Skoll World Forum Interviews: Spotlight On Africa Health Innovators

Welcome to Role Models for Change, a series of conversations with social entrepreneurs and other innovators working on the front lines of some of the world’s most pressing problems.

Peter:
Hello, Ari, and welcome to the Skoll World Forum, thanks for joining us today.

Ari Johnson:
Hi, Peter, it’s good to see you.

Peter:
So I’m really excited to hear about the work that you’re doing. And I suppose just to begin with, can you introduce yourself and explain exactly that, what exactly you’re working towards?

Ari Johnson:
So my name is Ari Johnson, and I am one of a group of Malian and American co-founders of Muso. And at Muso, we came together with a common commitment, shared belief that no one anywhere should die waiting for healthcare.

Peter:
What first inspired you to do this work? And why Mali? And why exactly did you begin when you began?

Ari Johnson:
Muso was founded by a group of Malians and Americans who shared a common concern about the connections between health inequity and poverty. And one of the first things that we decided to do was move in with the communities we sought to serve. And that was in Mali, on the edges, on the outskirts of Mali’s capital city Bamako. And that decision really changed everything for us, because those who we sought to serve became our neighbors, our friends, and eventually our teachers. So shortly after we moved in and we’re living on the edges of Mali’s capital, we started to encounter our neighbors in moments of crisis. A neighbor came to us panicked, she said, “Will you see my grandson?” And we could hear that she was distressed, and so we did what any neighbor would’ve done, we rushed with her to her home and found her one-year-old grandson. And he was struggling to breathe in respiratory distress soaked in sweat with a high fever.

And in that setting, we just mobilized his neighbors really, we worked to rush him to the hospital and try to get him there as quickly as we could. But by that point we were too late, and the next day we were sitting at this baby’s funeral, our neighbor’s funeral, reliving what it was like to be with him in some of his final moments. It was clear to us that he shouldn’t have died, we were angry that this could’ve happened, and we also felt culpable. We had a burning question inside of us as well, how could this have happened? Why did this happen? Before we had a chance to really get an answer to that question just a few days later something similar happened again, another neighbor encountered us in a moment of crisis and we accompanied them. Then it happened again, and again, and again.

And it got to the point where every day we would wake up in dawn and we would be encountering neighbors in crisis, struggling and failing to access the care that they needed and deserved for themselves, for their children. Every evening we would be accompanying our friends and neighbors as they tried to get their kids or themselves care. And it got to the point where we were attending the funerals of our neighbors, funerals of kids, babies, young moms nearly every week. We sat at the funeral of one of our neighbors who was a young mother, younger than I am today, who had died of a cavity essentially. She had had a cavity that turned into a dental abscess, she needed just a little bit of dental care, and then she needed a few dollars worth of antibiotics which she couldn’t afford. And that dental abscess turned into a bloodstream infection, and then I was sitting at her funeral with her next to her toddler.

And through these experiences, we continue to ask, “Why is this happening?” We had come in thinking initially very much like doctors, thinking about how we could be useful in health inequity, one disease at a time. And looking epidemiologically, malaria was leading cause of illness and death. So we said to ourselves, “Okay. Well, maybe we should start a malaria prevention and treatment program, that seems logical.” But as we accompanied patients and as we pivoted our research to really dig into this question, why are so many of our neighbors and particularly young mothers and children dying at this alarming rate? How did we end up at ground zero of the global child mortality crisis? We started sitting down with our neighbors and asking them to tell us their whole life story, from the moment they’re born to the moment they or their child or someone in their family became sick.

And then in great detail every step of the way, helping us get a window into their experience of illness and seeking healthcare, and how they see the health system. And through that process, our neighbors, patients became our professors. And they taught us not only had we got the solution wrong, but we had fundamentally misunderstood the problem. They explained to us that they didn’t have a malaria problem, or a diarrheal disease problem, or a pneumonia problem, or a newborn sepsis problem, or a dental abscess problem, they had a problem getting healthcare in time. They had a problem with delay, with healthcare systems that were designed to delay or deny them access because they’re poor.

Peter:
And that’s fascinating I suppose, that kind of approach. And I suppose possibly quite rare in the sense that it seems when you went to Bamako to begin with, there weren’t necessarily any preconceived notions that you had. And actually you went out to listen to the community themselves about their needs and what they were looking for, and that’s sort of how you went to develop and cater to them.

Ari Johnson:
Yeah. Well, I do think that those first decisions to move in and live with the communities we served and then to do research that listened deeply to their experience, those decisions were crucial. Because we did have some preconceptions about how we should proceed, we were originally thinking about tackling things one disease at a time. It became very clear that that wasn’t what we should be doing, that from our neighbor’s perspective, from the perspective of the communities we sought to serve, their fundamental problem was about getting care in time, no matter what condition they suffered from. So as we were attending our neighbor’s funerals, we started to ask ourselves, “Could we imagine a healthcare system that could reach every person without delay? Could we imagine a healthcare system that meets patients where they are? Could we imagine what it would take so that no one would die from delayed healthcare?” And yeah, so that question really led to the creation of Muso.

Peter:
Exactly. And sorry to interrupt that, just in terms of… So obviously as you said, right at the beginning, your goal is to tackle this huge number of preventable deaths. But I suppose, could you talk a little bit to that point? What kind of scale… Well, at least before you began your work, what kind of scale of the problem was there in terms of preventable deaths in Mali?

Ari Johnson:
In the communities we sought to serve, before we launched our first rapid healthcare system, the rate of child death was one of the highest in the world, 154 deaths per 1,000 live births. So about 15% of kids not making it to their fifth birthday.

Peter:
And I suppose logically after you began your work… I suppose, can you tell me… So you were speaking about the process of how that was developed, and then you put in place these systems of identifying these varying… So maternal healthcare and malaria treatment, and I suppose also this community-based approach. I suppose, can you talk about how that went on to be developed? Because obviously in your experiences, as you said very keenly in the first example of a child that passed away, you already drew on the neighbors of that family to try and help at the time. And I think did you kind of take that philosophy forward?

Ari Johnson:
Through our research we asked patients and families, particularly mothers, to map out for us their experience of the healthcare system. And to, in a sense, diagnose for us, what were the main barriers that they were facing that were delaying or denying them access to care? As they mapped out their experience in healthcare for us, we saw that there were a few very important barriers that patients were facing again, and again, and again. So fees, they couldn’t afford to pay. Distance, they couldn’t afford to travel. And then providers without the skills, or the things, the equipment and the infrastructure they needed to make the diagnosis and provide the care. So what we ended up building, rapid care targets those barriers, the financial to geographic and the quality barriers to getting care on time. Imagine instead, we have a healthcare system that begins by meeting the patient where they are, professional community health workers going door to door in their communities, finding patients either at their home or at their workplace and bringing the care to the patient as step one.

They are equipped and trained to provide evidence-based diagnostics and therapeutics across a spectrum of different conditions, and provide full integrated care for patients where they are. They are also triaging, identifying patients who have [inaudible 00:11:26] that they need a higher level of care. And those patients whose illnesses are either too complex or too severe to treat in the home or in the community, they evacuate by off-road ready ambulance to redesigned upgraded primary care clinics that we partner with, they’re public sector government clinics that we support to redesign. And then finally, at every level of care, no money changes hands, we remove all out-of-pocket fees, because those out-of-pocket fees are the number one barrier that delays or denies access for patients.

Peter:
And I suppose just taking a bit of a look at the bigger picture, obviously when we’re thinking about some of the healthcare challenges in Sub-Saharan Africa, obviously the systems that tend to be in the West, the Global North for example, for various reasons just aren’t applicable to countries like Mali who can’t have expensive hospitals everywhere. And so your approach obviously is to take those already living within these communities in order to address all of these various barriers, to have that kind of early awareness and early warning signs, and also I suppose more affordable treatment. It’s a much more contextualized approach to healthcare, is that right?

