DiasporaDx

According to data from the Substance Abuse and Mental Health Service Administration’s (SAMHSA) National Survey on Drug Use and Health (2020), 16.9% of adults ages 18 and older received treatment or counseling for emotional problems (not just those formally diagnosed) in an inpatient or outpatient setting or were prescribed medication to treat these symptoms. However in 2020, among adults formally diagnosed with any mental illness, only 46.2% received any services in the prior year, which suggests there are still significant treatment gaps that need to be addressed. Data on behavioral health (defined as mental health and substance use abuse) in the Black and African American population is well documented. For example, 70% of adults have experienced at least one traumatic event in their lifetime, however, Blacks and Africans Americans have the highest lifetime prevalence of Post-Traumatic Stress Disorder and are most vulnerable. The socioeconomic and environmental consequences of the global pandemic, referred to as COVID-19, elicited an urgent call and response to study behavioral health outcomes in developing nations.

Pre-pandemic, an estimated 116 million people were estimated to be living with a mental health condition across the African Region. In the United States and the African Region, persons of the African Diaspora are at an increased risk of suicide, developing a substance use disorder, and overdose. Several individual, provider, and systemic factors that impact help-seeking behavior in Black Americans and other ethnic minorities have been identified (Kim & Bostwick, 2020). Inadequate access to financial capital and limited investments from the government are cited as factors that impact the African Region’s efforts to expand its mental health workforce, contributing to significant disparities in provisions of behavioral health and primary care to underserved persons in the region. Within the past five years, academic research has focused primarily on developed or developing nations in the African Region with existing partnerships and access to financial capital and human resources. As a result, a fundamental component of research necessary to first understand mental illness from a cultural perspective and existing behavioral health and primary care services available in the current healthcare system in those underserved areas has yet to be identified. Improper assessment and failure to implement these results in creating innovative approaches in behavioral health treatment can contribute to inequity in healthcare services and waste of services, a phenomenon frequently observed in the U.S. which costs more than $60 Billion annually. In the absence of an intervention targeted to address the gap identified by the WHO Regional Director for Africa, the ratio of patients to providers will increase exponentially despite lack the lack of available facilities in the region and few of them being primary care facilities that offer pharmacology and psychological interventions.

DiasporaDx is an app developed to mimic an Integrated Behavioral Health Model (IBHM). This innovative program uses an integrated approach to increase access and referrals for behavioral healthcare for patients that present with mental health or substance use symptoms in primary care (Kroenke & Unutzer, 2017). The app will be available to all persons in Liberia free of charge. The app is considered an Electronic Health Record (EHR) system and will include encryption and firewall safety features to uphold federal, state, and local policies to maintain confidentiality, HIPPA, and privacy laws. 

2,000,000 Liberians are subscribers to mobile networks and 26% of the population has access to the internet as of 2020 according to the World Bank. DiasporaDx is designed to use an Afrocentric approach in screening, assessment, diagnosis, and treatment of patients in the region that present with and report symptoms of behavioral health including mental health conditions and substance use. This software will be integrated into Prime Pathology Center, an existing clinic which will serve as a satellite clinic, in Buchanan City, Grand Bassa County, Liberia.   

To access the software, prospective patients will download the app. There will be two versions of this software, with the administrator having access to the interface that presents both the “Provider” and “Patient” with limitations on access to sensitive data unless the Provider has administrative privileges. The “Patient” version of the app will then prompt the patient to create their profile and agree to the terms and conditions of using the software. Upon agreement, he/she/they will be granted full access to their patient profile. The Satellite Team Lead (STL) of the clinic with administrative access will receive the registration and assign the appropriate providers.  

The app will include (1) Patient History, (2) Screening/Diagnostic Tools, (3) Pharmacological history/traditional medicine, (4) Social Determinants of Health and Needs, (5) Treatment Preferences which includes psychopharmacology, psychotherapy/counseling, and case management. This software will incorporate Artificial Intelligence within the app using Deep Learning (DL) and intelligent computer systems to learn directly from raw data obtained from encoding complex interactions using layers of complex algorithms modeled after the human brain neural networks. This will occur by encoding data obtained from patient responses to screening tools, with the software being able to compute scores and identify probable diagnoses and appropriate treatment recommendations. Upon completion of scoring and generating diagnoses and best treatment approaches, the STL will provide a report and clinical summary to the Biomedical Scientist. The Biomedical Scientist will review the patient’s history, previous interventions, and agreement with recommendations to account for potential error. He/she/they will then collaborate with the Integrated Care Team (ICT) for the following services: Medical Doctor (assigned as the supervising physician), Physician’s Assistant (assigned as the PCP), Psychiatrist (assigned to prescribe psychopharmacological interventions if warranted), Registered Nurse (assigned to do routine virtual visits w/the patient via tele-health in the portal), and the Record Registrar (to ensure compliance of existing patient records including current contact information). 

