Forward Health Senegal

Senegalese people face various barriers to healthcare, contributing to delayed access to care, misdiagnosis, poor outcomes, and loss of life. A majority of households live hours from often poorly equipped health facilities. Once at the facility, patients wait hours to be seen by a clinician and for many, the cost of care is prohibitive. Clinicians and patients often don’t share one of Senegal’s 12 languages, contributing to mistrust in the health system. 

Forward Health is helping Senegal overcome these problems, in partnership with the Senegalese Ministry of Health. Within two years, Forward Health will make a doctor available to every Senegalese person via a phone call, and equip community health workers with cutting-edge smart diagnostic tools for use in consultations.

Piloting in August 2019 with a private sector solution, Forward Health aims to scale this solution to all of Francophone West Africa by 2030, covering a population of 100 million.

Senegal’s 16 million people lack access to quality health care. The country’s medical facilities are unable to meet the needs of the population with an estimated one hospital per more than 500,000, one health center per 175,000, and one health post per 11,500 people. Health facilities are severely overcrowded; after traveling long distances, patients wait hours to see a provider and may have to wait until the following day for an appointment. According to the World Health Organization, there is a shortage of qualified medical professionals, with .1 medical doctor per 1,000 population compared to 2.6 per 1,000 in the United States. The shortage is more acute in rural areas, where health posts are staffed by often overworked nurses forced to provide care despite substandard infrastructure, inadequate supplies, and a broken referral system with limited options to secondary or tertiary care. There are few incentives for qualified medical professionals to work in rural areas, where they know they will have limited support. With more than 12 languages spoken in Senegal, patients often do not share a language with clinical staff, further contributing to miscommunication, misdiagnosis, and mistrust.

In 2018, 50-year old Demba Siira Damba died tragically of bacterial meningitis. Her life could have been saved by a phone call. 

When Demba Siira first experienced symptoms, her family decided against going to a health facility because of the cost of care and language differences with the practitioners there. As her symptoms got worse and the family decided to go, the nurse on call was unable to make a diagnosis. 

Demba Siira was Forward Health co-founder, Aaron Cohen's host mother during the Peace Corps. The family called him at the time to ask for advice. Had they been able to call a quality medical professional instead, Demba Siira could have been diagnosed and she would have still been with us today. Instead, in 3 days, a wife, mother, grandmother, and friend was lost. 

Stories like Demba Siira’s occur frequently in Senegal. Forward Health was founded to serve Demba Siira and the millions of Senegalese people who lacks access to a quality doctor. The company will make this possible by phone, and reduce the costs and cultural barriers for seeing a doctor in the process.

Forward Health is implementing a telehealth solution that will enable patients to text a short code (i.e. 5311) from any mobile phone and receive medical device.  

Patients will be prompted for their language preference, location, and identifying information and then be called by a nurse located in a call center. The nurse will analyze their symptoms, consult them or transfer them to a doctor over the phone. A doctor will then consult them, direct them to their nearest health facility or pharmacy, have lab tests issued, or have a health worker or agent deliver services to them (i.e. malaria rapid test or medicine). In most cases (100% in the first 6 months), these phone calls will be guided by a paid community health worker, agent, or local nurse that will lead the patient through the process and utilize tools such as smart stehoscopes, otoscopes, and photos (i.e. for skin conditions) to capture other relevant data.

Forward Health’s partner, Viamo, will lead the technology implementation, which will consist primarily of the short code service, a call center integration and an Electronic Medical Record Integration. Forward Health is currently establishing partnerships with Senegal’s telecom providers. Forward Health is also establishing partnerships with companies like TytoCare for piloting the use of smart stethoscopes, and looks to have an ultrasound partner (i.e Butterfly iQ) by September 2019.

Forward Health is being co-founded by Aaron Cohen, a tech startup founder and former Peace Corps volunteer in Senegal, and Patrick Singa, a Rwandan doctor with years of experience founding telemedicine solutions to millions of consultations, working as a doctor for the United Nations, and running Rwandan hospitals. The company is being founded out of the Wharton School and Penn Medicine, top tier business and medical institutions that will help to establish the company's business and medical expertise is world-class.

