Equitable Integrated Self-care Support (EqUISS)

Although globally, progress has been made in reducing maternal mortality rates, this has been uneven as maternal mortality remains unacceptably high in sub-Saharan Africa (SSA), where a woman’s lifetime risk of dying in pregnancy or childbirth is 1 in 36 compared with 1 in 4900 in high-income countries. SSA accounts for two-thirds of global maternal deaths, and Nigeria accounts for almost a fifth of maternal deaths globally (58,000 deaths). Nigeria’s MMR stood at 512/100000 live births at the last National Demographic and Health Survey.

The 4-delay model adapted from Thaddeus et al. underscores the key drivers of maternal mortality and morbidity. We are primarily addressing the first delay with a secondary focus on the remaining 3 delays.

Delay 1: Low health literacy, self-efficacy, and self-care knowledge about how a woman can seek timely and quality care from a health facility for her and/or her baby.

In Lagos and Abuja, where mDoc operates, prevalence surveys done revealed up to 60% of women were overweight or obese. In addition, 40-50% of these women had anemia, indicating undernutrition in the setting of overweight/obesity. A majority (over 90%) of these women did not know their weight or BMI, or that they were obese. Both obesity and anemia are drivers of pre-eclampsia and eclampsia - key drivers in maternal mortality in Nigeria.

Delay 2: Reduced access to care with transportation, financial and trust barriers (on quality care at the facility, COVID-19 safety concerns)

Delay 3: Receiving the right care at the facility at the right time all the time, given overburdened, undertrained healthcare providers.

Delay 4: Community accountability to mobilize resources to support women's physical and mental health needs by tackling social determinants.

mDoc is a digital health social enterprise that integrates proven methodologies in quality improvement, behavioral science, data, and web and mobile-based technology to provide an integrated self-care solution (CompleteHealth ™ ) for women with regular health needs (e.g family planning and pregnancy) and chronic health needs such as hypertension, diabetes and, mental health conditions. We provide support for women from pre-conception to post-conception leveraging a four-pronged approach: 

Our Approach includes;
Coach-led multidisciplinary virtual self-care - through our digital health platform CompleteHealth™ where members have access to committed and knowledgeable coaches to provide 24/7 self-care support. The coach-led care system can be tailored to specific populations - some areas of focus include pregnancy, diabetes, hypertension, cancer, obesity, and mental health conditions.

NaviHealth.ai™, is a geo-coded health service directory that guides prospective users to locate appropriate health centers and/or services they require. The platform acts as a repository of healthcare providers, public and private healthcare facilities, and services, allowing patients to quickly access information on the location and services offered at these centers.
Women who access services at these facilities are able to give their reviews and ratings, which can be viewed on the NaviHealth.ai™ patient review system. This provides real-time feedback from the user's perspective on the quality of services received. The patient review system enables the user to answer questions based on the stated dimensions of quality, share a free text review, and rate the health facility in a five-star rating system. Reviews are measured across six dimensions of quality (safety, equity, effectiveness, patient-centered care, privacy & confidentiality, and timeliness). With these reviews, health facilities and providers are able to hear the pain points of these women which enables us to create strategies to help address highlighted challenges

In-person community-based NudgeHubs™ - where we meet the women where they are. The NudgeHubs™ are strategically located in areas with a high footfall of Women of Reproductive Age (WRA), which serve as channels where they can interact with experienced health coaches thus providing a safe space for the women’s voices and feedback to be heard. In addition, at hubs, we hold health screening programs and teach people how to use the digital platform and self-care devices, track and monitor health metrics such as blood pressure, BMI, and more. 

mDoc’s Quality Network (MQN™) - We offer tele-education classes that build the capability of health providers so that when our members
go to see them, they are more likely to receive the right kind of care at the right time, in the right manner, all the time. We have partnered with the University of New Mexico's Project ECHO to offer tele-education sessions so that providers are better capacitated to provide efficient, person-centered, evidence-based care. We see this as helping address the health worker supply shortages besetting our country

Our solutions are focused towards: 

• Women of reproductive age
• People living with or at risk for chronic diseases including mental health conditions, such as hypertension, diabetes and pre-diabetes, obesity cancer, and mental health conditions.

