Doc En Route

“The quickest way to alleviate poverty right now, is to have one telephone” -  Nobel Laureate Muhammed Yunus of Grameen Bank

A major healthcare challenge is how to deliver excellent healthcare services to an increasing number of people with limited human and financial resources.1 Amongst the Low-to-Middle-Income Country (LMIC), a combination of geography, isolation, socio-economic and urban-rural divide have long served as a unique additional burden to healthcare delivery.2 Key factors to these challenges include access/distance to and from health centres, access/distance from speciality services, and lack of good education sources. In addition, globally, there is an increasing burden of chronic disease and multi-morbidity (the co-existence of two or more chronic diseases) such as cardiovascular disease, lung disease and mental health.20-21  Global Burden of Disease data highlights that 70% of global deaths are attributable to non-communicable diseases (NCD) such as above.21-22 80% of premature deaths from NCDs occur in LMICs and a significant proportion of these deaths are attributed to multi-morbidity, in addition to deaths related to malnutrition or communicable disease i.e. acute/chronic infections.21-22 There is also abundant evidence showing increased use of health services by those suffering from multi-morbidity.21-23 The complex topic of multi-morbidity extends to issues such as lack of awareness of its consequences, polypharmacy and missed holistic health promotion opportunities.22 There is little research and data on how demographic factors e.g. lifestyle factors, socio-economic factors, education etc. influence the multi-morbidity disease course as potentially modifiable risk factors in LMICs.20-23

Example of Nigeria
Nigeria is an example of an LMIC and is Africa’s single largest economy according to the World Bank with a GDP of $509 billion in 2013.4 - 5 It has a population of approximately 160 million people. With an average annual economic growth rate of 7%, it is one of the fastest-growing economic markets in the world.5 Despite this, Nigeria has been riddled with economic volatility in addition to political and social unrest, a fall in oil prices and two major currency devaluations.4
These economic downturns had a major impact on the healthcare sector including i) lack of public and private sector coordination, ii) commercial pressures in the private sector that lead to poor quality work, iii) work environment that contributes to low motivation (unrest amongst doctors) with less than optimal productivity and high attrition – especially from the rural areas, and iv) lack of planning towards staffing projection needs resulting in an overproduction of some categories of health workers and a lack of others (Federal Republic of Nigeria HRH Strategic Plan 2008-2012).6-7

Consequently, the fragmented primary healthcare here is in severe need of bolstering.

Immature health care, infrastructure and insurance system
In addition, Nigeria’s healthcare system is piecemeal, fragmented and unfortunately ineffective.4  The public health system is consistently underfunded and almost 50% of the population lives below the poverty line. Although the Nigerian government is committed to providing universal healthcare, the practical reality on the ground is different with palpable discrepancies between public and private facilities.4 In 1999, the Nigerian government introduced the National Health Insurance Scheme (NHIS) but the program only really started in May 2005 and has barely increased the number of Nigerians with medical insurance. As of December 2016, only 4% had subscribed to NHIS who were mostly federal government workers.4 Private health insurance penetrance also remains very low. This means that more than 95% have no health insurance because NHIS participation is not mandatory to which many state and local governments refusing to adopt the plan. 
A significant proportion of sick children and adults do not receive the needed treatments due to prohibitory high costs of care.4, 8 This drives many to solicit care from unverified and unqualified sources. In addition to prohibitory costs, there is the issue of increasing travel distance to health facilities which often have poor equipment and infrastructure.4, 8 

Brain Drain & Medical Tourism
This crisis has been exacerbated by a shortage of doctors.9 There are presently 72,000 doctors serving a population of approximately 200 million. World Health Organization (WHO) recommendations are for a ratio of one doctor to 600 patients. In Nigeria, it is one doctor to 6000 patients.9 In comparison, India has a doctor-to-patient ratio of 1:2083 and the USA has a doctor: patient ratio of 1:500. To further compound this, approximately 2500 doctors are leaving Nigeria every year to work. Figures by the British government Department of Health as of February 2018 show that there are 5,405 Nigerian-trained doctors and nurses currently working in the National Health Service (NHS) in the UK. In total, approximately, 50% of Nigerian-trained doctors practice outside Nigeria for better work conditions, infrastructure and salary.10 This confers a shortage of medical expertise in Nigeria and more pressure on the existing numbers of doctors contributing to increased disease morbidity and mortality.
It is not only doctors that leave Nigeria for better work conditions, patients are also going abroad for better standards of healthcare.11 It is common practice for middle-class and wealthy citizens of Nigerians including government officials when unwell to fly abroad for treatment. This is called medical tourism and Nigerians spend a total of 1.6 billion dollars abroad on medical tourism every year.11 