Ari Johnson:
I don’t know if I entirely agree with that, because I think countries like the one in which I was born, the United States, has a great deal to learn from what the government of Mali, and the government of Cote d’Ivoire, and other governments that we and others serve in Sub-Saharan Africa are doing in healthcare. Serving sometimes as a physician in the United States, I think that our own healthcare system is far from perfect. And yeah, I think the United States has a lot to learn from healthcare systems in Sub-Saharan Africa as well. I mean, you’re talking about efficiency, and I can speak to that. This system of providing healthcare that meets patients where they are and that doesn’t charge any out-of-pocket fees, it might sound expensive, it actually isn’t, it costs just a shockingly modest amount of resources to do. In Mali our cost estimates are about $12 per person served per year to provide healthcare without fees, both in the home and at upgraded clinics.

Peter:
Yeah. Well, that’s a fraction of the amount compared to other budget spends you’d imagine. And I just suppose now, so obviously we’ve spoken about the systems that you’ve helped to put in place along with your Malian team. And so I just wonder, we spoke before about that area in Bamako having one of the highest mortality rates for under fives in the world. And some years down the line now, can you just talk about the impact that that’s had in Bamako and also other parts of Mali that you’ve been working in?

Ari Johnson:
Muso, the Malian government, and a consortium of academic partners conducted a seven-year study of this rapid care approach in urban Mali, and that study was published in the British Medical Journal of Global Health. And what that study found was that the rate of child death in these areas went from at baseline 154 per 1,000 down to 7 per 1,000 in this course of seven years. So to our knowledge, that’s the largest and fastest improvement of child survival and child mortality ever documented anywhere.

Peter:
Yeah, that’s obviously incredible results. And I suppose, to what extent do you think that this kind of approach, this community health worker approach can be used in other regions, other countries, whether that be in Sub-Saharan Africa or indeed other parts of the world?

Ari Johnson:
So delay, and delay in access to care is a problem, is an injustice that exists all around the world. It isn’t particular to Mali or to West Africa, it is a major cause of preventable illness and death in the United States and also worldwide. So at Muso, we are working to tackle a real global injustice of people not getting the care that they need and deserve in time. And by our analysis, we see more than half the people on the planet not getting the healthcare they need in time.

Peter:
Right, and so potentially there’s hundreds of millions of people that could be helped. And I just suppose, obviously you’ve been working on this issue for several years now, if not more than that. And I just wonder for you, what have been the biggest obstacles and challenges in the past and also the next ones I suppose that you foresee in the future? Obviously after beginning in Mali, you’re trying work in Cote d’Ivoire, a second country, also perhaps that has some lessons between the two.

Ari Johnson:
One challenge in the work, is that we are breaking down silos in this work together at Muso and with our partners. The work we’re doing isn’t about only one disease or only one level of healthcare, it is actually about redesigning how healthcare works, where it happens, who provides it, and how it gets financed. And redesigning healthcare to the bone, that is a challenging thing. National healthcare reform in any country is a challenging thing to do, and that’s a challenge that we and our Ministry of Health partners are taking on together.

So the Malian Ministry of Health in 2019 committed to a major national healthcare reform that is in the process of being implemented now that we are supporting. And Cote d’Ivoire, the Ministry of Health of Cote d’Ivoire committed to a new national community health strategy that we have been supporting from the design phase now into the implementation phase. So this is a very exciting time. It is not easy to make national healthcare reform happen, but we have the privilege of serving the leaders of sovereign nations that have a bold vision for the future of healthcare, and we have an opportunity to bring in some evidence-based design and some evidence-based strategies to support their efforts.

Peter:
And I just want to make sure that… If we properly painted the picture, to make sure it’s clear. But I suppose now, can you explain… Because I presume obviously the role has adapted slightly over the years. But when we think now about a classic community health worker in Bamako, for example, what exactly are their daily duties? What do they go about and do? And obviously I think it’s important to point out that the vast majority of them are women, as the name of Muso I understand alludes to.

Ari Johnson:
Absolutely, so a day in the life of a community health worker on our team whom we serve. Community health workers we support spend hours every day going door to door and searching for patients who need care. They visit every family in the communities they serve about twice a month, at least twice a month is their target. And community health workers are going door to door searching for patients who are sick and patients who need other care as well.

So they’re proactively searching for patients who are pregnant and need prenatal care, they’re also identifying every child under two who needs immunization. And they have a backpack that has the diagnostics and therapeutics that they can offer, and then they have a smartphone in their hand with their CHW app, their digital platform that supports and guides their work as well. And as they visit their neighbors one at a time, they are screening for illness, they’re diagnosing malaria, and pneumonia, and diarrheal disease, and malnutrition in the home. They are checking on vaccination status of kids, they are providing some prenatal care in the home. They’re also identifying the sickest patients who need evacuation, who can’t get care in the home, and arranging for evacuation by off-road ambulance of those patients to upgraded primary care clinics.

Peter:
And so obviously it’s transformational for the experience that they had, compared in the past where they would have to do the travel and often maybe they wouldn’t have the time or resources to do that, and now just these services are coming to their doorsteps quite literally.

Ari Johnson:
Patients all over the world face these kinds of challenges in different forms and to different levels of severity. But if I imagine myself as a parent having to make a decision between do I feed my sick child today and the rest of my family, or do I take that money that I would otherwise use for food and spend it on bus fare, and then fees, and prescription costs to bring my sick child in? What a terrible decision that no parent should ever have to make, between food and care. But that’s exactly the kind of terrible calculus that parents all around the world have to make because of healthcare systems that place the first point of care far too distant from patients, and that place the decision of care hand in hand with fees that many patients can’t afford to pay.

Peter:
Yeah. Just a couple more questions then I had for you, Ari. One, and it just stuck in my mind from the beginning, I’d be interested to know why exactly what drew you to Mali specifically. Obviously you said that you’d moved to Bamako, but what was the impetus for that?

Ari Johnson:
I was living in South Africa in the KwaZulu and Natal region of South Africa, and I was working as a research assistant. As a researcher I was writing and helping to publish research articles, book chapters, all about barriers to care for young people with HIV. And all of this research that I was participating in, I didn’t feel like I was making very much of a difference really. I was publishing, and publishing, and publishing, and my friends and neighbors in South Africa were dying.

At that time antiretroviral treatment was just beginning to arrive in the rural areas where I was living. And I was learning things about barriers to care through that research, but my research was sitting on a shelf. And so I became quite frustrated with that situation, I wanted to be of service. And around that same time, a mentor of mine had said, “Hey, you should connect with some other folks that I know who are getting something started in Mali. I think you see things in some of the same ways.” And that’s how I came to be connected with this amazing group of Malians and Americans who eventually started Muso, and I flew from South Africa to Mali to join them.

Peter:
Right. And now I suppose looking back over that long story, and obviously there’s huge amounts of progress that we’ve spoken about already today, I just wonder, looking ahead, what is it exactly… Could you, I suppose, describe to me what the world… Whether it is in Mali or more broadly when it comes to healthcare and preventable deaths, what kind of a place should it look like and will it look like if your aspirations come to fruition?

Ari Johnson:
If I’m ever blessed to have grandchildren, I want them to look at me in disbelief and ask me, “Really, when you were young, 5 million children died every year of treatable illness because they’re poor, that happened?” I want them to be in disbelief about that. Because that is an injustice that we have the tools to solve right now, that we can solve in our lifetimes. At Muso, we believe that no one anywhere should die waiting, and we see the global child mortality crisis, the global maternal mortality crisis as solvable now. We have the tools today to make the death of a child rare in every community on the planet, and that is what we are pushing toward, that is what we are struggling and striving toward today.

Peter:
Well, I think that’s a good point to end on. So thank you very much for your time, Ari.

Ari Johnson:
Thank you, Peter.

Welcome to Role Models for Change, a series of conversations with social entrepreneurs and other innovators working on the front lines of some of the world’s most pressing problems.

Peter:
Hello, Benjamin. Thank you very much for joining us today at the [inaudible 00:00:16] World Forum.

Benjamin:
Hi, Peter. How are you?

Peter:
I’m very well, thank you. Very well. So, I’m excited to hear about the work that you’ve been doing.

Benjamin:
Okay.

Peter:
I suppose if you could just start us off by introducing yourself and just giving us the top line of the work that you’re doing.

Benjamin:
My name is Dr. Benjamin [inaudible 00:00:34]. I’m an emergency physician based in Nairobi, Kenya, and founder and executive director of the Emergency Medicine Kenya Foundation. So this is an NGO I set up in 2015 to support governments and emergency healthcare providers to strengthen the emergency healthcare system in Kenya to save lives. We do this through capacity building, knowledge development, advocacy, and research.

