mTOMADY

Low-income households across sub-Saharan Africa face substantial financial barriers to healthcare. Despite widespread political and institutional commitment to achieve universal health coverage by 2030, over 800 million people in the region lack access to health coverage through insurance or state-funded care, and most are forced to pay out of pocket for health expenses. This pushes an estimated 1.6 percent of the population into extreme poverty every year - many more avoid care altogether, even in emergencies. Postponed care also increases vulnerability to disease, disability, and early death, which can be devastating to health as well as livelihood. In the most low-income, remote, or otherwise vulnerable communities across sub-Saharan Africa, the following financial barriers prevent many from accessing essential healthcare:

1) Insufficient access to affordable health coverage - In-person, paper-based processes create inefficiencies and high opportunity costs, putting coverage out of reach for many.

2) Insufficient resources to cover for health services. Lack of access to formal banking and unexpected expenses can make it difficult to save for health. 

3) Disproportionate financial burden. Health costs are more expensive and burdensome for the poor, who are forced to purchase in small, individual quantities.

What it is: mTOMADY is a digital health financing solution that connects key health systems stakeholders to reduce the burden of out-of-pocket payments and protect against financial risk across communities in the world's most remote, resource-constrained contexts. 

Processes and Technology: The proliferation of mobile communications and payment systems, further boosted by COVID-19 lockdowns and social distancing measures, have become ubiquitous in sub-Saharan Africa. Building on this momentum, mTOMADY integrates with the existing telecommunications and “mobile money” infrastructure to facilitate digital access to various health financing mechanisms in even the hardest-to-reach communities. USSD and offline first accessibility ensures mTOMADY works in low- and no-network settings and can be implemented in line with context-specific constraints.  

How it Works: Beneficiaries can use a SIM card or simple mobile phone to access various health financing services, including a mobile health savings wallet or insurance, and seek care at participating healthcare providers (HCPs). HCPs use an offline-first tablet to submit claims, which are scanned for fraud and digitally reimbursed. Health coverage providers manage beneficiaries, claims and payments from a web-based interface and can send behavioral nudges across the health system. mTOMADY has the potential to provide anyone, anywhere with need-based health financing services.

Our target population in sub-Saharan Africa are those facing the financial barriers to essential health services, including the 1.6% of the population driven into extreme poverty each year by health expenses and the many more who forgo care altogether. Currently, the majority of our beneficiaries are in Madagascar where 80% of the population live on less than 1.25 USD a day. Our main target groups are pregnant women (the maternal mortality rate is 426 per 100,000 live births) and the rural poor, who face higher opportunity costs for care, irregular income, and impacts of climate change on their livelihoods. 

mTOMADY lowers financial barriers to health in the following ways:

• Increased resources for health: The savings wallet can only be used for health expenses, reassuring savers and senders (such as family and friends), that funds will only be used as intended. Cost sharing mechanisms, like bulk purchasing or savings groups, help lower individual financial burden and extend existing resources.

• Improved access to insurance: Increased efficiency (smart pooling, fraud flags) and wider reach (digital signup) makes insurance more accessible and affordable. Quicker reimbursement reduces insurance non-acceptance or forced prepayment.

• Improved access to government/donor programs: Digital vouchers make it easy to access free and subsidized health programs.

Local expertise and insight has driven the design and implementation of our solution. mTOMADY started as a project of the NGO Doctors for Madagascar (DfM), an organization focused on improving access to essential health services and promoting health equity in Madagascar for over 10 years. Insights from DfM’s local leadership and knowledge, and deep connections to communities and organizations they collaborate with informed the development of mTOMADY. Our technology was also created in close collaboration with key health systems stakeholders in Madagascar, including the Malagasy Ministry of Health and the Institut National de Santé Publique et Communautaire. We also rely on partnerships with leading local and global research institutes to evaluate the impact and value of our solution, and provide insights for iterative adaptation. 

In addition, we value the insights and expertise of our staff in Madagascar, where our largest office is, and where our CEO is originally from, to inform both the technical development of our solution (the majority of our tech team is based in Antananarivo, Madagascar), and its implementation (we have operations staff in all regions in which we operate). Our team in Madagascar works closely with end-users, including staff at healthcare providers, partnering health mutuals, patients and community health workers to understand their needs and challenges, and make sure our solution addresses them. They do this to ensure that mTOMADY improves existing processes, rather than creating additional administrative burden. 

MIT’s Solve initiative is a leader in the space of leveraging innovation and social entrepreneurship to drive transformational, global change. One of the four core Solve challenges - building affordable, accessible, and high-quality health systems that serve everyone, everywhere - is exactly the challenge we aim to address. 

Participation in Solve Global Challenges would be an exciting opportunity to optimize our impact and scale. We’ve recently had a lot of traction in Madagascar and we are constantly working to increase the number and broaden the type of users on our platform and widen our portfolio of services in order to reach our target population at scale while maintaining financial sustainability. For example, we are already working on concrete strategies to expand in Ghana and Uganda. Becoming a Solver and participating in the nine month program would offer an invaluable opportunity to learn new approaches and best-practices, and to benefit from the expertise of the Solve and MIT network — helping us to go faster on a larger scale. In addition, we would value the opportunity to receive feedback on our current monitoring and evaluation processes to ensure we are maintaining best practices for impact measurement. Finally, media participation in Solve’s flagship events, and exposure through media and conferences would be an excellent way to help build strategic partnerships to advance a shared vision of equitable access to quality healthcare.

