Improving health through the power of peers and technology

African women and their families continue to be disproportionately affected by HIV and other preventable, treatable conditions. While progress in ending HIV/AIDS has been strong, the last two years of the global COVID-19 pandemic have compounded existing challenges and shortfalls, widening the gap in the global goal of ending HIV/AIDS by 2030.1

• Only 73% of people living with HIV are on treatment, still far off the 95% target by 2030. (UNAIDS 2021 data)
• Children are also being left behind – only around half of children living with HIV are on treatment, and in 2020, just 40% of children living with HIV had suppressed viral loads, compared to 67% of adults. 2

• People living with HIV/AIDS are increasingly at higher risk of death and severe illness due to co-morbidities:

• TB is now responsible for just 0.2 deaths per 100,000 people in the US3 but continues to be the second biggest killer in Africa at 378 deaths per 100,000.4 TB is the leading cause of death among people living with HIV, accounting for around one third of AIDS-related deaths globally. In 2020, an estimated 214 000 people living with HIV died from TB.5
• For the first time in over a decade, TB deaths increased in 2020. 6
• In sub-Saharan Africa, non-communicable diseases (NCDs) are set to become the leading cause of mortality by 2030 and are a particular risk for people living with HIV; for example, women living with HIV are six times more likely to develop cervical cancer than those who are not.7

• These preventable health conditions cause huge suffering and have a ripple effect across African communities – impacting everything from education to economic prosperity. 

• For example, the loss of a child's mother is a strong predictor of poor schooling outcomes and a child’s risk of dying before age 10 jumps by more than 60% after their mother dies.8
• Without a mother’s income, a family can be left without basic needs like food, shelter, and health care. 9

1. UNAIDS Global HIV & AIDS statistics. https://www.unaids.org/sites/d...
2. UNAIDS: Children Being Left Behind: https://www.unaids.org/en/reso...
3. STATISTA. Tuberculosis death rate in the United States from 1960 to 2019.
4. STATISTA. Leading 10 causes of death in Africa in 2019.
5. UNAIDS TB/HIV Fact Sheet https://www.unaids.org/sites/d...
6. WHO News Release: https://www.who.int/news/item/...
7. WHO Cervical Cancer Fact Sheet: https://www.who.int/news-room/...
8. Harvard School of Public Health. Preventing young mothers from dying—and the ripple effects when they do/
9. Global Citizen.

m2m trains and employs women living with HIV as Mentor Mothers to their peers, and equips them with digital devices using two tailor-made mobile applications for client and performance management at health facilities and during household visits. These tools provide real-time access to data and are essential in tracking clients’ HIV and other test results, critical antenatal and postnatal appointments for mothers and babies, and for active follow-up where needed. We bring a rigorous focus to monitoring and evaluation, shaping our programs based on robust data captured through a suite of innovative digital and mobile health tools, including:

Commcare App1: a custom-developed electronic client appointment diary used for comprehensive client management and follow-up;

Commcare App2: a custom-developed electronic family folder used for client management at community/household level;

DHIS2:  a centralized database used as a standard data repository for programmatic data.

During COVID-19, m2m rapidly adapted our services to continue to reach and serve clients using virtual digital tools. We now offer electronic services (eServices) alongside our face-to-face services, providing clients with a hybrid (in-person and virtual) delivery model. Our eServices include:

Peer-via-phone: a combination of bespoke and scripted scheduled phone calls focusing on key services, health promotion, pre-screening, client retention in care, adherence to treatment, COVID-19 and mental well-being.

m2m's Virtual Mentor Mother Platform (VMMP): an interactive WhatsApp-based chatbot providing clients with critical health information, including on healthy pregnancy and motherhood, accessible 24 hours a day in multiple language, supported by a helpdesk manned by a professional nurse.