Peter:
And I can’t remember, correct me on the exact figure itself, but I can’t remember, it was on your website. Was it 57 Kenyans?

Benjamin:
57, yes. Yeah. So, 57 people die every hour in Kenya, and this number is quite high. I mean, if you compare it to other countries that have well established emergency healthcare system. And it’s actually estimated even by the WHO that we could potentially have half this number by setting up emergency healthcare systems. And that’s pretty much what we do with the government to try and build up an emergency healthcare system. So, unlike many western countries, Africa and many other low and middle-income countries do not have emergency healthcare systems. The focus has always been on vertical programs like malaria, TB, HIV, but not really focusing on looking at the emergency healthcare aspects.

This is actually despite the fact that all these patients who come up the vertical programs at some point do need emergency medical care. And unfortunately with no working system, essentially in an emergency, everything pretty much fails and most people die, not necessarily because of the disease that they have, but because they actually could not get that acute immediate care. So, unlike other healthcare, unlike other medical conditions where you have time in an emergency, if that care is not provided, then most likely you will either die or suffer permanent disability or protracted hospital stay.

Peter:
Right. And so as you’re pointing out, that’s a huge percentage of you say 57 an hour and half of that potentially of those victims or those that pass away could actually be treated. So, looking at the scale of the problem in Kenya, it’s actually a massive, massive issue.

Benjamin:
Yes, it’s a huge issue and we’ve had a huge number… So, previously we had a lot of communicable diseases, the HIV, TB, malarias, but with the changing lifestyles and the growing population, then the non-communicable disease, the heart attack and strokes have also been on a significant increase. Actually the heart attacks and stroke make it to the top 10 list of conditions that kill people in Kenya.

And then there’s also, there’s still a burden of road traffic crashes. And if you look at things like your heart attacks and strokes and road traffic crashes, these are conditions that pretty much need emergency medical care because of the need for timely care to save lives. So, it’s a really growing burden of disease, I mean, burden in the country. And if we don’t fix the emergency healthcare system, we’ll then definitely lose more and more patients.

Peter:
I think Benjamin, we were just talking about the gravity of the situation and we’re speaking about the number of deaths. And a point you mentioned was just about the, I suppose historically the funding and the work has been going into some of that longer term issues and diseases as opposed to emergencies. Wonder what exactly do you think that’s been the case?

Benjamin:
So, a little bit is pretty much lack… I mean, emergency medicine as a specialty is a fairly new specialty globally. Probably in the US, UK in the last 50 to 70 years is when your emergency healthcare systems were being built compared to other healthcare system, other aspects of the healthcare system. And so in Kenya, and again, many low income countries, emergency medicine was not a specialty until 2017. And so we’ve not really had any specialists or any healthcare providers trained in emergency medical care. It’s not part of our undergraduate training programs. And thus, the technical know-how and knowing what to do, how to set it up has not really existed in the country.

And as I said, the burden, I mean, the biggest burden of disease has always been the HIV, the communicable disease, HIV, malaria. And our healthcare being largely donor funded also then has focused on the programs which donors tend to fund, which is your HIV, TB, malaria. No one really funds emergency care, yet it’s the one thing that connects the entire system. I mean, all vertical programs eventually at some point, I always say unless you die in your sleep, at some point you will need emergency care towards the end.

So, from a combination of lack of prioritization, lack of funding, lack of actually data to see the burden of emergency care, because it’s not really collected, a lot of this has contributed to why it’s not really been developed and people just die and everyone’s like, “Oh, sorry they were too sick,” but really the actual thing was the lack of emergency care. So, I came back to Kenya in 2012 from my training in South Africa where I did masters in emergency medicine. And for me the shocking part was the amount of patients we were saving in South Africa, they have a really good emergency healthcare system.

And I was like, “Why I never saw these patients during my training in Kenya?” And I quickly realized that part of the patients that we were resuscitating and saving their lives essentially in Kenyan setting, do not make it to hospital. They die out in the community or on their way to hospital or on arrival in the emergency department because we just didn’t have any system in place. And based on my experience, that’s really a lot of patients who die before you actually know about them.

Peter:
I suppose I just wanted to ask Benjamin about, what is really… As you described quite well, a lot of these cases are really tragic and these victims or people that are injured just aren’t treated. But I just wonder, and I suppose we can separate between what you are offering and what is tended to be the case, but what happens when there is an emergency in somewhere, typically in Kenya, when they need to call the emergency services and what actually happens from that process and how long might it typically take for them to be responded to?

Benjamin:
Yes, I like the part you said call emergency services. The question is, which ones? We don’t have any 999, 112 number. There is no single number you can call to get an ambulance service. We have ambulances in the country, but a lot of them are potentially largely private ambulance services. And also the government ones are more hospital based ambulances for transfer. So, there is no one number you call in case of an emergency. And so what people tend to do is to quickly identify how they’ll get to hospital. So, most of the people get to hospital by private means, whether it’s neighbors, taxi or your own car, if you’re driving. Or you find a boda boda, that’s the motorcycle guys, and they take to hospital. So you just find a means to get to hospital. So, that’s the first problem.

And of course, naturally there’s no care being provided to you as you get to hospital. And again, even after an accident, essentially it’s the good Samaritans on the roadside will pick you up and take you to a hospital. The other part of it is we’ve not really had designated emergency departments. So, most of the time you’ll just be taken to the nearest healthcare facility. But it’s very clear not every healthcare facility has a capacity to handle emergencies. So, you may end up in a facility thinking they will save their lives, but it’s just a dispensary or health center and they don’t really have the capacity to do that. So, then you now have to find another means of transport to the other hospital.

And that’s where sometimes you can end up going from hospital A to hospital B, hospital C, because they’re no really well designated defined emergency centers. A lot of the time it’s panic, of course. Everyone panics, quickly try to figure out how to get to hospital, whichever means possible and then go to the hospital. And then the other part of it is even if you’ve gone to the right hospital, again, because emergency care is not really taught as part of undergraduate programs and the departments are not designed as emergency departments, patients tend to wait in queue and a good number of patients die before actually seeing the doctor or the healthcare provider in the hospital because it’s just not designed that way.

Most of our health facilities are designed, a lot of patient clinics on a first come, first served basis. And this contributes significantly to the mortality again, or the mobility for these patients. Because yes, they got to hospital and may have gotten hospital time, but because there was no system at the emergency department level, at the entry level, then the patients pretty much potentially die waiting to get care.

Peter:
Right. Yeah, that sounds a really tragic situation. I just wonder when exactly, because before you mentioned that you did your masters in emergency healthcare in South Africa. And so obviously fairly early on you’d established that you’d be interested in working on this, but how exactly did it come about? Why were you inspired? Was there a particular incident?

Benjamin:
A lot of it was, I mean, I did my undergraduate training in Nairobi, the University of Nairobi. And for me it was when we had an emergency, I just tell you exactly what just happened. So, we’d be in the ward round and we’re seeing a patient who was deteriorating and all of a sudden it’s just confusion. No one really knows what to do. And we’re like, “Okay, let’s try this, let’s try.” We are not taught, it’s not something we are taught. So, we used to panic a lot. Even as a healthcare provider, I didn’t know how to manage emergencies before I got trained. You panic, you cannot do something and looking back, you’re probably not doing much and the patient dies and you’re like, “Oh, well there’s only so much I could do.” But unfortunately this just keeps happening and happening and happening.

And then you’re like, “I am not prepared to handle emergencies.” And for me that was one of the things I was like, I think I need to learn how to handle emergency care. Because the beauty about emergency care is you provide the care and you see kind of instant results in terms of survival and things like that. So, I went into medicine to save lives, not watch or supervise death as we call it. My objective of getting to healthcare into medicine or save lives, but I realized I was more supervising death than actually saving lives because I didn’t know what to do. And it’s not just me, just all of us didn’t know what to do because, well we weren’t taught emergency care, it wasn’t really part of the curriculum.

Immediately finished now my internship, I was very clear that I need to learn emergency care to save lives. Yes, I know medicine and fine, I can treat you if you have malaria, I can treat you if you have pneumonia, but if you’re dying, I probably will not be able to save your life. And that’s for me was a need to learn emergency care. But more importantly now coming back to Kenya after my training is to make sure everyone learns emergency care as healthcare providers and we would slowly start working to build a system.

