Afya Pamoja

Within primary healthcare facilities in Tanzania there are inadequate patient feedback channels. The typical facility receives just two pieces of patient feedback per month - typically via paper and pen through suggestion boxes. 60% of patients say that existing feedback mechanisms are inadequate. As a result patient voices are not sufficiently heard within healthcare decision making. This damages trust in the healthcare service and so reduces utilization of key services which negatively impacts healthcare outcomes. For example, a significant factor in maternal mortality is that 35% of all births are home births. The outcome is that in Tanzania there are 11,000 maternal and 103,000 under-5 deaths per year. Moreover, the rate of maternal mortality is 50% higher than in neighboring Kenya and Uganda.

Furthermore, insufficient patient feedback reduces the ability of healthcare workers and public healthcare managers to understand the real-time needs and challenges of patients on a local level. This limits their ability to provide targeted oversight (e.g. identifying abusive healthcare workers) and support, and reduces their ability to understand resource needs (e.g. identifying where antenatal folic acid supplements are out of stock), advocate for them effectively and then allocate them efficiently to facilities. 

The scale of this problem is large. In Tanzania, 6,000 public primary healthcare facilities provide essential healthcare services to 51 million people. Women and children are particularly reliant on these services for antenatal and early childhood care. These facilities also disproportionately serve low-income and rural communities who rely on public facilities for their healthcare needs.

Solving this feedback problem not only provides a direct benefit to citizens by enabling their voices to be better heard but also supports health facility performance management and drives improved top-down and social accountability. This results in improved trust, higher utilization of available health services and improved availability of quality healthcare services. 

Our innovation is a mobile patient feedback service. Using free SMS surveys patients’ provide feedback, through their own phones, on the services they received at a healthcare facility. 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, facility specific and actionable insights on the quality of services provided to drive responsive and accountable decision making. Lastly, updates are provided back to patients to close the feedback loop and build trust. 

Insights are provided on the availability of services (such as those required during antenatal care visits) and the quality of services (such as family planning guidance). Healthcare workers can then identify and address the needs of patients in a systematic manner through supportive performance management tools. Government health officials can also identify service challenges (such as healthcare worker attendance) and gaps and so divert support (such as audits) and resources to these issues. 

Compared to existing feedback mechanisms (such as suggestion boxes) a mobile service addresses barriers for patients and government. For patients it resolves the key fear around anonymity and reduces the literacy barrier to providing feedback relative to paper and pen options. For the government, the innovation increases the volume of feedback collected and enables it to be analysed in real-time in a systematic way and directed to multiple levels of the healthcare system. The solution includes a level of flexibility such that healthcare managers can collect data on specific issues as and when they need, receiving specific information on their highest priority issues. Lastly, to ensure adoption and sustainability, data is integrated into existing government health information systems and insights directed through existing performance management processes (such as monthly district oversight meetings).

We believe this solution solution has the potential to be the most cost effective life saving intervention in global health. Rigorous academic research in this field shows that improving patient feedback processes can have dramatic impacts on healthcare outcomes such as reducing child mortality by 38%. This solution builds on the benefits of traditional social accountability interventions (such as social dialogues and community score cards) by utilizing low-cost, digital technologies which are scalable. Our approach blends bottom-up feedback with top-down accountability by influencing government decision making. We achieve this through our partnership with the Ministry of Health, who we are co-designing the service with. 

In the pilot phase of our work we will focus on maternal, newborn and early childhood healthcare. The key beneficiaries of our intervention will be pregnant women, new mothers and young children. As a nationwide service it would impact those in both rural and urban settings. Public primary care clinics are disproportionately used by low-income houses making the impact skewed towards these households.

In the long-term our key outcome metrics will be maternal mortality, infant mortality and under-5 mortality. Replicating results from previous studies, which have shown reductions of 38% in these metrics, at a national scale in Tanzania would result in 40,000 under-5 lives saved per year. 

