mDoc: Nneka Mobisson and Imo Etuk on Believing in the People Executing the Work

Imo Etuk: My name is Imo Etuk. I’m co-founder and CTO [chief technology officer] of mDoc. 

Nneka Mobisson: I’m Nneka Mobisson. I’m co-founder and CEO [chief executive officer] of mDoc. mDoc is an AI-enabled digital health social enterprise that focuses on providing virtual self-care health coaching to people living with or at risk for chronic health issues. We primarily support people with lifestyle modifications that they need to adapt to live healthier lifestyles. Over the years, through co-designing with the people we serve, we have created a four-pillar approach.

We first connect people through our flagship platform. It’s an omnichannel platform called CompleteHealth™, where people have access to a virtual human health coach and now an AI health coach to support them in understanding their health and in identifying and co-creating health goals. Then, through our platform, we provide nudges, help them track their health, and build the health literacy they need to unlock the incremental behavior changes necessary for longer, healthier, happier, and more productive living.

Today, we have over 130,000 people enrolled on our platform. Over 86% of those we serve are women. The majority of them are low-income. They make less than $2 a day. They’re market women and traders, many of whom have moved from rural areas to peri-urban or urban areas to create a living for their families. For most of these women, one problem from a chronic disease can put them into abject poverty. Our focus is helping them build self-confidence and self-efficacy and restoring their agency to live healthier lives. At mDoc, we don’t prescribe, we don’t diagnose, we don’t treat; we see ourselves as complementary to the existing healthcare system.

We see ourselves as complementary to the existing healthcare system.

– Nneka Mobisson

Our second pillar is NaviHealth. We created what is like a Google Maps for healthcare, a geo-coded directory of health services, facilities, and providers so that people know where to go for in-person care, or telecare when they need that. We have layered it with a review system that’s aligned with the quality domain. The National Academy of Science came out with definitions of quality, which include effectiveness and timeliness.

We’ve layered the digital review system with those domains so people can give their feedback aligned with those domains. It’s less likely to make doctors and nurses defensive, and more likely to make them say, we’re doing great here, but we need to do better over there. We’re trying a systems lens approach to galvanize improvement in the system of care provision for the members we serve while ensuring that we’re integrating their voices to drive that change. Today, we have over 18,000 reviews, primarily from low-income women, sharing their experience of care.

Our third pillar is in-person. We learned early on that mobile phone penetration rates and the growth in these rates are not appropriate proxies for digital literacy. We recognized that we needed to create a phygital [physical and digital] approach. We have what we call NudgeHubs™. These are very small spaces, not clinics, but places where a person can walk in, meet with a coach in person, and learn how to enroll on the digital platform.

We have six hubs to date that are primarily in markets in Lagos. We also have what we call roving community ambassadors and tech whisperers. These are people in the community who will meet people in person, enroll them onto the platform, and support them. They carry backpacks that have devices able to help them monitor health. That matters because most of the people we serve cannot afford these devices themselves. We’re very much about meeting people where they are.

While the first three pillars are mainly focused on individuals, the fourth and final pillar is mainly focused on healthcare providers. We have a tele-education platform that supports healthcare workers as well as the people we serve. We train healthcare workers in clinical care and quality improvement, and we’ve expanded to do a lot on financial literacy, which is more for the people we serve. We also offer AI literacy for healthcare workers. We do this because we started recognizing that while we were building the capability of the people we serve, healthcare workers were getting left behind in digital literacy. Everybody is bringing their phone to health workers and saying, look at me, look at my graph, my blood pressure is improving. And a doctor is saying, okay, I don’t have time to look at this. Not because they don’t want to, but maybe because they haven’t been trained themselves on how to leverage digital health tools.

Today, we have trained close to 15,000 healthcare workers across Africa. This is also part of our systems thinking. We’ve helped to create tele-education hubs in certain countries in Africa with the belief that rising tides lift all ships. If we’re able to leverage technology to achieve massive wins in terms of educating healthcare providers, then people will receive better care. That’s the bottom line of our intention.

Those four pillars are what have enabled us to reach 130,000 people. We’ve been able to demonstrate a significant reduction in our key metrics, such as average systolic blood pressure reduction in people with hypertension. We’re finishing the paper for that, which we’re very excited to be submitting. It demonstrates that we have been able to show sustained reduction in blood pressure in people with stage 1 and stage 2 hypertension. That’s linked to an overarching reduction of over 13% in premature death from cardiac disease. We’re also very aligned with sustainable development goals. Impact is core to all that we do.

We are for-profit. We’re B2B [business to business], B2C [business to consumer], B2B2C [business to business to consumer], and increasingly B2G [business to government], but we do not curb access for anybody. 

Imo Etuk: We work with the Lagos state government, for example, and we’re increasingly trying to expand to other state governments, and hopefully the federal government, as well.

Sanne Breimer: You mentioned a paper that’s being published soon. Is that an academic or research paper?

Nneka Mobisson: Academic. We’ve had at least 50 different abstracts presented in scientific conferences, but only a handful of publications, primarily written by other folks. This one is in partnership with Purdue University in the US, who has helped us do the evaluation. I’m particularly excited about this because of the partnership and because we wanted peer-reviewed evidence of the impact of our work. We’re in the final phases of revising it.

In terms of impact, we have a theory of change that we’ve revised over the years, but that underscores that it’s about the behaviors. Changing behavior is so difficult, but there’s a lot of evidence that shows if you build somebody’s confidence and self-efficacy, they are able to make specific changes. They will be able to say, for instance, I can lose weight, or I can reduce my blood glucose, or I can get to normal systolic blood pressure if I just start walking 10 minutes every morning at nine o’clock.

