Impulso Previne

In Brazil alone, +300k people die from preventable causes every year, such as (i) heart attacks caused by untreated diabetes or (ii) newborns whose mother had no access to prenatal care, a challenge shared by all low and middle-income countries. That is despite the country's free and universal health-care system, with +1M nurses, 300k doctors and 200k health community workers. Why? Part of the reason is that these local health-care workers cannot be data-driven when deciding to whom/when they should provide prevention services (e.g. where are the pregnant women without prenatal care or the untreated diabetic population in this city). With 150 million people relying exclusively on the public health-care system, prioritizing people who need it the most is key. Most of the data required to do this is already collected: the majority of Brazil’s 42k public health units already use electronic health records (EHR), an expansion accelerated by the Covid-19 pandemic. The gap now is to turn this data into information and to deliver it to health-care professionals in an uncomplicated way, so that they can care for the right people at the right time.   

So far Brazil has not been able to do so. The result: millions of Brazilians that are not receiving the appropriate primary care and will therefore experience greater health issues over time: 

• More than 28 million hypertensive people do not measure their blood pressure; this is part of the reason behind the 100,000 deaths caused by strokes every year;

• More than 7.6 million diabetic people do not monitor their glycated hemoglobin; there are currently 10,000 amputations per year caused by untreated diabetes;

• More than one mother dies for every thousand births in Brazil alone;

Details below: Brazil’s new primary care measuring and funding system

In order to address this scenario, the federal government changed the way it funds primary care in the country. The changes are summarized below, as they introduced the right incentives but also new measuring challenges that our solution leverages to better measure and improve primary care indicators.

In 2019, Previne Brasil was launched as a program of primary care financing in which municipal governments get extra remittances (a value up to 9% of the federal budget for primary care for municipal governments) from the national government depending on how they meet 7 key performance indicators (KPIs):

• Percentage of pregnant women that had at least 6 prenatal care appointments during the pregnancy

• Percentage of pregnant women that did HIV and Syphilis tests

• Percentage of pregnant women with odontological care completed

• Percentage of women with cytology exams completed

• Percentage of kids with polio and pentavalent vaccines

• Percentage of hypertensive people with blood pressure measure per semester

• Percentage of diabetic people that requested glycated hemoglobin

Given these 7 KPIs, health officials from municipal governments need to guide its staff to make proper monitoring of prenatal care, kids' vaccination and measurement of blood pressure in hypertensive patients, for instance. 

However, there are two issues for local governments: unclear diagnosis and action-taking.

First, many health officials have problems accessing and understanding the System of Information of Primary Health-Care (SISAB), the main national database on primary care, that provides no easy way to show municipalities where they are in each key indicator vs. what the goal is. Second, if and when they overcome this challenge, there are no directions on how to improve in the KPIs that are lacking. 

As a result of these two issues, they are not able to make effective decisions to improve local health-care. The consequences are (i) less remittances from the federal government to fund primary care, further worsening the situation, and (ii) worse health-care provision for the local population that relies exclusively on the public health-care system (the country’s most vulnerable groups).

Impulso Previne is a virtual platform to help health officials from each of Brazil’s 5,570 municipalities better manage primary care in order to meet the criteria of Previne Brasil, the pay-for-performance policy to finance primary health in Brazil. Our platform provides both a diagnostic on indicators and technical assistance to improve them:

Impulso Previne is a virtual platform to help health officials from each of Brazil’s 5,570 municipalities better manage primary care in order to meet the criteria of Previne Brasil, the pay-for-performance policy to finance primary health in Brazil. Our platform provides both a diagnostic on indicators and technical assistance to improve them:

• Indicators' measurement and diagnostic: Previne Brasil’s 7 KPIs are calculated from nation-wide EHRs already collected at the local level by each local government. These indicators are used in the distribution of federal remittances for primary care throughout the country: the cities that meet the goals in each KPI receive bigger funds and vice-versa. Health officials have problems in accessing and interpreting the official IT system (SISAB), making ineffective decisions. Our solution, Impulso Previne, extracts open data, transforms and loads it (ETL process) in an easier, more action-oriented format, available to all 5,570 municipalities in the country. With Impulso Previne, the health official from a municipal government can analyze the performance of their city in the seven KPIs in the last year quarters and get suggestions of how to improve these indicators based on a customized action plan focused on supporting citizens that need it the most. Currently, besides using open data, we ask selected cities to provide private data, including several personal details of each of its inhabitants, from the municipal governments to manually create an identified list of citizens most in need of primary care (e.g. who are the unvaccinated children). 