Rising demand and Room for Innovation in the Nigerian Healthcare sector
Despite these huge challenges, there continues to be a rising demand for healthcare. According to Ernst & Young healthcare analytics, despite the low health insurance coverage, there have been rising demands for private health care coverage.4 It is predicted that spending on private health insurance will grow from 400 million US dollars in 2016 to 530 million US dollars by 2021 giving a growth rate of 6%.4 Total spending on the healthcare from the Nigerian government remains low at 4.2% of the national budget as of 2017.4 There have been modest increases in total government spending from about 21% in 2016 to a 24% increase in 2017. The government has also identified improved access to health care as a priority under the Economic Recovery and Growth Plan (ERGP) 2017-2020 with the promotion of a digitally-led economy as one of the strategies.12 This strategy aims to improve the availability, accessibility, affordability and quality of health services; expand health coverage to all local governments; provide sustainable finance for the health sector and reduce infant and maternal mortality rates. The Nigerian government, in addition, have identified key measures to improve healthcare including a) promoting the use of telemedicine, b) financing/aid arrangements with other countries where significant populations of Nigerian health workers live plus making efforts to enable easier transition to Nigeria; and c) actively managing brain drain.7 There, therefore, remain huge opportunities to improve the present situation. Using advancing technology, there is room to do things in a different way that complements and augments existing healthcare structures, as well as revolutionarily, creates new structures. 
Tools that can rapidly transform this landscape are mobile phone telecommunication services. Despite other socio-economic limitations, Nigeria has 85% mobile phone penetrance2 which allows for huge mobile healthcare (mHealth) capability and potential. It is estimated that more than 130 million Nigerians use mobile phones presently and in a similar vein, the telemedicine market is predicted to reach $130 billion by 2026.4  Health care software app technology has the potential to be used as a tool to i) aid in the amelioration of the existing ailment/illness, ii) to make individuals more health aware so they make better health decisions and iii) store and utilize data to improve future health decisions and health care services. 
Health insurance agencies in Nigeria have leveraged mobile phone use in the past. Rather than only targeting wealthier clients, some innovative private insurers had, in addition, developed tailor-made plans for lower-income individuals and families that take advantage of the high use of mobile phones in the country. For example, MTN, Nigeria’s largest mobile carrier, launched a service called ‘Y’ello Health Cover’ in 2014 where, for a prepaid weekly fee of 100 N(Naira), subscribers can visit one of 6000 NHIS-registered health management organizations and receive up to N350,000 in coverage, or about 1,000 US dollars.4 

Mobile Health (mHealth)
Mobile Health (mHealth), as defined by the application of ‘emerging mobile communications and network technologies for health care systems, which involve the use of mobile computing, medical sensors and communication technologies for healthcare’3 can transcend these challenges in providing faster, more accessible and affordable services. The penetration of mobile phone networks in LMICs surpasses other infrastructures like electricity and paved roads.13, 14 With LMIC majority populations owning a mobile phone and having broadband, there is an opportunity through mHealth, to build and deliver an increasing volume of personalized care, expand ‘subscriber/population base’, and create more incentives for other players/stakeholders driving forward sustainability in healthcare.13 The data in the literature support this with mHealth interventions overcoming widespread health system barriers such as health professional shortages, reliance on informal/untrained providers, transportation/service costs and lack of sources of reliable information.13,15 This has been particularly apparent in LMIC countries like Bangladesh, India, Mexico, Pakistan and Congo.13, 15 
For example, Mexico’s ‘MedicalHome’ health call centre service offers it's one million subscribers access to professional health advice at a fixed fee of US $5 per month and is billed directly to the customers' mobile phone invoice.13, 15 Congo also had a successful example of partnership with a mobile telecommunications network with their ‘Ligne Verte Toll-Free Hotline’ initiative to complement family planning initiatives in referring patients to nearby clinics for access to contraception and family planning information.13, 16 
There is also plenty of evidence that mHealth can facilitate efficient care, particularly of chronic conditions and targeted health care thereby enhancing patient self-management and quality of life as well as facilitating more effective use of health care workers.1, 2 Cameroon has effective telemedicine and teleconsultation service around managing patients with hypertension.13 
The fast advancing pace of development in information communication technologies has led to huge beneficiaries for the medical services industry. The majority of records can now be stored in digital format. Digital transmission and exchange of this medical information can be facilitated by improving the quality of care. Increasingly, more sophisticated health information tools (facilitated through mobile and computer-based data collection, aggregation and reporting) are expanding the capacity of real-time monitoring and prospective surveillance negating the need for paper-based surveys to monitor utilization and outcomes.13, 17  Many studies have also shown that mobile technologies and device functionalities (i.e. voice, SMS, electronic form) used in healthcare have better accuracy, reduced costs and time, improved data quality with fewer error rates compared to traditional pen and paper methods of data-collection. 13, 18-19 Consequently, LMIC governments have expressed interest in mHealth as a complementary strategy to strengthen their health-care systems and reach health-related Millennium Development Goals.14 India, for example, already has several mHealth programs and is working to integrate these services into its government healthcare system. It has been found that the importance of mHealth schemes has been found to be cemented after a country experiences a disaster.13 Similarly, this present COVID-19 pandemic will likely reinforce the need for robust health initiatives and strategies. WHO concluded, in their ‘New horizons for health through mobile technologies’ report that almost 90% of the world’s population could benefit from opportunities mobile technologies represent, and at a relatively low cost.’13 Other sectors in LMIC societies have benefitted from the utilization of mobile technologies such as election monitoring, online education, citizen journalism, mobile banking services and agricultural assistance to farmers.13 The health sectors have been slower to adopt these technologies into routine operations which would benefit patients and providers alike. If utilized strategically, mHealth can revolutionize health outcomes, providing anyone with mobile phone access to medical expertise and knowledge in real-time. WHO has therefore advocated the need for strategic policies and programmes to make aware and maximize the benefits of mHealth to local communities.13
Despite the promising potential with mHealth, WHO has noted a lack of result-based evaluation of mHealth interventions with only 12% of member states reporting evaluations for mHealth interventions and their impact on health outcomes.13 In addition, top barriers to mHealth interventions relate to (i) the need for further information and knowledge regarding assessing the effectiveness and cost-effectiveness of mHealth applications;13 (ii), conflicting health-system priorities; (iii) lack of supporting policies and; (iv) legal issues particularly related to data security and privacy.13 As such, there is a great need for preliminary research surrounding mHealth interventions and their challenges to allow for the most effective delivery of health care.

Consequently, there is an even greater need, not only to be able to deliver healthcare more effectively but to also find novel ways to measure important data parameters alongside this to further guide the impact of care.

