CLIMB to End Malnutrition and Neglected Tropical Diseases

Globally, 149.2 million children below the age of five are not developing at typical rates, 45.4 million kids are emaciated, and 38.9 million kids are overweight. In many low and middle-income countries, malnutrition and neglected tropical diseases constitutes the major public health crisis in rural and resource-constrained communities.

Rwanda is one of landlocked countries in East Africa where the rates of children with malnutrition has increased dramatically. The recent demographics and health survey reported that 33% of Rwandan children between the ages of six and 59 months have not reached an appropriate height for their age. Additionally, 22% of Rwandan children between the ages of six and 23 months are barely meeting nutritional standards. While 9% of children are either severely underweight for their height or age, 37% of children between the ages of six and 59 months are anemic.

Musanze district is one of the districts surrounding the Volcanoes National Park, a region with some of the highest rates of malnutrition. Malnutrition has always been associated moderate or advanced cases of intestinal worms, which remain most prevalent neglected tropical diseases across the region.

Approximately 50% of children are infected with intestinal parasites, which cause constant abdominal pain and reduce food intake or increase nutrient wastage via vomiting, diarrhea, or blood loss. These effects exasperate protein energy malnutrition, anemia, and other nutrient deficiencies. These parasites reduce the work capacity and productivity and cause physical and cognitive impairment.

While the World Health Organization (WHO) recommends interventions that improve nutrition in order to eradicate NTDs, current efforts and resources are invested in vertical programs with limited attention to hands innovations that integrate both malnutrition and NTDs.

The Rwandan Ministry of Health (MoH) in the Republic of Rwanda developed a plan for tackling NTDs with intended implementation between the years 2019 and 2024. In order to target NTDs, MOH made note of the connection between malnutrition and NTDs. More specifically, in addressing diseases like Soil Transmitted Helminthiasis and Schistosomiasis, efforts include improving hygiene and utilizing deworming strategies in order to reduce the prevalence of malnutrition. However, there have been a lack of and community informed innovations to accelerate the pace towards achieving this goal.

In addition to programmatic challenges, structural and policy gaps limit effort to eradicate malnutrition. In these cases, while over 80% of children are in schools, there is a limited integration and collaboration between education and health unit at district and community levels.

Persistent delays in eradicating malnutrition can be explained by the used of traditional approaches relying solely on public health messaging. In rural and hard-to-reach communities of Musanze district, such gaps lead to poor academic performance, increased dropout rates and developmental delays especially among school-aged population. 

We are proposing a Community-Designed Learning Incubators and Multidimensional Bundle (CLIMB), an integrated and innovative strategy to improve Health and Educational Outcomes in rural Rwanda. CLIMB accelerates improvements of malnutrition and neglected tropical diseases through its five components.

School and Community-based food production: Instead of relying on traditional procurement or distribution of food to schools and community members. Public schools and communities serve as food production sites.

Establish applied community learning hubs: CLIMB capitalizes on community-informed solutions to ensure a smooth adoption of best practices. Community learning hubs will be established at public schools and host hands on learning on nutrition. As such, community members will attend learning sessions at school where they learn best practices. Following each learning session, community members will receive an implementation toolkit including seeds and NTDs self-screening tools. They also assigned a coach who will perform home visits to facilitate the implementation of learned skills and practices.

Community hackathons and support groups: In addition to focused learning and coaching visits, Move Up global will organize quarterly community hackathons gathering community members to engineer new change ideas or solutions to persistent gaps. Hackathons will be facilitated by project coaches in collaboration with teachers, members of project club at selected school/community learning hub. At the end of the sessions, documented solutions will be compiled and develop a playbook to tackle malnutrition and NTDs. Further, community members will support their peers through role-plays and simulations.

Expanding the use of Beta ComScreen for school and community based-screening and case management: Move Up Global has developed and deployed Beta ComScreen, a tablet-based application used by community health workers to screen students for signs of malnutrition and NTDs. Over the past three years, Beta ComScreen has been used to screen hundreds of students at school and community level. We will train more community health workers and expand the use of Beta ComScreen to reach community members and children who are not enrolled in schools. This approach will enable early detection of malnutrition and NTDs and offer real-time education sessions. Further, Beta Com Screen will enable a timely referral of severe forms of malnutrion and NTDs to nearby health facility.

Establish a community collaborative on social entrepreneurship and public health innovations: Our project will leverage teachers as community leaders to elaborate and instill social entrepreneurship skills to community members with high risk of malnutrition. This will be used as a strategy to generate small community businesses gear to elimination of malnutrition and food insecurity. As such, while the initial phase will include seeds and intensive coaching visits, social entrepreneurship skills and tools will help members to develop a sense of ownership and business model that require limited technical support. The collaborative will support enable the dissemination of best practices beyond the primary intervention sites.

