Prior to COVID-19, Brazil had been hit with sizable reductions to health care funding as a result of fiscal adjustment. When the pandemic arrived, like in many places, the primary health care systems were put under further strain. São Paulo, in particular, saw primary care consultations drop by 49% during the pandemic in 2020.
The primary care health system was already suffering important reductions, so the pandemic had a huge impact. The fall in consultations reached 69% in April to May of last year, at the beginning of the pandemic, according to data from Datasus, from the Ministry of Health. The comparison data considered the average of procedures performed from 2017 to 2019.
We believe that sensitively used digital technology offers a breadth of opportunities to address systematic problems for public health in Brazil.
—Dr. Fabiano Guimarães, a family medicine doctor and director of the Brazilian Society of Medicine, told Brazilian state newspaper and online platform Folha de São Paulo that “the places with stronger primary care were able to organize more quickly, both in the creation of differentiated flows of patients with, and without COVID-19, and in the follow-up of chronic patients.”
For those places without a strong primary care set-up, however, patients — including those with noncommunicable diseases, or NCDs, such as diabetes, heart disease, and cancer — began to fall through the gaps. Unable to see a doctor in person, their conditions were at risk of further deterioration.
With plummeting care-seeking behavior and increasing health needs, the municipal health department of São Paulo took action in finding ways to plug the primary health care gap amid the pandemic, and specifically support those living with chronic NCDs. They did this by rolling out a pilot program between November of 2020 and March of 2021 in nine primary care clinics in the Itaquera and Penha districts of São Paulo, which are considered low-income suburban areas.
Endorsed by the municipal government and with cooperation from nurses and patients, the multidisciplinary team of the Novartis Foundation, Tellus Institute, and other partners piloted a free-of-charge chronic disease chatbot. Accessed through WhatsApp, the chatbot provides immediate digital medical counseling for patients in need, and helps mitigate systemic problems in public health, especially for the lowest-income populations. It gives them access to health care in their homes when they need it most.
In Brazil, 99% of the population with smartphones regularly uses WhatsApp. This made the messenger service an ideal platform for the novel chatbot system, allowing nurses to provide timely virtual care. The chatbot follows a predetermined messaging flow and empowers nurses to contact hypertensive and/or diabetic patients; evaluate their medical profile, risk factors, and vulnerabilities; initiate follow-ups; and schedule home visits or teleconsultations. It enables the chronically ill to be better served as they remain connected to health systems at all times, even throughout a pandemic.
So far, we have carried out 225 patient consultations. According to our internal data, 77% of patients followed the intended messaging flow and of the 50% of patients who evaluated the service, 90% rated it with the highest score.
The process of creating the app
During the first phase, which was the initial design phase, we mapped the care pathways, needs, and uses of the tool as part of the patient’s digital journey. During the second six-month prototype phase, hypertensive and/or diabetic patients were monitored using the chatbot. We designed the flow of conversations together with health care professionals and patients; systematized data evaluation for improved patient care; and ensured that the tool supports day-to-day clinic work.
Partners in the Cuidando de Todos chatbot program
The chatbot is part of the program Cuidando de Todos, Cuidando do Seu Coração of the São Paulo Municipal Health Secretariat. Novartis Foundation is the creator and enabler of this initiative, and the local implementing partner is Tellus Institute.
Together, they transform urban health realities by fighting chronic NCDs with the support of international partners including the American Heart Association, Swiss Tropical and Public Health Institute, Society of Cardiology of the State of São Paulo, Brazilian Society of Hypertension, IQVIA Brasil as impact assessor-partner, and Umane as a strategic investor partner.
Most importantly, we wanted the chatbot’s functionalities to match the needs of future users, both care providers and end users. Nurses from 20 health teams were trained in the use of technology, and their feedback brought great value as we designed a solution journey relevant for implementation in the health system.
Stage three of integration and scaling is yet to come. We aim to integrate the chatbot into the São Paulo Municipal Health Department’s e-health application so that it can be further scaled to benefit more than 2 million people across the city. Looking further ahead, the aim is to offer 24-hour support, optimize messaging, and integrate compatibility with voice messages.
The chatbot is premised on scalability, sustainability, and replicability. The successful pilot showcased that telecare for people with chronic NCDs — with the involvement of health professionals — can complement traditional health systems. We believe that sensitively used digital technology offers a breadth of opportunities to address systematic problems for public health in Brazil, during the pandemic and beyond.
Opportunities and challenges of digital care tools in Brazil
Throughout the process of implementing the health tech solution, we have learned that the successful inclusion of digital technologies requires listening to end users and developing solutions with them. It also requires an interdisciplinary team that understands the technology, as well as the needs of patients.
Low digital literacy, however, especially in low-income populations, can pose significant challenges to digital health solutions like our chatbot. In São Paulo, nurses told us that some patients feared the chatbot was a hoax or illegitimate; that it was linked with fake news or cyber propaganda; and that no real health professional was involved. This was especially true when personal data was requested. Addressing these fears and creating trust will be crucial to the continued development of the chatbot.
This pilot program has shown that low-cost and open-source digital solutions can make significant, positive change in the delivery of health care to low-income populations. What is essential to the success of such programs is the involvement and feedback of health care professionals and patients during the design process, to create human-centric design solutions. Such digital solutions will hopefully contribute to bringing systemic changes to public health systems around the world.
About the author
Priscila do Nascimento Costa
Priscila Costa is the design lead for digital solutions at Instituto Tellus. She is currently working on the Initiative Cuidando de Todos I Cuidando do seu Coração is conceived and supported by FN and has the Tellus Institute as an implementing partner. She is working to create digital solutions for the cost-effective management of urban public health, focusing on low-income populations and transforming urban health realities by fighting chronic noncommunicable diseases.