References
1. Shah DM. & Dave PN. MobiHealth: A System for Health Care in India. Proceedings of the International Conference on Advances in Computer, Electronics, and Electrical Engineering. 2012; 283 – 287
2. mHealth in the Global South: Landscape Analysis. Vodaphone Group Foundation and United Nations Foundation. 2008
3. Istepanian R, Constantinos SL, Pattichis S. M-Health: Emerging Mobile health System. In: Topics in Biomedical Engineering. Springer Books.
4. Oxford Economics/Haver Analytics and Ernst & Young. Global Analysis of Health Insurance in sub-Saharan Africa. 2018: 1-12
5. Doing Business Report, 2014: Economic Profile Nigeria. World Bank Group
6. World Health Organization (WHO) 2018. http://www.who.int/workforceal...
7. Federal Republic of Nigeria. Federal Republic of Nigeria Human Resources for Health Strategic Plan 2008-2012; 1-84
8. Adedini SA. et al. Barriers to accessing health care in Nigeria: implications for child survival. Global Health Action 2014; 7: 10.3402/gha.v7.23499
9. Muanya C. & Akpan A. ‘2000 medical doctors leave yearly’. The Guardian: Nigeria. 2018
10. Muanya C. ‘Why 50% of Nigeria-trained doctors practise abroad’. The Guardian: Nigeria. 2019
11. BBC News World 2016 – Nigeria’s Buhari ‘broke promise to end medical tourism’. (http://www.bbc.co.uk/news/busi... accessed on 9th April).
12. Ministry of Budget and National Planning. Economic Recovery and Growth Plan 2017-2020. February 2017.
13. World Health Organization. mHealth – New horizons for health through mobile technologies. Global observatory for eHealth series – Volume 3. World Health Organization Press.
14. The world in 2010: ICT facts and figures. Geneva, International Telecommunications Union, 2010 (http://www.itu.int/ITU-D/ict/material/FactsFigures2010.pdf, accessed 8th Apr 2020).
15. Ivatury G, Moore J, Bloch A. A doctor in your pocket: health hotlines in developing countries. Innovations: Technology, Governance, Globalization, 2009, 4(1):119–153.
16. Corker J. “Ligne Verte” Toll-Free Hotline: using cell phones to increase access to family planning information in the Democratic Republic of Congo. Cases in Public Health Communication & Marketing, 2010, 4:23–37
17. Bostoen K et al. Methods for health surveys in difficult settings: charting progress, moving forward. Emerging Themes in Epidemiology, 2007, 4(13).
18. Anantraman V et al. Open source handheld-based EMR for paramedics working in rural areas. In: AMIA Annual Symposium Proceedings. Washington DC, AMIA, 2002:12–16.
19. Patnaik, S., E. Brunskill, and W. Thies. “Evaluating the accuracy of data collection on mobile phones: A study of forms, SMS, and voice.” Information and Communication Technologies and Development (ICTD), 2009 International Conference on. 2009. 74-84.
20. Afshar S. et al. Multi-morbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using World Health Surveys. BMC Public Health. 2015; 15: 776
21. Hurst JR. et al. on behalf of The Global Alliance for Chronic Diseases Multi-Morbidity Working Group. Global Alliance for Chronic Diseases Researchers statement on Multi-Morbidity. 2020 (https://www.gacd.org/research/publications-and-references/gacd-researchers-statement-on-multimorbidity) accessed on 11th April 2020
22. Benziger CP, Roth GA, Moran AE. The Global Burden of Disease study and the preventable burden of NCD. Global Heart. 2016 Dec 8; 11(4):393-397. doi: 10.1016/j.gheart.2016.10.024
23. Cassell A, Edwards D, Harshfield A, Rhodes K, Brimicombe J, Payne R, Griffin S. The epidemiology of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2018 Apr;68(669):e245-e251. doi: 10.3399/bjgp18X695465
24. World Health Organization. Quality of Care: a process for making strategic choices in health systems. World Health Organization Press, 2006
25. Ludzik L. et al. New telemedicine techniques in dermatology – evaluation with reflectance confocal microscopy via a cloud-based platform. Folia Medica. 2016; 56(3): 21-29 
   

Aim

To assess the feasibility and effectiveness of a home health-care delivery service through the use of the mobile phone app ‘Doc En Route’.
Doc En Route is a unique mHealth service that aims to mobilize the best Nigerian doctors to deliver premium healthcare to patients within the convenience of their home or workplace utilizing health app technology to manage appointments, face-to-face consultations and prescriptions.
The overall aim is that once an appointment is booked by a patient through the ‘Doc En Route’ app, a doctor will be delivered to their door on the same day. There will therefore be no need for the patient to navigate through heavy city traffic, wait weeks to receive an appointment date, or wait long inside a doctor’s consultation office. As such, the patient can focus on just getting better but hopefully in a more efficient process helping to alleviate the healthcare burden on a wider scale.

Objectives
Primary Objective:
1. To assess the effectiveness of a home health-care delivery service through the use of a mobile phone app.

This will involve analysis of quantitative and qualitative data provided with consent from patient users of the service and relevant ethical approval. These data will be collected mainly in a prospective manner and retrospectively, for example, for audit purposes.

Examples of key indicators measured will be i) number of patients who actually use the service ii) if the patient made a clinical improvement or there was the resolution of the issue after the home visit, iii) metrics around patient-centeredness and patient experience such as good communication/good hand-hygiene during the consultation, iv) simplicity, timeliness, reliability, safety, affordability/cost-effectiveness of the service including use of the app and v) whether they would recommend the service to others. These metrics are based on WHO standards for quality of care.24 

Secondary objectives:
2. To measure the total number of medicine errors over a given period as a quality of care marker of safety
3. To assess how many patients who used the home service that required referral to the emergency department after using the service. This reflects the attentiveness to additional medical care and the degree of health burden. If these figures are low, they may also show the degree of ability to care for and improve a patient’s health without the need for additional medical attention
4. To measure and evaluate in a longitudinal manner serial clinical measurements such as blood pressure, BMI and blood sugar levels amongst our patient cohort measured at the initial consultation and every 12 months thereafter. Similarly, documented co-morbidities will be evaluated to rate and degree of multi-morbidity as well as relevant risk factors.
5. To determine whether the patient has become more health aware since utilizing the service.
6. To determine whether the patient has enrolled on any health insurance or health management organization since using the service.
7. To determine doctor/health professional feedback in delivering healthcare to patients in their homes using mobile healthcare app.
8. Evaluate various forms of communication/marketing tools which impact engagement and utilization of this service.