So, actually when I came back, my first priority was to just disseminate the knowledge to healthcare providers about emergency care and how to handle various emergencies. We develop protocols and guidelines because I believe every healthcare provider needs to know emergency care to a certain level and then there needs to be well-trained emergency healthcare providers in any healthcare system.

Peter:
And so I think you mentioned the start that you are also working with government authorities, but how exactly has that process developed?

Benjamin:
It’s been an interesting journey working with government and actually we work mainly with government and we’ve had incidences that have really come to light, even highlighting the gaps in emergency care. One incident I was mentioning earlier was a gentleman who died in an ambulance having waited for at least 18 hours to get care and after a road traffic accident. And this led to series of litigation and hospitals were sued and the discussion then said happening around, and it had happened even from before, but it became amplified that we need to build emergency care system.

So, what we’ve done with the government is ensure that we put in the legislation around emergency care. It’s in our constitution 2010, it’s in the Health Act 2017. So, we’ve really supported the government to start putting in this legislation because without legislation on the right policies, then the government is not able to develop the framework, is not able to budget for the framework. And in 2021, we launched the Kenya Emergency Medical Care Policy 2020/2030, which is probably only… There are handful of countries that have actually emergency medical care policies and Kenya is one of them. I’m sure there are no more than 20 from the last year was checking.

And this has really strengthened the ability for us then to continue working to strengthen the emergency healthcare system, again based on the WHO emergency care framework. And only last month the government put in the emergency care fund, which ideally is supposed to then help, for those who cannot afford emergency care services, then the fund comes in and thus, you’re able to access emergency care even though you do not have any money with you.

So, we’ve been working step by step with the policy makers to develop these policies and make sure that these policies are holistic and address all aspects of emergency care because at the end of the day, emergency care is a right and it’s enshrined in our legal system now and it’s enshrined in all our policies. And so now beyond that aspect of it, then is looking at how is it being delivered and supporting those who are delivering emergency care services. And that’s why I say we support the government and emergency healthcare providers to make sure that those providing the care are able to provide the appropriate care in a timely fashion.

Peter:
I suppose how is that playing out? And I suppose are there already the fruits of that labor being benefited from? I suppose, is it now there are… So, if a patient now arrives at some kind of medical institution, they’re able to be, well go through the emergency procedure as such.

Benjamin:
I’d say there’s been significant difference. When I came back in 2012, the only thing we had was a constitution that said every Kenyan has a right to emergency medical treatment. But since then we’ve had significant legislation. We’ve had the Health Act 2017 that defined more what kind of emergency care should be provided. We’ve had the Kenya Emergency Medical Care Policy 2020/2030, which is I guess as I mentioned is probably we are one of the countries in the world, well maybe of 20 countries globally that has an emergency medical care policy.

And recently we’ve just had the government legislate, the emergency care fund that’s supposed to essentially ensure that everyone can access emergency medical treatment, even if they don’t have money to pay for it. So, there’s been quite a significant development from a legislative perspective. And the Kenyan health system is broken down within the county governments, which is for seven counties. So, a lot of the counties have also been developing their own emergency medical care plans.

We now have dispatch centers that are mushrooming in the various counties to provide that central coordination of ambulance services and having a number to call for the county ambulance to come pick you up. We’ve supported, of the 250 public emergency departments that we’ve mapped out across the country, already supported 140 of them, 142 of them and provided them with guidelines, equipment. We’ve renovated whole emergency departments to improve the infrastructure and process and patient flow. So yes, also emergency medicine was recognized as specialty in 2017.

I’d say in the last 12 years has been significant understanding, significant growth around emergency care and a lot of the foundation has been laid out. We’re at a point where now it’s just a matter of scaling it up to make sure that we are catching all the 47 public ambulance services. We are catching all the 250 emergency departments. The protocols and guidelines are being implemented across board. The policies being implemented, the policies are being implemented as they’ve been designed. So, we’re at a point where a lot of the foundation has been laid out and now it’s just a matter of scaling it up to make sure that it cuts across the country.

Peter:
Right. And I suppose you making that point about those 250 sites weren’t mapped at all, and that’s quite shocking obviously and quite a crucial factor. But I just wondering in terms of now mapping the impact. Obviously it’s hard to measure to some extent, but in terms of the amount of patients that have benefited thanks to this new system, do you have any idea?

Benjamin:
So, essentially most of the EDs see 150 patients a day. So from the ones we’ve actually supported so far, well estimate from the data we have, it’s 4.6 million patients pretty much receiving quality emergency medical care annually. We are working to collect better data and refine the data being collected as part of the improvements for the emergency healthcare system. But currently from the data we have is like 4.6 million patients are having an improved quality of emergency medical care annually.

Peter:
And when it comes to, I know obviously we’re talking about the west and the systems of emergency care are very much in place, even if they do have problems, they’re well established. And you gave the example as well that you think that South Africa’s system is also quite impressive. But just to what extent can you learn from those other models and to what extent, I suppose are there particular contexts in Kenya that need to be adapted to?

Benjamin:
So, I think yes. I mean, the good thing about I’d say where we are at as a country is we’re not starting from scratch. We’ve had experiences and we’ve been able to learn from other systems in the US, UK, South Africa. Again, I mean in Western countries, the resources are, yes, you have all the resources I guess. And so as we develop our systems back home, there’s a lot of thought process that is going into it to make sure that it’s cost-effective and sustainable. I think for us, that’s the difference, and looking at what are the evidence-based practices that we can implement that will essentially provide the exact out outcomes at an affordable cost for the country. Because there’s no use setting up a system that’s not sustainable.

I know, yes, I mean the US emergency healthcare system is extremely expensive and thus looking at having very strict criteria. In fact, we were doing it now with emergency care regulations that we just did with the government is to say, what exactly will we pay for? So, looking at as a government, well the government as it is, it’s more cost-effective to pay for life-saving care than to say you’re going to pay for every person who shows up in the emergency department. That’s just not possible. So, it’s been well-defined in the new emergency medical care treatment fund regulations about what exactly is emergency care and focusing on that life-threatening care that people present with and making sure that’s what’s being catered for.

As we build the entire aspects, all other aspects of the system is pretty much focusing on providing that lifesaving care or limb saving care as a baseline. And then as more resources get available, probably expanding it to the next level. In emergency care, we normally triage patients into categories and say, “This is priority one, this is priority five.” So, we are currently trying to build a system and we cater for priority one and two, for example, and hopefully down the line we’ll get to be able to cater for everyone else.

Peter:
I suppose from your perspective, again to go back to the point you were making about how you’re in this to save lives, and at this point you’re saying that figure, 150 before. I just wonder how rewarding is it? Do you know that this work that you’ve been going on for over 10 years now is genuinely saving real people’s lives and presumably the families all across Kenya are able to have their loved ones still with them?

Benjamin:
It’s saving lives. I mean, a lot of this is an anecdotal because what we do is we connect all the healthcare providers we train through WhatsApp in different forums and it’s good to see them say, “Thanks to the training, we were able to implement this protocol.” Or, “Thanks to this protocol, we’re able to do A, B, C, D, and the patient survived.” So, we have a lot of anecdotal evidence. In fact, there was one, there was a bus crash and there were multiple casualties and one of the providers were like, “Thank God we had the training before,” because they were able to manage all the mass casualties. And for him, I remember I was very impressed with that because for him, the main thing was no one died. “No one died in our emergency department. We were able to quickly triage, appropriately manage and transfer the patients.”

So, his joy was previously people would die in the emergency, but in this one instance, no one died is the emergency department. There’s another healthcare provider from [inaudible 00:22:19] who told us that before we trained them, no one survived cardiac arrest in their hospital. And subsequently from our training, they actually have seen patients come back, get their pulse back and return of circulation just because they’re now well-trained. So, I think emergency care is the one thing that, as I mentioned and potentially also why I went into it, is there’s just instant gratification. You’re able to really provide that timely care that will pretty much make that difference in terms of whether you live or die.

Peter:
Right. Yeah. It must have immense job satisfaction then.

Benjamin:
Yes, definitely does.