• Remote technical assistance: even with a good and clear diagnostic, health officials in municipal governments with few technological and financial resources have issues to implement action plans that effectively solve problems of primary care performance. Given the scenario, besides the platform of indicators, we offer remote technical assistance for these officials in vulnerable areas that need help to improve their government outcomes. 

Impulso Previne was built from bottom-up. We learned about the new federal program and its indicators and measurement challenges from public health officials themselves. Its idealization and development included several interviews, usability tests and validations with these professionals in order to launch a platform aligned with their true demands. Additionally, our target user is in-house: over 20% of our own team are former public health officials that experienced first-hand the challenges around measuring primary care indicators.

As opposed to other platforms available, like the government’s SISAB, Impulso Previne was builded to be the one place where health officials from municipal governments can find both data analysis to make informed decisions and support to improve the quality of primary care, as well as increase the remittances received by the city from the federal government.

Impulso Previne directly serves public officials from all 5,570 governments that are responsible for the performance of health-care services labeled by Previne Brasil, the pay-for-performance system of financing public health in Brazil. Since helping the officials to enhance the performance of primary health-care involves improving the cities’ health services, our solution impacts the life of citizens of the cities attended by Impulso Previne. Until now, the platform had more than 23K views from almost 400 cities scattered in all regions of the country. We provided technical assistance to over 40 municipalities with about 30k inhabitants each, a GDP per capita of $4,400, an average HDI rate of 0.64 (medium development) and a mostly black population. All of the attended municipal officials say their cities suffer from the lack of financial and technological resources to offer effective primary care services and, after using Impulso Previne, when asked how much they would recommend the platform for their peers on a scale from 0 to 10, they answered 9.2 on average. 

The reason behind this positive feedback lies in the concrete problem they face: local officials cannot currently meet the goals determined by Previne Brasil, because they have no access to easy-to-understand diagnostic data nor clear recommendations on how to act. Therefore, they cannot improve the health-care services offered for citizens. Impulso Previne then emerges as a solution for their issues. With our platform, municipal officials can monitor the 7 KPIs, being assisted with recommendations of what must be done to improve the service outcomes. 

For example: when the city has a weak performance in the KPI related to blood pressure measurement of hypertensive patients, the platform presents the number of people who need to have their pressure measured and some actions the officials can run to reach out to these people, such as strategies of active search, constant medical appointment booking, and massive medical screenings. This is already available nationwide. Besides this use of open data, we are currently piloting the use of private data, provided by the local government itself, collected from EHRs. In this example, it allows Impulso to provide a list (with names, phone number and address) of the hypertensive people that have not had their pressure measured recently, greatly enhancing the government’s ability to identify and provide care to this population. 

This is what we did in the example that follows. To show the impact of Impulso Previne in the municipal management of primary care, we have highlights from São José do Herval, a city in the state of Rio Grande do Sul assisted by Impulso for over 1 year now, allowing us to analyze early results.

From the graph above, we can see that the city had low percentages of hypertensive people with blood pressure measured and a low number of diabetic people who requested glycated hemoglobin in the past 6 months. After Impulso’s support, the municipal government more than tripled its performance on both measures.  Considering that we asked for private data - personal details of inhabitants - from São José do Herval's officials to manually create an identified list of citizens most in need of primary care, we could promote a nominal search of people who needed to be attended immediately. Currently, we can do this for a small selection of cities, as the process is not automated.

To better assess whether Impulso’s work can be linked to the improvements, we compare this case with a randomly-selected city with similar population and in the same state (Multiterno), that we never interacted with. The control-city has not experienced any improvement in its NCDs population in the same period, as shown above, which supports the causal relationship between our work and the health improvements. 

An independent, formal and comprehensive impact evaluation, with randomly-selected municipalities as treatment vs. control group, will begin in November 2022 and last for 12 months.

We are well-positioned to serve municipal officials around Brazil because of (i) the composition of our team, (ii) the close contact we have with officials (both virtually and in-person) and (iii) our strategic partnerships.

Our team is composed of professionals in public health - most of them once worked in the health-care frontline, as hospital administrators -, technology industry and government sector. When someone, for instance, proposes a new feature for the platform based on their difficulties working as a hospital manager, people from our team who had success in another government institution can provide insights from that experience to UX specialists in the team that will draw the solution. The end-product from this melting pot then truly meets the demand of health officials scattered in cities throughout the country. 