DiasporaDx is designed to serve Western and Eastern Africa, collectively referred to as Sub-Saharan Africa, long-term. With half a billion inhabitants and a population expectancy projected to increase by 3.9-4.0% between 2024 to 2025, there continues to be immense economic barriers in Africa. This pilot will target Liberia whose population is 5,193,416 as of 2020, with as many as 1 in 5 Liberians suffering from a mild to moderate mental disorder according to WHO estimates in a 2016 report. A 5-year strategy (2016-2021) was proposed by the Government of Liberia with the support of WHO and partners to develop a “strong and comprehensive system of mental health care” that mimics a system similar to healthcare in the US. However, similar to the barriers identified by the WHO Regional Director for Africa, funding and access to human resources continue to be significant barriers.   

This solution is necessary in a fragile economy that lacks access to financial capital, poorly developed national health insurance schemes, and limited human resources. Human resources, for the purpose of this proposal, is defined as trained health care providers available to address the increasing need of underserved persons that present with symptoms of a mental health conditions. According to the WHO Regional Director for Africa, as of 2022, there are currently less than two mental health workers for every 100,000 and this does not include medical doctors. This data suggests that despite WHO’s efforts, the mental health crisis in Africa, and more specifically in the underdeveloped Sub-Saharan region, continues to be inadequately addressed. The WHO Regional Director for Africa has issued an urgent call to the Member States to devote funding to address needs of population. Therefore, we plan to improve the existing healthcare system, feasibility for providers, and patients access to and quality of healthcare services by: 

1. Creating a central processing center for the region, specifically in Liberia, using an existing clinic that will serve as a “Satellite Office”. This method will increase access to patients in remote or rural areas that are historically marginalized and have limited to no access to a provider.  

2. Developing an app that is accessible on any device and free of charge. Offering this service free of charge addresses the financial barrier identified by the WHO Regional Director of Africa, with $2 USD being recommended as the bare minimum amount required to provide mental health services to patients with a mental health condition.  

3. Implementing an Integrated Care Team (ICT) incorporates a biopsychosocial and spiritual approach that is comprehensive and provides individualized patient centered treatment.  

4. Artificial Intelligence increases efficiency for providers by increasing the number of patients that are able to receive services, incorporating Natural Language Processing (NLP) to identify cultural nuances used to describe symptoms and increase accuracy in diagnoses which reduces disparities in prescribing patterns and treatment recommendations, and involving patients in decision-making for treatment to reduce chronicity of symptoms and adverse outcomes. 

Dr. Shane´ J. Gill is a Post-Doctoral Research Fellow at Thomas Jefferson University in the Department of Family and Community Medicine and a Visiting Professor in Counseling at Thomas Jefferson University. Prior to beginning the research fellowship TJU earlier this year, she acquired 10 years of experience in behavioral health as a counselor primarily serving marginalized populations. As a woman and person of color, she became vested in exploring the appropriateness of Eurocentric therapeutic approaches for counseling racially and ethnically marginalized clients with mental illness and addiction after observing high rates of recidivism in people of color in outpatient and inpatient treatment. This interest contributed to Dr. Gill becoming a member in several professional organizations including the American Counseling Association, Association of Black Psychologists, Counselors for Social Justice, of which she serves as the chair for the Restorative Justice and Re-Entry committees of the International Center of Addictions and Offender Counseling, the Allentown Human Relations Commission (former Chair), and a current member of the Delaware Valley Regional Planning Commission. Dr. Gill’s role is to provide education to practitioners and communities we serve in the research trends specific to disparities in health, health policy, law, and quality of life for marginalized populations and those deemed to be most vulnerable based on social determinants of health.  