Peter:
I suppose I just wanted to ask then, looking ahead, what are the next steps you’re developing? I think you mentioned on that scale of one to five, but then also I suppose, what’s the big picture goal in the future? What will Kenya look like in your ideal when it comes to emergency healthcare?

Benjamin:
Oh, that would be fantastic. I mean, it’ll look at what looks like here. Okay, you have an emergency and you don’t need to worry. You don’t need to panic. You don’t have to think, “Where am I going? Who am I calling? How am I getting there? How much money do I have to pay for my care? Which hospital am I going to?” So, you don’t really have to think about that. You just have to remember the one number, dial 999, 112 and everything has to be taken care for you. I mean, they will come, pick you up, provide you that care initially in your homes, in the office, wherever you’ll be at, and provide you that care and route to the hospital. Take you to the appropriate emergency department that has trained healthcare providers and the resources and it’s been designed well to be an emergency department.

And they happily receive you and provide you that, again, continue that care that you required. And all this discussion, all this just happening flawlessly. It’s up to when you’re nice and stable, then maybe additional questions can come up, but in the initial phase, the system just takes care of you. It’s the same thing that happens here in the UK. Same thing that happens in the US. You don’t panic because you’ve been hit by a bus. You just lie there and the system takes care of you. So, that’s really what we’re trying to figure out in our Kenyan context where the system just takes care of you.

Peter:
Right. And so it is a world without unnecessary death.

Benjamin:
Exactly.

Peter:
Okay. Well, brilliant. Well thank you so much for your time then, Benjamin.

Benjamin:
Not a problem. It’s been fun. Thank you.

Speaker 1:
Welcome to Role Models for Change, a series of conversations with social entrepreneurs and other innovators working on the front lines of some of the world’s most pressing problems.

Speaker 2:
Hello, Niniola. Thank you very much for joining us today at the [inaudible 00:00:16] Skoll World Forum.

Niniola Williams:
Thank you for having me.

Speaker 2:
So to begin with, could you just begin by introducing yourself and telling us a little bit about your work?

Niniola Williams:
Sure. So my name is Niniola Williams, and I lead an organization focused on public health in Nigeria. The organization was founded in 2015, which was a year after we lost my aunt. Her name was Dr. Ameyo Stella Adadevoh. And so the name of the organization is DRASA Health Trust, her initials, and then Health Trust. And she was the doctor that identified and contained the first Ebola patient in Nigeria, but in the process of doing so, she lost her life. And so a year afterwards, we decided to start an organization that would work alongside the government to really build resilience in the health sector and improve the state of things to make sure that that kind of thing wouldn’t happen again.

Speaker 2:
Right. And I suppose from that experience, it was a decade ago, I think, more or less now, do you think that from your personal experience and seeing what happened there, the flaws in the system, the gaps in the system had led to unnecessary deaths?

Niniola Williams:
Yes, absolutely. I think the system was not well-prepared at that time. There were a lot of things that could have been done differently, and if we had put the right things in place before that emergency came in, there could have been a lot more positive outcomes. And so that’s really what we’re looking at. How do we make sure that we prevent preventable deaths? How do we stop people from dying from causes that they don’t have to die from? Or how do we reduce the burden of disease in the country?

Speaker 2:
Could you tell me a little bit about what that was like, obviously with your aunt and that case for you and what that experience was like, I suppose on a more personal level?

Niniola Williams:
It was a very painful experience. She was someone that I was extremely close to, and in addition, I was already working in public health at the time. I was working for an organization that was doing a lot of work in Liberia, Sierra Leone, and Guinea, the first countries to be hit by Ebola. So we had already reoriented all of our programs to focus on responding to the outbreak and to the epidemic. And so it was unreal when this now became something that was personal that was affecting my country and my family specifically. And so we did everything we could to try and save her, but it wasn’t successful. And that’s why it’s so important to me that DRASA Health Trust lives on to continue her legacy and to ensure that we’re doing everything that we can to change the system and to improve things so that this kind of thing can’t happen again.

Speaker 2:
With Nigeria, what is the disease burden and the kinds of risks that are out there in terms of health?

Niniola Williams:
Yeah, I think it’s easy to focus on the big epidemic outbreak, pandemic-prone diseases that make headlines. But in Nigeria, the biggest burden is actually the day-to-day infections that kill people, especially children under five. So malaria, diarrheal diseases, respiratory infections. And so our focus is not just on the Lassa fevers, the mpoxes, the Ebolas, but even the day-to-day infections. And really what that looks like is how do we improve the quality of care and access to care so that people don’t have to die unnecessarily.

Speaker 2:
So how exactly have you gone about developing that system from the ground up?

Niniola Williams:
I think changing a system is very hard, whether you’re changing a health system or an education system, it’s extremely difficult. But for us, I think the lesson we learned from my aunt was that one person leading a small team of people could literally change the course of history. She changed the trajectory of Nigeria’s history by containing that virus, even though she sacrificed herself in the process. And so for us as an organization, we focus on investing in individuals. We could focus on the infrastructure and the other bigger things, but we believe that to change a system, you have to change the people in that system. And so for us, we work from the ground up as well as from the top down. And from the ground up, what that looks like is building a network of health champions across the country who are people that are taking responsibility for their own health, but also influencing the health of those around them and changing the systems that they work in.

Speaker 2:
And I suppose then how effective have you found that sort of people-centric, people-led approach in terms of those outcomes?

Niniola Williams:
For us, it’s been wildly successful. And I mean, again, this was something we just decided to try and see what would happen. But we’ve refined our model over the years and we’ve found that it’s been so successful because we’re putting the responsibility in the hands of the people that really need to be the ones driving the change. We as an organization, it’s impossible for us to own it and to scale it. We need to partner, we need to collaborate. We need to build the capacity of the people who exist in the system to be able to run this thing. And so I always tell my team that we need to work ourselves out of a job. We need to be able to hand over this model and hand over this expertise and understanding to the people who can really make a difference for the mass populous. Nigeria’s population is huge. And if we really want to make a difference, we have to put the capacity in the hands of the people that are the decision makers from the top down, but also the people who are doing the work from the bottom up.

Speaker 2:
And so how do you go about exactly finding, identifying these people and then employing them if they’re not already working in the health services or just getting them on board? How does that practically work when you’re doing that kind of outreach?

Niniola Williams:
So practically, we have identified certain groups of people that we believe are the best influencers to change the health system. So of course, we’ve started with health workers working in health facilities across the country, being that we want them to be able to improve their patient care, the quality of care that’s given, as well as be those sentinels for detecting if there’s any problems in the communities where they work. But in addition to health workers, we also work with community leaders because we know that there is a lack of trust between many community members and the formal health sector. A lot of people in Nigeria seek care through traditional means and informal means. And so we need those community leaders and religious leaders who are already influencers to be part of the solution. In addition, we work with secondary school students, that’s high school students, because Nigeria’s population is very young, and we have a huge youth population that’s really not been engaged in health challenges, especially when it comes to public health.

And we’ve found that they’re so innovative and they come up with all kinds of solutions to the problems that they see every day in their neighborhoods, in their schools, that cause health problems. And so using them as health champions has also been very effective. And then we also work with people who work at the borders, so international airports, seaports and land borders, because we know that a lot of these diseases are imported, but also we export a lot to other countries. And so really making sure that we have those emergency response systems ready and ready to work in those entry points and exit points across the country.

Speaker 2:
Right. And I just suppose then from this kind of approach that you’re now taking, as you say, with much more on, well, you are working from the top down as well, but this sort of grassroots approach and using people like influencers and the like. I just wonder, to what extent is this a breakaway from what’s been done in the past? How is it different from other solutions that have been offered before?

Niniola Williams:
Yeah. I think the thing is people focus so much on the formal health sector in Nigeria trying to strengthen it, and that’s important as well. But for us, we know that a lot of these public health emergencies start with people in a community somewhere, often quite rural or remote. And so if you don’t have health champions in those places, trusted people who can both serve as connection to the formal health sector as well as trusted authorities within that community to serve and to guide and to advise on what to do, that’s when you now end up with bigger problems. And so for us, it’s really bridging the gap of, yes, we want to focus on the formal health sector, but we also want to bring in these other sort of formally marginalized groups. Nobody’s engaging youth on such issues because oh, they’re children, what do they know?