When it comes to direct contact with the people we serve, we have been working closely with municipal officials by offering virtual technical assistance for more than 50 municipal governments in the use of data and technology to solve issues in primary health-care.  In addition, we have a direct connection with a group of 280 local health secretaries (out of 5,570 in total in the country) through instant messaging (WhatsApp) in which we constantly send updates about Previne Brasil and our platform and receive their impressions, requests and concerns. We also make sure to make in-person contact with municipal governments: our Board of Directors engages in multi-day field-trips at least one per month, along with 4-5 rotating team members, to guarantee they are updated on the challenges faced by officials on the ground, and they fully understand how the health indicators we focus on are linked to real people and their stories, by shadowing health workers on both health units and home visits. From this contact with health officials, we had an active participation of them in the idealization, development and validation of the features of our platform: through several interviews, field visits and usability tests we could ensure we considered all the concerns regarding our target public. As a result, the references to create the platform came from cities with distinct characteristics and challenges, so the final product is not biased in terms of the city's demography, size, technological development and geographical location. 

Another strategy to keep up with the communities we attend lies in the partnerships we have with major organizations in the public health field, such as the Ministry of Health, the National Council of Health Secretaries (Conass), and the National Council of Municipal Health Secretaries (Conasems). From these partnerships, we can (i) make contact with people directly working on the development of Previne Brasil, (ii) increase the number of public officials and municipal governments we have contact with given the large pool of cities the major organizations directly work with, (iii) improve our credibility among people working on the public sector due to the visibility given by those major organizations and (iv) join events and conferences led by those major organizations that have municipal officials as part of the attendees. Recently, we were present in the annual congress of the National Council of Municipal Health Secretaries (Conasems), which had municipal officials from cities of all the regions of the country. There we could promote our platform and services to municipal officials of more than 250 cities around the country.

This challenge will advance our work with (i) funding to overcome technical limitations and expand our impact, and (ii) credibility to further advance new partnerships.

First, the award would allow us to create new features for Impulso Previne's platform. Currently, we ask for private data, including several personal details of each of its inhabitants, from the municipal governments to manually create an identified list of citizens most in need of primary care. With the grant prize, our priority would be to launch an intranet portal in our platform that replaces the current manual practice, providing each municipal official automatically with a customized database of individual details of its citizens. Besides the public data, available on the national databases we collect information from, this intranet program would be fed with private data collected automatically from EHRs used by the cities. This way, the municipal official would be fully equipped with personal information of each citizen that actively helps him make proper searches of people most in need. We expect this will not only improve the primary health-care outcomes of cities, but also guarantee no one is left behind by the public health system. To create such an intranet portal, the grant would also be useful to hire 10 more developers on Impulso Previne's tech team. We know that in conservative projections, which do not consider the indirect gain of a saved life and the costs the national system of health would have if patients became ill, each dollar invested in Impulso Previne right now increases almost 9 dollars in the remittances from the federal government to the cities attended. However, in the long run, this value will be bigger with the implementation of the intranet portal, as we will help municipal officials to attend to the people who are currently being neglected, be it because of their race, socioeconomic condition or residence location. As a result, we will achieve the numbers detailed in the question about impact goals.

Additionally, the prize recognition from MIT Solve and Bill and Melinda Gates Foundation would increase our credibility. Since the foundation of ImpulsoGov 3 years ago, networking has played an important role to make us reach both the donor companies that fund us and the cities we attend. Through the National Council of Health Secretaries (Conass), the National Council of Municipal Health Secretaries (Conasems) and the Ministry of Health, official partners of Impulso, we could access data of all the cities throughout the country for the platform construction, besides individual connections we builded with some cities indicated by such institutions. With the contacts of our directors and board of trustees, we could reach out to several for-profit and nonprofit organizations that fund our services, like Novo Nordisk and Sanofi. With the recognition from the challenge, we expect something greater: networks with bigger governments and funders from Brazil and other countries. This would lead to the development of new products that will strengthen our vertical and horizontal impact, deepening our services with each city and reaching more citizens respectively.

We saw an innovative business-model opportunity where others saw only obstacles. Most people and organizations are unwilling to launch govtech initiatives in Brazil because the government is not an easy stakeholder to partner with. I leveraged my own previous career in government service and a data-driven mindset to realize that if we launched ImpulsoGov as a tech non-profit and made our products free to use, we would align our incentives with the government’s, facilitating data sharing and user engagement. Also, by hiring some of the country’s best tech talent we could provide local governments with free, high-quality digital products, resulting in an extremely low customer acquisition cost (CAC), allowing us to scale fast with a small but powerful team. The result is an extremely high impact-per-dollar rate, which made it easier to fundraise with both philanthropic and private health-care donors.

Private companies that provide IT services and products to government's health departments do exist, including around Previne Brasil, but (i) none of them is free of charge to the government, and (ii) they fail to employ the best tech talent since they are not sufficiently funded (the government is not a reliable payer). As a result, we have both a (i) cheaper (in fact, free) and (ii) better product than anyone else. This is already concerning some private companies: two of the major private players in the Brazilian public health-care market have reached out to propose "partnerships" after they read about our partnership with the National Council of Health Secretaries .

