Virtual Self-Care for Women and Moms

Approximately 60 percent of global maternal deaths occur in Africa with Nigeria contributing the greatest burden of maternal mortality globally after India. Gaps in care, fragmented antenatal and postnatal services and a lack of care prioritization across the reproductive lifecycle of women have led to high maternal mortality and morbidity in Nigeria. There is a need for holistic, integrated end to end self-care support for women. mDoc provides a high-tech high-touch integrated self-care set of solutions that provide virtual holistic self-care to women from preconception through the six months of their infant’s lives. Virtual coach-led multidisciplinary care support integrated with in-person community-based health hubs and bi-weekly tele-education classes for women, their partners and health workers prioritize prevention, proactive care management, monitoring and empowerment, by leveraging a holistic lens for personalized support that builds self-efficacy while ensuring 24/7 care.

The 4-delay model adapted from Thaddeus et al. underscores the key drivers of maternal and neonatal mortality and morbidity. We are primarily addressing Delay 1 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 self-care and when to seek care from facility for her and/or baby

In Lagos and Abuja, where mDoc operates, recent prevalence surveys that we have conducted revealed up to 60% of women were overweight or obese, yet 40-50% of these women had anemia, indicating undernurition in the setting of overweight/obesity. 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 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 physical and mental health needs by tackling social determinants.

mDoc is a digital health social enterprise which harnesses behavioral science, quality improvement methodologies, data and technology to provide an integrated self-care solution (CompleteHealth) for women with regular health needs (e.g family planning and pregnancy) and with chronic health needs such as diabetes and depression. We provide support for women from pre-conception to post-conception. We leverage a four-pronged approach: 

1. We connect women with virtual coach-led care to co-create health goals and 'nudge' them to make lifestyle modifications.
2. We provide convenient, accessible in-person screening and self-management support through community-based 'nudge hubs'. Here, mDoc coaches hold screening programs, coach members, teach them how to use the digital platform, track and monitor metrics such as blood pressure, BMI and more. Members join peer-based workshops on exercise, nutrition and financial literacy. 
3. We help women navigate where and when to go for in-person quality care. We've created a geocoded directory of health services and providers to drive this - navihealth.ai. 
4. We leverage tele-education platforms to train health providers so that when our members see them, they are more likely to receive the right kind of care in the right manner all the time. We also educate women through tele-education classes once a week.

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. Majority of our female members of reproductive age have a household income of less than 100 USD a month with over 60% living in urban or peri-urban Lagos and Ogun States in Nigeria and the remaining spread across peri-urban areas in Central and South-Eastern Nigeria. 

We’ve found that mobile or smart phone 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 first hand what is working and iterate as needed. 

It is established that to reduce maternal and neonatal mortality, women need access to care in their communities. By leveraging digital platforms in the context of high mobile phone penetration rates, we can dramatically increase access. We leverage a B2B2C subscription-based tiered pricing model and will not curb access for anyone in the setting of an inability to pay. Our focus on holistic care and lifestyle modifications decrease the risk of a neonate experiencing the burden of chronic conditions such as diabetes, depression, anxiety from her mother and improves overall physical and mental health of mother baby dyad.

When we set up, advisors told us it felt like we were creating four companies. In order to tackle the complexities of healthcare systems in Africa, it was clear 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-centred 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 behavior. 

We are 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.

We leverage technology across all four pillars.

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

Given we have a high percentage of the over 4000 women of reproductive age that we serve with low digital literacy, we leverage a multichannel approach and have integrated the platform with telegram, WhatsApp and two-way SMS. Our Android and iOS mobile apps are in development. 

2. Digital nudges are currently programmed by the coaches, we are moving to automation using Artificial Intelligence and 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. We used Open Data Kit (ODK)  to capture the geo-coded data with a coverage area of over 50% of Lagos. 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 with cross-learning through ibox (through our partnership with University of New Mexico Project ECHO).