But in fact, they’re extremely innovative and creative and they come up with the best solutions. And so empowering them and giving them that responsibility gives them an opportunity to contribute to their local communities in a way that they really haven’t had before. In addition, again, looking at the entry points into our country, it’s something that we haven’t looked at before. There are airports we’ve worked in where they didn’t have a plan for if there was a fire or a bomb or a plane landing with sick people on board. And so taking them through the process of developing systems to detect and respond to that and then simulating what happens if that is a real situation and testing their response and making sure that it’s robust, those are the things that we feel have been the gaps all along that we’re now trying to fill.

Speaker 2:
Right. And I’ve done quite a bit of reporting on the past on this community health worker approach in a few different countries, in places like Liberia and other parts of the world, Bangladesh. And obviously they do tend to this kind of model as well as being quite effective, efficient in terms of early detection. But also, I suppose as you’re suggesting now, working with community leaders also helps to convince, I suppose, when it comes to things like vaccinations, local communities. I suppose, can you just speak about the added benefits of taking that localized approach?

Niniola Williams:
Yeah, I think again, there’s a really big issue with trust across communities in Nigeria when it comes to engaging with people that seem to be representing the government in one way or another. And so for us, getting these community informants who are just local leaders, maybe the head of the Market Association, the head of the Motorcycle Association, the head of the Hair Braiders Association, people who are well respected for their trades and really have no connection with the government and getting them to be equipped and educated and informed on what to do to support their communities has been effective because there’s that level of trust that you can’t beat. You can’t bring an outsider in or have someone who’s being paid by the government and get the same level of trust with the community members that we’re working with.

Speaker 2:
Yeah, it’s definitely my preferred kind of influencer, the health influencer, rather than social media so much. And I just wondered then, so what has the impact of this all been? Presumably one of the big milestones, and I know said you don’t focus on this, but looking at the COVID-19 response, but what is the success that you’ve managed to get from this?

Niniola Williams:
So to date, we have developed a network of over 54,000 health champions across the country, which sounds like a lot, but Nigeria’s a huge country. So we’re still pushing. And for us, the impact is really seen when we have success stories that come out of what these health champions are doing. So during COVID, of course, a lot of them were mobilized by their local governments and by the communities to serve, and they were on the front lines of the response, quite frankly. And that’s for us is the beauty of what we’re doing when we see those emergencies come and our health champions are ready to step into the roles that are required to support and prevent illness from spreading. But in addition to that, we get stories all the time from our students, from our health workers, on things that they’ve done that have really transformed the system.

And so for example, with our health workers, we have a diploma course that we take them through. It’s a 12-month course where they come out as health champions on the other side of it. And we’ve had health champions come and tell us that they go back to their health facilities and they find that their management is not supportive of the changes they want to make. Typical story. But then you have a health champion who will come tell us that what she decided to do as a nurse was get all the nurses together, put their personal funds in a pool and get a local tailor to create utility belts out of local fabric where they could have a little pocket sanitizer in there with a few other materials that would help prevent the spread of infection in their facility.
So rather than waiting for the management to change the system, they changed the system from within and others saw them and were like, “Oh, wow, how did you do that? How did you go about this?” And then that is where you now see organic change being generated from the people who are really the ones, again, like I said, that have the responsibility to do that.

Speaker 2:
Right. That’s amazing. I can just imagine different sort of colorful versions of those two as well. And so I suppose as well now, despite that, I imagine there’s still some pretty significant challenges ahead. What are the main difficulties that you’ve found bring about this new kind of approach, and what are the ongoing challenges as well?

Niniola Williams:
Yeah, I think one of the biggest difficulties we find with our health champions is how do we support them when they go back to where they’re coming from to make sure that that’s an enabling environment for them to thrive in the way that we hope that they will. So for example, with our healthcare workers, we make sure that we give them soft skills, advocacy, communication, reporting, presentation skills, because they need to be able to be those quote, unquote, “activists” for change within their health facilities. They’re not decision-makers. They have bosses. They have chief medical directors who are often not always buying into the vision that they have. And so that’s a challenge across board. Leadership within the health sector is tough. And so while we work from the bottom up, we also work from the top down. We work directly with government agencies on developing policies and legal frameworks to ensure that we can implement those changes at the level from federal, all the way to state, all the way to local communities. Because if our health champions don’t have a conducive environment to work in, then they can’t be successful.

Speaker 2:
And I wonder as well, I suppose, linked to that, it might be a challenge in some ways. Have there generally been misconceptions about the kind of work you’re doing and how to find the right solution? I know you mentioned before that often a lot of the focus is on some of these diseases like Ebola and some of these bigger headline-grabbing challenges. But I suppose, yeah. Are there misconceptions and misunderstandings about the work that needs to be done and the work that you are doing?

Niniola Williams:
Yeah, I think it was very difficult in the early stages of the organization because people felt like we were trying to change something and put changes in place that they felt was like insurance, paying for something that they may need one day. And we had to orient people’s minds to realize that what we’re talking about is, yes, it will help us be ready for those bigger emergencies that may come. But day to day in Nigeria, people are dying and suffering from infections that are preventable. And so for us, that’s our main focus actually, not just the pandemic-prone diseases. And when you look at the economic impacts of those daily infections, it’s so vast. You have one person going into a health facility for a very simple procedure, developing an infection while on admission. And from a three-day procedure, they end up in the hospital for three and a half weeks.

They now have a huge bill they have to pay, they’ve lost time from work, their family members have to scramble and ask around for help to pay the bills. The impacts on that family unit and that community are huge. And so if we can’t get that right, we’re not even able to quantify the impact of what’s going on. And so for us, I think the misconception has been that, oh, we are here for when there’s an Ebola or a COVID, but in fact, we’re here to strengthen the system and change the system for the daily needs that people have, which include making sure that people don’t get sick unnecessarily.

Speaker 2:
But I suppose also on the other side of the coin, whilst the focus is definitely needed on there, when it comes to the growing issue when we speak about pandemic preparedness, obviously when we speak about the community-led approach and the early detection, this could be very valuable in preventing the spread, especially in a country like Nigeria with 200 million, more than, population.

Niniola Williams:
Yeah, I think these days looking at global health security is so important. And so for us, again, we’re positioned at those entry points in the country not just because we think it’s cool, but because it’s extremely important. We have a responsibility as a nation of 200 plus million people to the rest of the world to secure our borders and make sure that we’re doing the right thing. And so for us, I think there are so many emerging and re-emerging infectious diseases these days. And everything that we do as an organization takes a One Health approach because what we’re seeing increasingly in public health is a focus on human health alone is not enough.

We have to look at the environment, the water sources, the soil. We have to look at the agricultural sector, the animals that we’re consuming, the animals that are moving across borders. I mean, if you look at all of the epidemics and pandemics in the last recent history, all of them came from animals. And so even in my team, we have veterinarians on the team as well as medical doctors because it’s equally important to take that holistic approach in looking at how do we protect public health.

Speaker 2:
And I did mention before in terms of the impact when we look back to Ebola obviously, and the lessons learned from that, I’ve done some reporting in the Congo, which also has obviously had some ongoing issues with Ebola. But when it came to some of the learnings from that, the infrastructure that was built when COVID arrived as well, the mortality rates were much lower thanks to those systems. I wonder, in COVID in particular, were you able to benefit from the new systems and the lessons that you’d learned from before?

Niniola Williams:
Yeah, absolutely. I think Nigeria was in a much better place to handle COVID than Ebola. There were a lot of changes that were made through those years. However, I think, again, the big piece that we keep overlooking is the community piece. And that’s really why we’re focused there. Even during COVID-19, there were communities that were in complete denial about COVID-19. It’s a government conspiracy. They just want to inject us. They just want to take our babies. The normal thing, exactly what we saw during Ebola happening again during COVID. All kinds of local remedies coming up to say that, “Oh, if you drink this, you’ll be fine.” And so again, that’s where our health champions had to step in and be the trusted voices of reason and sharing scientific evidence-based information in a way that the local communities could understand and accept.

Speaker 2:
And now you said, obviously, even though you’ve got now tens of thousands of these health champions, Nigeria is obviously a massive country. And so what are you going to look to develop next? I think scaling up those numbers and making sure there’s sort of a wider representation around the country.