The following set mTOMADY apart:

• Adaptable, modular infrastructure for flexible implementation. A diverse range of projects can run on the same multi-payer platform.

• Accessibility in remote, low-income communities. mTOMADY doesn’t require beneficiaries to have internet access or even their own phone. An offline-first interface for healthcare providers ensures functionality in low- and no-network settings.

• Integrated with existing mobile communications and payment infrastructure. End-to-end digitization of payments and data improves efficiency, transparency, and accountability. 

• Automated, real-time behavioral nudges. Reminders and vouchers boost beneficiary participation, and micro-payments incentivize health workers. 

Instead of one-size-fits-all, mTOMADY enables a tailored approach that addresses immediate barriers like insufficient resources (health savings wallet, vouchers), as well as underlying causes like inequitable health financing systems (improved pooling, digital insurance). In addition, data-driven features can be used to boost adherence, accountability, and impact (behavioral nudges, fraud flagging, impact tracking).

Our key impact goal for 2023 is to protect over 500,000 patients annually from financial risk in health. To do this, we aim to be operational at over 500 healthcare facilities in three countries in sub-Saharan Africa. 

In five years, we aim to have made substantial progress toward our vision 2030 - which is to protect 15 million patients annually from financial risk in health. 

We track progress toward our impact goals in two key ways 1) by monitoring key metrics on a real-time KPI dashboard, and 2) scientific evaluation. 

1) We use an automatically updated KPI dashboard to key metrics. The indicators we use are aligned with the UN Sustainable Development Goal 3, and track metrics related to both healthcare coverage and financial inclusion (beneficiary numbers, amount saved to health wallet), healthcare utilization (visits to healthcare providers, number of in-facility deliveries, disease surveillance data), and value and efficiency (reduction in claims reimbursement time). 

2) We work with leading global health research institutions to evaluate the impact and value of mTOMADY, including the Charité Global Digital Health Lab, the Heidelberg Institute of Global Health, Kwame Nkrumah University of Science and Technology, and the Consortium for Advanced Research Training in Africa, among others. Close collaborations like these provide insights based on scientific evidence, which we use to take an iterative (build-measure-learn) approach to the design and implementation of our solution, and ensure we make meaningful progress towards our impact goals.

The technology itself is a platform for secure healthcare payments and data exchange that connects patients, healthcare providers, and public or private health programs over the existing mobile communications and payment infrastructure. The platform is accessible to patients and community health workers via SMS and USSD, and to healthcare providers via offline-first mobile devices. The mobile health wallet and health payment functionalities are integrated with local “mobile money” services. 

When designing our technology, the focus was building on existing resources and local assets, and maintaining a flexible, adaptable technical infrastructure that can easily address context-specific needs and constraints (mobile money and local telco integration, USSD functionality, offline-first flows, automated nudges, non-phone owner accessibility). mTOMADY circumvents restrictions like phone ownership, and reduces barriers stemming from paper and cash based systems, such as distance to a health facility, time, cost, and accessibility, making the technology highly scalable and reaching those who had, until now, been structurally excluded. 

Diversity, equity and inclusivity are at the core of what we do. 

We have a diverse team that collaborates across our offices in Antananarivo, Madagascar, and Berlin, Germany. Currently, the majority of our software developers are based in Madagascar, and it is our aim to continue to grow this team as we expand. To do this, we are focused on developing the technical skills among our team in Madagascar through a mentoring program that involves capacity building and pair-programming. In addition, we promote the advancement of gender equality in hiring and in the workplace. mTOMADY has policies in place aimed at ensuring staff and partners observe high standards of business and personal ethics, which are related to non-discrimination, human rights, and environmental and social commitments. A robust whistle blower policy is in place to encourage and protect staff that want to share questions, concerns, and suggestions. 

We respect the cultures, customs and values of the people in the communities in which we operate while working to fulfill people’s human rights by improving the economic, social and environmental conditions in which they live. We do this by advancing healthcare equity and inclusivity, and especially by putting the most vulnerable and the most in need of care at the forefront of our efforts and projects. 

mTOMADY generates revenue by offering our solution through a software-as-a-service delivery model with a per user subscription. Customers include public (government) and private (insurance, donor) payers seeking to extend health coverage, lower costs, and reduce barriers to health care. 

Our plan for becoming financially sustainable includes sustainable grant and non-grant revenue. Our end game strategy prioritizes government and institutional adoption, or providing services to government agencies and large-scale donors, while also leveraging opportunities for commercial adoption.

mTOMADY was launched in 2019, and since then has become the largest digital payment platform for healthcare in Madagascar. We are currently working with partners across the public and private sector in Madagascar and beyond, including donors and government stakeholders, on sustainable initiatives to lower financial barriers to health in the long term.