Our solution does not require a high level of bandwidth and connectivity. Mentor Mothers can capture data on their devices while offline and without internet connectivity, and later sync data to the server once an internet connection becomes available, uploading to DHIS2, a centralized database that is used as a standard data repository for the organization’s programmatic data. Routine data are collated from the paper-based client management tools through the use of tally sheets and summary sheets. DHIS2 also uses trackers that are used to collect data on group based program activities. m2m is contributing to the African Union’s digital health strategy, and supporting governments in the countries where we work to draft and implement digital health strategies. In Uganda, m2m helped to draft Uganda’s National Community Health Strategy, including the Digitize, Equip, Supervise, Compensate (DESC) framework for digitizing the community health space, and is serving as an advisor for implementation of the strategy.

m2m’s core clients are pregnant women, mothers, their infants and families. Maternal mortality and morbidity are the most significant health challenges facing vulnerable women and adolescent girls in sub-Saharan Africa (SSA), exacerbated by the barriers they face in accessing Sexual Reproductive Health (SRH) care, including the impact of social norms on their personal agency, and the limited access they have to financial resources and health information. While the number of women and girls who died each year from complications of pregnancy and childbirth declined significantly between 2000 and 2017, from 451,000 to 295,000, over 800 women still die each day. However, the levels of maternal mortality remain unacceptably high in SSA – 533 maternal deaths per 100,000 live births, or 200,000 maternal deaths a year, constituting over two thirds (68%) of all maternal deaths per year worldwide [1]. The tragedy is that almost all maternal deaths can be prevented, as is illustrated in the disparities across regions and between the richest and poorest countries. In high-income countries, the lifetime risk of maternal death is 1 in 5,400, compared to 1 in 45 in low-income countries. According to the World Health Organization, Sub-Saharan Africa also had the highest neonatal mortality rate in 2020 at 27 deaths per 1000 live births, and a child born in this region is 10 times more likely to die in the first month than a child born in a high-income country [2]. While country-level neonatal mortality rates in 2020 range from 1 death per 1,000 live births to 44, the risk of dying before the 28th day of life for a child born in the highest-mortality country was around 56 times higher than the lowest-mortality country.

These high rates of maternal and neonatal morbidity and mortality in SSA as a result of preventable causes (including infection, malnutrition, obstetric complications, inadequate antenatal and postnatal care, and a lack of financial resources) need to be addressed. The risk of adverse pregnancy outcomes is distributed highly unevenly across and within population groups, with women living in poverty, adolescent girls, women with advanced gestational age, rural women, and women living with certain health conditions (such as high blood pressure, hypertension, diabetes, or sexually transmitted infections, including HIV) disproportionately impacted. With 44% of its population below the age of 15 years, SSA is the youngest region in the world, with a large proportion of the population either having entered adolescence or due to enter adolescence within the next decade, SRH is one of the most significant health challenges facing adolescents in SSA. Pregnant adolescents do not benefit equally from routine antenatal care, so a more targeted approach is necessary to address their specific needs.

[1] Maternal mortality rates and statistics - UNICEF

[2] Newborn Mortality (who.int)

Over the past two decades, m2m has provided employment opportunities to nearly 12,000 women living with HIV as m2m Mentor Mothers and Peer Mentors. Our programmes are designed to reach the most vulnerable, disadvantaged women, children, and families, strengthen public health systems, and contribute to the achievement of UNAIDS 95-95-95 Fast Track Targets for HIV epidemic control, the Sustainable Development Goals, and the African Union’s Agenda 2063. Our experience over two decades, and deep links within the communities we serve, positions m2m to partner with national and local governments—to reach and serve those most vulnerable; to strengthen local and national health systems; and to play a leading role in advocacy to realise the full power and potential of CHWs.

Trust: Our Model is cited as best practice for sustainable, people-centered approaches in the UNAIDS Global AIDS Update 2020 and has been profiled in UNICEF and UNAIDS flagship reports.

Knowledge: We combine cutting-edge global maternal and child health knowledge—working directly with UN Agencies and the WHO—with Mentor Mothers’ on-the-ground community understanding and lived experience. m2m Head Office in Cape Town houses the Department of Technical Programming and Support, with technical and strategic information experts who work closely with country teams from design of programming, through implementation, monitoring and evaluation, and QA/QI for performance management and improvement.