We started out with a chronic disease model for both men and women, expanded our focus to include pregnant women with or at risk for chronic health conditions and then expanded our support for women of reproductive age regardless of risk. Below are some of our impact metrics:

Accountability

• 78% of our members report improved knowledge and efficacy compared to baseline.

• 64% Increase in self reported exercise. 

Outcomes

• Average systolic blood pressure decline in people with hypertension (including those with co-morbid diabetes) over a 4 month period.
• Average diastolic bp decline was lower (8 point decrease). 

We are intentional about being evidence-based and disseminating the evidence. Below are some of the presentations we have done with our partners on our work.

Our theory of change is rooted in the notion that a fusion of digital nudges 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 health worker

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 behaviour 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

Our current solution reaches 4,000 women of reproductive age directly, and indirectly 600,000 women through our tele-education of health workers. 

In one year: We will reach over 100,000 women. By intentionally setting up anchor community-based hubs, partnering with key organizations and integrating artificial intelligence, we aim to serve over 100,000 women by June 2021.

In five years: Our goal is to ensure that we will be serving over one million women by June 2025. We expect that we will have dramatically expanded access throughout Nigeria and will be serving women in anchor African countries - Nigeria, Ghana, South Africa, Senegal and Kenya.

We are working hard to contribute towards achievement of SDG 3. Our focus on the intersection of reproductive, maternal and neonatal health with chronic disease and mental health care offer a compelling opportunity to focus on scale over the next few years. 

In Phase 1, we tested the concept in partnership with the Nigerian Police Medical Services, one of the largest health aggregators in Nigeria. We tested a digital hypertension management program for both men and women through collaboration with 3 facilities and learned about opportunities and limitations of a digital only approach.

In Phase 2, we set out to understand what it would take to scale our digital service and test in-person hubs through partnerships with public and private facilities while expanding our technology platform functionality and reach (adding SMS-based capabilities etc), testing prices with our population. This phase helped us understand the value of community-based hubs and roving coaches to drive female member acquisition, conduct user-testing with pregnant women to understand their needs, improve bilateral referrals while measuring impact. We are working on understanding optimal coach/member rates depending on women needs e.g.post-partum depression support while achieving reliability.

In phase 3, we are adding functionality to enable us serve larger populations of women, systematically build out hubs in densely populated areas in Lagos, Abuja and grow our digital user base through hospital/community organization partnerships including in Ghana and South Africa. We believe we have curated an approach that is widely scaleable, beyond country boundaries.

As we look to scale our solution, a few barriers exist which are outlined below:  

Legal/Regulatory : We have an ambitious scale up plan across multiple countries with extensive variation in regulatory frameworks for telehealth, if they exist at all, and for new business set up.

Financial: There will be inadequate investment and financing to drive the ambitious strategy year on year.

People: Difficulty in sourcing and hiring the talent required to achieve the vision

Market/Socio-cultural: Despite high out-out pocket expenditure for health in Africa, majority of digital health pilots have been free which has created market distortion to some extent where there is an expectation of free services

Reputational: We have found in our women-centred work (and across all our service lines at mDoc) that because dignified, respectful care is not the norm, our members are eager for us to be the sole healthcare support service asking us to prescribe medications etc which is not in our purview – this may lead to frustrations with mDoc

As shown below, we have developed a risk mitigation strategy to address the potential barriers to impact that we have identified. 

Legal/Regulatory:  There are multiple African countries without existing telehealth strategies or countries with minimal regulation or stifling regulation. In addition to COVID-19 pandemic potentially creating a massive opportunity for supportive regulation, we are current conduction a regulatory assessment of the countries we would like to scale in and believe partnerships will facilitate easier entry into the countries before full scale.

Financial: To effectively scale our person-centered platform, we need impact investors who are willing to invest in patient capital. We are creating the funnel to support this.

People: Sourcing talent is difficult but we have support from USAID technical assistance and Ashoka Globalizer to refine our recruitment strategy and organizational strategy.