Dr. Gill is currently conducting research on culturally responsive practices in primary care to identify the impact of providers’ perceptions on race in screening, assessment, diagnosis, and treatment of Black, and Indigenous, and Patients of Color (BIPOC) with behavioral health concerns in primary care settings that use an Integrated Behavioral Care Model (IBCM). As an innovator, Dr. Gill is best positioned to pilot this initiative as she actively has sought to establish collaborative relationships with organizations in the Caribbean and Africa. She strives to identify cultural factors that influence definitions of mental health and substance use, differences in presentations of these conditions and symptom, attitudes and beliefs across the Africa Diaspora globally who are most vulnerable using an Afrocentric approach, and non-Western practices in treatment. Dr. Gill also serves as the board advisor and clinical liaison for Prime Pathology Center (PPC) in Liberia. The PPC is a well-suited partner for this project as they have the access and understanding of the Sub-Saharan population. PPC has established itself as a trustworthy clinic in the region, with patients traveling from rural areas to access their services. 

Dr. Gill is also best positioned for this research as Jefferson will offer a diverse patient group to begin to test the technology and research before it is disseminated globally. Patients will be recruited from Thomas Jefferson University (TJU) Center City, as well as the Jefferson affiliate sites. Patients will consent to participate in neuro-imaging to identify the presence of molecular or cellular biomarkers for psychological trauma. Dr. Gill is actively working towards a way to understand the target population’s psychological trauma through involving them every step in the proposed project.

Prime Pathology Center (PPC) is a medical facility that currently provides medical provisions to approximately 1,900 residents in Buchanan, a city in Grand Bassa county, Liberia. DiasporaDx is an app being developed in partnership with Assutech, a software developer in The Gambia, West Africa, with similar products being reviewed and compared. PPC is exploring options to implement existing software in the clinic and transition from written records to EHR systems as a hybrid model and conduct an experimental study to explore the efficacy of this approach prior to fully piloting DiasporaDx. Regulations on the use of Artificial Intelligence and patient protection are being developed. Upon completion, all patients in the clinic and prospective patients will have access, with modifications being made to the pilot based on satisfaction surveys and feedback received from participants. 

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Liberia's Gross Domestic Product is 675.7. As stated previously, the 5-year strategy proposed by the World Health Organization was designed to address the lack of sustained economic and human capital necessary to address disparities in behavioral health for Liberians between 2016-2021. This plan, designed to increase interdisciplinary providers in community based settings and to promote psychopharmacological interventions proved to be effective in increasing training; 160 people had been trained by the Carter Center, an NGO in the United States, in mental health in partnership with the Ministry of Health. However, finances continues to be a significant barrier in continuity of services. 

DiasporaDx aims to solve the economic crisis that continues to cripple behavioral health services that disproportionately affects West and East Africans. For the purpose of this pilot, Liberians will be the target sample representative of this population. Funding from Solve will allow for continued development of an innovative software that uses Artificial Intelligence (AI) that incorporates Natural Language Processing to effectively identify symptoms to efficiently assess, diagnoses, and treat patients of the African Diaspora. Furthermore, there there is increased efficiency for providers and increased provider to patient ratio using a satellite office model, with providers being able to have contact with patients in remote areas, thereby reducing further marginalization that has historically resulted in persons being undeserved and posing a significant economic burden to the Liberian Ministry of Health. Due to this initiative being multidisciplinary, DiasporaDx aims to continue establishing partnerships with other entities in public health, behavioral health, medicine, and technology aimed at continuing to reduce disparities in healthcare for vulnerable populations globally, offsetting costs to patients, and easing burdens of providers. Solve would offer an invaluable opportunity to connect with leaders of the field and further this important work.

Pre-pandemic, more than 116 million people were estimated to be living with a mental health condition in Africa according to the Regional Director of the World Health Organization (WHO) for Africa. The rate of substance use and suicide has increased exponentially on the continent, with 11 people per 100,000 dying by suicide per year compared to the global average (9 people per year). According to a recent publication by the World Health Organization, Africa is "home" to six of 10 countries with the highest suicide rate, with 20 suicide attempts occurring after each completed suicide. With the population having increased by 49% and continued lack of access to financial capital, investments, and mental health policies that would promote development of facilities of proper staffing to address this increased need, innovative solutions to supplement human resources is necessary to combat the mental health crisis on the continent long-term. 

