Building a For-Profit Health Model That Reaches the Poorest

What is mDoc?

We’re a Nigeria-based, impact-driven business that provides virtual self-care health coaching to over 150,000 members, primarily women, living with or at risk for chronic disease—diabetes, pre-diabetes, high blood pressure, cancer, depression, and anxiety.

We support people the 99.9% of the time that they’re not in a healthcare facility. Essentially, while you’re living your life, we support you on understanding your health, understanding what you can do about your health, and then guiding you to really hone in on lifestyle modifications. We do that by leveraging behavioral science, data, technology, and quality improvement methodologies.

When we started mDoc, we really thought it was just going to be a wellness app that would provide people with nudges and build health literacy supplemented by some engagement with peer coaches. Given the populations we serve and the healthcare context we work in, it has necessarily grown into more than that.

Would you explain that context?

The context is a healthcare system that historically has not met the needs of its citizens. Public health is oriented around fighting infectious disease, not addressing chronic disease, which is a large part of why we see such poor metrics when it comes to health or life expectancy.

For example, it’s common to use maternal health as a rough indicator for the overall health of a country. Nigeria contributes about 20% to the global burden of maternal mortality. Only India has a worse record. When mDoc did a prevalence study, supported by Merck for Mothers, we found in some areas, 40% to 60% of women have overweight or obesity and over 30% of women were living with elevated blood pressure. Nigeria has a population of 230 million. These are big problems.

And just 5% of Nigerians have health insurance. If you’re going to a clinic, people will say, “What’s wrong?” You can’t possibly be going for a wellness visit. Medical care focuses on emergent conditions.

Most of our members earn under $2 a day. They are market women, petty traders, drivers, folks who are struggling economically. They haven’t received the right support from a knowledge perspective and don’t have an ecosystem of care.

How did you come to do this work?

My dad dedicated his life to empowering people through technology. When I was in college, he had a stroke because he had uncontrolled high blood pressure. If he’d had the support and lifestyle coaching that he really needed, I believe he would still be alive today. That experience is at the core of my passion for global public health and my focus on reducing premature deaths.

While I was doing a master’s in public health, my mentor, who was at the CDC, said if I wanted to have impact at the macro level I needed to understand what it’s like to deliver care at the micro level. I went to Yale for medical school. When I realized I didn’t truly understand the economics of healthcare, Howard Forman, who had started the MD-MBA program, encouraged me to apply. I was part of the second cohort. Yale SOM gave me a private sector lens that was a critical complement to the public health lens.

After my pediatrics residency, rather than doing a fellowship, which is often the typical path in medicine, I went to McKinsey. I wanted to build the capabilities to really solve challenges in the healthcare space. My path was confusing to some. I still meet friends who say, “You were supposed to end up at the World Health Organization.” That wasn’t ever my intention, but of course, I didn’t know exactly where I was going to end up. I didn’t know entrepreneurship would be the route.

How did that path become clear?

After McKinsey, my husband, Imo Etuk, and I decided that we wanted to move back to the continent. He pursued some opportunities around telecom in Kenya and Nigeria. I led the Africa portfolio for the Institute for Healthcare Improvement (IHI), a Massachusetts-based nonprofit which collaborates with partners around the world to do quality improvement through micro experimentation and rapid cycle testing.

Imo and I spent a lot of time talking about what we were seeing around us—the unfairness, the lack of equity. We decided to bring our interests and our capabilities together. We considered doing something with telemedicine, but there were already lots of dial-a-doctor players. I felt the space needed more innovation. We saw real potential for a digital tool targeting prevention and lifestyle modification.

People said, “Are you crazy? We haven’t solved the chronic disease problem in America. How can you solve it in Africa?” But I’m a big believer in anything can happen. At McKinsey, they teach you to ask, “What will it take to make it happen?” We operationalized mDoc in 2016 as co-founders with me in the CEO role and Imo as CTO.

Why Nigeria?

Our vision was always to be a Pan-African company. And more recently we’ve seen global opportunity. But we chose to start in Nigeria in part because we’re Nigerian but also because, alongside all the serious challenges, Nigeria is an incredible place for supporting innovation.

We’ve found all sorts of unexpected partners. Early on, to generate revenue—to just pay the bills—I was leveraging my quality improvement experience from IHI and doing training for hospital CEOs and other healthcare leaders. One of them was the head of public health for the Nigeria Police Medical Services, one of the largest aggregators of healthcare in the country. She said, “A lot of our policemen have hypertension; please work with us.” We did a pilot that demonstrated impact around hypertension.

The police officers used the app, but we also arranged some in-person discussions at police medical service clinics to learn how they felt about the experience. Those gatherings turned into peer group coaching. I remember one policeman who was so proud. He’d lost all this weight through our program. He explained how, when he went to the bar, instead of drinking three beers, now he’d just drink one. When others were skeptical, he said, “Just sip it slowly.”

