Afya Pamoja (Health Together)

In Tanzania there's insufficient patient feedback provided on healthcare needs and experiences. The typical facility receives just two pieces of feedback per month through suggestion boxes. This prevents healthcare workers and officials from being responsive to patient needs. This is an issue during disease outbreaks as services must evolve rapidly and there is a lack information on local challenges.

Afya Pamoja is a mobile patient feedback service where patients can provide feedback for free, using their own phones, on the healthcare challenges they face (e.g. symptoms) and their healthcare experiences (e.g. medicine availability). This data is shared with the government to provide localized and real time insights to drive decision making.

If scaled globally, mobile patient feedback systems could improve the early detection of disease outbreaks and enable governments to respond faster and in more targeted ways. This would ensure all communities are heard, no matter where they were.

Across Tanzania's 6,000 primary care facilities - which provide essential services to 50 million people - there's insufficient patient feedback provided on healthcare needs and experiences. The typical facility receives just two pieces of feedback per month, provided through suggestion boxes. 

This prevents healthcare workers and officials from understanding patient needs and reduces patient trust the in healthcare system. The government can therefore not address challenges in service delivery during disease outbreaks (such as the localized need for additional medicines and testing equipment). Low levels of patient trust also result in low service utilization.

Evidence from the Ebola outbreak shows that patient feedback improves service delivery. Case reporting increases by 70% and deaths reduce by 40%. Care utilization increases by 10% and under-5 mortality declines by 38%. Healthcare workers and the government are demanding improved feedback mechanisms. Facility managers often use improvised but ineffective solutions, such as books and WhatsApp groups. Within the Tanzanian government’s digital health strategy they aim to collect feedback from 30% of patients by 2023.

Our innovation is a mobile patient feedback service. Using free SMS surveys through patients’ own mobile phones they can provide feedback on the health services they demand and receive during a disease outbreak. This data is analyzed and provided to healthcare workers and government officials in the form of easy to use alerts, dashboards and quality reports. 

The service provides healthcare staff with large volumes of real-time, localized and actionable insights on service needs and quality. Evidence shows that when patients are engaged in this way they provide 200 times more feedback.

This could include insights on the symptoms patients are experiencing as well as on the availability of services related to the disease outbreak, such as medicines and testing. It could also provide insights into levels of comprehension of the disease and sentiments towards vaccines.

With this information disease outbreaks can be more rapidly detected and services can be quickly and locally adapted to meet evolving needs. This can inform both national policies and local behaviors. It can lead to changes through the reallocation of resources, advocating for additional resources and alteration of staff and clinical behaviors.

Our solution primarily serves healthcare workers and government health officials by providing them with targeted, real time and localized insights to support their decision making. Currently, they struggle to hear the voices of patients in a structured manner, limiting their ability to respond to their needs. These healthcare workers typically work in small primary care facilities and are managed by local government teams who support healthcare oversight and delivery. To ensure our service meets their needs we are partnering directly with government health authorities to inform service design. This includes prioritizing the right areas of feedback and integrating the insights into their existing work to avoid additional effort on their behalf.

Our solution also serves the 85% of the Tanzanian population who rely on public primary care facilities for their essential healthcare needs. This includes pregnant women, new born and young children, those being treated for HIV/AIDS, malaria and TB. They primarily live in rural communities but are also across peri-urban and urban environments. Currently these communities are underserved with 81% of the facilities they use failing to meet government quality standards, 28% of women reporting abuse during childbirth and 33% of doctors being absent. 

From 50 interviews we know that patients want to provide feedback and that existing feedback mechanisms are too difficult to access (requiring high levels of literacy and excessive time to be spent) and they have concerns around their anonymity. Lastly, they say that they have a lack of trust that their feedback will be responded to and acted on. To develop our solution we have conducted regular workshops with the community to understand what features need to be part of the services and what areas they would like to provide feedback on. The mobile service will directly impact their ability to provide feedback and indirectly through improved healthcare services.

A mobile patient feedback service directly supports the ability of healthcare workers and government health officials to respond to a disease outbreak. It provides them with real time and localized insights. This includes informing them how to deliver new services to respond to the outbreak but also how to adjust existing services in the presence of the outbreak. 

