Nut4Health

Chronic and acute malnutrition is one of the main problems facing the planet.  In fact, it is recorded in Sustainable Development Goal 2 of the United Nations, Zero Hunger. Despite this, according to the latest report on the state of food security and nutrition in the world from Food and Agricultural Organization, 850 million people suffer from hunger in the world, and it is expected to increase to a billion people. COVID-19 has aggravated the situation noticeably, worsening the situation in South America and Sub-Saharan Africa.

According to UNHCR (2021), main consequences of malnutrition are early mortality, reduced physical capacity and economic productivity, decreased intellectual and learning capacity, blocked growth and physical development, metabolic deficiencies and propensity to cardiovascular diseases. Early detection and treatment of cases is key to reducing these affections, diminishing risk of complications by 20%.

Most impoverished countries suffer from significant deficiencies in the institutional health system, such as lack of doctors and health personnel, poor infrastructure and inefficient and ineffective operating systems. In this context, an international approach called Community Based Management of Acute Malnutrition (CMAN) has been designed for the treatment of acute malnutrition. This approach enables community volunteers or technicians selected and trained at community level to carry out activities to prevent child malnutrition, identify cases at household level and refer them to health centers depending on the state of malnutrition.

This system has a great potential to make up for the lack of health personnel, but it also exhibits a series of inherent problems which prevent its operation:

(1)     Late diagnoses: community volunteers lack incentives to search cases and families consider malnutrition as structural, causing children to be diagnosed when they already present complications. Cost of treatment of children is multiplied by 4 and the mortality rate rises to 30%. 

(2)     Lack of trust from donors/civil society: this limits the quantity of funds which donators and society invest in this type of interventions, making it impossible to reach every child.

(3)     Absence of aggregated, reliable and real-time information sources: there’s a lack of monitoring instruments which would allow a global vision on malnutrition’s situation and serve as an early warning system for decision making and policy design

Nut4Health is a technological platform (web/app) that allows: (1) to deploy a decentralized network of community agents that early search for cases of malnutrition through a pay-for-results system that allow for intervention in cases where they are still treatable and recoverable; (2) to offer community agents a solid base of information and training that would enable them to exercise counseling work with families based on national health protocols, as well as a decision tree that would guide them in the decision-making process on the nutritional situation of families. (3) an early warning system that allows us to understand the "epidemiological" situation of malnutrition and facilitate decision-making. This platform is designed to operate in a blockchain and which would also provide absolute transparency and traceability on the use and management of funds

How does it work?

Nut4Health is a mobile/web app that supports CA counsel and diagnose malnutrition in patients in its early stages. The app helps the CA through a decision making tree, enabling them to counsel families in nutritional habits and risk factors of malnutrition as well as guiding them through the process of diagnosing children. If the technology deployed gives any of the following results: “in risk of malnutrition”, “Moderate Acute Malnutrition” or “Severe Acute Malnutrition”, then a case is registered and a notification is automatically sent to the closest health centre, with the CA responsible for the supervision and follow-up of the cases. If a case of malnutrition is detected, the app opens a Smart Contract that is validated when the child gets into the health centre and is identified through the same app, creating a record for the CA that can be exchanged for a payment at the end of the month. 

With this system in place, we manage to deploy the CA into the communities to actively search for early stages of cases of malnutrition and support families with a counselling system to prevent malnutrition. Moreover, the CA feeds the information system with real time data that is visualized in an admin website to favour an informed decision making process for health authorities. 

Early identification of cases mitigates malnutrition and associated risks related to mortality, morbidity and overall development of children by 30% and divides cost of treatment by four, increasing the capacities of health centers to deal with other diseases.

Nut4health targets people suffering from malnutrition all over the world. More concretely, is focused in the prevention of under 5 children and pregant women, to ensure normal development. 