Forward Health envisions a digital-first healthcare system in Senegal, in which the first point of care for patients involves an interaction with a mobile device. Within the next 10 years, Forward Health believes that Senegal will have the most innovative, high-quality primary healthcare system in the world by empowering new types of community health workers and technology-enabled service delivery.

Rapidly developing systems and technologies are changing the way healthcare is being delivered globally. Our solution is innovative in using human-centered design in the application of these technologies in a policy sandbox.

Telemedicine for primary care and medical device technologies are our tools. In Senegal, these innovations have not yet been tested. Designing new systems that incorporate these technologies and that are designed with the patient in mind from the get-go can create quality healthcare that is far more widely distributed and accessible to Senegalese people than previously imagined. In the future we envision, care can be delivered more efficiently for the poor than for the average American today. 

For example, an ear infection for a child is a common occurrence that, if left untreated, can lead to complications such as mastoiditis and hearing loss. Even in the United States, this can often require days to receive an appointment with a doctor and wait times. Forward Health will make it possible for a Senegalese mother to take her child next door and get an appointment instantly. She will be able to see a community health worker (CHW) without any wait time, and have that CHW use a medical device that instantly sends data to an available doctor who can immediately diagnose the infection and prescribe medication that will be delivered by bike or drone. Such models of healthcare delivery have implications that go beyond Senegal alone -- they have the potential to help foster a global healthcare revolution.

Short-run

• A basic Unstructured Supplementary Service Data (USSD) and SMS service
• Cellular phone and 3G
• Tyto Care mobile medical devices
• Web-based database for content management (Electronic Medical Record)

Long-run

• More complex mobile medical device technologies for diagnostics such as portable ultrasounds
• Smartphones/tablets for photos and video calling
• Big data and analytics for preventative care

Our solution will be powered by Viamo (www.viamo.io), a comprehensive, fully operational software platform for delivering and monitoring information services via IVR, SMS, USSD, and social messaging channels. The Viamo platform is directly integrated with mobile network operators in more than 20 countries, allowing us to access local airtime rates with a high reliability voice and text connections. It is a proven, scalable solution, supporting life-enhancing engagements with more than 1 million people per month. The platform includes a hybrid call center application optimized for health applications, combining high-quality local phone connections with cloud-based data reporting and online care flows.

Tyto devices will also be a part of our solution from the get-go. Devices include an exam camera, basal thermometer, otoscope  (for examining the ears), stethoscope (for heart and lung sounds), and a tongue depressor (for the throat). These devices are extremely simple as they are designed for unskilled-workers, they are durable, and use little data. Devices like these are a key part of adding value for patients, such as with pediatrics, and in our becoming a data company long-term.

Because technology has rapidly improved the efficiency in which we can deliver diagnostics and consultations and this has yet to be applied to Senegal, where there are dire efficiency gaps due to a lack of human capital and infrastructure. There is overwhelming evidence that the Senegalese medical system is under-resourced. 70% of Senegal's doctors are based in Dakar. Forward Health's application of technologies will reduce costs and improve quality by helping people access the agglomerated resources in Dakar that they could otherwise not access.

The aim is to serve 1000 people in the initial one month pilot from mid-August to September 2019. 

We will scale nationally in 2020 and within a year anticipate serving at least 300,000 people through consultations.

By 2025, we believe we will be able to consult over 5 million people per year across Senegal and 2-3 other countries.

July 2019: Finalize Memorandum of Understanding with the Ministry of Health enabling Forward Health to work within the public system;

August-September 2019: Launch pilot and gather data on first 1000 consultations. Adapt model as necessary;

September 2019-May 2020: 1. Raise capital (Seed Round) to scale nationally; 2. Gather necessary legislative approvals; 3. Establish deeper partnerships with medical institutions, medical device companies, and businesses/nonprofits;

May 2020-May 2021: 1. Scale nationally; 2. Develop higher value added services with mobile medical devices/diagnostics

May 2021-May 2022: 1. Develop higher value-added services such as insurance; 2. Begin process of scaling to another country

May 2022-2025: Raise capital (Series A) and scale to 3 countries in the region

The highest barrier/risk is the regulator. The Senegalese government can be  prone to corruption. There are little barriers regulating telemedicine but regulations around private company interactions with the public health system and health workers' permission to provide services could bring about unpredictable challenges. We aim to integrate with all health facilities (for references and prescriptions for example) in addition to developing our own methods of in-person delivery -- having a reliable partner in the regulator is critical.