By amplifying the voices of patients to support responsive public health decision making during a disease outbreak patients have more trust in the healthcare services. They can also more readily access the services they require through improved government action.

We have secured approval from the central and regional government to run our pilot in the Dar es Salaam region which provides healthcare to 6 million citizens through 700 facilities. We have also developed a prototype of our mobile services in partnership with a third party SMS platform. We will initially launch our service in five facilities in the July in order to prove operational feasibility, before expanding to 100 facilities by the end of the year to pilot the service at scale.

We are currently testing our prototype with small groups of patients to ensure we are meeting their needs and we will achieve high levels of adoption. We are also conducting user research with our government partners to understand the precise areas of feedback they would like collected and the best ways to share insights with them. 

For government: Digital feedback collection using structured questions allows it to be analyzed in a systematic manner. This generates robust insights shared in actionable formats. The service can be rapidly tailored to local decision maker needs. For example, healthcare managers can suggest questions and these can be quickly included in surveys. We are also testing different formats to move from data to action. This includes triggering automated SMSs and emails sent to healthcare managers.

For patients: By using patients' own mobile phones our service reduces barriers to patient feedback to just a few minutes of engagement and ensures anonymity. This generates higher volumes of feedback to increase the quality of insights. Lastly, a mobile feedback service allows for two-way communication, so follow-ups to patients can be made closing the loop.

Business model: We are partnering with mobile operators to access subsidized SMS fees to support this high impact service. Secondly, we are deploying the service in private healthcare facilities to subsidize government costs. We are also exploring ways to monetize the data we collect, sending targeted advertisements to patients and conducting consumer research for third-parties. Lastly, we are exploring providing additional financial services to patients through our service such as credit or savings products for healthcare expenses or health or funeral insurances products.

By building a service to improve the communication between government and citizens our goal is to catalyze more responsive government decision making across all aspects of healthcare and in other areas of public services.

Current: 0. We are currently testing our prototype and have not yet launched the service in any healthcare facilities.

1-year: 2,000,000. We will be operating in 200 public primary healthcare facilities, across three regions of Tanzania, which provide essential primary care services to 2,000,000 citizens. We expect to be collecting feedback from 100,000 patient visits per month.

5-years: 50,000,000. We will be operating in all 6,000 public primary healthcare facilities in all 31 regions of Tanzania, which provide essential health services to 85% of the population. We expected to be collecting feedback from 5,000,000 patient visits per month.

Note that the goal of our service is to drive system wide improvement in healthcare decision making and accountability. As a result we consider all citizens utilizing the facilities we operate in to be beneficiaries of our service.

When we consider how we will measure progress towards improvements in service outputs and outcomes we will measure the scale, level of patient engagement and levels of government engagement we achieve.

• Scale: 
  • Year 1: Operational in 200 facilities (which serve 2,000,000 citizens)
  • Year 5: Operational in 6,000 facilities (which service 50,000,000 citizens)
• Patient engagement: 
  • Year 1: 
    • Achieve 25% patient adoption of patients visits to facilities (collect feedback from 100,000 patient visits per month)
    • Quarterly updates shared back with patients on changes made at the facility level
  • Year 5: 
    • Achieve 50% patient adoption (collect feedback from 5,000,000 patient visits per month)
    • Quarterly quality assessments shared back with patients including changes made at the facility level
• Government engagement: 
  • Year 1:
    • Develop quarterly action plans at the facility level
    • Patient feedback is on agenda of monthly facility oversight meetings,
    • Patient feedback is on agenda of monthly regional health monitoring team meetings
    • Weekly patient feedback alerts sent to facility managers and health monitoring teams
  • Year 5:
    • All of the above
    • Patient feedback is used to support annual regional budget allocations from central government
    • Patient feedback is used to determine annual national healthcare priorities
    • Produce and publish annual facility quality assessment scores
    • Produce annual report on patient feedback for key healthcare officials 

3 full-time staff

1 part-time staff

Our team has a complementary set of diverse skills and experiences which make us well-suited to tackling this problem. 