We’d planned to do something with physical locations down the road but seeing how we could use the live gatherings to reward people for positive habit formation and other steps, we asked the CEOs that I’d trained if they had spaces we could rent. Fifteen of them offered space for free.

Our first “nudge hub” was a container on the grounds of one of the biggest general hospitals in Lagos. It was incredibly popular. And the healthcare providers loved it because they could send people diagnosed with hypertension or diabetes to us for lifestyle coaching.

The nudge hubs have become places where members can use blood pressure machines or glucometers—devices they can’t afford themselves. They can participate in exercise classes or programs around nutrition. The hubs also help with technology issues. Mobile phone penetration is high, but owning a phone isn’t the same as digital literacy. Members benefit from in-person engagement around technology, around health literacy, even around the idea of coaching. It’s all new.

And the interactions help us understand what members need. We work hard to meet people where they are. About 30% of our members have basic phones. We have resources they can access through SMS. Of the 70% that have smartphones, many can’t afford to pay for data, or the phones aren’t charged because there are so many issues with electricity. A lot of times, when folks walk into a hub, their phones start pinging and pinging. It’s the first time they’ve had access to Wi-Fi in a week and everything is syncing.

And recently we’ve started to integrate an AI coach that members can talk to because literacy is an issue for some members.

Before we get to the AI coach, would you say a bit more about the human coaches?

For so many people, it’s the first time they’ve had reliable access to any kind of support around their health. They come to really trust their coach. We’ve had members name their babies after their coaches. We’ve had people tell us that we’ve saved their lives. It’s amazing to have that kind of impact. But many members want to count on their coach for everything.

We couldn’t be clearer that we don’t diagnose, we don’t treat, and we don’t prescribe. But we’re functioning in a system that doesn’t have free emergency care, so every week now, a member will have blood pressure so high that they should go to a hospital immediately. But they say, “Leaving my shop at the market means I lose the money I was going to make. Going to the hospital means I have to get on three buses. And then I’m going to have to pay for the doctor. I’m not going—please help me.”

It puts a huge burden on mDoc. What are the boundaries of our responsibilities? Where do we stop if there’s not an easy answer for where another part of the healthcare ecosystem begins? How do we connect members to further care when the infrastructure, processes, and systems don’t exist to link to?

Our original business plan was to have peer coaches who provided encouragement and basic support. We had to change that. Now, our coaches are primarily nurses and doctors. In the healthcare environment we’re operating in, it’s what we had to do.

But it isn’t the solution it might sound like. In our education system, a nurse can graduate without knowing how to take a proper blood pressure or measure a member’s waist circumference. For mDoc, we still have to make significant investments in training and mentoring.

For Nigeria, the healthcare system has been struggling with a mass exodus of healthcare workers going to the U.S., the UK, and elsewhere. All of the challenges of the country’s overburdened, minimally equipped healthcare system are compounded by a lack of experienced clinicians who might otherwise be delivering care and providing new clinicians the practical apprenticeship that’s key to medical education.

What is it like to work in a healthcare system that has so many gaps?

It’s traumatizing at times. We recently had an employee who needed to get to a hospital by ambulance. That’s not a straightforward thing in Nigeria. We were so worried. Thankfully, there’s another relatively new company, ERA, that leverages technology to deliver emergency services. They were incredible at getting us ambulance service. And then we were able to use relationships that we’ve built with providers and hospitals to get our staff member to a private hospital where we could rely on the care that was provided. If it was that difficult for people who do healthcare to get a team member good care, what does it mean for trying to solve this for 230 million people?

There are such big problems. So we rely on other innovators. We partner. We adapt to where we are and to the opportunities that arise. We got a lot of pushback from advisors early on. We describe the company as being built on four pillars. Advisors said it sounded not like four pillars but four companies. That might be true in some circumstances, but I was adamant that an ecosystems approach was needed. We needed a health system strengthening approach.

What are the four pillars?

The app and the nudge hubs represent two pillars. Another pillar is the mDoc Quality Network, MQN. When the CEOs who offered spaces for nudge hubs suggested maybe we could do training in exchange for those spaces, we realized teaching has a real value here. That was underscored when members began showing providers their blood pressure graph in their mDoc app only to be shooed away. Many providers haven’t been trained in how to engage with and leverage data. We offer that training.

MQN has expanded into a tele-education hub for a number of organizations. It’s a B2B stream of revenue. Elsewhere in Africa telemedicine providers have had issues when the existing health services saw them as threats. This is a way for us to clearly show we’re partners in strengthening the system.

The last pillar is NaviHealth.ai, which is kind of a Google Maps for healthcare. Members can see which healthcare facilities are nearby, and they can see reviews from other members. It allows members who are in a position to pay for healthcare a seamless way to access care.