During the pilot phase of this work (the first 12 months as outlined in this application) observing impacts on end heathcare outcomes is unlikely. Therefore the primary outcome we intend to track is the proportion of mothers who attend four or more antenatal care visits (which is likely driven by a combination of improvements in care quality and patient utilisation). Beyond this we will also track secondary indicators of healthcare quality such as the proportion of live births attended by skilled personnel, the proportion of women experiencing abusive language during facility visits and the proportion of mothers utilizing vaccination services for their children.

In the long-term our goal is to expand the service to drive impact in other aspects of healthcare service being delivered by primary care facilities. This includes HIV/AIDS, TB, malaria and family planning services.

When assessing the overall impact of the service we consider not only the depth of impact achieved for women and children (where the goal is to save lives) but also the scale of the impact achieved, which is determined by the number of people reached by the service.

We have expertise in this field and have an excellent network across public health, government, fundraising and technology sectors. 

Dr. Helga Mutasingwa, Chief Medical Officer is a Tanzanian doctor and public healthcare professional with 6 years experience. She managed ICAP’s HIV-patient retention program in the Dar es Salaam Region, visiting public healthcare facilities, patients, facility staff and local government health monitoring teams on a daily basis. She has a deep, personal understanding of the challenges faced by the Tanzanian healthcare system due to lack of feedback, and has a strong network throughout government. 

Robert Smith, COO, has 7 years’ experience and has built scalable digital performance management systems for social enterprises in East Africa. He previously worked for CHAI, advising the Rwandan government on the roll-out of the national Universal Health Coverage plan. 

Patrick Anyanga, the CTO, is a Kenyan tech entrepreneur who has over five years’ experience building scalable digital products in East Africa within the healthcare and agriculture sectors. 

Simon DeBere, CEO, has 6 years’ experience in developing growth strategies for social enterprises and civic tech companies in East Africa. He studied the MPA-ID program at Harvard Kennedy School so is trained in policy analysis.   

Connections to mentors and organizations in the following areas would significantly help our success and growth:

Product design guidance: How to rapidly prototype,  how to build for scale from the beginning

M&E advice: how to build a learning organization, how to measure success

GovTech inspiration: connection to those working in the CivicTech / GovTech space. Ideally in emerging markets.

Afya Pamoja is the first organisation to have the vision and feasible operational plan to deliver a digital patient feedback service at scale in Tanzania, and put the voices of citizens at the heart of public health decision-making. At scale, our service will be the first in Tanzania to directly communicate the views and experiences of patients from anywhere in the country all the way up to the Minister of Health. We are the only service in Tanzania which provides healthcare managers with a low-cost, digital mechanism for accessing large-volumes of real-time data and insights into service quality directly from patients. 

By facilitating data-driven decision-making by public healthcare managers we are directly building capacity within government institutions in order to drive improvements in service delivery and ultimately healthcare outcomes such as maternal and infant mortality. This differentiates us from other digital health services which typically focus on care providers or the private sector.

Current performance management systems focus on measuring the volume of healthcare services delivered, but do not cover the quality of care. Afya Pamoja will be groundbreaking in providing real-time insights into care quality, so that this can be optimised. We are also able to guarantee patient anonymity during the feedback process, something patients worry about with existing systems.

The evidence base which supports our service comes from academic and empirical research into care recipient engagement interventions. While these studies demonstrate a clear impact of such interventions, all of them have relied on analogue methods which are expensive and hard to scale. We are taking a digital, low-cost, scalable approach to deploying similar interventions. We will be the first to replicate this impact at scale in a sustainable way. 

We are deploying an innovative 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.

We are pioneers in combining CivicTech and GovTech models by linking the voices of citizens directly to public sector decision-makers. Up to now, digital health companies in East African markets have focused purely on GovTech solutions without civic engagement features. We passionately believe in the power of elevating the voices of citizens to build institutions and deliver large-scale, durable impact.