In our member population, approximately 19% of women have basic phones while the rest have smartphones.  Approximately 30% of female members' phones are owned or co-owned by their husbands or partners. The majority of our female members of reproductive age have a household income of less than $3 USD a day with over 60% living in urban or peri-urban Lagos and Abuja and the remaining spread across peri-urban areas in 33 states in Nigeria. These are market women, petty traders, many of who have moved from the rural areas to the urban/peri-urban areas to garner a living to support themselves and their family members back home.  They don’t have access to low-cost high-quality care, and they are deeply vulnerable to the catastrophic burden that complications from a chronic disease such as diabetes or hypertension can place on them including when pregnant, throwing them into abject poverty when happens. They all have chronic diseases (or risk factors for these conditions).

We have co-designed with the people we serve an integrated high-tech high-touch self-care platform that truly meets women where they are. This omnichannel platform which includes SMS and USSD as well as our AI-powered chatbot enables virtual self-care health coaching to women so that they build the knowledge and confidence necessary to make the lifestyle modifications around nutrition, exercise, medication adherence to live healthier lives.

We’ve found that mobile or smartphone ownership is not a proxy for digital literacy and have had to double down on digital training through a mix of in-person support for our female population, coach and peer walk-throughs by phone, and short video tutorials. We've held regular 'user-testing' parties with women, using focus group discussions, scenario testing, and observation to understand what it takes to drive engagement and impact. As a result, we communicate with our members across multiple channels including bi-directional SMS, WhatsApp, Telegram, and voice. Given our coaches have a direct connection with the women, we are able to hear firsthand what is working and iterate as needed.

At mDoc, we use data, quality improvement, and behavioral science to provide a tech-enabled care ecosystem. Our values center on using evidence-based guidance and partnerships to amplify preventive self-care for low-income populations. We've worked very closely with the communities we serve to create our innovative high-tech high-touch integrated self-care platform to support women with regular and chronic health needs for the 99.9% of the time they are out of healthcare facilities. We have numerous partnerships with the government, public and private hospitals, patient associations, and faith-based organizations to amplify our reach. These partnerships are reflective of our core model where we set up roving/stationary hubs to coach people on self-care.

An average of 750 women of reproductive age are onboarded to our self-care support program weekly by our roving community ambassadors in various health facilities in Lagos and Abuja, Nigeria. Our NudgeHubs™ are also located in the communities that we serve which provides an avenue for members to receive in-person care. Our team of health coaches then continues to interact with these women through our omnichannel approach (leveraging various media platforms to constantly engage these women).

In our member population, approximately 19% of women have basic phones while the rest have smartphones. Approximately 30% of female members’ phones are owned or co-owned by their husbands or partners. However, we’ve found that mobile or smartphone ownership is not a proxy for digital literacy and have had to double down on digital training through a mix of in-person support for our female population, coach and peer walk-throughs by phone, and short video tutorials. We've held regular 'user-testing' parties with women, using focus group discussions, scenario testing, and observation to understand what it takes to drive engagement and impact. As a result, we communicate with our members across multiple channels including bi-directional SMS, WhatsApp, Telegram, and voice call. Given our coaches have a direct connection with the women, we are able to hear firsthand how our solutions help them and iterate as needed.

Furthermore, each month, we organize several community outreaches where we interface with people mostly from underserved communities. These outreaches are geared towards improving the health literacy within these communities and providing guidance on self-care and lifestyle modifications.

At mDoc, it is so important for us to figure out how to accelerate the mechanisms that will help us scale our impact-driven work so that it is affordable, accessible, reliable, and valuable at a low cost and drives measurable impact across Africa and potentially in underserved communities in the US. To that end, we are eager to join the Solver network which will enable us to optimize our integrated self-care platform at scale.

We have a number of learning questions that we are struggling with and we would like to answer with support from the Solver Network in understanding and testing solutions to them. We have outlined just a few below:

• Behavioral Science

  • How do we harness behavioral rewards and real-time feedback to drive adherence to lifestyle modifications when low-income populations often can't afford tracking and measurement devices?

• Community

  • It seems that community groups are key to driving long-term improvement. What can we learn from organizations in the Solver Network on the use of digital groups to motivate engagement for woman-centered chronic disease management in a digital setting?