Finally, our incentives are aligned with the government incentives: we want to provide better health services for all, not to profit. Unlike private, for-profit companies, we gain nothing from successfully selling  ineffective products to more and more governments  (since we don't charge for them). Therefore, we direct our energy and resources not towards sales efforts but towards developing highly-effective products that can change public health-care provision, and then provide them for free. We even adopt and encourage open code and open data (we are currently developing an API to release all our non-identifiable datasets to the public), since we benefit from allowing other companies, NGOs, academics and civil society to build upon our work. IDB officials are already using ImpulsoPrevine to run fast and precise diagnostics on municipalities they consider supporting, for example - an evidence of the lack of alternatives available when it comes to high-frequency primary care information in Brazil.

We believe the “govtech non-profit” approach will irreversibly improve the philanthropic landscape in Brazil, and beyond. By leveraging a data-rich (but information-poor) public health-care sector, we are showing that even limited resources can be channeled by technology to dozens (and soon hundreds) of municipalities, directly benefiting millions of people at a very low cost per person.

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

• (I) Help municipal governments that use Impulso Previne achieve the goals determined by Previne Brasil. To do so, we will offer free consulting appointments for municipal officials in which we will diagnose the shortcomings of the on-going primary care practices in the city, create a plan of action with suggested activities and monitor the effectiveness of the actions being implemented. As a result, we expect to directly impact the following number of people, as compared to a scenario without our product and support::

+159,953 hypertensive patients with blood pressure measurement

+39,120 diabetic people requesting/receiving glycated hemoglobin;

+2,071 pregnant women with the adequate number of prenatal consultations;

+1,350 pregnant women with syphilis and HIV tests;

+2,942 pregnant women with proper dental health-care;

+117,335 women with cytology exams completed;

+6,486 children with polio or penta vaccine;

• (II) Have 10.000 users accessing Impulso Previne's platform. To do so, we will promote the platform through communication channels like the press and social media. To have the largest reach of municipal governments, we will keep using the National Council of Municipal Health Secretaries (Conasems), our partner, to promote the platform to municipal governments through their email and Whatsapp chains. In addition, we will keep in touch with municipal officials through newsletters and emails with updates about Previne Brasil, both inviting them to use the platform and to share with their peers from other cities.

• (III) Create a new feature for the platform from private data (not only public data, as we currently offer). The individual space will have personalized tools for the official to intervene based not only on public data, available on the national databases we collect information from, but also on private data, such as personal details of each citizen scattered throughout the city (from EHRs). To create this feature, we will make additional interviews, field visits and usability tests with municipal officials to understand which features and tools would best address the challenges they face in an intranet system, based on the feature pilots we have already developed and successfully tested (e.g. São José do Herval, mentioned above). 

For the next five years, we have two main objectives, with the respective action plans and its results below:

• (I) Increase the number of cities supported by Impulso Previne's platform to +500, making it a reference of primary care management in the entire country. Secondly, we intend to (II) expand the number of cities with access to the intranet portal, organizing data from 150 million individuals in the platform, feeding its customized features. To achieve both goals, besides investing in product development, we will showcase our platform and its services through wider marketing strategies, such as being present at big health-care events around the country and the globe. In addition, we will increase our contact with municipal governments through our strategic partners like the National Council of Health Secretaries (Conass), the National Council of Municipal Health Secretaries (Conasems) and the Ministry of Health.

In order to verify the progress of Impulso Previne in achieving the impact we desire, we use metrics that indicate (i) the outcomes of the platform, (ii) the results of our remote technical assistance and (iii) the performance improvement of the cities we attend. In addition, our alignment with the UN Development Goals is perceived as our contribution for a more sustainable world.

First, the metrics used to qualify our outcomes are (a) the number of municipal governments using the platform on a regular basis, computed by a check-in software, the number of 'unique users' using new features in the platform, calculated by Google Analytics, and (b) the satisfaction of officials with the information displayed on the platform and (c) its new features, collected through constant surveys.

To check the progress of the remote technical assistance services, the metrics analyzed refers to (a) the number of consulting requests by municipal officials, (b) the number of consulting appointments realized and (c) the Net Promoter Score (NPS), a customer satisfaction methodology developed to assess the degree of loyalty to the platform - after using it, we ask users how much they would recommend Impulso Previne to someone else on a scale of 0 to 10.

