 municipalities, 127 health teams, and 380,000 residents.

We see two major barriers to achieving these goals:

• Our first and biggest limitation is financial. Georeferencing and messaging services that are necessary for the maintenance of our services, despite the high impact, require a good investment to function. Georeferencing is only necessary once, during the creation of the solution, but the messaging service is recurring.
• As for the market, we also need the collaboration of municipal managers to prioritize the use of our solution in their municipal systems.

We are currently working with the Votorantim Institute, which finances the implementation of these and other projects - together with specialized consultancy - and a list of partner municipalities in its portfolio.

We develop products and services for local governments to overcome their challenges in both diagnosing and improving local primary health care. Our customers are the local public health officials. The impact measures are on the most vulnerable citizens that benefit from better public health service provisions made available by the government after our intervention actions (e.g. better coverage of Pap smears in women of reproductive age). Currently, this is all done 100% free of charge, which is key to speeding up our partnerships with local governments; in the long run, we plan to be financially sustainable by leveraging a freemium model.

*(All the values presented in this application has an exchange rate of US$1 = BRL 5.2159)

We are currently working with private social investment

Our product is part of one of the initiatives of the NGO Impulso Gov, which provides services through private social investment. This strategy has been increasingly successful, as shown in the chart below:

Impulso Gov believes this strategy to be effective, as its research shows that the main source of philanthropy in Brazil is through private social investment, in which 89% of philanthropic sources are represented by companies and endowment funds. So far, partnerships have been mainly established with companies (pharmacy chains and hospitals) and endowments in the health sector, but the intention is to expand the relationship with companies in the areas of technology and finance, as they are the largest donor industries in Brazil. Considering the lack of endowments in the health area in Brazil, the creation of a long-term endowment fund is also considered, considering that the few existing competitors do not have preventive health as their main work. The philanthropy of wealthy families, valued at almost half of the funds collected in all donation campaigns in the country, is also another strategy that they seek, since they signed the partnership with the Behring Foundation, the search for organizations working with public health has been noticed. since the pandemic.

Win this challenge is essential for us to gain the attention our solution needs to raise more funds for the next steps and more funding for our proposal among Impulso Gov initiatives.

In the long term, we are thinking of developing the freemium model.

The solution was conceived as an open-source solution, under the MIT license, and will remain so. We do not want to compete with public or private electronic health record producers. Our software allows supporting organizations that want to integrate the solution into their local information systems and even commercial solutions.

However, we will open the solution and seek funding to offer strategies unrelated to the sale of the code, such as extra consultancy, in case the municipality wants to hold more exclusive synchronous meetings of remote technical assistance to have the support of the technical team.

It's worth noting that this will be an amount that will have fees below market value, so we continue to make our support as equitable and affordable as possible.

We have evidence that charging for these extra services will be enough to keep the platform and its other features free. If we estimate that 15% of the municipalities using the platform will pay for these extra services - an average contract value of US$ 10,350* -, over time a decreasing part of our revenue will depend exclusively on private social investment. Eventually, the income gained from freemium will be enough to cover all costs for our projects in 4 years and beyond, as shown in the chart below.

• This number is not random: for a Brazilian government to acquire a service, it can do so without bidding if it is below US$ 10,350 per year. Therefore, by pricing the service within this limit, we circumvent all obstacles related to public sector purchasing processes.

The only reason we haven't done it yet is that we don't allow governments to pay for our services, but they've already asked about it. The following situation has happened at least 10 times in the past: (i) we tell a specific municipality that we can provide identified lists of high-risk citizens for them to identify and care for, but we are currently at the limit and cannot do so immediately; (ii) the government's response is “we can afford it, so you can direct resources to prioritize this analysis”. (We haven't made any progress in that regard because we still don't have the internal structure to manage paid government customers, so the conversation ends there). This has happened repeatedly even though we clearly state that all of our products and services are 100% free at this time. Therefore, we know that there is a willingness to pay for what we are offering. Our assumption of 15% of customers as paid customers is probably an understatement, as we will operate below the no-bid threshold, removing financial and legal hurdles on the government side.