We built the review system using the National Academy of Sciences’ quality domains. Because of that orientation, healthcare providers haven’t found it to be punitive the way many online review systems are. We can give them feedback like, “You are doing really well on effectiveness, but not so great on timeliness.” That too has opened up an opportunity for us to work with facilities to improve their system of care delivery.

Would you say more about mDoc’s business model?

We wanted to demonstrate to the world that it’s possible to do innovative work on the continent in an unapologetically for-profit way while serving low-income populations. We decided not to seek venture funding because we didn’t want to lose control or our focus on social impact. We’ve managed to bootstrap thanks to significant grant support. But we’ve also actively sought different revenue streams. With consumers, we offer some level of services to everyone regardless of their ability to pay. We have tiered pricing plans that allow access to additional services. Companies also offer our coaching to employees as a benefit. That’s another B2B revenue stream on top of MQN training.

Recently, we developed a B2G model. In 2022, the National Health Act set a goal of every person having basic health insurance by 2030. That led to a huge effort at the subnational level to drive uptake and utilization of state insurance plans. We’re working with some of them. When folks enroll onto our platform, we’re able to tell them about insurance options. If we enroll them in state insurance coverage, we receive essentially a capitation fee. The health insurance serves our members. And from a business perspective, the strong reimbursement mechanisms of B2G are so important.

How about impact?

We have a paper coming out demonstrating that our digital coaching platform had a 10-point reduction in average systolic blood pressure for women. That translates into a 13% overall reduction in mortality. We’re really proud of that.

And we’ve gone from 23 minutes average moderate physical activity a week in our engaged members to over 90 minutes. The WHO target is 150 to 300 minutes, so we have a ways to go, but are we on track to get there? Absolutely.

mDoc started incorporating AI tools in 2020.

With COVID, people were asking us for help literally around the clock, things like, “I’m pregnant. I’m bleeding. I’m outside the hospital. It’s locked. What do I do?”

At that point, few hospitals were digitized. Since we had been working closely with both the hospitals and their patients, we were a connection between them. The hospitals would call us and say, “Please let people know we’re only accepting new cases on Monday and Wednesday and only these types of patients.” The hospitals were so stretched; we were so stretched.

We had the support to build a rule-based chatbot that could respond to some non-urgent needs of our members. It took a big load off of our team.

Obviously, AI has evolved dramatically. But because we’ve been using it, internally we’ve been building AI literacy. We’ve been able to define our infrastructure needs and build a rhythm and cadence to leveraging AI while measuring what we’re doing in a meaningful way.

Would you describe the development of mDoc’s AI coach?

We’ve been intentionally slow around full deployment of Kem, our AI health coach. We wanted to build the internal evaluation system that let us be sure Kem is meeting key metrics around accuracy, empathy, safety, contextualization, and equity.

We’re in the process of publishing a paper that compared healthcare workers without AI support, healthcare workers using a LLM for support, and the LLM by itself. Healthcare workers performed better with the LLM. But it was the LLM alone that provided the best care across the board.

What’s your takeaway from that?

For me, it underscored that there are environments and use cases where it’s really important to recognize the potential and value of LLMs. In this instance, AI can provide better evidence-based support, more empathetic, contextualized, and complete care than what a patient is otherwise able to access.

That data showed us we needed to deploy Kem as a coach. We had been thinking it would ultimately replace 40% to 60% of what human coaches do, but frankly it could be more.

Do you see it going to 100%?

I don’t. But, however much we use AI, I can’t overstate how critical it will be to have the right people on our team. We’ve already seen that an AI coach is conferring a greater degree of anonymity and trust than even with a human coach; people are talking about everything from sexual harassment to suicide. That means we will need to have the right clinicians in the loop.

We do see Kem allowing us to quickly achieve growth in the Nigerian market and beyond. But even relying on AI to do a large part of the coaching, we need the right people in every role to continue to deliver high quality in a personalized, patient-centered manner while remaining financially sustainable as we scale. Without bringing all those pieces together, we don’t succeed. And to be very frank, we haven’t figured it all out yet.

I can’t convey how difficult it is to charge what we charge and be able to pay for the talent we need to grow. Our biggest challenge is talent. When I’m on a panel and I’m asked, “What’s the one thing you would change?” I say the education system. My dad always said everybody has capability, but our expectations about what’s possible, our beliefs about what matters and what success looks like, are shaped by the systems we grew up in or are living in.

This work has made me so grateful for the education that I’ve had. For the support from mentors, from Yale, from other institutions. Imo and I appreciate the people who helped us to get here to take on these big challenges. And we’re trying to do the same for the people that we work with on our team, and also the people that we serve.

This is definitely the hardest thing I’ve ever done in my life. And it’s exciting. What keeps me awake at night, and what gets me going in the morning, it’s the impact opportunity, it’s the business opportunity, and it’s the overlap of the two.