DiasporaDx differs significantly from current approaches being used on the continent, and specifically, in West Africa, which is considered part of Sub-Sahara Africa. This region, the poorest in Africa, relies on external economic and human resources that are volunteered. DiasporaDx incorporates the use of Artificial Intelligence, specifically, Machine Learning (ML) and Natural Language Processing (NLP). Integrating NLP in DiasporaDx will allow the Integrated Care Team (ICT) to understand patient symptoms of mental illness conditions and substance use in context, taking into account terms and phrases, definitions, and cultural implications of symptoms. This concept is a relatively new phenomena in the United States as part of decolonization efforts in counseling, in which educators seek to transition from Eurocentric philosophies about learning, education, and training. However, these efforts have yet to begin in medicine. Understanding the cultural context of presenting symptoms and factors that exacerbate symptoms through NLP, allows algorithms to be created within DiasporaDx that understand relationships, increasing the software's effectiveness in identifying individual risk factors, predicting outcomes, and prognosis for these conditions. 

DiasporaDx will be available as an app for mobile and web devices free of charge. This innovation revolutionizes medical and behavioral health in West Africa in the following ways: (1) DiasporaDx is the first mobile app specifically for assessment, diagnosis, and treatment of behavioral health conditions, (2) DiasporaDx is the first mobile app that incorporates artificial intelligence in a virtual integrated care model observed in primary care models internationally, (3) DiasporaDx is the first interactive software that will explore the use of language and identify patterns in a high risk population and unique treatment recommendations, (4) DiasporaDx improves provider efficacy by increasing time available for patients and access to an assigned ICT modeled after the patient-centered approach which increases the amount of patients available to access treatment that have limited means and transportation, and (5) AI and existing assessments within the software are universal and can be applied to other vulnerable populations to create culturally responsive treatment approaches and reduce behavioral health disparities while decreasing total costs, increasing patient access, and provider efficacy.  

DiasporaDx's impact goals are as follows:

• 50% (800-900 patients) of the patient population at Prime Pathology Center (PPC) will have access to and be active users of the prototype of DiasporaDx within the next 9-12 months: This writer and team at PPC will collaborate with the Registration personnel to contact current clients at the practice that have a contact number on file. Contact will be made with each patient. This writer will have developed a brief script to introduce DiasporaDx in English and the native language. DiasporaDx will improve the client to provider ratio, aid in transitioning from paper to an EHR system and centralized processing, and standardized process for screening, assessment, diagnoses, and in the future, ordering medications from the partnering pharmacy. 
• DiasporaDx will establish a Memorandum of Understanding (MOU) or other contractual agreements as required by law with Liberia Telecommunications Corporation (Libtelco), a government owned telecom and LTC Mobile, Android, and Apple, to include DiasporaDx as a free app on mobile and web devices within the next 12-16 months. The applicant and team at PPC will contact LTC Mobile and the secretary for the president to schedule a consultation. Dr. Gill will collaborate with a local entity to establish an MOU and agreement. This agreement provides that at least 2,000,000 persons of the population that have a mobile device access, and 22% that have internet. Exploration of an "off network" option will be explored for persons without internet to promote access for persons in remote areas. This solution will address ongoing barriers to internet access including power in the region as the World Bank expands region support to finance solar panel energy systems and transfer of electricity in four countries in the region, Liberia being one of those countries. 
• DiasporaDx/Prime Pathology Center (PPC) will register 30% (600,000) of the population in Liberia for a free DiasporaDx account over the next 24 months and half of the population within the next 3-4 years: Dr. Gill will identify total functional costs for this app on android and iOS software including updates and revisions. PPC will obtain funding through grants and investments to ensure that this app is free of charge to users.  Funding is $0.46, well below the $2 USD value per person in Africa. This app would reduce if not eliminate cost for the services that have the most costs including screening, assessment, diagnosis, and treatment. This service is available for persons with or without insurance as many low-income companies lack a national insurance scheme. 
• DiasporaDx/Prime Pathology Center (PPC) will identify 2-3 clinics/centers and/or hospitals in low-incomes countries in West Africa modeled similarly to PPC. DiasporaDx will collaborate with these centers to pilot use and implementation of DiasporaDx to reduce staff/provider burden and increase patient access using a satellite office model within the next 5-6 years: This goal will allow for expansion of services in other low-income countries with a similar demographic and economic barriers are Liberia, collectively addressing the deficit of mental health providers in the region.