Market/Socio-cultural: Market distortions have led to people often expecting free telehealth services. Conducting extensive price-testing with consumers.

Reputational: Members often want us to extend our services to prescription, yet we see ourselves as supplemental to the existing healthcare system. We are there for the 99.9% of the time they are outside of the facility. We are doubling down on our referral service to high quality care through navihealth.ai so we can help women get the in-person care they need.

Total Number on this solution team at mDoc: 19

Full-time Staff: 13

Part-Time Staff: 1

Volunteers/Interns: 2

Contractors: 3

My co-founder and I and our leadership team have the breadth and depth of expertise in healthcare and technology in Africa that is necessary to actualize and drive large-scale measurable improvement in the populations we serve in a financially sustainable way. Our team of seasoned health and technology professionals has been working on driving behavioural change in the context of chronic health needs for the last 3 years in populations with diabetes, hypertension, obesity, cancer and more. We are women-led and over 70% of of our team members are women. I am a mechanical-engineer (MIT) turned pediatrician (Yale, Children's Hospital Of Philadelphia) with a background in development and consulting. Prior to mDoc, I led the Africa portfolio for the US NGO, Institute for Healthcare Improvement and worked at McKinsey before this. I am an Ashoka Fellow, a Forbes Africa New Wealth Creator, and a World Economic Forum Young Global Leader. Imo Etuk, also co-founder is CTO/COO with a background in Elecrical Engineering (Temple) and Finance (NYU Stern MBA). He was a General Manager at Wananchi Telecom in Kenya prior to mDoc. We have a robust data and engineering team with machine learning expertise, clinical team with coaches that are poised to help us scale ambitiously. Majority of the team is located in Lagos and Abuja with additional team members in the US, South Africa, Canada and Rwanda.

An integrated set of high-tech high-touch solutions requires partnerships to drive co-creation, amplify impact and ultimately achieve population health, improve member satisfaction and reduce costs. At mDoc, we use data, quality improvement and behavioural science to provide a tech-enabled care ecosystem. Our values centre on using evidence-based guidance and public and private partnerships to amplify preventive care to low-income populations. We have partnered with public and private sector to augment impact.

Public: Ministry of Health, Lagos Research and Innovation Council  - where we work with government facilities to provide support to their patients. Medical and Laboratory and Science Council of Nigeria for verification of labs on navihealth.ai

Private: Google for SDGs Accelerator, Healthcare Leadership Academy of Africa, Making More Health (Ashoka and Boehringer Ingelheim) for Social Enterprises, Ashoka Globalizer (Ashoka and Phillips), Private Hospitals and Patient Associations, Merck for Mothers (funding part of our reproductive and maternal health work as part of a broader consortium), USAID 

Academic: University of New Mexico's Project ECHO to build capability in providers, MIT Africa Program

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 generate revenue from the support we provide to organizations as well as individuals. During the COVID-19 pandemic, on the B2C side we have provided services free of charge to members.  We also generate revenues through our 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.  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 2022. 

We started the year at mDoc with the mantra of SQG - Standardization, Quality and Growth. Further standardization of our service while ensuring quality and person-centredness at all times and using the principles of behavioural science to drive change, all in pursuit of ambitious growth. To achieve scale in low-middle income market with varying comfort levels with tech, we need help from the Solver Community on the following:

1. Marketing - We have done almost no marketing to date and our growth has been largely organic. As we look to large-scale growth, we need to have a robust marketing strategy that understands the context in which we are working and considers the channels where we can reach women of reproductive age. In the last few months, we've gotten calls from our corporate partners telling us we need to be intentional about promoting mDoc given the quality of our work. 
2. Growth strategy - We are keen to pressure-test our growth strategy with Solver mentors and would appreciate insights on pricing strategies. We also believe Solver partners can help connect us to facilitate entry into new markets.
3. Investment - As we look to raise funding this year and grow rapidly, we are keen to identify strategic impact investors who understand our focus on impact and scale.
4. Behavioral Science - We'd like to partner with the MIT Community to help us better design studies that explore how different nudges and rewards are driving improvement in the heath of the women and babies we serve.