• Scale

  • Is our solution simple enough to effectively scale? And is our current scale strategy through partnerships the right approach?

  • Our enrollment approach to date has been largely in person. What can we learn from experts about leveraging media to reach more women, build their telehealth literacy and help them make lifestyle modifications using the digital platform to improve their health? Are there opportunities to collaborate with other organizations that are focused on building digital and financial literacy in low-income populations?

• Impact at Scale

  • How do we track whether we are making an improvement when our members often can’t afford devices or have digital barriers?

  • How should we approach designing a rigorous evaluation of our impact?

• Financial Sustainability

  • With healthcare budgets declining and minimal opportunities with the government as a payor in Nigeria in the short term, how do we further reduce the cost to our members?

  • How can we ensure that we cover our costs which allows continual reinvestment back into the work to ensure greater expansion to meet the vast needs?

In tackling the complexities of healthcare systems in Africa, it was clear to us that a new model of integrated care would be required. 

We focus on creating a tech-enabled, connected ecosystem of care. By integrating preventive and mental health self-care support and building self-efficacy, through a digital platform that enables woman-centered collaboration with trusted care teams, online peer support, capacitated facility providers, and community-based nudge hubs, an enabling environment is created for women to enhance their health behavior. 

We are currently in the process of incorporating Artificial Intelligence and Machine Learning to drive scale. In so doing, we can drive systems change that will improve the lives of women and their babies at scale.  In the context of Covid-19, this intentional focus on an integrated platform has enabled us to be agile and responsive to women's needs. We developed a set of educational infographics based on evolving guidance on pregnancy and chronic conditions for women. When the coaches reported heightened anxiety and fear from women who were being turned away by facilities for ante-natal care (ANC) and post-natal care (PNC), we expanded our tele-consultation services beyond chronic care to virtual ANC, PNC, and neonatal care, ramped up our tele-education courses to health workers to build their capability on COVID-19 diagnosis, and management and initiated weekly tele-education courses on ANC, PNC and infant care for women and their partners. We updated navihealth.ai with data on open facilities.

In Africa, where preventative care behavior is not the norm on either the supply or demand side in most countries, our theory of change is rooted largely in the notion that a fusion of digital nudges and face-to-face support can facilitate the trust and collaboration needed for people to understand and embrace the value and impact of preventative holistic care. 

To date, we have over 59, 000 women of reproductive age members with diabetes, hypertension, obesity, depression, anxiety, cancer, and pregnancy receiving self-care support through our platform. We track their engagement, behavior change using metrics such as exercise duration as a proxy (as it does not require self-care measuring devices which are sometimes out of reach for our members).    We have seen approximately 83% of members with improved knowledge and health literacy, an  increase in average exercise duration per week from 28 minutes to 84 minutes per week, 

8.3 mmHg reduction in average systolic blood pressure in people with hypertension (translates to 4-5% reduction in probability of all-cause mortality. 4330 healthcare providers trained in chronic disease prevention and management)

Our goal is to drive a 30% reduction in the premature mortality rate for women living with chronic diseases in alignment with SDG 3.4.

Over the next few 5 years, we will continue to target key indicators such as a decline in systolic blood pressure (SBP), diastolic blood pressure, (DBP), fasting blood glucose (FBG), and waist circumference (WC) which all have an impact on cardiovascular risk and associated mortality. At mDoc, we've designed for scale at the outset and our long-term vision is for a tech-enabled connected ecosystem where providers are capacitated to deliver evidence-based care and people with chronic health needs are empowered with cost-effective self-management techniques digitally and in-person. In the next 10 years, we aim to have helped over 5 million people at risk for or living with chronic disease across sub-Saharan Africa improve their habits and live measurably healthier, happier, longer, and more productive lives and have contributed to SDG 3.4 in doing so.

One of our core values is to be evidence-based and evidence-generating. We believe that to create truly equitable health systems, we must co-design with the communities we serve, use robust data systems to learn, iterate and refine as we continuously focus on improvement at scale. To date, we track 31 indicators across our theory of change (please visit www.mymdoc.com to read our impact reports and see our impact) including process measures, outputs, short-term and long-term outcomes. Our digital platform enables the real-time tracking of inputs from the women we serve as well as health coaches. 