Core to our organization is the involvement of the people in the communities we serve in all aspects of designing and implementing our projects. m2m trains and employs local women living with HIV as Mentor Mothers—community health workers who increase access to healthcare for women and their families. m2m Mentors operate in homes and health facilities at the heart of communities across ten countries in SSA. Since 2001, they have provided life-saving services to over 14.5 million clients, predominantly pregnant women, new mothers, and their infants.

m2m is committed to the principle of “nothing about us without us.” m2m employs local staff (the overwhelming majority are former clients), with deep roots in their communities and personal experience of the challenges facing clients and service providers. All programming is anchored in a community engagement model, involving input and feedback from community members and leaders. Programming will be introduced and promoted through quarterly community dialogues and other existing community meetings, networks, and local traditional leaders. m2m will work closely with the health service and relevant Ministries at local and national levels to create awareness and build skills to promote the delivery of a coordinated approach. Moreover, we will provide feedback loops on program results and impact to key stakeholders and decision-makers. Through community engagement, we incorporate the needs, recommendations, and leadership of women and girls most at risk of maternal mortality and help to advance more equitable maternal and child health outcomes.

In Uganda, m2m reached 121,787 clients (as at 2022). The client reach across all 10 m2m supported countries was 1,212,244 (as at December 2022).

m2m is applying to the MIT Solve Challenge as winning would enable m2m to accelerate our digital health strategy, including AI as a component of our strategic information and digital systems, and enhance our ability to provide vulnerable pregnant and postnatal mothers and their newborns and families with targeted services to improve their health and reduce maternal and neonatal morbidity and mortality. Both mentorship and partnership will accelerate m2m’s use of AI to optimize care for pregnant and postnatal women and their newborns in ten countries of m2m operation in SSA.

In addition, it would increase m2m’s visibility and create opportunities for additional partnerships with other organizations towards achieving improved health outcomes and the global goal of Universal Health Coverage. The opportunity to collaborate through MIT’s ecosystem and Gates WFO Innovation Accelerator, learning from a cohort of experts will strengthen m2m’s ability to further develop and strengthen our digital health strategy and solutions, providing access to digital technology experts and cutting-edge developments in its use in health care. 

The magic of our model is that it is peer-based and local: integrated services are delivered by people from the same community as those they serve—meaning they are rooted in shared realities and experiences. Our female-led, community-centred approach is successful because it is built on principles of empathetic care and shared experience. Trust is at the centre of the relationships between Mentor Mothers and their clients, deep connections, and mentoring drive better access to and retention in care. The earlier we identify pregnant women, mothers and babies most at-risk, the sooner we can provide education and support to promote safe motherhood, prevention of mother-to-child transmission of HIV (PMTCT), reproductive maternal newborn and child health (RMNCH), and HIV testing and uptake of antiretroviral therapy (ART) among our clients. m2m Mentors, women living with HIV and from the same community that they serve, enroll clients for services and mentor them to ensure uptake of services and adherence to any treatment they need. The use of our mobile health tools enables Mentor Mothers to track test results and important ante- and post-natal appointments for women and their babies. Access to real-time data ensures a rapid response and enables Mentor Mothers to conduct active client follow up and follow up on treatment defaulters to bring them back to care. Our robust data and the relationships of trust that Mentor Mothers build with women from pregnancy through the critical first years of their child’s life are core to our impact. We currently reach more than 1.6 million clients annually. In 2020, m2m met or exceeded the UNAIDS 95-95-95 targets for ending HIV and achieved virtual elimination of mother-to-child transmission of HIV among our enrolled clients for the seventh consecutive year.

Goal: To transform m2m's health service delivery through digital technologies, with the aim of improving client outcomes and enhancing the efficiency of the organization's operations.

Objectives:

Develop a central repository of data from all sources, including electronic health records, surveys, and community health worker reports, to create a data warehouse of clean, longitudinal client data that will improve decision-making and facilitate reporting.

Implement a client-centric app that replaces multiple data collection tools with a unified, single client management system, streamlining data collection and enabling community health workers to focus more on clients and their ongoing health journeys. -

Integrate AI technology to optimize client outcomes by providing tailored care and support through basic telehealth services, including phone calls, chatbots manned by professional clinicians, self-monitoring services, and options to engage clients virtually in a low-resource primary healthcare setting.

Create a data cleaning and quality assurance process to improve data quality, automate data quality checks at entry, and ensure interoperability across systems.