DiasporaDx will use the following indicators to measured progress towards the impact goals specified above:

• DiasporaDx will establish a Memorandum of Understanding (MOU) or other contractual agreements as required by law with Liberia Telecommunications Corporation (Libtelco), a government owned telecom and LTC Mobile: The indicator that will be used to measure this progress is indicator 9.a.1. An MOU will be established and overseen by a legal entity. Progress will be measured by the number of persons with technology access over a 12 month period the correlation to downloads/registration and first time use DiasporaDx stemming from campaigns.
• DiasporaDx/Prime Pathology Center (PPC) will register 30% (600,000) of the population in Liberia for a free DiasporaDx account over the next 24 months and half of the population within the next 3-4 years: The specific indicator that will be used to measure this progress is 3.4.2, 3.5.1., and 3.5.2. Progress will be measured based on the following: (1) percentage of patients registered and actively using the app, (2) reducing in or alleviation of symptoms and improved functioning, and (3) participation in treatment. The percentage of active patients will be determined by those that attend their routinely scheduled appointment with an Integrated Team Member or Register Nurse (RN). These values will be compared to the number of cancelled appointments or those rescheduled using reports obtained from the software via the administrative portal. To determine reasons for cancellations that may reflect social determinants, participants will be prompted to select barriers. Patients will be required to complete a routine screening tool to assess suicide risk. Language used to describe the desire to die to harm self, suicidal self-harm, and non-suicidal self-harm will be identified. The plan, intention, means, will be explored and the frequency, intensity, and duration. These data will be plotted to determine the change in symptoms and contributing factors. Correlation to existing symptoms using other standard instruments will be identified to establish the presence of mental health symptoms. Attendance at counseling appointments and psychopharmacology appointments will be documented as an indicator of participation in treatment.
• DiasporaDx/Prime Pathology Center (PPC) will identify 2-3 clinics/centers and/or hospitals in low-incomes countries in West Africa modeled similarly to PPC: The indicator that will be used to measure this progress is 3.c.1. PPC will contact The Carter Center, the Mental Health Program that partners with organizations in Liberia to train mental health staff. Progress will be measured by the amount of eligible community health workers trained to achieve the recommended standard of 2.5 medical staff per 1,000 people to provide adequate primary care. A comparable ratio for the population in Liberia will be determined, with measurements on recruitment, training, retention, and caseload, being documented as part of a longitudinal study. 

Research on mental health conditions on the continent have revealed similar patterns observed in the Black/African American population in the United States; Africans have a high probability of meeting diagnostic criteria for a mental health condition, high prevalence of substance use and addiction, suicide, and poor participation in treatment. Black men and women have the highest suicide and overdose related deaths in the United States. A similar pattern has emerged on the continent, with 20 suicide attempts occurring for every completed suicide. In the United States and Africa, adolescents of the African Diaspora (including Black, African America, and African adolescents) are most vulnerable, with the highest prevalence of emotional and behavioral disorders, post traumatic stress disorders, suicide, and substance use (Gran-Ruaz, 2022; Mabrouk et al., 2022). Accessibility, limited finances, and limited personnel contribute to gaps in mental healthcare exist on the continent and are even more pronounced in low-income countries in Sub-Sahara Africa. 

Due to a 3.9-4.0% projected growth in West and East Africa, the poorest region on the continent, we hypothesize that the percentage of the population with undiagnosed mental health conditions will also increase, with adolescents and persons in remote areas being most at risk consistent with the research (Mabrouk et al., 2022). Therefore, DiasporaDx would fill an urgent gap in mental health and medicine, providing behavioral health screening and treatment (psychopharmacology, counseling, and case management) free of charge and this service being available offline. In an article published by the Carter Center, mental health conditions have increased significantly since the civil war in Liberia. However, across the continent, there are fewer than two providers for every 100,000 persons with a mental health conditions, far below global standards. 