There will inevitably be cultural and financial challenges but neither should be unpredictable or a major hindrance. Both founders have experience implementing projects in the region with success, and both founders have experience in raising angel investment and aid grants.

We are fortunate to have an excellent partners in government at this time. Connections at the highest levels and partnerships with multilaterals can significantly mitigate political failure. The founders have experience and networks in these areas and will formalize them more deeply -- such as partnerships with multilaterals -- post-pilot. 

Cultural barriers will be overcome through talking to patients/clients and adapting our service as necessary. Financial barriers will be overcome through the process of fundraising and partner institutions such as the Wharton School will help in this regard.

At present the company has two co-founders, Aaron Cohen and Patrick Singa who will be working on the pilot project full-time with 3 part-time medical staff, and 4 part-time operational staff (paid community health workers). If the pilot is successful, the co-founders will come on full-time and within the first year, scale to 50 part-time medical staff and 100 operational staff.

In addition, the company has numerous advisors and partners that are contributing in an part-time capacity. These will be discussed further in the sections below.

The team is multilingual and has a unique combination of local expertise, relevant medical expertise, and startup and business acumen.

Co-Founders

Patrick Singa is a Rwandan medical doctor that built a telemedicine service in Rwanda to 2 million registrations and a million consultations per year. Patrick is entrepreneurial and has run public hospitals in Africa as well as worked as a doctor for the United Nations across Africa.

Aaron is an American  tech entrepreneur with extensive experience in Senegal, both on the ground in the Peace Corps and at a high-level with the United Nations/with Senegalese government. Aaron is currently an MBA student at the Wharton School with access to investor resources and business support, in addition to connections to Penn Medicine for medical support. 

Other close partners and advisors include Youssou Ndiaye, the Director of Programming of the Minister of Health in Senegal; Chris Hedrick a successful entrepreneur and director in Senegal with close ties to key nonprofits; Emily Dally the Director of Impact at Partners in Health, and Kellen Eilerts, an executive at Viamo, Forward Health's technology provider.

Ministry of Health and Social Action, Senegal: critical partner, regulator, and manager of national health system in Senegal. Finalizing an agreement to integrate with the public health system;

The Wharton School: premier MBA program. Aaron Cohen is a current MBA student at the school and the school will be useful for fundraising and partnerships;

Penn Medicine: a world-class medical institution to ensure we are providing the best possible care;

Viamo: technology platform provider currently building our MVP solution;

Peace Corps Senegal: partner for distributing quality information to locals and services such as trainings throughout the country;

The business model is to collect fees for consultations that are equal to the cost of seeing a doctor/nurse in a public hospital. Because of the cost efficiency benefits of using telemedicine, this is profitable, whereas a brick and mortar operation -- such as a health post -- generally operates at a loss in Senegal's case. 

Long-run the company will focus on higher value added services such as maternity care, innovative models for insurance products, and innovative data-use models to drive down the costs of consultations and drive profitability verticals outside of healthcare.

The operation will be profitable or at least breakeven within 2 years. Long-term profitability as mentioned will be driven by key innovations in higher value added health services, insurance products, data plays.

We are going to use technology to flatten access to healthcare in Senegal: drive down costs, increase quality, make it more accessible to millions of people who can't talk to a doctor in their language. This fits so well to two of the Healthy Cities challenges. 

We also have a lot to learn. The MIT Solve community is clearly one with great resources in innovation in healthcare startups and more. We want to be an eager member of this community that can learn but also help its members revolutionize healthcare around the world.

In the near future, medical device innovators like Butterfly IQ, and innovators at the intersection of technology and patient-centered care. We want to be a true innovator but for the purpose of providing the best care in the world to the poorest people in the world. We have the bold vision that this is possible and profitable -- and that this is because of a truly unique moment because of technology and innovations in care.

AI is a big part of our future vision but not our initial vision at this stage. Would love to learn more about this though.

This is a solution we could absolutely focus on in the medium-term and we believe we have the potential to be the best preventative care mechanism in developing countries. However, at this time we have a laser-focus on providing consultations. Preventative care is a step for us after a year-in.