Dr. Helga Mutasingwa, the CEO, has over 5 years’ experience as a medical doctor and a public health professional in Tanzania. She works in primary healthcare facilities meeting with staff and clients daily, and reporting regularly to local government on the quality of service delivery. She knows the challenges that healthcare managers have in understanding client needs and identifying ways to optimise service delivery. Helga’s professional network provides critical access to local and central government.  

Patrick Anyanga, the CTO, has over 5 years’ experience designing, building and scaling digital services across East Africa in the healthcare and agriculture sectors. 

Simon DeBere, the CFO, has worked in East Africa in social enterprises, government institutions and civic technology. He has experience in growth strategy and building financially sustainable social interventions which reach rural communities.

Rob Smith, the COO, worked for 5 years in East Africa in public health and agriculture. He has seen first-hand how governments need client feedback from healthcare facilities.

The fundamental feature of our service is to raise the voices of citizens to influence the delivery of essential public services. Societal inclusion is central to our concept. In designing our solution we engaged key stakeholders through interviews with 100 facility clients, 50 healthcare workers and 40 members of local and central government. We tested our product design to incorporate feedback and ensures that it meets the needs of our stakeholders.

Inclusive decision-making is at the core of Afya Pamoja’s concept and our founding team is also committed to prioritizing DEI values as we build our team. We know that the long-term success of our organization will be dependent on our ability to build a team with diverse skills and backgrounds, which is also representative of and can connect with the communities and institutions we serve.

Our co-founders include one Tanzanian woman, one Kenyan man and two British men. The full leadership team have made a commitment to hire only East Africans at all levels of the organization going forward. We also want to maintain broadly equitable levels of gender representation at all levels of the organization's structure. Over the next few months we will increase the size of our leadership team and so we will have the opportunity to increase our representation of Tanzanians and women at senior levels. We want to embed DEI best-practices within several areas of our day-to-day work, particularly in relation to hiring, staff performance management and team decision-making. In hiring and performance management we use procedures which mitigate risk of bias, for example, use of panel interviews and rubrics for performance management. We also have a flat team hierarchy and during meetings actively provide opportunities for all staff to share their views. This helps establish an inclusive culture where everyone’s voices can be heard and decision-making is inherently participatory for all staff.

Being an MIT Solve organisation would provide us with valuable early-stage funding, and access to expertise and networks which can significantly accelerate our progress and ability to scale our service. Being part of an ecosystem of organisations seeking to solve social issues would help to provide us with an inspirational and motivational community with whom to share ideas. We would benefit from the direct support of 9 months of mentoring and connections, and the credibility of being involved with the program would open doors for us for future funding opportunities.

Early-stage funding would be very valuable since each additional sum raised at this point has a significant impact on our ability to successfully pilot and scale this service.

There are three areas in which we would benefit from additional advisory support; advice on longer-term fundraising, development and testing of aspects of our business model and technical support related to public health system structures. Firstly, on fundraising we would like to speak with former Solve fellows who could provide detailed feedback on our pitch materials and connect us to potential future funders for an initial conversation. Secondly, as described in the previous section we would like to test some of our ideas on channels for future revenue generation with experts from fintech, telecoms and pharmaceutical industries. Finally, as we are seeking to embed our service within existing government structures and processes, we want to speak with organisations and individuals who have experience in health systems strengthening and working closely with government. 

Designing a sustainable digital health service at national scale that is free-to-use to use for citizens requires a high degree of business model innovation. As we scale, we must keep our product and operating model as low-cost as possible and we must find stable revenue and funding sources. We have a range of ideas which we would like to test and refine with experts from academia and business leaders across public health, pharmaceutical, telecommunication and financial services industries.

On the cost side, partners and advisors could help us with our objective to develop a light-touch, highly digital and automated operational model which would allow us to minimize the need for a larger, more costly team structure.

On the revenue side, we would benefit from connections which could accelerate our ability to establish stable revenue streams. For example, at mid-scale we believe our service can also provide great value to pharmaceutical companies and health insurers who will benefit from a new set of market insights. We want to understand how we should package and charge for such a service while maintaining our ethical commitments to government and client stakeholders.

As a secondary area for support, we’d like to connect with fundraising experts who have experience raising from some of our target funders who could assess our pitch and written materials and advise us on how to improve these to impress donors. 