Methodology
For a pilot study, 100 patients will be recruited over an 18-month period from those who use the ‘Doc En Route’ app service. The inclusion criteria will be adult patients ≥18 years of age, who have been selected to use the ‘Doc En Route’ App and have full consent capacity. Those who are < 18 years or who have physical/mental ailments that impair their capacity for consent, shall be excluded from the study. Patient consent will be requested for the study by the doctor on their first appointment consultation with the consent outcome documented in the app. Once patients consent for the study, they will form part of the participant research study group to which data will be collected prospectively.
A patient first requests a doctor through the ‘Doc En Route’ App and selects the available doctor in the area. That doctor receives the appointment through the app and comes to see the patient in their home or workplace on that same day. Patient details and addresses are marked to the relevant doctor only in a confidential manner. Once the doctor has arrived, the doctor will then click the arrive button on the app, proceeding to handwashing, and subsequently starting the consultation by first requesting patient consent (see patient examples below). The doctor will then go through their presenting complaint and other relevant histories like previous medical history and current medication history. With the patient’s verbal consent, the doctor will proceed with clinical examination as appropriate as well as routine observations including pulse oximetry, blood pressure, pulse, temperature, Body Mass Index (BMI) and blood glucose. Once the clinical examination is complete, the doctor will formulate a diagnosis, and give relevant clinical advice as well as safety netting. If the patient will need to be referred to the emergency department, then this will be done with a written note from the doctor to accompany the patient and a telephone discussion directly with the local hospital for a referral. If the patient does not need a referral to the emergency department, and if medication needs to be prescribed, the doctor will supply this via the ‘Doc En Route’ prescription script which the patient can pick up from their local chemist or arrange through ‘Doc En Route’ for home delivery. The prescription will be uploaded to the app. Once finished, the consultation will be terminated on the app, the patient will be thanked for their cooperation and the doctor will proceed to handwashing again. Clinical history, examination, diagnoses, advice given and various data measurements collected, will be documented under patients' structured notes pages on the app. Following the appointment, the patient will receive a questionnaire immediately, then another one at one week after, to find out information such as whether symptoms had improved and around key factors listed in the objectives. The patient will then be offered a routine health check in 12 months' time. Again, serial observations and measurements will be taken akin to the initial appointment. All clinical notes and data for the patients will be stored in password-protected and encrypted files on Google Cloud.

Doctors delivering the ‘Doc En Route’ service, will be highly trained by both Nigerian Medical Association and UK medical standards/General Medical Council (GMC) so that patients can be guaranteed a reliable and safe same-day appointment at their convenience with doctors they can trust. Doctors will undergo additional training modules as part of the mandatory induction to provide additional preparation for their role. Phone appointments and video/ telemedicine calls can also be provided to the service depending on the clinical circumstance or as a form of triaging patient requests. However, face-to-face appointments will be the main mode of healthcare delivery to steer away from the dangers of misdiagnosis that can be associated with video/telemedicine calls25 thereby providing safe and accurate consultations. 

In addition to the observations and serial measurements, multi-morbidity data can be extracted from a wide variety of patients within the study group. Quantitative and qualitative data points will be analysed appropriately, and statistical tests will be selected based on the type of data i.e. continuous or categorical and whether the data is normally distributed or not. Statistical software packages such as IBM SPSS or StataCorp STATA software will be used to analyse the data. A p-value of < 0.05 will be considered statistically significant.

Various marketing strategies will be evaluated that increase awareness of the health benefits and engagement with mHealth tools such as Doc En Route in lieu with WHO recommendations. Initial consultations with Doc En Route will be encouraging patients and promoting steps, if not done already, towards initiating a change of perspective and taking further ownership and management of their own health; empowering them to make better health decisions. For example, this could be managing their weight or lowering blood pressure or registering with a health insurance agency so they make fewer out-of-pocket payments. This will hopefully lead to improved outcomes of health and well-being for a patient and that of a nation. In order to achieve this, we will be working with the Centre of Communication and Social Impact, which is a Non-profit Organization founded by John Hopkins Center, USA and based in Nigeria, who have nearly 20 years of expertise in utilizing the role of strategic communication to impact health behaviour and social development.

Patient examples:
Patient x is a 31-year female who lives in Lekki, Lagos. She is presently having sweats and thinks she may have a temperature. She feels breathless and is coughing. She pays a one-off cost and books an appointment using our health app. She is seen by one doctor on the same day. The doctor makes an assessment of a lower respiratory tract infection and prescribes and starts the patient on antibiotics. The patient was also referred to a local hospital for assessment for malaria to which our company covers initial hospital emergency department costs. She was also diagnosed with malaria and given antimalarials and made a rapid recovery.

Patient y is a 52-year male office worker in Abuja. He has known high blood pressure. His older brother died of a stroke a few years back. He is keen to know how to take active steps to prevent him from getting a stroke. He books for a subscription which allows him to see a primary care doctor at regular intervals in the year to keep on track of his blood pressure with provided home blood pressure readings and ensuring compliance with antihypertensives. Lifestyle modifications such as reduction in his salt intake and need for exercise were also actively encouraged. He takes these recommendations on board. His blood pressure has been well managed. He has not had any evidence of high blood pressure-related complications including stroke.

Through this App, we will be able to track our total number of health care workers, medicines used, and resources needed- giving a clearer picture of whether patients are actually getting the quality of care they need when they need it.

This person-centred data will allow us to more accurately recognise and diagnose local diseases and optimise healthcare management in the region.