To analyze the impact of Impulso Previne in the cities’ performance in primary health-care, the metrics used are (a) whether there was an achievement of the goals established by Previne Brasil, (b) an increase of the federal remittances received by the city for primary health-care according to the goals achievement and (c) a growth (the percentage increase depends on the challenges faced by the city) in the number of citizens registered in the primary care database of the city and the country.

In addition, we have been using some indicators of the UN Sustainable Development Goals as progress standards. We have the SDGs 3, 10, 16, and 17 as the goals we intend to achieve. By now, we have been pursuing the following targets and indicators, with their respective relationship to our work: 

• 3.1 - By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births

  • 3.1.1 - Maternal mortality ratio.

Given that our indicators platform informs municipal officials about the status of prenatal appointments for all the pregnant women of the city, the number of HIV and Syphilis exams being done on pregnant women and how many odontological appointments pregnant women have been doing in the city, municipal governments are better informed to take responsive actions that decrease maternal mortality.

• 3.2  - By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births.

  • 3.2.1 - Under-five mortality rate.

Considering that our platform informs municipal officials about the kids who need to take the necessary vaccinations at the proper age, municipal governments are better equipped to take action against under-five mortality.

• 3.4 - By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.

  • 3.4.1 - Mortality rate attributed to cardiovascular disease, cancer, diabetes or chronic respiratory disease.

Considering that our platform informs municipal officials about the number of hypertensive people measuring their blood pressure and the number of diabetic people receiving glycated hemoglobin, municipal governments are better equipped to diminish the mortality rate attributed to cardiovascular disease and diabetes.

For the future, we intend to keep pursuing such indicators, expanding our performance in each of them (specially those with numbered metrics) and we expect our new projects will meet others goals, targets and indicators.

The theory of change of Impulso Previne is divided into Assumptions => Product => Activities => Outputs => Short-Term Outcomes => Long-Term Outcomes, as it follows:

Assumptions: 

• Insufficient primary health-care performance. In Brazil alone, +300k people die from preventable causes every year, such as (i) heart attacks caused by untreated diabetes or (ii) newborns whose mother had no access to prenatal care. That is despite the country's free and universal health-care system, with +1M nurses, 300k doctors and 200k health community workers.

• Lack of information is one cause. Why? Part of the reason is that these local health-care workers cannot be data-driven when deciding to whom/when they should provide prevention services (e.g. where are the pregnant women without prenatal care or the untreated diabetic population in this city).

• The data exists already. Most of this data is already collected, however: the majority of Brazil’s 42k public health units already use electronic health records (EHR). The gap is to turn this data into information and to deliver it to health-care professionals in an uncomplicated way, so that they can care for the right people at the right time.

• Stronger incentives to perform are now in place, but are insufficient. A new federal program redefined primary health-care financing in Brazil, strengthening the incentives for each municipality to perform in the key indicators exemplified above, but local governments need (i) better and easier-to-understand data and (ii) technical assistance to actually improve in these metrics.    

Product:

• Turn data into information, and information into action. Impulso Previne is a free online platform for local health officials, centralizing information, public and private data analysis, and suggestions about primary health-care in one place.

Activities:

• Clear diagnostic for each municipality. Clear infographics of the city showing seven indicators regarding primary care, including women's and kids' health, prenatal care and non communicable diseases.

• Actionable recommendations. A customized list of actions municipal officials can take to solve the shortfalls presented in the infographics for each of the seven indicators and the value of the extra remittance the city can get if it succeeds in the indicators.

• Customized, direct assistance. Free remote technical assistance offered by public health experts from our team to municipal officials that need individual assistance besides the platform.

Outputs: 

• Local officials understand the incentives. The municipal officials access ImpulsoPrevie and are able to fully understand the functioning of Previne Brasil, the federal government's pay-for-performance policy, highlighting the importance of monitoring the quality of the services and motivating action-taking toward improvement.

• Local officials understand the diagnosis. The municipal officials are able to comprehend the results and goals of primary care services offered by their cities through an user-friendly interface where they find objective issues they must address to improve the quality of the services.

• Local officials take data-driven actions. The municipal officials are able to act towards health-care performance improvement through the delimitation and implementation of an effective plan of action, developed alongside Impulso’s data products and technical team.

• Local officials achieve better health outputs (and get more federal resources). The municipal governments are able to achieve the goals determined by the federal government in Previne Brasil and extend effective practices that lead to (i) bigger federal remittances for the cities and (ii) better health outcomes (e.g. more women in appropriate prenatal care).

Short-Term Outcomes:

• Improvement of Health Outcomes. Better outputs in the 7 key indicators result in better short-term health outcomes, as well-documented in the literature (e.g. more frequent prenatal care leads to lower child and maternal mortality rates; higher rates of child immunization result in fewer sick children)   

• More resources to invest in primary care. The municipal government has more budget to spend on primary health-care according to the goals achieved.