We would like to partner with a range of individuals and organisations to benefit from their expertise, mentorship and potential funding opportunities. Within the MIT Solve network we have identified the following:

Solve Members:

- Firefly Innovations at CUNY Graduate School of Public Health and Health Policy - A valuable opportunity for us to benefit from expert advice into how we can optimise our service to maximise the impact we deliver, as well as expertise in measuring and evaluation through experiment design.

- Bill & Melinda Gates Foundation - As a major funder of global health initiatives BMGF are interested in our mission and early conversations with them would enable us to refine our pitch for future funding.  

- Pfizer - Our service offers an exciting value proposition to pharmaceutical companies who are seeking to gain additional market insights. Through MIT Solve we would be able to explore this opportunity.

- Novartis Foundation - As above for Pfizer.

- Intuitive Foundation - Our mission aligns with the foundation's vision so there may be interest in funding opportunities.

- Twilio.org - Technical advice on how to refine our communication and data systems. 

MIT Faculty:

- Professor Lily Tsai - Expert in citizen engagement and government accountability in LMICs.

- Nathan Eagle - An expert in SMS communication within public health in East Africa.  

Solvers: 

- PENSA *600# - There are some elements of our service which are comparable to PENSA and so we would seek to learn from their team.  

Women represent the vast majority of clients who seek care at primary healthcare facilities in Tanzania. These facilities provide basic, essential services such as family planning, maternal and child care. As women are the primary care givers in many Tanzanian communities, women also carry the burden of healthcare for children. Sadly, healthcare outcomes for women and children in Tanzania are poor. Maternal mortality rate is twice as high as in Rwanda, a neighboring country, and the infant mortality rate is 4%. Afya Pamoja elevates the voices of women by enabling them to express their views on these essential public services through a safe, free-to-use, anonymous service, which builds healthcare systems which are more responsive to their needs and ultimately delivers better outcomes for women. Our service puts women at the centre of influencing service delivery and policy. Prior studies on patient engagement have shown that involving citizens feedback can reduce infant mortality by as much as 38%.

Afya Pamoja’s service is designed to be as accessible as possible to women. 77% of women own a mobile phone in Tanzania and SMS technology is widely-used and accessible through the most basic phones. We have tested our product with over 50 women and incorporated their feedback into the design and the survey content.

Over time we aim to offer more value to women by issuing outbound prompts and reminders about important pieces of healthcare information and by providing connections to relevant financial services such as medical expense cash loans and health insurance.

Afya Pamoja’s service provides healthcare workers and public healthcare managers at the sub-regional level with more detailed insights into the availability of medicines on a facility-by-facility basis. Our survey asks facility clients to report on the availability of essential drugs, whether they were paid for, and whether advice was given into their usage and possible side-effects. Currently there is no established, large-scale, digital mechanism for collecting such data and much information is recorded in paper format. Our service provides a richer set of data than is currently available and is sourced directly from facility clients so is a form of community-led monitoring.

This service informs a number of decisions taken at the local government level, for example, adjusting the medical supply orders for specific facilities. At the facility level this information enables facility in-charges to decide whether certain departments or individual healthcare workers within their facility require additional training on the usage of certain drugs and client interaction. Furthermore, from our conversations with 50 healthcare workers we know that facility in-charges want data from client feedback in order to advocate to public health managers for additional resources, since this helps them to make a stronger case.

During COVID-19, research by The Global Fund’s Disruption Impact Report shows that HIV testing fell by 41% and malaria diagnoses fell by 31% on average in LMICs. Such significant shifts in demand leads to disruption to the medical commodities supply chain, and these become more complex given the regional variation that occurs. In relation to malaria we ask clients seeking antenatal care whether they received drugs and a treated bed net during their facility visit. For clients seeking ante retro viral therapy we gather data on whether drugs were offered to clients at the facility.

If we received funding from The Global Fund we would use these funds for two objectives. Firstly, we would build and establish our service to cover the HIV healthcare vertical. This would significantly accelerate our ability to provide insights on the ART supply chain to public health managers. Secondly, we would also develop an additional SMS service to trigger outbound messages to connect clients in areas with a specific drug shortage to other facilities or pharmacies where drugs are available.