Develop a reporting database with summarized and analysed data for reporting, data visualization, and ad-hoc analysis to facilitate responsive and predictive decision-making by m2m’s programs and country teams.

 To ensure a clear pathway to impact, m2m measures the impact of our activities in contributing to health and wellbeing, behavioral change, and care/treatment outcomes, including reducing maternal and neonatal mortality and other adverse birth outcomes, and improving reproductive, maternal, and newborn health. We will employ a robust Monitoring and Evaluation approach to track key indicators through our signature performance management dashboards that routinely identify quality assurance and quality improvement (QA/QI) needs, and support data-informed decision making. We will use our digital client management tools—to track priority appointments and individual progress against key indicators and measure aggregated progress against program indicators, including attendance of services. m2m's QA/QI approach brings implementation science and effectiveness to the table, and our evidence- and science-based frameworks will bring deep data analysis and applied research to the world. 

Contribute to reduced maternal and infant mortality (aligned with SDG3 goal of less than 70/100,000 births by 2030)

Improve reproductive, maternal, and newborn health

As an integrated primary healthcare organization, we align our progress towards contributing to impact by measuring different indicators aligned to global and regional goals including the SDGs (SDGs 3, 5, 6 and 17). We measure developmental, preventive care, and treatment of disease indicators for our youngest 0-3 years. While we also measure disease prevention, care and treatment, and school attendance for our older children and adolescents 3-19 and for all our clients we ensure quality primary prevention, health promotion, care and treatment align to the global UNAIDS 95-95-95 plus 10s goals, the 2030 ending of pediatric AIDS, triple elimination of HIV, Syphilis & Hepatitis B and cancer. High level indicators are:

• 95% of our children achieve their developmental milestones as per WHO guidance
• 95 % of our clients know their TB/HIV status
• 95 % of those who are TB/HIV positive indicated of treatment
• 95% of those remain in care and are cured for TB and or virally suppressed
• All eligible clients are screened for hypertension and diabetes & linked to care (90%)
• All eligible women are linked to cervical cancer screening and treatment (80%)
• Elimination of mother-to-child transmission of HIV among our cohort (<5%)

At mothers2mothers (m2m), our integrated primary healthcare hybrid service delivery model and theory of change is based on a socio-ecological framework that recognizes the multiple levels of influence on individual behaviors. Our experience since 2016, when we began our digital transformation, shows that the combination of our Peer Model and technology support leads to improved health outcomes. We believe that having the right resources, both human and non-human, and implementing activities from client intake to risk profiling and packaging services along the continuum of care, from health promotion and education to prevention, screening, care, treatment, and disease control, is key to achieving person-centered care.

Our approach focuses on the continuous packaging of services, risk assessments, and health education to ensure that the right services are provided to the right individuals. This, we believe, will lead to improved client outcomes through a results chain, with the virtual elimination of transmission of HIV among m2m clients, achieving the 95-95-95 goals for the last three years in a row, and contributing to impact and the Sustainable Development Goals (SDGs) and Universal Health Coverage (UHC).

To achieve our goals, we use a multi-pronged approach that combines direct services and technical assistance. We use social and behavioral change communication (SBCC), underpinned by a gender-transformative approach, to promote social norms change at an individual and societal level. We also work to strengthen health services by supporting supply chain management and youth-friendly health service delivery platforms and staff.

At the program implementation level, m2m Peer mentors, community-based local implementing partners, and health facilities, supported by our core partners, work as an integrated team to deliver services. This approach enables us to leverage the strengths of each partner and ensure that services are provided in a coordinated and effective manner.

Through this approach, we believe that our integrated primary healthcare services will lead to improved health outcomes for our clients, including achieving developmental milestones for children aged 0-3, ensuring that 95% of our clients know their TB/HIV status and receive treatment if needed, and eliminating mother-to-child transmission of HIV among our cohort. We also aim to screen all eligible clients for hypertension and diabetes, link them to care, and ensure that all eligible women receive cervical cancer screening and treatment.