This should help to promote better primary care services which reduce the burden of common illnesses sustainably contributing to the key to attaining universal health coverage, as defined by the UN Sustainable Development Goals.

References
1. Shah DM. & Dave PN. MobiHealth: A System for Health Care in India. Proceedings of the International Conference on Advances in Computer, Electronics, and Electrical Engineering. 2012; 283 – 287
2. mHealth in the Global South: Landscape Analysis. Vodaphone Group Foundation and United Nations Foundation. 2008
3. Istepanian R, Constantinos SL, Pattichis S. M-Health: Emerging Mobile health System. In: Topics in Biomedical Engineering. Springer Books.
4. Oxford Economics/Haver Analytics and Ernst & Young. Global Analysis of Health Insurance in sub-Saharan Africa. 2018: 1-12
5. Doing Business Report, 2014: Economic Profile Nigeria. World Bank Group
6. World Health Organization (WHO) 2018. http://www.who.int/workforceal...
7. Federal Republic of Nigeria. Federal Republic of Nigeria Human Resources for Health Strategic Plan 2008-2012; 1-84
8. Adedini SA. et al. Barriers to accessing health care in Nigeria: implications for child survival. Global Health Action 2014; 7: 10.3402/gha.v7.23499
9. Muanya C. & Akpan A. ‘2000 medical doctors leave yearly’. The Guardian: Nigeria. 2018
10. Muanya C. ‘Why 50% of Nigeria-trained doctors practise abroad’. The Guardian: Nigeria. 2019
11. BBC News World 2016 – Nigeria’s Buhari ‘broke promise to end medical tourism’. (http://www.bbc.co.uk/news/busi... accessed on 9th April).
12. Ministry of Budget and National Planning. Economic Recovery and Growth Plan 2017-2020. February 2017.
13. World Health Organization. mHealth – New horizons for health through mobile technologies. Global observatory for eHealth series – Volume 3. World Health Organization Press.
14. The world in 2010: ICT facts and figures. Geneva, International Telecommunications Union, 2010 (http://www.itu.int/ITU-D/ict/material/FactsFigures2010.pdf, accessed 8th Apr 2020).
15. Ivatury G, Moore J, Bloch A. A doctor in your pocket: health hotlines in developing countries. Innovations: Technology, Governance, Globalization, 2009, 4(1):119–153.
16. Corker J. “Ligne Verte” Toll-Free Hotline: using cell phones to increase access to family planning information in the Democratic Republic of Congo. Cases in Public Health Communication & Marketing, 2010, 4:23–37
17. Bostoen K et al. Methods for health surveys in difficult settings: charting progress, moving forward. Emerging Themes in Epidemiology, 2007, 4(13).
18. Anantraman V et al. Open source handheld-based EMR for paramedics working in rural areas. In: AMIA Annual Symposium Proceedings. Washington DC, AMIA, 2002:12–16.
19. Patnaik, S., E. Brunskill, and W. Thies. “Evaluating the accuracy of data collection on mobile phones: A study of forms, SMS, and voice.” Information and Communication Technologies and Development (ICTD), 2009 International Conference on. 2009. 74-84.
20. Afshar S. et al. Multi-morbidity and the inequalities of global ageing: a cross-sectional study of 28 countries using World Health Surveys. BMC Public Health. 2015; 15: 776
21. Hurst JR. et al. on behalf of The Global Alliance for Chronic Diseases Multi-Morbidity Working Group. Global Alliance for Chronic Diseases Researchers statement on Multi-Morbidity. 2020 (https://www.gacd.org/research/publications-and-references/gacd-researchers-statement-on-multimorbidity) accessed on 11th April 2020
22. Benziger CP, Roth GA, Moran AE. The Global Burden of Disease study and the preventable burden of NCD. Global Heart. 2016 Dec 8; 11(4):393-397. doi: 10.1016/j.gheart.2016.10.024
23. Cassell A, Edwards D, Harshfield A, Rhodes K, Brimicombe J, Payne R, Griffin S. The epidemiology of multimorbidity in primary care: a retrospective cohort study. Br J Gen Pract. 2018 Apr;68(669):e245-e251. doi: 10.3399/bjgp18X695465
24. World Health Organization. Quality of Care: a process for making strategic choices in health systems. World Health Organization Press, 2006
25. Ludzik L. et al. New telemedicine techniques in dermatology – evaluation with reflectance confocal microscopy via a cloud-based platform. Folia Medica. 2016; 56(3): 21-29 
   

The primary goal and meaningful solution for this intervention are improving access to healthcare.

This is based and exacerbated by contextual factors with Nigeria being a lower-income country in Africa with almost 90 million people (almost 50% of the population) living in multi-dimensional poverty.
This only becomes starker in health care settings where in Nigeria, there is one doctor for every 50,000 people compared with the WHO standard of one doctor for every 600 people.
On top of this, approximately 2500 doctors leave Nigeria each year to practice abroad. Nigerian Medical Association has also 80,000 registered doctors on its books in Nigeria. Nevertheless, only 35,000 doctors actually practice.
Distance and road traffic add to the geographical discordance between specialist healthcare settings in the cities and those who live in more rural settings.
All this has contributed to a dangerous milieu of healthcare inaccessibility, healthcare brain drain (short staffing – long wait & delay) and increasing medical tourism demand (Nigerians leaving the country to seek better healthcare).
Therefore, there is a pressing need to innovate and do something different.
Despite the level of poverty, 130 million Nigerians use mobile phones with the telemedicine market predicted to $130 billion by 2026.
Nigeria is also one of Africa’s fastest-growing markets for mobile technology adoption – 85% mobile phone penetration; 35% smartphone penetration.
Thus this is a mobile app intervention that connects users to a doctor/healthcare practitioner, to which the healthcare practitioner will provide healthcare services at the convenience of the patient's home, again using the app to connect to the patient's address.