Within five years we will operate a nationally-scaled, sustainably-funded digital feedback service in all 6,000 of Tanzania’s public sector primary care facilities. Our service will be fully integrated into government technology systems and used by regional-level governments for day-to-day service management as well as informing budgeting, annual strategy and policy processes at the national-level. 85% of Tanzanians use public sector facilities, thus based on current population growth projections, by 2026, our feedback service will positively influence the healthcare services of 60 million Tanzanians. We will achieve this goal by scaling in close partnership with the government, expanding our service into new regions and embedding our service into government workflows and technology systems in order to ensure a smooth transfer of ownership.

Two years after our initial launch we will also establish our service in other countries. From our initial research in Kenya, Uganda and Nigeria, we believe there is consistent demand for this service. Across these four countries there are 40,000 public sector facilities serving 300 million citizens. Replicating previous empirical results could result in avoiding the deaths of over 400,000 under-5 children per year.

Our service drives improvements in service quality and outputs, such as improved doctor attendance and medicine availability, and increases service utilisation, such as at ante-natal care visits. This leads to improved healthcare outcomes, such as reductions in maternal, infant and under-5 mortality. Research in this field has shown that patient engagement interventions can drive a 38% decrease in under-5 mortality and using a digital approach we aim to replicate this impact with a scalable mechanism. At national scale, replicating the impact of this prior work, such a program has the potential to save 40,000 under-5 lives per year.

All Tanzanians, especially those from marginalised communities, will benefit from this service, due to the improved healthcare outcomes. Women and children, who disproportionately rely on public sector services, will benefit disproportionately. 

By adopting an evidence-based approach to service design, we will publicly share learnings and insights from our work to influence policy and other healthcare NGOs working in the field of citizen engagement.

During this first phase we will focus on testing and refining the early stages of our theory of change. We will not do a casual evaluation on end healthcare outcomes in this phase but instead complete that in the next phase. This will be done using existing government data sources and tracking maternal, neonatal, infant and under-5 mortality over a multi-year time horizon. 

The key research questions for this first phase are (1) will patients engage with a mobile patient feedback system and do their behaviours change when given the opportunity to do so, (2) will healthcare workers and government health managers engage with patient feedback data and do their behaviours change in the presence of high quality patient feedback and (3) does a mobile patient feedback system improve indicators of healthcare quality.

To understand the impact we will measure three categories of metrics: (1) patient adoption of the service, (2) healthcare worker and government engagement of the service (e.g. how often the data was used in decision making and performance management), (3) changes in key service outputs:

1. Patient adoption will be measured through our technology platform with the number of responses tracked on a per facility basis. This data will be compared to facility records of the number of relevant visits to produce a measure of relative adoption per facility. Across the 100 facilities we will run monthly A/B tests of different product features. From this data we will learn how to increase patient engagement.

2. Healthcare worker and government engagement of the service will be measured through both self-reported and observed metrics of engagement. These include: The proportion of facilities developing action plans using patient feedback, the proportion of government monthly meetings where patient feedback is discussed, the proportion of facility managers replying to their automated weekly patient feedback alerts. Across the 100 facilities we run quarterly A/B tests of different approaches to data sharing. From this we will learn how to increase government engagement in the service.

3. Data on key service outputs will be collected using existing health information system data sets collected by the government and supplemented by our own data. This includes data on: (1) service utilisation, (2) drugs, reagent and other commodity stockouts, (3) facility staff attendance (4) service availability. We will examine changes which occur over the 12 month pilot, helping us refine the most promising theory of change.

Alongside collecting the above metrics we will also conduct a range of on-going qualitative interviews and focus groups with the goal of better understanding how patients, healthcare workers and government officials  interact with the service. The focus of this phase is to better understand how to refine the service and qualitative insights collected in a consistent manner will be valuable here.

To track the innovation’s performance over the next 5-years we will measure (1) Scale: Number of facilities reached, (2) Impact: Changes in mortality healthcare outcomes (existing government data), (3) Sustainability: Annual cost per facility (internal financial records).

From reviewing over 10 rigorous studies of social accountability mechanisms, our theory of change centres on two sets of activities. Firstly, it’s possible to collect and analyze large volumes of patient feedback - demonstrated in Kenya and Tanzania (Okeke 2019, UNICEF 2020) - and secondly, sharing targeted patient-centred insights with healthcare workers and officials to drive behaviour change, increase accountability and improve decision making (e.g. planning, resourcing, performance management).