Overall, our integrated primary healthcare hybrid service delivery model and theory of change is designed to achieve person-centered care that addresses the multiple levels of influence on individual behaviors and promotes social norms change at an individual and societal level. We believe that our approach, supported by technology and a gender-transformative approach, will lead to improved health outcomes and contribute to the achievement of the SDGs and UHC.

Our evidence-based Model has been identified globally as a scalable solution that strengthens networks of care and directly addresses local health system challenges that prevent women and children from receiving safe, high-quality, care and support (see Why our Team for more information). Through our integrated approach, we ensure our clients receive access to quality health services during pregnancy, childbirth and postpartum continuum, regardless of where they seek care.

m2m’s digital health platforms have successfully used technology to maintain strong human relationships and drive behavior change for disease prevention and the promotion of health seeking practices. We understand that digital solutions are complementary to face-to-face service delivery. We bring a rigorous focus to monitoring and evaluation, shaping our programs based on robust data captured through a suite of innovative digital and mobile health tools, including:

• Commcare App 1: A custom-developed electronic client appointment diary used for comprehensive client management and follow-up.
• Commcare App 2: A custom-developed electronic family folder used for case management at community level.
• DHIS2: A centralized database used as a standard data repository for programmatic data.

During the COVID-19 pandemic, we rapidly adapted our services to reach and serve clients using virtual digital tools. Now, we offer eServices alongside our face-to-face services, providing clients with an innovative hybrid (in-person and virtual) delivery model. Our eServices include:

- Peer-via-Phone services: a combination of bespoke and scripted scheduled phone calls focusing on key services, client retention in care, adherence to treatment, COVID-19, and TB screening.

- m2m’s Virtual Mentor Mother Platform (VMMP): an interactive WhatsApp-based chatbot providing clients with critical health information, including on healthy pregnancy and motherhood, 24 hours a day

We plan to adapt our face-to-face services, eServices (Peer-via-Phone and VMMP), and digital health platforms (Commcare App1 and App2, and DHIS21) in sub Saharan Africa, using Artificial Intelligence (AI) to stratify clients’ antenatal risk/risk of adverse birth outcomes. Using data (biomedical, clinical history, diagnostic screening, fetal monitoring, genetic, demographic, and behavioral) will enable us to differentiate clients by risk profile for active follow-up, education/counselling, and linkage to services, promoting behavior change, improving health outcomes, and accelerating the decline of maternal mortality to less than 70/100,000 births by 2030 (SDG 3). We will produce and disseminate data and reports, create knowledge forums, and put information in the hands of local and national decision-makers to create a pool of data for improving AI models stratifying antenatal risk.

Building on our existing mHealth systems to include an AI component will enable client data to be analyzed and used to guide recommendations towards health services and reduce or eliminate risk of adverse maternal, neonatal and child outcomes. 

m2m is committed to the principles of diversity, equity, and inclusion, and opposed to all forms of discrimination on the grounds of race, gender, disability, nationality, religion, sexual orientation, or HIV status. Our model is based on female social and economic empowerment, and inclusive community engagement to address gender and health inequities. Our clients are among those most vulnerable and marginalized – pregnant and postnatal women living with HIV, their HIV-exposed or infected children, and their families. Equity is core to our approach and impact, positioning local women living with HIV as the agents of change at an individual, community, and systems level. Since 2001, m2m has employed over 11,700 Mentor Mothers, often their first formalized employment. Mentor Mothers become economically and socially empowered, and act as change agents reducing HIV-related stigma, and demonstrate that women should be at the heart of solutions to improve maternal and child health. Equity is a key consideration at all levels of the organization, with women constituting 89% of staff and all m2m Country Directors being local women or leaders from their region. m2m’s employment equity policy promotes inclusive and equal opportunities in the workplace, including accessibility for employees living with disability. 

mothers2mothers (m2m) is made up of three affiliated registered non-profit organisations with a common, shared vision and mission, each with a separate Board. m2mSA: m2m operates across sub-Saharan Africa through its lead South Africa-based organisation, designed to ensure strong implementation and decision-making at the local level and access to resources globally. m2mI: In the United States, m2m is registered as mothers2mothers International Inc., a nonprofit organisation under section 501 (c)(3).  m2mUK: m2m operates in the UK and in Europe as mothers2mothers (UK) Limited, a charity registered with the UK Charity Commission.  In each African country where we implement programmes, m2m is registered according to the country’s laws and regulations and operates as a branch of m2mSA. m2m entities in the US and UK play a key role in driving resource mobilisation efforts with individual, corporate and foundation donors.  