This solution means for the users: no unnecessary travel for healthcare, no traffic, no long hours waiting in hospital corridors, time to diagnosis shortened, less rushed and more focused consultation in the comfort of the patient's home and family thus improving the quality of care. In a country like Nigeria, this also amounts to increased safety, as less chance of personal attacks on the road.
For the healthcare professionals, this provides a flexible way to provide medical consultations and further economic opportunities for them to stay in the country to serve their populations.
Ultimately, this intervention provides a small ripple to address this burden of inequality of health accessibility.

The team consists of three UK-trained Nigerian doctors and one Nigerian IT technician. Two of the doctors are primary healthcare specialists. The team leader also has additional experience working for a primary health care delivery model using an app. The members of the team regularly go to Nigeria and are well accustomed to the healthcare settings there. They are ready to launch the app in Nigeria this autumn 2022. The team have already formed links with local doctors at Lagos University Teaching Hospital who are interested in joining this service to deliver healthcare within this capacity. There is interest and relationship with Lagos State Ministry for Health, as well as Healthcare Medical Organisations (HMOs- health insurance companies) e.g. Avon HMO who would like to incorporate this app service and mobile phone companies like 9mobile. The team has been to Nigeria prior, to undertake a survey of the local population issues around healthcare, as well as the proposed solution, to see if a viable proposition, to which was significantly positively received by the local communities and this feedback, was what helped shape ideas of the app and service delivery.

We are applying to Gates Challenge – firstly because its expertise and know how in providing/leveraging solutions to African settings like Nigeria.

Secondly, with any great idea or concept, particularly launched in a lower income country like Nigeria, financial sustainability is vital.

Our economic model is below and we are applying to the Gates challenge for support of this.

App Development Cost (NGN 3,160,000): Required to build the Doc En Route App including incorporating a payment platform. (Already done)

Website Build cost (NGN 216,000) (already done):

Company registration and trademark fees (NGN 205,000):

Branded laptop bags/pen/notepad/prescription notepads (NGN 1,160,250): Required to equip Doc En Route doctors in Lagos for home medical consultations with clients.

Medical bags and equipment (NGN 400,000):

Recruitment (NGN 100,000): We aim to recruit the best doctors in Lagos Nigeria. This cost will enable a thorough recruitment process and allow for doctor vetting to strict UK clinical skill performance standard.

Training and induction (NGN 337,500): This will enable us invest in relevant training for our doctors towards providing an excellent standard of care to our clients.

Mandatory compliance training (NGN 225,000):

Marketing Cost (NGN 10,000,000): We aim to keep this cost to a minimum by initially optimising ‘lower cost’ marketing avenues (Radio/TV/Experiential Marketing/Social Media). The ‘heavier cost’ avenues including billboards, TV and etc will need to be utilised if client build up remains stagnant.

Start up cost with ‘heavier cost’ marketing avenues = NGN 13,818,750 + 10% buffer = NGN 15,200,625

GBP equivalent @ NGN 450/GBP1 = GBP 33,779 or 40,552 dollars

Start up cost with ‘lower cost’ marketing avenues = NGN 5,818,750 + 10% buffer = NGN 6,400,625

GBP equivalent @ NGN 450/GBP1 = GBP 14,223 or 17,075

This is the expected state of Doc En Route’s business finances on opening day. This shows the projected balance for monthly variable cost items required to keep the business running.

1 ‘On Call’ Doctor: 1 month salary @ NGN 5,000 per day on a standby basis (based on a 31 day month) = NGN 155,000

Medical Director: 1 month salary @ NGN 800,000

Operations Manager: 1 month salary @ NGN 250,000

IT Support officer : 1 month salary @ NGN 150,000

Total Monthly variable cost = NGN 1,355,000

6 months cashflow required to cover monthly variable costs = NGN 8,130,000 + 10% Buffer

= NGN 8,943,000

GBP equivalent @ NGN 450/GBP1 = GBP 19,873 or 23,863 dollars

12 months cashflow required to cover monthly variable costs = NGN 16,260,000 + 10% buffer = NGN 17,886,000

GBP equivalent @ NGN 450/GBP1 = GBP 39,747 or 47,730 dollars

Pricing strategy is based on a subscription based model

*Based on NGN 35K client fee price point per consultation*

Individual Plans

1. One off Home Doctor consultation @N35,000
2. Annual Subscription (Monthly payments @N35,000) 16% discount applied.

• 14 Home doctor consultations redeemed within 12 months
• Basic health check ups every 6 months
• Prescription delivered to your door

3.   Annual Subscription (One annual payment @N385,000) 25% discount applied

• 14 Home doctor consultations redeemed within 12 months
• Basic health check ups every 6 months
• Prescription delivered to your door

*Based on NGN 35K client fee price point per consultation*

Family Plans

1. One off Home Doctor consultation @N35,000 (Per family member)
2. Annual Subscription (Monthly payments @N120,000) 18% discount applied.

• 14 Home doctor consultations redeemed within 12 months per family member
• Basic health check ups every 6 months
• Prescription delivered to your door

3.   Annual Subscription (One annual payment @N1,320,000) 26% discount applied

• 14 Home doctor consultations redeemed within 12 months per family member
• Basic health check ups every 6 months
• Prescription delivered to your door

These are just initial costings to allow us to be financially viable.

The Solve Award will allow us to even lower our costs further to allow us to reach the impoverished even further.

Business forecast for the sector

According to Ernst & Young healthcare analytics, despite the low health insurance coverage, there have been rising demands for private health care coverage.4 It is predicted that spending on private health insurance will grow from 400 million US dollars in 2016 to 530 million US dollars by 2021 giving a growth rate of 6%.4

Total spending on healthcare from the Nigerian government remains low at 4.2% of the national budget as of 2017.4 There have been modest increases in total government spend from about 21% in 2016 to 24% increase in 2017. The government has also identified improved access to health care as priority under the Economic Recovery and Growth Plan (ERGP) 2017-2020 with promotion of a digitally led economy as one of the strategies.12 This strategy aims to improve the availability, accessibility, affordability and quality of health services; expand health coverage to all local governments; providing sustainable finance for the health sector and reducing infant and maternal mortality rates.