Niniola Williams:
Yeah, I think for us, that’s exactly it. Before we think of looking into any other countries, we need to deepen our depth within Nigeria because it’s such a diverse country, so many different ethnicities and subcultures, and we can’t address all of them in the timeframe that we’ve had so far. And so really what we look at now as an organization as we look forward is how do we institutionalize what we’re doing? We have a model that works, but how do we make this part of the system where it doesn’t have to be DRASA driving the process, but it’s the government and it’s the system driving the process.

And so what that looks like for us tangibly is the curriculum we’re using to train our students in schools, how do we embed this in the education system so that every student, whether they’re a member of our clubs or not, get to become these health champions. How do we embed our health worker program into the pre-service education systems? That’s universities and colleges. So whether you’re studying to be a nurse or a midwife or a doctor, you get to understand these concepts before you graduate. And so really, right now, a lot of our work is advocating with the government, working alongside them to change the systems at that level so that those health champions become something that is part of the system.

Speaker 2:
And I suppose just one more question for you now is just to do with, and obviously it’s very interesting for me to hear about that focus on students and youth. It’s not often taken account of in these systems. But I just wonder, when you look to the future, and could you, I suppose, describe what you would like, what you’re aiming for in terms of what the world will look like for when these children are adults or maybe the next generation of children, and how will the future Nigeria look like?

Niniola Williams:
Yeah. I think the vision that we have for Nigeria is a Nigeria where every community is equipped with people who have the information they need, evidence-based truths, to make sound decisions about their personal health and the health of their families. We’ve seen so many tragic incidences where things have turned out negatively simply because people don’t understand, ignorance, or lack of trust, or lack of access, or lack of quality care. And we just really want to see a country where my children and my children’s children can have a health system that supports them to be the best citizens they can be, to go forward and change the world in whatever way they may want to.

Speaker 2:
Well, thank you so much for joining us today.

Niniola Williams:
Thank you for having me.

Welcome to Role Models for Change, a series of conversations with social entrepreneurs and other innovators working on the frontlines of some of the world’s most pressing problems.

Nneka Mobisson:
I am Nneka Mobisson. I am Co-founder and CEO of MDoc. MDoc is head headquartered in Lagos, Nigeria, and we provide virtual health coaching to people living with or at risk for chronic health needs, as well as regular health needs. So when you think about chronic health needs, hypertension, cancer, diabetes, obesity, depression, anxiety, and then regular health needs like pregnancy. We leverage behavioral science, technology, data science, and quality improvement methodologies to really create an end-to-end integrated platform for self-care. Today we serve over 111,000 people across Nigeria, and we’re really demonstrating that leveraging telehealth and telehealth platforms you can at scale drive population health outcomes improvement.

Matthew Beighley:
What’s the problem? Why is there a need for this work?

Nneka Mobisson:
So more than 28 million people across Sub-Saharan Africa have died prematurely from chronic disease. This is very personal for me because my father was a hardworking, middle class professor from Nigeria who just wanted two things in life. One, to transform the technology landscape of Nigeria, and two, to spend more time with his family. But unfortunately, my father died from complications from a massive stroke that he had at the age of 52, largely because he didn’t really have access to a medical team to support him in managing his uncontrolled high blood pressure. And the reality is that his problem is not at all unique. We’ve seen, and WHO highlights that over 20% of the over millions of people living with chronic disease like high blood pressure, diabetes, et cetera, will die prematurely. And the reality is that many of these chronic diseases, or the complications from these chronic diseases are actually preventable by adopting healthy lifestyle modifications, really focusing on nutrition, on exercise, physical activity, on sleep, and on so many other elements around behavior change.

And so at MDoc, we’re really trying to address that problem, helping to support people in understanding what they need to do, nudging them on how to make those healthy habits and those adjustments, those incremental adjustments to their lives, so that they’re actually living those healthier, happier, and more fulfilled lives. And that’s how we’re leveraging technology to really do that.

Matthew Beighley:
Let’s explore it from a patient’s perspective. Give me a case study. Like, you’re a patient. How did they engage with MDoc? What does it look like day to day?

Nneka Mobisson:
Absolutely. So we’ve created an integrated, what we call an integrated ecosystem for self-care supports. And so I’ll start there because when we started at MDoc, everyone was like, “This is like, four companies. Why are you doing so much?” And I think it’s recognizing that we had to really build support around patients. We had to build support around individuals and actually communities. So it’s really, we leverage this four pillar approach. The first pillar is really the virtual coaching platform. It’s called Complete Health. It’s AI enabled, and where a member actually can interface with their dedicated health coach who will support them, understand first of all what their needs are and what their desires are. We really focus on what matters to them as opposed to necessarily what matters to us. And so they co-create the health goals of the member. We actually don’t call them patients because we don’t prescribe and we don’t diagnose at MDoc.

And so we say they are other folk’s patients, but they’re our members. And so after they enroll, they complete a baseline assessment. All of this is on the phone. If they have challenges from a digital literacy perspective or if they only have a basic phone, we also have support on how they can actually do that. And they always have the human health coach to support them. That human health coach is backed by a nutritionist, a fitness coach, as well as an emotional wellness coach. So depending on what the member decides in terms of their specific health goals at that point in their life journey, they then can have access to that broader team of supports as well as peer communities online who can also support them on achieving those goals. And then that’s kind of what Complete Health does, the platform.

It helps them help track their records. They have a personal health record tracking diary, et cetera. The second pillar is Navi Health. So Navi Health is essentially our Google Maps for healthcare. Because we don’t prescribe and we don’t diagnose, we do have to support people in terms of finding where to go for in-person preventative promotive or urgent or emergent care when they need it. And we’ve created this so that it also has reviews so people can actually provide the reviews of their experience. We’ve been very intentional, recognizing that a lot of times, healthcare providers feel defensive about reviews and worried about reviews. And so we’ve leveraged the six domains of quality that the National Academy of Science came out with. These domains are like effectiveness of care, timeliness, patient-centered care, and we’ve essentially generated a system for that feedback across those domains so that healthcare providers and facilities actually know what they can specifically focus on in terms of making improvements to their systems.

The third pillar is the in-person experience. So we recognize that mobile phone penetration rates are not an appropriate proxy for digital literacy, and so we created what we call nudge hubs. These are essentially health kiosks in the community. They’re not necessarily a destination, ideally, it’s a place you pass by because we serve over 110,000 people who mostly make less than $3 a day. And so they don’t have the funds to spend on a blood pressure machine or a scale. And so they can walk in, meet with a coach in person, learn how to onboard on the digital platform, and then also track their metrics on a daily basis as much as they want to. We also have roving community ambassadors. So these are people who have gone through our program who have a backpack with the devices, and meet people in person, in their communities, whether it’s outside of church or outside a mosque.

They’re really meeting people where they are. And then the fourth and final pillar, that’s tele-education. So we recognized that we were really supporting people in developing their self-efficacy and their agency, and they were showing up at clinics and saying, “Hey, look at my blood pressure. It is gone down. See how much I’m exercising.” And doctors would be like, “Okay, okay, okay. I don’t have time for you. Okay, it’s okay. It’s okay.” And so we realized we were doing so much around capacitating people and we weren’t also supporting healthcare providers. And so we created this tele-education platform to really support healthcare workers. And so we’ve trained over 15,000 healthcare workers in chronic disease management, but as well as also in digital literacy and now in AI literacy to really provide that support that they need in being able to provide better care. So highlighting that four pillar approach, I’ll give you an example of one of our members, Mrs. Folake.

So she is a 35-year-old pregnant woman who has a history of diabetes as well as pregnancy-induced hypertension. And she was just frustrated because she’s overweight, this is pre-pregnancy, and was really, really worried about how diabetes and hypertension were going to affect her baby and herself. And so her physician actually referred her to MDoc, and the physician knew about MDoc because she always attends our tele-education sessions. And she said, “Look, maybe you’ll benefit from having a coach that you can talk to who can support you on some of the nutritional changes that you can make, some of the exercises that you can do to really ensure that you’re healthier during this pregnancy.” And so she then enrolled on our platform, signed up, was able to speak to a coach within 24 hours. And I highlight that time point because our data showed us that when the first synchronous interaction between a member and a coach happened after seven days of enrollment, it had a dramatic impact in terms of their engagement.