Our business model is based on sound financial management practices, effectively managing and assessing risks, strategic and effective management of organizational costs and overheads, and building sufficient financial reserves to support our 2022-2026 Strategic Plan. Restricted grants from foundations, corporations, and bilateral and multilateral funders represent the majority of our funding. Bilateral and multilateral donors, which are primarily coordinated through the Business Development team in Cape Town, with input from the European and North American teams, make up our biggest source of multi-year project funding.

Once received, restricted awards for programmatic, country, or Head Office needs are managed through m2m’s financial management systems at Head Office, which track the expenditure of the award against award budget, and then disburse to the appropriate country offices. Financial management and reporting is managed from Country Offices and Head Office.

Unrestricted funding is raised through various efforts including campaigns, events, individual giving programs, community fundraising, cause-related marketing and proposals to foundations and corporations. Primarily driven by the m2mI and m2mUK offices, under the leadership of a Global Development and Strategic Engagement Director, teams engage with key partners and constituencies to cultivate an informed, values-aligned community of financial support.

Unrestricted funding is utilized catalytically for program innovation, growth and research. Without the flexibility of this type of supportive funding, m2m would be unable to operate as effectively in deepening our services to meet the changing needs of women, children, adolescents, and families.

With two decades of experience delivering RMNCH, HIV prevention and care, and ECD programming, m2m uses our expertise, including our understanding of service delivery costs and expenses, to minimize wasted funds through accurate and efficient forecasting and budgeting of unit costs, based on detailed expense costing and knowledge of activity costs. The project team, together with senior management at country and Head Office level, review budget planning and spending on at least a monthly basis.

m2m views sustainability as an ongoing process, involving the interaction between strategic, organisational, programmatic, social, and financial elements. In terms of financial sustainability, m2m’s Global Resource Mobilization team is actively involved in exploring new donors and avenues base to obtain a range of funding, particularly unrestricted funds to complement our current United States Government (USG) funding and develop long-term partnerships with new donors.

m2m’s experienced Global Resource Mobilization team works across three continents to ensure financial sustainability through multiple funding streams and currently has a diverse income base for its programs, which includes long-term financial support from influential donors such as USAID, PEPFAR and UNICEF, and significant support from private trusts and foundations. m2m has a committed fundraising team, with dedicated staff based in both Cape Town (m2m HQ), the United Kingdom and the United States. To achieve impact and enhance sustainability, all staff are recruited locally so that knowledge and empowerment are retained within the community served. m2m adheres to the following guiding principles in ensuring sustainability: 1) building the capacity and skills of m2m staff, health workers and beneficiaries, rather than providing material support dependent only on continued donor funding; 2) establishing communication channels with strategic partners to promote long-term relationships that extend beyond any =project period; 3) working hand-in-hand with government and civil society organizations to develop best practice, rooted in an understanding of the local environment and context that further builds on existing structures and mechanisms and weaves m2m services into existing health services.

As mentioned above m2m’s experienced Global Resource Mobilization team works across three continents to ensure financial sustainability through multiple funding streams and currently has a diverse income base for its programs, which includes long-term financial support from influential donors such as USAID, PEPFAR and UNICEF, and significant support from private trusts and foundations. In 2022 our revenue was dominated by the strength of our implementation roles under key U.S. government (USAID and CDC) awards, including our prime implementer roles in Angola, Lesotho, and Mozambique. Moreover, m2m has also been implementing as a leading sub-implementer in Malawi and Zambia. We have key opportunities to deepen our prime and sub-implementation roles in 2023 in Lesotho, South Africa, and Zambia. In addition, our revenue portfolio includes key partnerships with foundations and trusts, including corporate foundations, such as the Denise Coates Foundation (Malawi), Johnson & Johnson (key country support, as well as digital health across m2m), Merck Foundation (South Africa), and Roche (Ghana and Malawi).