Our solution targets the population of Musanze district, one of five districts in the Northern part of Rwanda, very well known for its proximity to Rwanda's national park, volcanos and a growing ecotourism industry. Despite its lush natural beauty, many people in the district live in dire poverty and suffer from diseases and parasites that could be mitigated through education and simple cost-effective health interventions. Musanze district had a total population of 307,078. It has an average annual growth rate of 1.8% where Males stand at 174,760 and Females at 193,803. District-wide school attendance remains very low (38.6%) for the preschool-age population (3-6 years), widespread (95.4%) for the primary school-age population (7-12 years), and moderate (71.7%) for the secondary school-age population (13-18 years).

The pilot sites include Nyabirehe and Rwinzovu public schools of Gataraga sector covering approximately 23,000 people. These two schools serve approximately 3000 students.

Our solution is locally designed and will be implemented by the communities we serve. In fact, 100% of the implementers are from the communities we serve. Over the past three years, Move Up Global has partnered with Ireme Education for Social Impact, a grassroot and women-led organization to study and address the root causes of poor academic performance in Musanze district. In this partnership, have established a community advisory board and linked community health with education systems guided by the Knot Framework, our innovative strategy to strengthen health and education systems linkages. Preliminary results show remarkable improvements.  

Over the past three years, we have installed electricity and internet as an opportunity to enhance the use of technology to address schools and community needs. Further, we have launched the school-based nutrition learning hub where members of the community come to learn best feeding practices. We have built a chicken farm and garden on land donated by the school.

To eradicate neglected tropical diseases, we have developed and deployed Beta ComScreen, an application used by community health workers to screen students for NTDs and malnutrition.  We have hired a community health worker who has screened over 600 students.   We have adapted and implemented the Food and Agriculture Organization (FAO)’s food insecurity assessment tools for the use at community level.

Teachers were trained to act as expended public health workers. During COVID-19, we have trained teachers in infection prevention and control and launched a soap making project. Within 6-12 months, our project has achieved remarkable milestones including: 

• 125,000 healthy meal plates were distributed. 
• 453 home visits were conducted.  
• 655 students were screened for malnutrition and NTDs. 
• 15% decline in students with malnutrition
• 20% decline in students with presumptive signs NTDs 
• >5000 of eggs produced and distributed. 
• 6000 bar soap produced

Our solution serves 3000 people. However, we anticipate an early adoption of our solution with possibility to cover an entire district covering approximately 400,000 people within 2-3 years. 

I believe that MIT Solve is best placed to provide support to refine the design and implementation of this idea. 

Technical support: There is a need to get technical support on the use of technology to enable evidence-based decisions. Inputs from MIT Solve community will be invaluable. 

Business development: There is a growing interest from the Ministry of Health and Ministry of Education officials on the way this solution could be scaled up. Insights of MIT solve members will be instrumental from business development and monitoring and evaluation. 

Traditional solutions to tackle malnutrition and neglected tropical diseases rely of short quick fixes including food distribution and mass distribution of deworming medications. As such, traditional approaches rely on health care providers and health facilities. 

In contrast, our solution community-designed innovation to tackle the root causes of malnutrition and NTDs while capitalizing on health and academic outcomes. 

1) Instead of relying on health care workers (Nurse and Doctors), teachers and other community members are mentored to become an extended public health workforce. 

2) Instead of relying heavily on health facilities, our solutions orient teachers and community health workers on effective tools. Teachers have a frequent access to children and are the best positioned to identify the student and families' needs. 

3) Our solution places technological tools into teachers and community health workers to ensure an early detection of malnutrition, NTDs and timely referral to health facilities. As such we prevent the "five failures":

• Faillure to prevent.
• Faillure to detect. 
• Fallure to link the affected into care. 
• Faillure to treat. 
• Faillure to integrate and rehabilitate. 

4) Our solution is cost-effective and improve both academic and health outcomes.

We plan to scale-up our solution to increase our coverage by 50% with the ultimate goal to eradicate malnutrition and NTDs among school-aged population through partnership with private and public sector investors, we will build a center of excellence to catalyze learning and translation of our best practices into national policies. 

We have developed a number of process and outcome indicators. Below is the list of key measurements: 

% of cases of malnutrition (acute and chronic malnutrition: Disaggregated by gender and site. Data will be collected by using Beta ComCreen app. Collected through observation.

% of cases with neglected tropical diseases:  Disaggregated by gender and site. Data will be collected by using Beta ComCreen app.

% of absenteeism: Disaggregated by gender and site. Data will be collected by using Beta ComCreen app.

% of people with increased health literacy (skills and competencies in nutrition and common NTDs): Disaggregated by age group and region.