We had to actually pull that up to within 24 to 48 hours to really be able to have them trust us, trust that there was actually this health coach that really cared and was going to care about you and support you, and then that really drives engagement and has an impact on behavior change and ultimately on outcomes. And so in their conversation, it was clear that she had never seen an eye doctor for her health. Now, when you have a history of diabetes and hypertension, you may have ocular changes, so changes in your eyes. And so she was able to leverage Navi Health, so our Google Maps for healthcare, to help her find an eye doctor nearby. And she was able to go for that. And throughout the pregnancy, the coach was able to support her, nudge her when she was worried.

When she actually went to the facility and they were shooing her away and not trying to actually interface with her, she was able to actually leverage her coach to support her even when she was at the healthcare facility. Ultimately, she’s had her baby. In fact, we’ve had a number of members who’ve named their babies after their coaches, and she’s successfully managing her blood pressure and her diabetes until this very moment.

Matthew Beighley:
So you’re actually changing behavior.

Nneka Mobisson:
We are. It’s very hard. And I think we’ve chosen a difficult and a very complex problem, but we fundamentally believe, I mean, our data shows us it is possible. It is possible in low-income populations who really have very limited access. It’s possible if you act with patient urgency, and you make every effort to understand what matters to that person in that moment. Because I can’t tell you how many people actually don’t want to talk about their health initially. Or especially for women, for mothers, they want to talk about the health of their children before they even focus on themselves. And so there’s been so many women with elevated blood pressure that we’ve actually been worried about where they’re saying, look, we had one woman who said she was not willing to engage until her coach supported her and answered her questions on how to take care of her baby.
She had a question around, “Can I put palm oil on the umbilicus of my baby?” Her newborn baby. And the coach had to support her on that and really on how her baby was feeling, et cetera, before she could actually then start talking about the elevated blood pressure that the woman still had.

Matthew Beighley:
I know it’s working from the stories you told me. Is it possible to measure? Do you have a sense of impact?

Nneka Mobisson:
Yes, yes. So when it comes to blood pressure, so if you look at Nigeria today, over 35% of our adult population are living with elevated blood pressure. And actually, we did a prevalence study. We conducted a prevalence study just because when we started MDoc, there was so little discussion about chronic disease. And if you just even look historically at funding, only 2% of all global funding has gone to chronic disease. And so there was so little data that we said, “Okay, let’s do a prevalence study.” And we had supports to do this. We specifically focused on women of reproductive age, and we were able to actually see that about 35% of people had elevated blood pressure. Majority did not know, and this reflects even in our numbers on our platform today.

About 40 to 60%, depending on location, were overweight or obese. Between two to 3% living with diabetes. And then about 50% of women had nutritional deficiency anemia, essentially an iron deficiency anemia. So now if you look at that, that means you have a number of risk factors for chronic disease, even if the person’s not living with chronic disease at that moment. But you have this overlay of obesity and nutrition. So people are theoretically eating more unhealthy foods because that’s what’s cheaper. So at MDoc, because we kind of leverage this holistic self-care platform and really focus on behavior change and what people can do in that moment, we’ve been really laser focused on demonstrating, one, the behavior change, and then two, the impact on outcomes.

From a behavior perspective, our best proxy is actually exercise, because exercise is actually what you can do even if you have no access to any type, you don’t need a pedometer, you can literally, we can guide you on how to exercise even if you’re living in one room with nine people. Even if outside, there’s flooded roads, there’s water everywhere. We can support you on what to do if that’s your reality. And so we’ve been able to go for an average duration of exercise for our members that we serve, actively engaged members went from 23 minutes to now 93 minutes a week. Now, is that anywhere close to WHO’s recommendation of 150 to 300 minutes? No. Are we getting there? Absolutely.

And I think that’s the point that we’re trying to highlight in terms of behavior change. It takes time being able to see a 4x increase for us, and we’re seeing it steadily increase because we’re understanding how to motivate, how to help people understand to make those small changes. When it comes to outcomes, if you look at our members with elevated blood pressure, over 70% have improvements in their blood pressure, have controlled blood pressure, and we’ve been able to see an over 13 millimeter mercury reduction in average systolic blood pressure.

Why is that important? Well, the evidence says to you that when you have a 10 millimeter mercury reduction in your average systolic blood pressure, you are able to reduce premature mortality from cardiovascular disease by about 13%. So we’re able to essentially show that we’re actually reducing the risk of premature mortality in the people that we serve. We’re seeing the same results with glycemic control, so blood sugar control. We’re seeing the same results also with PHQ scores. So when it comes to people living with depression, so if you look at people with chronic disease, a lot of people living with chronic disease also are struggling with depression or anxiety or both. And so we also track how the reduction in terms of, it’s called patient health questionnaire, nine scores, and this just shows you that over 50% of our members have had a reduction in terms of their PHQ scores.

So improved depression symptoms first at the 12-week mark, and then at the six-month mark. And so it’s really incredible to see improvements in depression, improvements in anxiety, and then these hypertension and glycemic control improvements. In addition, we serve a lot of people with cancer. When it comes to Nigeria and most of Africa, the reality is that we’re really struggling with early diagnosis and people are coming in at a very late stage. And so in many cases, a lot of the people that we serve have metastatic cancer or are essentially at the terminal stage, and we’ve been able to see a 2.1x increase in terms of duration of life when they come on our program.

Why do we think that’s happening? Well, again, the evidence shows you that even regardless of your prognosis for most types of cancer, not all. If you invest in healthier living, if you focus, for instance, even on your BMI, if you focus on what you eat, if you focus on exercise, that you are more likely to have a better prognosis, you’re more likely to have better quality of life. And we’ve seen that even in the members that we serve with cancer.

Matthew Beighley:
Last question. What’s your vision? What would you to see?

Nneka Mobisson:
So I’m pausing because when I started this, I was just focused on Africa. I was leading the Africa portfolio of a US-based NGO, and I was so frustrated with development. Everyone was talking about how funding shouldn’t be siloed and vertical and how we had to have integrated approaches to care, and it was just lip service. No one really seemed to care. We were seeing incredible growth in terms of mobile penetration across Africa, and I couldn’t get people to really engage in this notion that we could actually leverage technology to support people. I couldn’t get folks to understand or engage again on the fact that we were worried about whether a woman had her four antenatal care visits, a pregnant woman, but we weren’t even talking about the quality of the care or what she could do or whether we were ensuring that she understood what she could do. Or understanding that she’d been living with high blood pressure for all these years, but she didn’t even know it, and we weren’t really caring about that.

And it mattered to me because of my dad, because my dad was a genius as far as I was concerned. I mean, I guess every child more or less might think that their parents are geniuses, and he really was a genius. And all he focused on was work. All he focused on was transforming the technology landscape of Nigeria. And so how is it that this genius didn’t focus on himself? He smoked cigarettes, he drank a lot of beer, I think just to cope with the sheer stress of Nigeria. And so realizing that how many years later the status quo hadn’t changed, I got angry. Honestly, I just got so angry. And I was like, “I can’t do this. I have to do my part in changing the system for the continent.” Understanding that data that millions and millions and people of Africans were dying prematurely from chronic disease, it really, really angered me.

And so my vision initially was to really transform, one, how people receive the care that they needed to live those healthier lives. And then my vision, my ultimate vision was, I want to ensure that truly by supporting people, by empowering them, by helping them build that confidence, that self-efficacy, by helping really foster that agency in them to take control of their lives from a health perspective, that we will see a transformed continent. A continent that’s filled with fulfilled, happy, healthy, prosperous, and productive people. And then COVID hit. And all of a sudden, we had all sorts of folks from around the world saying to us, “This can really work in our country. Why aren’t you thinking about it for us?” I had so many folks from the US saying, “We have these problems. I would love a coach. I actually just want to be well, and I still want a coach. I’m healthy, but I still want a coach.”
And so our vision, honestly, is to transform lives across the world now. Transform the lives of the vulnerable, transform the lives of the marginalized. Transform the lives of the neglected. The people who have been left alone, who have historically been failed by their systems, we believe that we can support them to take that control that they need, making those small adjustments to their behavior so that ultimately they’re living those healthier, happier, and more fulfilled lives. And so they can be there not just for themselves, but for their families, for their communities, and we’ll see that impact for generations to come.