If successful, DiasporaDx would provide behavioral health services to at least 440,000 Liberians (22% of the population has access to internet service and 2 million have a cell phone). PPC has a labor workforce of 23; the addition of this software would reduce the human output and improve time management, centralize services, and improve the patient to provider ratio compared to ratio across the continent. However, persons that do not have access to a cell phone or internet would not benefit from these services (78%). Users would gain access to an Integrated Care Team (ICT), routine screening, and culturally relevant treatment to promote early detection and intervention. Short-term, patients would report alleviation of symptoms and improved functioning. Long-term, prevention of progressive symptoms, addiction due to maladaptive coping mechanisms, and reduce risk of suicide can be achieve through early intervention and combined treatment methods using an interdisciplinary and ICT model. Confounds would include financial capital and investment of the Liberian government in behavioral health services, quality of internet and network coverage, and feasibility of increasing access to cellular devices and internet for persons in remote areas. These confounds suggests that participation of the government and government owned entities necessary for this technology to be successful and instrumental for it's implementation and maintenance in Liberia and in West and East Africa long-term. 

DiasporaDx is a prototype that incorporates Artificial Intelligence (AI) in screening, assessment, diagnosis, and treatment of behavioral health conditions in the African Diaspora. This prototype is a mobile and web app. This prototype will include Natural Language Processing (NLP) which will be developed by Assutech (a software developer in West Africa) to mimic current technology in which the system will interpret language, identify semantics, and understand knowledge of these terms. This information will be used in comparison with standard behavioral health diagnoses and existing assessments to create pre-determined conditions in the app. Consumer responses will be computed and yield a probable diagnoses and treatment recommendations. For persons that may present with disabilities, for example, difficulties with hearing, the use of voice translation can be selected as an alternative in which prompts can read documents and potential responses to the participants. 

The leadership team at PPC has equal distribution of cisgender males and females that identify as heterosexual. Members of leadership identify as religious, representing the two main religions in the region and country-Islam and Christianity. Culturally, leaders are diverse, with the ethnic heritage being representative of West, East, and South Africa. Within the past 2-3 years, PPC has begun to conduct research on the United Nations Sustainable Development Goals that pertain to diversity, equity, and inclusion. PPC has identified an operational definition of social justice and advocacy in medicine and an integrated care model, with emphasis on equality and equitable from a systems perspective, in a country and region striving to separate from colonial and Western influence to re-establish independence. 

PPC defines equality as the recognition of our collective humanity. Collective humanity means that all persons should be afforded the same rights, liberties, and opportunities without undue and unwarranted hardship caused by another party exerting influence or engaging in oppressive and/or discriminatory practices. A contemporary issue on the continent are anti-gay legislations, with the Ugandan parliament passing one of the most restrictive bills that mandate punishments for persons that identify or openly engage in activities considered to be consistent with same-sex practices. Similar legislation has been enacted in Ghana and Zambia. Efforts to preserve African culture and values and reduce Western influence and colonialism continues to be of the utmost importance as the continent has yet to recovery from the consequences of slavery and exploitation of Black bodies. At PPC, our philosophy as people of faith, is that we are called to act on behalf our fellow man without prejudice, bias, or judgement. Charity and commitment to service are core values that influence our approach to DEI that is still developing on the continent. 

PPC strives to engage patients by being patient-centered; patients are able to self-identify as it pertains to their race/ethnicity, gender, sex, age, and religion/spirituality, with an option to decline to disclose this information. Broadening the use of terms that are used on the continent to describe identify to respect the cultural norms while offering a choice to decline not to answer promotes autonomy of patients. Ableism is another matter that we are attempting to address due high comorbidity of our patients with medical conditions. This includes researching and pricing assistive and adaptive technology that can incorporated in the practice as part of our expansion efforts and in the prototype to increase access and quality of care while representing another group of persons not frequently recognized in the discussion about discrimination. Expansion of medical services, including HIV/AIDS testing, assessing for sexual and physical assault, domestic violence, identity development, counseling, and case management for persons that identify as transgender has become of increasing importance as residents of countries with restrictive countries seeking asylum. Advocacy for research on migration patterns, social determinants, and comprehensive health needs of this population is necessary to ensure our practice and services are representative of the populations we serve. 