Dropout rate: Disaggregated by gender and site. Data will be collected by using Beta ComCreen app.

% of families with reported food insecurity: Collected using Beta ComScreen from FAO’s Food Insecurity Assessment tool

Household income: Direct survey. Wealth index: Rwanda has published ubudehe categories. We will use it to assess changes in categories at baseline and endline.

Pass rate: Only students. Desegregated by gender and site. This will measure changes in academic performance before and after the intervention.

Our solution is centered on schools as centers for community transformation and incubators to eradicate malnutrition and neglected tropical diseases. Our Theory of Change is guided by the following steps: 

Step I: Conduct a landscape analysis and expand the use of the Knot (Ipfundo) Framework, which capitalizes on building strong linkages between education and community health systems. In Rwanda, public schools have no health worker. As community leaders, teachers are often seen as role model. They are the first to identify cases of neglected tropical diseases and malnutrition. They have a better sense of students and families in most need. Rwanda has reached the primary school net enrolment rate of 98%. This high attendance provides an opportunity to use schools as the center for community transformation. We will train teachers and other community leaders to serve as an extended public health workforce tackling malnutrition and NTDs.

Over the past three years, we have used the Knot at Nyabirehe primary schools. Preliminary assessment reported a remarkable improvements in early detection and referral of children with signs of malnutrition. A thorough landscape analysis will assess the effectiveness of the Knot Framework as a strategy to eradicate malnutrition and NTDs.

Step II: Expand school and community learning labs on nutrition and diseases prevention: The current school-based learning lab produces over 3000 eggs and vegetables are harvested every week to feed 1200 children at Nyabirehe primary school. We will expand our project to double the number of children fed and invite community members learn hands on techniques to grow healthy food and prevent NTDS. Seeds and chicken or other animals will be distributed to for members of the community start their own projects.

To ensure fidelity in community uptake of the project, CLIMB coaches will visit households to ensure ongoing skills building and technical support. We will expand current learning labs to cover Rwinzovu school and surrounding communities.

 Step III: Develop a community of practice on nutrition and NTDs: We will launch a collaborative to facilitate sharing best practices and accelerate the pace toward elimination of malnutrition and NTDs. Social entrepreneurship and public health innovations will be key to this collaborative. Community hackathons and CLIMB playbooks will enable development and dissemination of tested change ideas.

Step IV: Decentralize technological solutions (Beta ComScreen app) to prevent or ensure detection and referral of cases of malnutrition and NTDs. We will avail Beta ComScreen application to community health workers and teacher to use for NTDs screening among children and community members.

Phase V: Research, data sharing, and data-driven decisions: Routine data sharing meetings will be organized at community and district level to discuss changes overtime and seek community and leadership inputs.

Our screening application (Beta ScomScreen) is based on CommCare. 

Beta ComScreen application is used by community health workers to screen students for signs of malnutrition and NTDs. 

Diversity, equity and inclusion are at the core of our solutions. We foster to engage community members with various experiences and backgrounds. The decision-making process involves a diverse group of stakeholders. We have defined ground rules which enhance the principles of diversity, equity, and inclusion. Rwanda promotes Gender equity in all domains. Our implementation oversights and coordination will be led by woman leaders from the community we serve. To optimize equity, and inclusion, we have launched a community advisory board which advises and guide the design and implementation processes. 

B2B will remain our business model. There is a growing interest for organizations to learn more community-designed solutions to address persistent gaps in health and education. We will leverage this interest to optimize our business model with emphasis on three areas: 

1) We will launch a regional center of excellence on social innovation and community transformation, which will facilitate workshops and coaching sessions to organizations interested in community driven interventions to address health and education outcomes. These organizations will purchase our services and offset operations expenses. 

2) Incubator projects which have reached the maturity will be transformed into social enterprises and generate revenue which will run our ongoing operations. 

3) Our model will be competitive to grant makers interested in community-defined innovations. As such, we will compete for grants and continue to pitch our solutions to individual donors and private foundations. 

Once our center of excellence is well established, we will compete for regional consulting work, targeting innovative solutions to address academic and health outcomes across the region. We hope this will generate substantial income to offset operations and expand our solution. 

Products from our solutions will be sold in local and regional market. As such, we believe that we will be able to not only sustain our solution but also to increase the revenue. 

Over the past three years, we have successfully secured grants from corporates and family foundations including Aspen Global Innovators Group, World Connect, Hartwick University, and other private foundations and individual donors. Over $100,000 were raised to support our incubator projects. Moving forward, we will pursue larger grants to facilitate the impact dissemination and orient other actors interested in boosting the quality of health and education.

We will also leverage the Rwandan government support to replicate our solutions. We believe that the government and partners will offset the cost to expand out solution.