Malnutrition not only increases child mortality, but it also increases morbidity and impacts brain development causing largely irreversible delayed motor and cognitive development, which in turn have economic and social consequences:

By reducing morbidity, Nut4Health reduces future costs of treatment due to sickness and chronic diseases, and time spent looking after sick children, which in turn increases productivity. It is estimated that costs of treatment of cases of severe malnutrition are multiplied by 4 when complications arise, and when looking overall consequences of malnutrition, for every $1 spent on direct nutrition interventions, $18 are obtained in economic benefits.

Acting in early stages of malnutrition is vital for brain development and educational success. Shifting a child from acute malnutrition to well-nourished would increase schooling by 1,25 grades and wages by more than 9%, and even more, an increase of one standard deviation in reading and vocabulary tests raises wages by 35 percent. Higher education and cognitive capacity results in higher productivity and economic development. 

Nut4Health also benefits the local environment and society by generating job opportunities: it deploys a network of community agents which can individually register in the app and search actively for malnutrition cases by means of payment-by-results. Additionally, with a syndromic decision tree, Nut4Health provides training to agents in nutrition, generating the possibility of absorption by health centers and improving their prospects.

Nut4health arises from the pain of the two founders of the project, Blanca and Borja, from working on various famines and experiencing first-hand the failure of malnutrition intervention models. In 2018, they developed a comprehensive diagnosis of malnutrition interventions, in a listening process in which they worked with national health systems, international organizations and communities to co-create an intervention model that incorporate technology to prevent and early detect malnutrition. Since then, a platform adapted to end users (agents in rural communities and treatment centers) has been developed, two pilot projects have been deployed in Guatemala and Mauritania with great success and learnings, and an impact evaluation system has been incorporated with a difference in difference methodology to analyze impact.
We implement the project with a system of developmental evaluation, designed to learn and improve every aspect of the intervention (from technology, to incentives or processes). 
Nut4Health currently has three senior software developers who work closely with the affected communities, two nutritionists in the intervention countries and four coordinators of community agents in the communities in which we intervene. We also have two professionals in charge of alliances with health systems and two people working in funding and business development.
Nut4health team is, first of all, diverse, with staff hired from the communities that we serve; It is a team that works horizontally both internally and with the communities themselves; and it is a team guided by passion and purpose to end hunger.

Currently we are supporting 2000 families in the pilot project in Mauritania and 1500 families in Guatemala. We have deployed 28 community agents and diagnoses 14500 children with more than 800 children treated in the health centers. 

NUT4Health specifically needs three supports: (1) help for the development of a business plan that allows the scalability of the solution, as well as the identification of the main financing streams that promote the growth of the deployment of Nut4Health;
(2) Support in the field of public and institutional relations to access different actors that favor and support the implementation of Nut4Health within the main international organizations related to hunger and with the national health systems of the main countries affected by hunger. malnutrition. (3) Technological support for the development of solutions for international payment systems with agents through telephone or blockchain payment methods that reduce transaction costs; support for the adaptation of a diagnostic tool for malnutrition photography through the use of Artificial Intelligence.

Nut4health is innovative for different reasons

1. Technological innovation: Nut4Health uses cutting edge technologies to prevent malnutrition: 

• Firstly through a payment by result system of Smart Contracts that builds up connection between payers (Health Systems, International Organizations and private partners) and Community Agents: guaranteeing a trazable and transparent system over blockchain that allows to assess where every dollar goes and what is the impact of it. 

• Nut4health integrates a web-app to register cases of malnutrition and uses human centered technology (online/offline) to guide the community agents with limited digital capacity through the diagnosis and registration of all the data necessary to tackle malnutrition. 

• An automated system of communication connected to an API to inform health centers about the patients identified with malnutrition through SMS, WhatsApp or Voice mails so we make sure treatment centers has knowledge about the patients and their immediate needs. Additionally, treatment center can make use of a simple software to register cases and evolution of the patients.

• A real-time data visualization web with cases, severity of the cases, location and more in deep data to facilitate policy decision making that allows to understand the situation of the hunger epidemic and helps to deploy systems to prevent it. 