These activities drive changes in two types of outcomes. Firstly, increasing trust in services leads to increased service utilisation (Mselle 2019). Improved trust is achieved by allowing patients to provide feedback on the services and following up on this feedback. Evidence from similar services suggests that this can increase utilization by 20% (e.g. antenatal care visits) (Gullo 2016). Secondly, this service can increase service availability. This is achieved by better understanding patient needs and increasing oversight of individual healthcare workers and facilities. Studies (Callen 2020) find that providing data to managers increases facility oversight visits by 104% and doctor attendance by 75%. This results in improved resource allocations (e.g. medicine and staff allocations) and improved staff behaviours. Evidence from similar services suggests that it can increase availability of essential medicines by 41% (Blake 2016).

This results in improvements in healthcare impacts such as maternal, infant and under-5 mortality. Seminal work found that social accountability mechanisms can reduce under-5 mortality by 33% (Bjorkman 2009). A more recent RCT of over 250 health clinics in Sierra Leone found that patient feedback services reduced under-5 mortality by 38% (Christensen 2021). They also found that these effects persist during disease epidemics resulting in case reporting increasing by 62%. 

Afya Pamoja’s solution builds on the benefits of traditional social accountability interventions (such as social dialogues and community score cards) by utilizing low-cost, digital technologies which are scalable. Unlike recent work (Raffler 2020, Arkedis 2021) which finds limited impact from just bottom-up community feedback mechanisms, our approach blends bottom-up feedback with top-down accountability by influencing government decision making. By supporting decision makers, our work builds on recent work (Kosack 2021) which suggests accountability programs involving officials are more effective than those which rely on social accountability alone.

There is clear demand for these services from the government. A mobile patient feedback system is a key part of the country's digital health strategy (Ministry of Health 2019) and we are currenting signing a partnership with them to launch this service. From our 50 visits to facilities, the array of improvised feedback mechanisms observed demonstrates healthcare workers’ demand for patient feedback. Previous pilots (Grossman 2017, UNICEF 2020) have shown that mobile patient feedback systems result in patients providing upto 200 times more feedback, demonstrating a willingness to adopt such services. We build on this work by collecting data from patients in a structured, more actionable format.

Our core value is to use existing, well established mobile technologies and deploy them into a new setting. We create value by deeply integrating these technologies within government institutions.

Afya Pamoja is an accessible digital solution. We rely on using widely accessible and relatively simply mobile technologies (e.g. SMS and USSD) to connect patients with medical professionals and public health manages. With mobile penetration now over 85% in Tanzania, now is a unique time when we can connect with nearly the entire population and in low-cost and scalable manner. However, given that smart phone penetration is just 25% and largely concentrated to urban areas, we will focus on feature phone technologies to give a voice to the widest set of citizens possible. Our goal is not to be driven by the technology but rather to be driven by the needs of citizens.

Technology enables direct citizen engagement: Our ideas are rooted in the idea that citizens understand their experiences best and want to share views on public services. Afya Pamoja is the only direct patient feedback service in Tanzania. Although other feedback services exist - for example through community healthcare workers - none leverage the high mobile penetration and directly target the patient. The underlying technology for mobile surveys has been thoroughly tested across East Africa and therefore our innovation is connecting this communication technology to effective decision-making tools for public health managers. The challenge does not primarily lie in collecting the data but rather in our ability to leverage the data collected from the
technology to derive meaningful and action orientated insights. This end-to-end solution is our innovation.

From our founding team's inception this has been a core and on-going conversation within our work. Our founding team comes from a diversity of backgrounds and we believe this is core to our success. We believe open conversation among all team members accompanied by a willingness to take critical view about DEI issues within our organization is vital. 

