A handful of lessons learned from the early days of a health-tech start-up in a middle-income country

My husband often comments on the way I run. He’s convinced that there is some correlation — rooted in aerodynamics — between my ‘strange’ form of running and my ‘unbelievable’ endurance. He often marvels at how I don’t stop, even on the hilliest of roads. What I keep telling him, is that I tilt forward because after initially setting a target for myself before I commence the run, I am so focused on looking only at the next step I have to take and reaching the next easy milestone — usually a well-known pothole in the road- and never the full extent of the road ahead. If I spend more than 2 seconds staring at the daunting enormity of the upward incline of the next hill, I stop. Without fail. The run is finished.

I look at our entrepreneurship journey at mDoc in much the same way as I do my runs. mDoc is a digital health company headquartered in Lagos, Nigeria that supports people with chronic health conditions such as diabetes, hypertension, overweight/obesity and cancer to make small changes to their behavior to improve their health. We have big targets of course, but we’re pretty intentional about hitting smaller and incremental milestones. Sometimes I am so afraid of looking at our big targets because I have. No intention. Of stopping. This journey.

Now that we are on the last day of our 2nd full year at mDoc, here are some of the many lessons we’ve learned on this startup rollercoaster ride.

1. Smart phone penetration as a proxy for smart phone usage means zilch!

When we first started out, we talked to 1000 people trying to understand their pain points with chronic disease and their receptivity to using technology to help them achieve their health goals. One of the questions we asked initially was “Do you have a smartphone?” That was an error in itself. We were schooled by our team who told us the better question is “Do you have a WhatsApp phone?” And even that in itself did not tell us what percentage of people who have a smartphone actually know how to use it for anything other than watching videos or reading daily devotionals on WhatsApp or Facebook. We now ask a series of questions that help us understand with much greater depth how potential members use their phones and just as importantly, we watch them use their phones and we watch them use our platform — over and over again. Many of our members during enrollment will tell us “Yes I have a WhatsApp phone, but I prefer using text” or we hear from young 50-year olds (doctors and nurses included) — “If there is anything I need to add on the phone, I just give it to my child to do for me.” But they are so keen on getting help that they assure us that they will be on point to chat with their mDoc coach, and they do. Needless to say, we’ve recently added an sms-based support service and are adding on USSD in 2019. Our youthful tech team has been astonished at the serious lack of digital literacy in even the most educated of us which brings me to the next lesson.

2. Your in-person approach is equally as important as your tech platform.

When we first launched, we weren’t under any misconception that people would automatically jump on our digital platform, sign up for the program and get started on miraculously changing their lives. We knew we would have to provide some level of in-person guidance and navigation, but we had no idea how much. We’ve had to step up our in-person approach in a more integrated and thoughtful way for a variety of reasons. People have such strong convictions in their religion, many times in their specific pastors and in the fact that someone somewhere out there in the universe may have given them this chronic disease of hypertension or diabetes, that even acknowledgement of the condition is going against God. We have a number of people who with long time histories of hypertension will exclaim when an mDoc coach shares the implications of uncontrolled hypertension, “I reject that In Jesus Name!” Indeed, we’ve seen that people’s belief systems can serve as key barriers and facilitators to making improvements in their health. Religion and spirituality are truly social determinants of health and offer a huge opportunity for those of us in the healthcare space, but more on that another day. We have found that having our virtual coaches also spend time in-person with our members is key to seeing behavior change and an improvement in their health. We’ve started small in-person hubs based in the community that enable people to meet up with peer coaches and people like them. We now hold regular in-person nutrition and exercise workshops and more to supplement the virtual support and our members love them.

3. When it comes to healthcare, there really is no such thing as a silver bullet, no matter how unsexy that seems.

We provide support to people the 99.9% of the time they spend outside of a healthcare facility. Part of that support is providing navigation and reminders on when it’s time to see a physician for routine checkups. We soon realized that the comprehensive database of healthcare facilities, services and providers that we needed to help navigate people did not exist. So, early on, we had to build a digital repository of healthcare services ourselves, and we are still adding to it every day. At the same time, we knew early on that we’d have to invest in supporting hospital and clinic providers in learning evidence-based clinical management integrated with quality improvement methodologies so that if our members went to them for in-person care they’d be more likely to receive the right kind of care, at the right time, in the right manner, all the time. But we’ve had to step up our support in training and mentoring, especially as we see people coming to us with more and more issues not addressed at clinic visits, often because of system issues and resource constraints. In the early days, our non-Africa-based advisors were telling us we were doing 4 businesses at once, but they finally saw this year how it all comes together for an integrated care approach that is a necessity in the settings we work in.

4. There is a huge thirst for learning among both individuals and health providers

Our health systems have a lot of challenges, we see that every day, but we have seen SO many providers who are keen to learn more, who are thirsty for the latest knowledge on how to manage diabetes and hypertension. We also see daily, new members who have been fed with so much misinformation about their health: “I’ve been told diabetes doesn’t last forever, when will my diabetes go away?”, “I don’t take my drugs because I heard that if I take them, I will never be able to stop…” “Warm water will cure the diabetes.” When we first started out, we started incorporating health talks after doing patient surveys because we were blown away by how little people understood of their conditions. This lack of knowledge may be because of our overburdened system, or it may be because the hierarchical culture of healthcare obviates the need for providers to go into excruciating detail so that people understand more than “Take this pill twice a day.” We’ve doubled down on addressing education needs, and in 2019 we’ll be tracking the impact of these knowledge building efforts in great detail.

The 5th and final lesson of what feels like a million lessons is about the entrepreneur. It’s about preserving self.

5. Invest in G-squared…God. And Gym.

I work out and/or run 5–6 times a week. By no means am I an athlete, but I am heavily dependent on working out for getting my mind right. Working out is a wonderful antidote for anxiety which I have found entrepreneurship causes all the time. There are tons of studies that actually show that a whole set of endorphins — neurochemicals in your brain- are released when you exercise, and I tell you they give me the greatest sense of euphoria and the best “you got this” mentality. And no, I don’t belong to a gym, I work out right at home or wherever I am using my laptop or phone. Jillian Michaels is my girl. When I run, I am listening to fast-paced gospel…sometimes interspersed with Sounds of Blackness’ Optimistic and Jidenna’s Long Live the Chief providing me with the positive fuel I need to kick off my day.

The additional mindfulness element is key — when I feel the sensation of my feet hitting the road, while I’m listening to affirmative music and looking at the world around, I know mDoc is going to conquer it all.

In the early days of mDoc, I told myself that I had so much daily pressure, I could excuse myself from being Ms. Fit and Trim — even though mDoc is a lifestyle modifications company. When I started not being able to fit into my killer outfits that were supposed to help me ace my pitches to investors…and I couldn’t justify spending money on buying new clothes with my non-salaried self, I quickly brought back the pressure and started living the life I was trying to get others to adopt. And as one of our team members says, we are walking advertisements for mDoc so focusing on G-squared helps me rein it in.

These are just a handful of lessons we’ve learned along the way, there are so many more. See you in 2019!