We've been deliberately slow to raise external equity investment. When we first started mDoc, advisors told us we were running four companies but we understood that we had to build an integrated care platform for both patient and provider because of the fragile health systems in most African countries. Now that we are clear on our platform and business model, we need funding to drive scale. We have a target of 750k. We're keen to identify impact investors in the Solver network.

To scale, we need rock stars who are curious, problem-solvers, who put people first yet are as eager as we are to demonstrate a profitable pan-African digital health platform at scale. We would like support in helping determine how to recruit them.

We're collecting a lot of great data and want to partner with the Solver network to explore the different ways to analyze and disseminate it.

We are currently members of the inaugural cohort of the Google for Startups  Accelerator on SDGs, and through the accelerator, we were introduced to Dr. Rebecca Littman, a former postdoctoral researcher of the MIT Human Cooperation given our focus on amplifying our use of behavioural science. We are keen to partner with the MIT Human Cooperation Lab and MIT Applied Cooperation Lab (Erez Yoeli and David Rand) to co-design studies that help us understand better how to use behavioral science principles to motivate women to make lifestyle modifications and build their self-efficacy in the setting of disabling environments.

Given our tech-enabled nudge hubs located in the community that we believe are critical for driving engagement, we are also keen to learn from Mariana Arcaya of the MIT Urban Studies and Planning Department because of her focus on the linkage with neighborhoods and health. We want to be more intentional on using our hubs to support women to address the social determinants of health and would like to leverage Dr Arcaya's expertise to problem-solve this.

Given our focus on chronic conditions in women and our use of quality improvement methodologies, we would be very interested in working with the Medtronic Foundation, part of the Solver network, which has a focus in both Quality Improvement and cardiovascular health in low-income settings. In particular Medtronic Foundation, has been active in South Africa where we are looking to scale to. We'd be keen to explore opportunities to replicate our model there with Medtronic.

Women are at the center of our solution. We've seen an increase in 20% in knowledge in the women we serve and 78% indicate that they have increased self-efficacy. Studies have shown that a large increase in health literacy across enough individual members of a community could provide community-wide health benefits while increased digital literacy can drive economic empowerment for women. By providing personalized education and self-care support, we can drive population-level improvements in health and digital literacy for women and girl that will have a measurable impact on their health and the health of the community. 

During the COVID-19 era, we have seen a dramatic increase in our teleconsultations and our encounter with women. We have also seen a rise in existing member's engagement with our digital platform. We started tele-education sessions for women with our coaches providing videos and one-on-one calls with the women ahead of the sessions to teach them how to use Zoom.  It' the first time they have ever used a videoconferencing platform. We've had weekly participation of 80-100 women in these sessions, many with their partners and family member. By leveraging our platform and personalized coach support, our focus is on the holistic empowerment of the woman, so that she, her children, and her community are lifted up.

Through our partnership with Project ECHO and Healthcare Leadership Academy of Africa (HLA), we provide tele-education and in-person training for frontline workers, hospital CEOs and middle managers that focus on quality improvement methodologies (rapid testing, feedback cycle loops) integrated with prevention, diagnosis, and management in reproductive and maternal care.  We focus on QI methodologies because they are working in contexts where resources are almost always constrained. 

We build the capability of providers to enable them to deliver the right kind of care at the right time, in the right manner, all the time. While we provide in-person training in chronic disease management and QI directly to partners e.g. hospital heads of department, we also offer in-person training and mentoring through our HLA partnership. Here, we provide quality training and mentoring in the healthcare sector to hospital providers, CEOs and middle managers. These partnerships allow us to help them operationalize patient-centred improvement efforts.