• Additionally Nut4Health is currently integrating different systems to avoid misdiagnosis: a photo-diagnosis app based on AI, an automated MUAC…

2. Intervention-model innovation: the combination of technology and community based intervention  transforms the way health services are provided in impoverished countries. The payment-by-result scheme allows the system to screen malnutrition patients in rural communities at a low cost while finding the cases in early stages. This, on one side, prevents long-term impacts of malnutrition on kids, and on the other, relieves the workload of the health centers improving the effectiveness and cost of treatments. Additionally, this allows the creation of an early warning system with real time data for decision making. 

3. Empowering communities: moreover, Nut4Health integrates rural communities in the malnutrition screening process and create livelihoods for young population in rural and periurban areas, creating a sense of empowerment in the community at the same time that fostering economic development in the region.

Our strategic plan has a timeframe from 2022 to 2026, by this time: 

·      Total number of cases early detected and referred to health structures: By 2026, 24,100 cases will have been referred to health structures, of which 13,014 are women and 11,086 are men.

·      Total number of cases admitted to health centers: By 2026, 20,485 of the referred cases are admitted to health structures, of which 11,062 are women and 9,423 are men.

·      Increase the coverage of cases of health structures by 25%: By 2026, have noticed a 25% coverage compared to the moment before the intervention of the health structures with which the cases are referred in 5 different countries.

·      Total number of anticipated diagnoses (from Severe Acute Malnutrition to Moderate Acute Malnutrition): By 2026, having prevented 2,985 boys and girls, of which 1,385 are men and 1,600 are women. The indicator that makes it possible to measure this metric is the ratio of severe acute malnutrition vs global, and the impact is measured through the arithmetic mean.

·      Total number of cases of malnutrition prevented: By 2026, having obtained an annual reduction of 20% in the incidence rate of malnutrition by introducing 21,700 women in the nutritional counseling program.

·      Total amount of resources raised for Nut4Health will be 5,645,000EUR

Nut4Health has a strong evidence-based system to measure progress and impact based in two methodologies: 

- A developmental evaluation in order to test the intervention models logic, refining strategies accordingly and to track the complexity of the intervention’s context, supporting innovation and adaptation with real-time, or close to real-time, feedback about the processes which guide the intervention (identification of community workers, counselling, referral and admission of malnourished…), thus facilitating a continuous development loop. To do so we have developed a dashboard of indicators with information about processes, results and impacts that helps us to keep track of the interventions once Nut4Health is deployed. We collect data over numer of diagnosis made, number of cases of malnutrition identified, number of admissions in the treatment centers, evolutions of cases in treatment center... 

- Se have designed an impact evaluation strategy  with the support of University College of London researchers to evaluate the causal effect of our intervention (early identification of cases and counseling) on the incidence and prevalence of acute malnutrition in children under 5 years of age and intervention costs. To do so, we have established control and intervention groups following the Difference-in-Difference approach and a whole system of data collection to be able to assess impact in every deployment. To do so we use a standarized nutrition survey (SMART Survey) that is made before and after in the treatment and control areas. Additionally we are designing a software to automatize data cleaning, data processing and publication to have access to real time data and indicators about processes, results and impacts that could help us not just to assess the impact of Nut4Health, but also to disseminate them and create transparency over the whole system. 

The issue of acute malnutrition is complex and has multifactorial and interrelated causes. Countries where it occurs share deficiencies in health institutional systems such as lack of doctors, healthcare personnel, infrastructure, and systems due to the international system. To tackle it, an international protocol called Community Based Management of Acute Malnutrition (CMAM) has been developed. It relies on community-selected and trained volunteers to carry out activities aimed at preventing child malnutrition, identifying cases at the household level and referring them to treatment centers. In the absence of incentives, diagnoses are made when it is already very late and children have complications, which increases treatment costs and mortality rates. Moreover, volunteers working at the community level do not have the necessary knowledge to develop nutritional counseling activities.