Long-Term Outcomes:

• Improvement of Health outcomes for NCDs. Better outputs in the 7 key indicators result in better long-term health outcomes around noncommunicable diseases, as well-documented in the literature (e.g. a treated diabetic person is less likely to have a heart attack than an untreated diabetic).

• Externality: Data-based culture in the public sector. Local-level public health officials in Brazil are better equipped to make data-driven decisions concerning other, equally important local health indicators, strengthening an evidence-based decision-making culture in the public sector and other health outcomes

A summary of this theory of change can be found in the image below:

Impulso Previne is an end product from a process of data extraction, processing, treatment and availability. First, data is collected from SISAB, eGestor and eSUS databases (platforms constructed by the federal government of Brazil for the national system of Health). The information, in python scripts, from such databases is treated and directed to GitHub, a repository where GitHub actions update data on the docker hub container, where it goes through application packaging, and it is finally delivered to the analytic database and, then, production database - both under PostgreSQL hosted in google cloud SQL. After this sequence of extraction, processing and treatment, the data becomes available through Google DataStudio in information panels that are displayed on Impulso Preview website in a react app. (Part of the funds we are fundraising will be used to develop an in-house front-end application, to increase the end product’s flexibility and allow for more complex features, such as the private-data-fed intranet described above).

Impulso Previne is then accessed through different devices, ranging from desktops to tablets with internet access. Currently, most of the municipal officials accessing our platform are using desktops, through Google and Bing, from the local health department’s buildings, although they can even access it through cell phones during field activities.

The local, public health employees do, because they are required by law to do so; but they use it only at the individual-level, not at the system-level, which is what we are changing with our product.

How they collect the data

The primary care data in Brazil is collected by staff from SUS through either home visits or health center appointments. At first, all the data was computed through paper documents. After a digital revolution in the national health system (SUS), electronic health records (EHRs) replaced most of the physical documents, although they still exist in certain marginalized cities throughout the country. Importantly, in 2016, eSUS emerged as the main digital database for primary health-care data collection, developed by the Ministry of Health and freely available to all municipalities. Today, the majority of Brazil’s 42,000+ public health units already use electronic health records (EHR). Now, most of the processed data available for us comes from on-line systems distributed in the following path, as required by law:

• Medical Appointments: the data is mostly collected by doctors and nurses through a computerized on-line system of collection and simplified on-line system of collection.

• Medical Procedures: the data is mostly collected by doctors and nurses through a computerized on-line system of collection and simplified on-line system of collection.

• Home Visits: the data is mostly collected by community health agents through an android application (or in paper and later transferred) and records in a simplified on-line system of collection.

• Medical Records: the data is mostly collected by doctors and nurses through a simplified on-line system of collection and private systems.

This data is used, at the individual-level, by several officials, ranging from doctors to health coordinators, to arrange medical appointments and follow-up with patients, among others. All the information is sent to a centralizer, so they must be or become digital at some point. For this reason, when a city has documents in paper, there is a representative of the city government who collects the papers from each hospital to send information for the platform of the ministry of health in Brazil. Likewise, if a city has a digital process of computing information, a robot is responsible for feeding that platform. In both cases, this data from cities goes through a nationally standardized database that constantly delivers information for a national centralizer to be processed and published in public portals through which we access data for our platform.

Why they collect the data

Importantly, all this information and processes is done because it is required by law, not because local officials make strategic use of the data. They use it only at the individual-level (e.g. to check when a pregnant women had her last prenatal care), not at the system-level (e.g. how many pregnant women have not had their prenatal care and who are they), which is what we are changing with our product. 

The local, public health employees do, because they are required by law to do so; but they use it only at the individual-level, not at the system-level, which is what we are changing with our product.

How they collect the data

The primary care data in Brazil is collected by staff from SUS through either home visits or health center appointments. At first, all the data was computed through paper documents. After a digital revolution in the national health system (SUS), electronic health records (EHRs) replaced most of the physical documents, although they still exist in certain marginalized cities throughout the country. Importantly, in 2016, eSUS emerged as the main digital database for primary health-care data collection, developed by the Ministry of Health and freely available to all municipalities. Today, the majority of Brazil’s 42,000+ public health units already use electronic health records (EHR). Now, most of the processed data available for us comes from on-line systems distributed in the following path, as required by law:

• Medical Appointments: the data is mostly collected by doctors and nurses through a computerized on-line system of collection and simplified on-line system of collection.

• Medical Procedures: the data is mostly collected by doctors and nurses through a computerized on-line system of collection and simplified on-line system of collection.