Prime Pathology Center (PPC) uses a Business to Consumer (B2C) Model. In Liberia, the center is registered as a Limited Liability company that provides comprehensive medical services to residents of Buchanan City, Grand Bassa County, Liberia and surrounding areas. There are two types of patients: insured and non-insured. The center currently accepts Omega Insurance, Saarls Insurance, and the National Insurance Company of Liberia. Non-insured patients receive services at no cost. 

Patients complete a brief intake to identify the medical services required unless referred by another provider for a specific service. Currently, we receive referrals from hospitals, schools, clinics, and other neighboring organizations to increase patient flow. We are composed on 23 staff in total including a Medical Doctor, Physician Assistants, Nurse Practitioners, Psychiatrists, and Registration staff. These persons are considered to be part of the Integrated Care Team (ICT) that actively participates in direct care of patients and treatment recommendations based on the risk and needs assessment. Patients collaborative in clinical decision-making, consistent with best practices to determine the need. At present, general statistics about mental health in the region including suicide and substance use and medical conditions have been identified. However, less is known about Grand Bassa County. Clients report to the client on site or staff report to the client's residence or community for services as part of routine health screening and to prevent the onset of chronic medical or behavioral health symptoms. 

PPC provides the following  services after the provider and client collaborate to assess the needs and services: general medicine, dental treatment, maternity services, and laboratory services (i.e., chemical pathology, medical microbiology, hematology, molecular biology, and imaging). PPC is the only clinic in this county that offers dental and laboratory services. Patients receive wellness exams and routine care and treatment consistent with their diagnosis. If necessary, patients are referred to a neighboring hospital for specialization services or complex procedures. Insurance is billed based a tier-system and the appropriate diagnostic codes. Consumer feedback is obtained to assess the quality of services and improve the existing business model. 

Prime Pathology Center (PPC) will implement the following strategies to become financially stable within the next 4-5 years:

• Identify 2-3 additional national insurance schemes in Liberia or neighboring countries that will offer credentialing to the clinic and/or providers. If permission is granted, credentialing will be pursued and the clinic will be listed as a "group practice" or individuals listed to begin marketing an increase clientele. When added, billing of these providers will commence. 
• Establish a sliding scale fee: PPC will identify the average income for individuals and families in Liberia depending on family size. If this information is not available, a comparative country in Sub-Saharan Africa will be identified and those values will be applied. The minimum fee for persons that qualify will be $0. Knowledge of income and proof of income will be required. 
• Grants: PPC will apply for funding through the following: Health in Africa Fund, Doris Duke Charitable Foundation, THET and Johnson & Johnson Collaboration, the Chalker Foundation for Africa, and The West African Health Foundation. 
• Create an apparel item to sell as part of a marketing strategy with the proceeds being invested to finance healthcare for clients. This includes traditional engraved clothing that is duty free from the continent and world wide shipping. In our collective efforts to support other groups and organizations, capital raised will support local hospitals in Liberia, target maternal mortality and nutrition, both of which are crises in the region. 
• Donations: a professional website will be developed. Donations will be accepted via the secure website. Donors will have the option to select a category to donate the funds. This can include but is not limited to supplies, equipment, *solar power, healthcare services, etc. 
• Fundraising event: PPC will host 1-2 events annually to commemorate achievements. Ideally, this event will include an invitation to other leaders and professionals to network and explore cooperative economics in which clinics, hospitals, and other facilities can share resources and financial capital to offset the cost and economic burden on patients and providers. 
• Social Media Campaigns: PPC will invest in developing social media accounts including Facebook, Instagram, Twitter, and YouTube. As part of our outreach efforts, PPC will identify 2-3 students to serve as interns to manage our social media handles under the supervision of Dr. Hussain, the owner of PPC. Interns will have training in graphic design, illustration, and media. Campaigns on events, open calls for donations, success stories, and live streaming with staff to discuss urgent topics on behavioral health in West Africa and Liberia will contribute to increased exposure and raising awareness about our services. Exploration of local media campaigns, interviews, and participation at summits and conferences to gain exposure and explore funding opportunities will be discussed with the team. 

Prime Pathology Center (PPC) has not previously applied for funding. Funding has been limited in this region. Dr. Gill, the writer of this application, has recently onboarded, and is now educating other members on search strategies for funding, criteria, and funding strategies. Dr. Gill is receiving training and actively applying for two additional grants to supplement the MIT grant if awarded to carry forth this initiative and investments.