Base on this the theory of change of Nut4Health comprehends a series of processes listed below

A group of young people (screeners) in communities are identified and trained in the use of Nut4Health, and a distributed network of screeners is deployed to use the platform to register malnutrition cases based on a pay-for-result system and refer them to the nearest health structures, providing income to these young people and motivating active case finding as an immediate effect. In parallel, personnel from the health structures are also trained to validate malnutrition cases and guide treatment. Upon identification of a case in the field, health personnel receive a notification with family data to ensure their admission and receive primary care. Nut4Health increases the coverage of malnutrition cases, anticipates malnutrition diagnoses before children present complications, and reduces treatment costs.

Additionally, along the screening process, when families at risk of malnutrition are found, they are introduced in to the Nut4Health mobile counseling program (SMS or WhatsApp) that accompanies them during the 1000 days window. This increases the information families have about nutritional knowledge, habits, and practices, as well as care during pregnancy and breastfeeding, and aims to impact by causing behavior changes to prevent malnutrition.

All the information collected by community agents and health personnel feeds into the platform's database, which automatically generates reports, graphs, and reports based on key metrics in food and nutrition security, providing actors involved in decision-making with an early warning system and increasing efficiency in the allocation of resources and management of nutritional crises.

Finally, Nut4Health aims to contribute to global policy influence on food and nutrition security and be part of the network of actors as a tool that facilitates coordination. Through evidence generation and communication activities, participation in key coordination meetings is sought, and public debates are influenced by taking the intervention model to the most fundamental conversations. Additionally, by consolidating the platform's construction on blockchain, traceability in the use of funds and immutability in data is sought. In this way, coordination and efficiency of humanitarian and development action systems are increased, impacting the amount of funds allocated to food and nutrition security interventions.

Nut4Health is a platform that brings together the use of four technologies:  1. Mobile and web app: This tool is composed of 3 main modules, which in turn have a series of sub-modules that are responsible for covering certain functionalities. The main modules are defined below:

Backend Firebase: Backend platform as a service that provides a set of tools for developing Web and mobile applications.

Web application: It provides utilities such as the management of system users, contracts, patients, diagnoses, payments, etc.

Mobile application: It is oriented to the community agent and with which it is possible to obtain and record data about the potential children malnutrition, as well as to manage the contracts and payments of the assigned agent.

Figure 1: Web-App tech architecture

2. SmartContracts deployed over Kaleido Blockchain: the previous architecture interacts with a series of SmartContracts developed in Udemy to register the critical process of the platform: diagnosis and payments, so transparency and traceability can be guaranteed for donors and public administrations.

3. SMS app: Nut4Health interacts with an own/developed (www.esavia.org) app to send structured and timely SMS and WhatsApp to provide counseling to pregnant women and mothers to prevent malnutrition during a period of 1000 days from conception until children are two.

4. Artificial Intelligence for malnutrition diagnosis: currently Nut4Health is involved in a partnership with Vody´s, a tech startup, in applying AI technology to automatize diagnosis through body modelling, building a Deep Learning  regression model to predict malnutrition from body measures.

Figure 2: AI development for Malnutrition prediction.

Diversity is an ethical commitment at the core of Nut4Health and the promoting organization, SIC4Change.

The hiring processes in are guided by a principle of interculturality, understood as the generation of spaces and bridges between different cultures and visions from diversity to foster a mixed organizational culture. 

Nut4Health currently has a diverse team that is 50% male and 50% female. The team also includes four ethnic identifications (Caucasian, Poular, Haratin and Latin), and one person with disabilities.

Additionally, we are deeply committed to foster women in tech, two out of three of the software developers of Nut4Health are women. 

This diversity is fostered with a horizontal model of management, based on a Teal Organization, that enhances the capabilities of the whole team empowering individual capacities at the same time that collective intelligence.