• Home Visits: the data is mostly collected by community health agents through an android application (or in paper and later transferred) and records in a simplified on-line system of collection.

• Medical Records: the data is mostly collected by doctors and nurses through a simplified on-line system of collection and private systems.

This data is used, at the individual-level, by several officials, ranging from doctors to health coordinators, to arrange medical appointments and follow-up with patients, among others. All the information is sent to a centralizer, so they must be or become digital at some point. For this reason, when a city has documents in paper, there is a representative of the city government who collects the papers from each hospital to send information for the platform of the ministry of health in Brazil. Likewise, if a city has a digital process of computing information, a robot is responsible for feeding that platform. In both cases, this data from cities goes through a nationally standardized database that constantly delivers information for a national centralizer to be processed and published in public portals through which we access data for our platform.

Why they collect the data

Importantly, all this information and processes is done because it is required by law, not because local officials make strategic use of the data. They use it only at the individual-level (e.g. to check when a pregnant women had her last prenatal care), not at the system-level (e.g. how many pregnant women have not had their prenatal care and who are they), which is what we are changing with our product. 

The diversity, equity and inclusivity embraced by Impulso Previne's team are viewed in (i) our efforts to make our platform accessible for everyone, (ii) the additional assistance we give to communities most in need through the virtual technical assistance, (iii) our future plans around inequality in data, and (iv) the representativity of our team. 

When developing the platform, we made a selection of cities from all the regions of the country with distinct characteristics and challenges to validate our prototypes, given the final product is used in the whole country with contrasting realities. This way, the platform is not biased with the predominant characteristics of only one region of the country or of cities with similar realities in terms of the size of population, rural-urban geography, or technology-founded public services. In addition, we made all the efforts to make the platform interface the most accessible application we could. The interface is adaptable to different electronics, be it a cellphone, a desktop or a laptop, for instance, with different screen sizes, to make sure every official can access the services regardless of their devices. Usability tests also helped us to make the platform accessible: to give examples, we found the best color palette for users with eyesight problems; we made the graphics and information texts available in few clicks for people who are not very used to navigating on web; and we turned the numbers shown in the platform comprehensible for people with no basis in math (e.g. showing percentages together with the practical numbers behind it).

Additionally, our remote technical assistance serves as an additional tool to promote equity among the cities attended by the national system of health (SUS). Despite the comprehensiveness of SUS in Brazil, we understand that cities with few citizens and low budgets for primary care are not able to offer the best services for their citizens. For this reason, the remote technical assistance with public health officials from our team are currently focused on attending underserved cities with (i) a mostly black population, (ii) HDI rates of 0.7 at most (medium development or less), (iii) GDP per capita of $5,000 at most and (iv) 30,000 citizens at most.

When it comes to future plans, we intend to enhance the intersectionality approach of our services through the implementation of the intranet system. Given that the municipal officials who use our platform will have access to private data, such as the ethnicity of the patients and their home addresses, we plan to better understand with the officials which issues substantially affect marginalized people, such as black pregnant women, for instance. This way, we aim to create new features for the platform that directly address veiled challenges for underprivileged communities, such as an active search of black pregnant women in a neighborhood with the highest rate of maternal mortality of black women due to prenatal negligence. 

After all, we want to embrace diversity, equity and inclusivity at all levels of meaning in our processes in the same proportions we started our organization with a great representation of the population. In the whole organization of ImpulsoGov, including who work with Impulso Previne, we are currently 30 people: almost 60% of our team is made up of women, including senior leadership; more than 40% are black people; more than 40% are part of the LGBTQIA+ community; over 30% have non-technical backgrounds. We believe in the far-reaching capacity of the national system of health in Brazil in attending its citizens and we are committed to improve its possibilities to reach everyone who needs help.

We develop products and services for local governments to overcome their challenges in both diagnosing and improving local primary health-care (using the KPIs from Previne Brasil). 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 prenatal care for pregnant women). Currently, this is all done 100% free of charge, which is key to speed up our partnerships with local governments; in the long run we plan to be financially sustainable by leveraging a freemium model (as detailed in the question below). 

The canvas below summarizes the business model laid out above.