We are proud of what we have been able to achieve - sustained improvements in blood pressure reduction, blood glucose and BMI reduction, improvements in self-efficacy, health literacy and digital literacy, and overall lives saved. 

Our theory of change is rooted in the notion that a fusion of virtual and face-to-face support coupled with regular tele-education for facility-based health workers can facilitate the trust and collaboration needed for women to invest in preventative holistic care supplemented by linkages to community social support that will drive measurable improvement in health and reduce morbidity and mortality of women and their babies. The figure below highlights the detailed theory of change that drives our work:

Inputs/Interventions

HIGH-TECH CARE

B1. Women-centred, women-refined digital platform for collaborative self-care

B2. Provide virtual coach-led multi-disciplinary care team support to meet women where they are

B3. Tele-education classes for women as well as healthcare workers

HIGH-TOUCH CARE

B4. Community-based ‘nudge hubs™’ through partnerships to provide a connected ecosystem that facilitates optimization of holistic support 

Outputs

WOMEN

C1. Improved “out of facility” health service quality

C2. Robust coach-led multidisciplinary teams that improve end-to-end care support for women

C3. Online peer groups that drive behavior change

FACILITY

C4. Adequately trained health care providers with improved clinical service quality

COMMUNITY 

C5. Connected and strengthened ecosystem of care for support to women pre-conception 

Outcomes

D1. Happy and engaged women with Improved knowledge and self-efficacy

D2. Improved Behaviors including exercise, nutrition

D3. Increased access to care

D4. Improved morbidity e.g. control of chronic conditions, improved mental health

D5. Improved sustainability and resilience of health systems

We leverage technology across all four pillars.

1. Coach-led multi-disciplinary team - Our CompleteHealth platform is web-based. On the backend, we use PHP and Node.js. On the front end, we use HTML/CSS and react.js. The database architecture is SQL and MongoDB. 

Given we have a high percentage of the over 59,000 women of reproductive age that we serve with low digital literacy, we leverage a multichannel approach and have integrated the platform with Telegram, WhatsApp, USSD, and two-way SMS. Our Android and iOS mobile apps are in development. 

2. Digital nudges are currently programmed by the coaches, we have built an AI-enabled chatbot to augment our personalized self-care support and are actively expanding the application of machine learning to help reduce the dependencies on the coaches for nudges and non-urgent support to women and babies.

3. Patient navigation for in-person care when needed through our geo-coded directory of health services, facilities, and providers - navihealth.ai.  On the front end, we use react.js, back end Node.js, with a MongoDB database architecture. 

4. Tele-education of health workers and women and their partners through our tele-education platform powered by Zoom as well as live stream channels including Facebook (to reach our member population) with cross-learning through ibox (through our partnership with University of New Mexico Project ECHO).

We are intentional about diversity in the workplace and we do not discriminate based on gender, religion, race, age, ethnicity, sexual orientation, education, and other attributes. Given the under-representation of females in the technology space in Africa, we are deliberate in our recruitment efforts to expand the pipeline for data and engineering roles to include females and have devised multiple strategies to foster an inclusive, diverse workforce. We are a female-led organization, with 60% of leadership positions held by females.

We leverage a B2B2C subscription based model with tiered pricing. For businesses, we offer a per member per month fee for members while for individuals we offer the same - we have a freemium service and our lowest tier costs approximately 80 cents a month. We generate revenue from the support we provide to organizations as well as offerings and member subscriptions for our self care plans,self-care product sales and training programs. 

To date, we have bootstrapped, leveraged revenue generated from our clients, awards and grants to refine and grow our enterprise. We are now positioned for aggressive scale which requires impact investment. We have been fortunate to have funders and partners who understand our goal of building an impact-driven financially sustainable healthcare model that changes the narrative for health. While we have accepted grants, it is just as important to us to demonstrate continued clinical impact at scale as it is to show a viable business model, not dependent on grants. We expect to break even by 2024.

We have a robust B2B business with partners on recurrent contracts. We continue to see robust growth from the B2B business. On the B2C side we are seeing 28% percent month on month growth over the last 12 months.