Our objectives are primarily two fold, firstly to recruit and training nearly entirely staff from the regions we work in. In the long-term our goal is build an East Africa led organization. This means actively searching for top talent in our markets, fairly assessing it and then investing in it. To date we have delivered on this goal and have hired 6 Tanzanians into our organization. We have agreed to heavily scrutinize any non-East African hire we may be interested in hiring in the future. 

Secondly, we are focused on building a transparent and collaborative culture among both our leadership team and at all levels of the organization. We want a diverse set of perspectives to have oversight of most decisions and be empowered to share their views freely. We recognize that this is more than just process and requires on-going investment to ensure this culture is established and maintained. We discuss this topic in monthly team meetings and dedicate part of our quarterly team retreat to this topic.

We are a revenue generating non-profit with funding from a range of sources. 

Grant funding: Initially our service will be funded through philanthropic capital from global health and civic engagement funders who are motivated by high-impact, low-cost, scalable ventures (e.g. Bill and Melinda Gates Foundation). Initially this money will be raised from philanthropic capital and will be sufficient for us to test our product and expand to a scale at which we can undertake rigorous testing on the impact of our service, by partnering with academics to run a Randomised Control Test. By proving our impact through the results of this study we will be able to crowd-in funding from the likes of Global Innovation Fund, USAID DIV and FID, who provide multi-year large-scale grants of up to $15m for programs with robust impact evidence. 

Government cost-sharing: Within 3 years we expect to achieve government cost-sharing arrangements with local government authorities covering a portion of our operating costs, specifically those related to fees incurred in working with facility staff who are already on the government payroll. We are encouraged that a similar organisation, Jacaranda Health in Kenya, has been able to achieve such a funding arrangement with government.

SMS fee subsidies: Ministry of Health has access to a zero-rated SMS short-code for digital health services already agreed with Tanzania’s four major telecommunication companies. Once we have piloted our program and proven our ability to deliver impact we will negotiate access to this short-code and receive a zero-rating. The Director of Technology has already indicated that this is feasible. 

Revenue-generation: Longer-term we want to develop a series of complementary revenue-generating services. Given we have privileged data from and access to reach a segment of care-seeking individuals we believe that we can sell health insurance, medical expense loans and a range of services to pharmaceutical companies, in order to subsidise our operating costs. 

Overall funding share: At scale, across all 6,000 facilities in Tanzania, our service will cost $6m p.a. to run and within 5 years we expect to cover 40% of this cost through SMS fee subsidies from telecommunications companies, 20% through government cost-sharing arrangements, 20% through long-running grants and 20% through complementary revenue-generating services

There are two phases on Afya Pamoja's path to financial sustainability. Phase one runs from the pilot through to the point of having robust evidence for our impact. This phase will last two years and is primarily funded by mobile network subsidies and grant funding. The Tanzanian government has agreed with mobile network operators to zero-rate the SMS costs of this service, which reduces our costs by 60%. In year 1 we require $150,000 of funding and in year 2 we require $300,000, enabling us to operate in 500 primary care facilities. We seek grant funding from four primary sources, social innovation funders (e.g. USAID DIV), major global health donors (e.g. BMGF), foundations (e.g. Segal Family Foundation), and civic engagement donors (e.g. Omidyar Network). We have received encouraging feedback from many of these donors.

In phase two, once impact is proven (e.g. through an RCT) and we are scaling to serve all 6,000 facilities, we will cover operating costs by generating income through a range of sources. 

• Charge or agree cost-sharing arrangements (e.g. paying CHW per diems) with government and their development partners (e.g. bilateral donors). 
• Monetise our data through offering market insights to organisations such as health insurance providers and pharmaceutical companies. 
• Partner with lenders to sell finanical services such as health insurance and loans for medical expenses, charging our partners commission. 
• Using our RCT results we will use innovative outcome funding structures. 

Through this approach we will achieve financial sustainability for a national service within 4 years. 

$500,000 raised from a diversified set of funders in the past 12 months:

- Multilateral organizations in Tanzania (UNICEF)

- Venture philanthropists 

- Social entrepreneurship funders (Echoing Green)

- Development Innovation Funders (Fund for Innovation in Development)