Impulso Previne has the following budget*, divided into three steps, as shown below:

Steps

Description

Budget

Percentage of resources acquired

A

(2021 - March 2022)

Product discovery method, validation of prototypes and MVP

US$ 162.944,503

100%

B

(May 2022-May 2023)

National escalation and continuous adjustments of the platform

US$ 939.327,13

26%

C (June 2023- January  2024)

Automatized and customized support based on private data

US$ 920.157,19

16%

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

To collect the necessary resources for step B, we will continue relying on private social and philanthropic investment, as described below:

• Private social investment and philanthropy

Until now, our services relied on private social investment, and this strategy has been increasingly successful, as the graphic below shows:

We believe that this strategy is effective, as our research shows that the main source of philanthropy in Brazil is through private social investment, in which 89% of the philanthropic sources are represented by companies and endowment funds. By now, we majorly have partnerships with companies (drugs and hospitals chains) and endowments in the health sector, but we intend to enlarge the relationships with companies from the technology and finance fields, given they are the biggest donor industries in Brazil. Considering the lack of endowments in the health field in Brazil, we also consider creating an endowment fund in the long run, considering that the few competitors existing do not have preventive health-care as their main work. Philanthropy of wealthy families, valued almost half of the resources collected through all the donation campaigns in the country, is also another strategy we have been looking for: since we partnered with Behring Foundation, we noticed that many Brazilian wealthy families have been searching for organizations working with public health since the pandemic, and we intend to take advantage of such opportunities.

To obtain funds for the step C, the goal is to decrease reliance on donor funding to a fee-for-service model, as described below:

• “Freemium”: fee for the service provided by the platform

Impulso Previne will have free and paid services:

The free services will be (i) the visualization of the key performance indicators (KPIs), (ii) the list of general recommendations on how to improve their performance and (iii) three consulting appointments with the public health specialists of Impulso Gov in our remote technical assistance program.

Paid services will be:

• Nominal tools: nominal tools are very valuable for municipal officials because they fast  their work. From the use of private data, it is possible to create a tool that demonstrates who needs to be delivered with glycated hemoglobin, for instance. This way they can push their health staff to make an active search on the residence of those people, teaching them how to use the supply and how to monitor their diabetes. This degree of precision in providing municipal officials with clear numbers and information about who needs to be attended is valuable and this service will be charged.

• Extra Consulting Appointments: if a municipal official wants to hold more than three meetings at the remote technical assistance to have the support of Impulso's technical team for the implementation of the initiatives idealized in the previous appointments, these extra meetings will be charged.

It is worth mentioning that this set of paid services, like nominal tools and extra consulting meetings, will have fees below the market value so we keep making our support as equitable and accessible as we can.

We have evidence that charging for these extra services will be enough to maintain the platform and its other features for free. If we estimate that 15% of the municipal governments 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 revenue obtained from freemium will be enough to cover all the costs of our projects in 4 years and beyond, as shown in the graph below.

*This number is not random: for a Brazilian government to purchase a service, it can do so without a bidding process if it is below US$10,350 per year. Therefore, by pricing the service at this threshold, we bypass all obstacles related to public sector purchasing processes.

Given that in the step A of Impulso Previne we could obtain 100% of the budget necessary for the development and launch of our platform, we know that our plan of financial sustainability has been successful until now. To this end, step A's budget was acquired with private social and philanthropic investment. We made partnerships with five organizations that supported the project with contributions made between October and December 2021 that were executed between October 2021 and March 2022, as shown below:

Supporters of the step A

Organization 

Donation received

Behring Foundation

US$ 28,754.91

OPY Institute

US$ 38,339.88

Dynamo Institute

US$ 35,464.39

Novo Nordisk

US$ 19,169.94

Sanofi

US$ 19,169.94

Umane (investment for steps B and C)

US$ 402,570.00

Looking forward, we are confident that we will (i) be able to raise substantial funds from new donors, and (ii) effectively implement our freemium model described above. Here is why:

• Raising more donations: Right now, we are close to partnering with organizations like the Inter-American Development Bank, the Brazilian Development Bank, Sanofi and Novo Nordisk and we expect these partnerships, among 50 companies and 30 foundations we are looking to partner with, will be enough to fully fund step B. For this reason, we will advance with private social investment to meet the graph with our annual budget.

• Successfully selling the freemium model: the only reason why we have not done so yet is because we haven’t allowed governments to pay for our services, but they have already asked about it. The following situation happened at least 10 times in the past month: (i) we say to a specific municipality that we can provide identified lists of high-risk citizens for them to individually identify and provide care to them, but we are currently at capacity and can’t do so immediately (since our current process is too human-intensive); (ii) the government response is “we can pay for it, so that you can direct resources to prioritize this analysis”. (We have not moved in this direction because we don’t have the internal structure to manage paid government clients just yet, so the conversation ends there). This happened over and over despite the fact that we clearly state that all our products and services are 100% free at the moment. Therefore, we know that there is willingness to pay for what we are offering. Our assumption of 15% of customers as paid-customers is probably underestimated given that we will operate below the no-bidding threshold, removing both financial and legal obstacles on the government side.