Our partnership with ECHO has allowed us to dramatically increase our tele-education support for healthcare workers in the context of COVID-19. We provide bi-weekly training sessions on screening and managing COVID-10 in women and babies in low-resource settings. Our focus has not only been on COVID-19 but also on building their capability in maternal and neonatal care in the context of COVID-19. We have had volunteer experts train from all over the world with health workers joining from Burkina Faso, Kenya, South Africa, and Nigeria.

At our core, mDoc provides people with regular health needs and provides them with virtual nudges and support. Our vision is to reach 250,000 women-infant dyads with personalized care support by 2021. We've just made our first hire of a machine learning expert whose focus is to help us scale our support for women. The COVID-19 pandemic has highlighted the power of a digital platform for tracking the health of mom and baby and receiving educational guidance, personalized coaching support and facilitated online communities of other expectant or newly delivered mothers. At the same time, it has put a lot of pressure on our coaches who have had to manage a plethora of urgent and emergent cases in the context of unavailable services and increasing need from the women including in mental health support. 

We want to scale quickly to ensure we reach more women who clearly need it but we need to leverage artificial intelligence to help us segment the non-urgent support from the urgent needs that can only be attended to by the coaches and our care teams.

In line with WHO guidelines, our focus is on providing respectful, dignified individualized, person-centred maternal and newborn care, with provision of relevant and timely information, and psychosocial and emotional support. At mDoc, we have prioritized a focus on self-care because we see this as a key element of primary care.  By focusing on this in the setting of chronic self-care management, we position ourselves as being side-by-side with individuals, facilities and businesses to ensure a healthier population, capacitated health providers and driving a more productive economy.

At mDoc, we use a combination of digital tools and face to face support to personalize services for women with regular and chronic health needs, track their lifestyle changes (exercise, nutrition, medication adherence etc),resulting outcomes (improvements in blood pressure, blood glucose, self-efficacy), while helping them navigate where and when to go for preventative care and providing feedback to them and their healthcare providers.

In a country where preventative care behavior is not the norm on either the supply or demand side, 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 the value and impact of preventative holistic care. Poor women, in particular, are at high risk of the catastrophic burden that chronic conditions can place especially when care is inaccessible, inconvenient, unaffordable or unreliable.

Many women visit public secondary and tertiary hospitals for care because they do not trust the primary health care centers if they exist. At the same time, these hospitals are overburdened and hence patients are subjected to long waiting times, poor quality and undignified care.

Our partnerships with public facilities have helped to reduce their patient burden, while enabling us to provide peer-based support and person-centred guidance to patients while helping them onboard to the system and empower them in self-care. We supplement the existing system. Partnerships with public facilities enable us not only to amplify our reach of patients but also to reach lower-income patients.

We are working to optimize quality of care in a healthcare system that has not served the needs of its citizens. Our presence at public (and private facilities) together with our technology platforms allows us to offer support to members 24/7 while helping them understand how to self-care and monitor their outcomes. Our partnership with University of New Mexico’s Project ECHO allows us to reach more providers to build their capacity in offering reliable person-centred quality care. Through our Merck for Mothers funded program, we have been able to expand the care we provide to pregnant women. 

Majority of our members have a household income of less than 100 USD a month. A high proportion of females have basic phones, while most men have smartphones. We’ve found that mobile phone ownership is not a proxy for digital literacy and had to double down on digital training. We’ve also developed an SMS-based solution with two-way SMS nudges, and member paper handouts and harness voice calls to drive engagement with our members. We hold bi-weekly workshops at our hubs and for many of our members, the exercise classes have been their only experience with trained exercise guidance in their lives.

Our evidence-based curriculum focuses largely on lifestyle modifications and preventative care e.g. a 35 year old pregnant woman with diabetes when onboarded onto our platform will be screened for her cardiovascular risk as well as depression. She will also be asked when she last had a breast or cervical exam and guided on where and when to seek this screening. She will receive coaching on the lifestyle modifications she can make to improve her health and nudges on exercise etc. Lifestyle modifications cut across disease conditions and as such we’ve recently expanded our support and plan to expand widely across preventable care for women and infants.