Rather than only targeting wealthier clients, some innovative private insurers have developed tailor-made plans for lower income individuals and families that take advantage of high use of mobile phones in the country. For example, MTN, Nigeria’s largest mobile carrier, launched a service called ‘Y’ello Health Cover’ in 2014 where, for a prepaid weekly fee of 100 N(Naira), subscribers can visit one of 6000 NHIS-registered health management organizations and receive up to N350,000 in coverage, or about 1,000 US dollars.4 It is estimated that more than 130 million Nigerians use mobile phones. In a similar light, the telemedicine market is predicted to $130 billion by 2026.4

Our intervention makes use of existing technology for a new population in a population with high penetration of mobile readiness to transform a health care setting in inertia. In this way, that is the innovation. So that millions more can come to healthcare through this method and transformation. This can even be more catalytic as could trigger a new model and wave of sustainable healthcare throughout the continent of Africa.

Over the next 5 years, we would like at least 20% of Lagos's population to use our App helping to bring about a revolution in the healthcare setting in Nigeria. The hope is that this technology will cut across socio-economic lines, such that accessibility to healthcare will not be determined by how much money you have in your pocket. And the quality of health consultations, again will not be determined by how rich you are. The hope is that this will bring about a transformational impact on the lives of these individuals, hopefully improving health outcomes, quality of life and even life expectancy in these regions.

Our success will be audited by whether the key milestones if met below:
1. To assess the effectiveness of a home health-care delivery service through the use of a mobile phone app.

This will involve analysis of quantitative and qualitative data provided with consent from patient users of the service and relevant ethical approval. These data will be collected mainly in a prospective manner as well as retrospectively, for example, for audit purposes.

Examples of key indicators measured will be i) number of patients who actually use the service ii) if the patient made a clinical improvement or there was the resolution of the issue after the home visit, iii) metrics around patient-centeredness and patient experience such as good communication/good hand-hygiene during the consultation, iv) simplicity, timeliness, reliability, safety, affordability/cost-effectiveness of the service including use of the app and v) whether they would recommend the service to others. These metrics are based on WHO standards for quality of care.24 

Secondary objectives:
2. To measure the total number of medicine errors over a given period as a quality of care marker of safety
3. To assess how many patients who used the home service that required referral to the emergency department after using the service. This reflects the attentiveness to additional medical care and the degree of health burden. If these figures are low, they may also show the degree of ability to care for and improve a patient’s health without the need for additional medical attention
4. To measure and evaluate in a longitudinal manner serial clinical measurements such as blood pressure, BMI and blood sugar levels amongst our patient cohort measured at the initial consultation and every 12 months thereafter. Similarly, documented co-morbidities will be evaluated to rate and degree of multi-morbidity as well as relevant risk factors.
5. To determine whether the patient has become more health aware since utilizing the service.
6. To determine whether the patient has enrolled on any health insurance or health management organization since using the service.
7. To determine doctor/health professional feedback in delivering healthcare to patients in their homes using mobile healthcare app.
8. Evaluate various forms of communication/marketing tools which impact engagement and utilization of this service.

Our goal of reaching 20% of the Lagos population with our intervention (and the data points prior provided and measured) helps to address and align with UN SDGs of good health and well being and reducing inequality in healthcare so that those who cannot afford healthcare can get sustainable healthcare in a meaningful way. It also addresses reduction in poverty as if we can get the population to have less health burden (as defined by co-morbid status and severity) and increasing life expectancy as well as improved quality of life (QOL), then this allows for those individuals to pursue more uninterrupted economic opportunities for their lives thus helping to reduce poverty, and support/improve health infrastructure in the region, two of the other UN SDG goals.

Theory of change will demonstrate that the app will connect doctors in the region to patients with illness, providing timely, robust and safe care for patients, hopefully improving healthcare outcomes in the region.

Activities include:

a) Doctors seeing patients

b) Training of Doctors to align with mandatory training modules

c) Certification and validation of Doctors (to ensure safety, probity for our doctors and establish a high quality of care metric for our patients

d) Marketing - so the local population and other collaborative services know who we are.

Outputs:

Service delivery and short-term outcomes:

a) Doctors seeing patients

b) Training of Doctors to align with mandatory training modules

c) Certification and validation of Doctors (to ensure safety, and probity for our doctors and establish a high quality of care metric for our patients

d) Marketing - so the local population and other collaborative services know who we are.

Medium-term outcomes:

a) Better chronic condition management -  blood pressure control, better asthma management or diabetes management, or weight loss

b) Correct acute management - prescription of drugs including antibiotics, referral to emergency or specialist services

Long-term outcomes:

a) Improved health and accessibility

b) Improved quality of life and life expectancy

c) Better health care infrastructure

We are leveraging the technology of Apps and SMS technology as relatively low-cost, but maximally effective interventions to cause transformation in the lives of this population. These technologies provide scalability, ease of use for the patient population and high penetration already amongst the population and are forecasted to even have a greater impact, as early data from health apps used in this context are showing this impact. App nearly complete and ready for deployment in Autumn 2022.

The company Doc En Route collects the data with each patient's consent. If the patient does not consent, the data is destroyed. The data is stored in a password-encrypted Google cloud-based system. The incentive is that these data points will give a clearer picture of how to improve personal healthcare and healthcare of the wider population in the region.

CEO - Dr Norris Igbineweka (Black Nigerian British) (male) (doctor)

CFO - Dr Oprah Solanke (Black Nigerian British) (female)(doctor)

COO - Dr Ijeoma Akunna (Black Nigerian British) (female) (doctor)

IT - Mr Afolabi Scott (Black Nigerian) (male) (doctor)

Subscription-based model.

We are applying to Gates Challenge – firstly because its expertise and know how in providing/leveraging solutions to African settings like Nigeria.

Secondly, with any great idea or concept, particularly launched in a lower income country like Nigeria, financial sustainability is vital.

Our economic model is below and we are applying to the Gates challenge for support of this.

App Development Cost (NGN 3,160,000): Required to build the Doc En Route App including incorporating a payment platform. (Already done)

Website Build cost (NGN 216,000) (already done):

Company registration and trademark fees (NGN 205,000):

Branded laptop bags/pen/notepad/prescription notepads (NGN 1,160,250): Required to equip Doc En Route doctors in Lagos for home medical consultations with clients.

Medical bags and equipment (NGN 400,000):

Recruitment (NGN 100,000): We aim to recruit the best doctors in Lagos Nigeria. This cost will enable a thorough recruitment process and allow for doctor vetting to strict UK clinical skill performance standard.

Training and induction (NGN 337,500): This will enable us invest in relevant training for our doctors towards providing an excellent standard of care to our clients.

Mandatory compliance training (NGN 225,000):

Marketing Cost (NGN 10,000,000): We aim to keep this cost to a minimum by initially optimising ‘lower cost’ marketing avenues (Radio/TV/Experiential Marketing/Social Media). The ‘heavier cost’ avenues including billboards, TV and etc will need to be utilised if client build up remains stagnant.

Start up cost with ‘heavier cost’ marketing avenues = NGN 13,818,750 + 10% buffer = NGN 15,200,625

GBP equivalent @ NGN 450/GBP1 = GBP 33,779 or 40,552 dollars

Start up cost with ‘lower cost’ marketing avenues = NGN 5,818,750 + 10% buffer = NGN 6,400,625

GBP equivalent @ NGN 450/GBP1 = GBP 14,223 or 17,075

This is the expected state of Doc En Route’s business finances on opening day. This shows the projected balance for monthly variable cost items required to keep the business running.

1 ‘On Call’ Doctor: 1 month salary @ NGN 5,000 per day on a standby basis (based on a 31 day month) = NGN 155,000

Medical Director: 1 month salary @ NGN 800,000

Operations Manager: 1 month salary @ NGN 250,000

IT Support officer : 1 month salary @ NGN 150,000

Total Monthly variable cost = NGN 1,355,000

6 months cashflow required to cover monthly variable costs = NGN 8,130,000 + 10% Buffer

= NGN 8,943,000

GBP equivalent @ NGN 450/GBP1 = GBP 19,873 or 23,863 dollars

12 months cashflow required to cover monthly variable costs = NGN 16,260,000 + 10% buffer = NGN 17,886,000

GBP equivalent @ NGN 450/GBP1 = GBP 39,747 or 47,730 dollars

Pricing strategy is based on a subscription based model

*Based on NGN 35K client fee price point per consultation*

Individual Plans

1. One off Home Doctor consultation @N35,000
2. Annual Subscription (Monthly payments @N35,000) 16% discount applied.

• 14 Home doctor consultations redeemed within 12 months
• Basic health check ups every 6 months
• Prescription delivered to your door

3.   Annual Subscription (One annual payment @N385,000) 25% discount applied

• 14 Home doctor consultations redeemed within 12 months
• Basic health check ups every 6 months
• Prescription delivered to your door

*Based on NGN 35K client fee price point per consultation*

Family Plans

1. One off Home Doctor consultation @N35,000 (Per family member)
2. Annual Subscription (Monthly payments @N120,000) 18% discount applied.

• 14 Home doctor consultations redeemed within 12 months per family member
• Basic health check ups every 6 months
• Prescription delivered to your door

3.   Annual Subscription (One annual payment @N1,320,000) 26% discount applied

• 14 Home doctor consultations redeemed within 12 months per family member
• Basic health check ups every 6 months
• Prescription delivered to your door

These are just initial costings to allow us to be financially viable.

The Gates Award will allow us to even lower our costs further to allow us to reach the impoverished even further. 

Business forecast for the sector

According to Ernst & Young healthcare analytics, despite the low health insurance coverage, there have been rising demands for private health care coverage.4 It is predicted that spending on private health insurance will grow from 400 million US dollars in 2016 to 530 million US dollars by 2021 giving a growth rate of 6%.4

Total spending on healthcare from the Nigerian government remains low at 4.2% of the national budget as of 2017.4 There have been modest increases in total government spend from about 21% in 2016 to 24% increase in 2017. The government has also identified improved access to health care as priority under the Economic Recovery and Growth Plan (ERGP) 2017-2020 with promotion of a digitally led economy as one of the strategies.12 This strategy aims to improve the availability, accessibility, affordability and quality of health services; expand health coverage to all local governments; providing sustainable finance for the health sector and reducing infant and maternal mortality rates.

Rather than only targeting wealthier clients, some innovative private insurers have developed tailor-made plans for lower income individuals and families that take advantage of high use of mobile phones in the country. For example, MTN, Nigeria’s largest mobile carrier, launched a service called ‘Y’ello Health Cover’ in 2014 where, for a prepaid weekly fee of 100 N(Naira), subscribers can visit one of 6000 NHIS-registered health management organizations and receive up to N350,000 in coverage, or about 1,000 US dollars.4 It is estimated that more than 130 million Nigerians use mobile phones. In a similar light, the telemedicine market is predicted to $130 billion by 2026.4

As well as selling services, we are seeking donations and grants.

We are forming partnerships with interested parties and collaborations for future funds with following departments:

Lagos state Ministry of Health

Tytocare (virtual health company)

9mobile (mobile service in Nigeria)

Avon (HMO/medical insurance company)

We have just started and hoping to launch this year Autumn.