Our focus is helping people understand and build their health literacy. Then, by co-creating these micro-goals, we help them understand that it’s about the power of just showing up, and we help them develop those habits. We use the power of data as a way to drive or unlock the rewards that drive intrinsic motivation for change. We track all of that. We look extensively at our data.

We have peer-reviewed data on the tele-education program, for instance, because we partnered with Northwestern University in the US and the University of Abuja. We look at all of these metrics, and we’ve been able to demonstrate improvements in self-efficacy, health literacy, and exercise. So many people that we serve don’t do things like check their blood pressure if they’re not near a hub, or near our community ambassadors. If they go to a public hospital, they have to pay to have it checked. They may only check it once every three months. 

Our proxy is exercise because you don’t need anything to do that, except for mobility, and even if people are less mobile, we support them. We have a multi-disciplinary self-care team, nutritionist, fitness coach, and emotional wellness coach that support them in those aspects. We’ve been able to show improvement in exercise duration going up from an average of just 23 minutes a week to 93 minutes. The World Health Organization says you should have between 150 to 300 minutes a week. It’s not there yet, but it’s on the way up. We recognize the improvements that we’re able to support our members to have.

Sanne Breimer: What would you say is distinctive about your approach compared to what’s already been offered or what other people do?

Imo Etuk: I think it’s our focus on quality improvement coupled with the way we deliver our services through that four-pillar approach. We follow the [philosophy of] of Lean Six Sigma, where you use the resources you have to make the impact you are hoping for. Quality improvement is embedded in everything we do. We constantly run cycles to see what is working and quickly pivot if something is not working because we realize that we do have limited resources, and we want to make sure that we’re deploying them in the right manner.

Nneka Mobisson: The four-pillar approach is another key element of what makes us distinctive. We’re offering an integrated, omnichannel platform. When we first started, people gave us such a hard time, saying things like, four pillars, four companies. Or you’re doing too much. It’s interesting because now people are saying that this makes complete sense. 

When you’re working in systems that have historically failed the needs of their citizens, you have to build the ecosystem support, the infrastructural support, and oftentimes you have to do this through partnerships, so we’re very grateful for partnerships in creating a connective, integrated ecosystem that elevates people. This integrated approach is what’s so distinctive about us.

The omnichannel aspect makes it much harder for us to measure impact. Often, someone doesn’t have a smartphone, or it’s their husband’s phone, so we have USSD [unstructured supplementary service data], and we have an SMS [short message service] curriculum. Sometimes there’s no electricity in an area for weeks on end, and it costs ₦500 to ₦1,000 to charge a phone for one hour. Then, we can have the community ambassador meet someone and support them without a phone.

The quality improvement approach is built around small tests of rapid change and co-design. We apply that early to the people that we serve, and because we’re an adaptive learning organization, we’re able to rapidly integrate what they’re saying to us then test and see if it works, or drop it before implementation. 

For instance, when we were testing Kem, our AI coach chatbot, with women in the market, a lot of our members were saying, I want to take this home with me. They were holding up their phone, saying I want to talk to Kem, but I can’t type. So we very quickly pivoted to, how do we create a voice mechanism that works with our members? We were able to then integrate and test that. Concurrently, we created an integrated platform that allows us to delve into single aspects to meet specific needs. We’re very attuned to listening to and co-designing with our members, and we quickly respond to their needs. 

Sanne Breimer: Thinking about the Rippleworks support you’ve received so far, what’s something that turned out to be surprisingly helpful to scale? 

Imo Etuk: We realized that, in order to scale, we had to fill many gaps. Rippleworks’ ability to identify our needs correctly, and their openness to connect us constantly with experts in the field to fill those gaps, helped us plug those holes and scale. For example, we went through a sales course because sales is a very specific skill set. A lot of people on our team said, I can sell, but Rippleworks connected everyone to an expert who gave us a playbook with a step-by-step of how to sell. The year before that, it was product management.

To build on that, we realized that there were a lot of skill gaps within our team, as well, and our team has been involved in many learning sessions with Rippleworks members. Being able to interface with Rippleworks members that way helped us galvanize the work we’re doing at our organization.

Nneka Mobisson: Being a for-profit social enterprise that’s primarily grants funded, and being so focused on impact, one of our challenges has been around ensuring that we’re organized and structured as a business, in a way where impact is fully intertwined with profitability. For a time, we ignored sales and marketing to focus on impact, so we’re pretty late to the game in the sales bit. It’s not just that Rippleworks helped us with this sales expert, it’s that they approach everything with such humility and intentionality. They really want to know what is important to you. They also have a lot of respect. 

They found the perfect sales consultant to work with our team. She flew to Nigeria, spent time with the team, and we developed such a solid relationship with her that after a few weeks, we were asking for her to come back. We now know that for this next stage, we need someone like her working hand in hand with us. We’re currently exploring bringing her on as a consultant to work with us for the rest of the year.

That is a big testament to Rippleworks’ ethos and how they approach social enterprise. Our team has participated in a number of learning and leadership sessions. Many times, they’ll refer back to the feedback they got from Rippleworks, and they’ve integrated that feedback into some aspects of the organization as well, like by setting up what we call expert office hours. We were able to get additional support and guidance from experts on topics such as org redesign, which we incorporated into mDoc. 

For example, in France, they have this staff delegate system where some members of your staff are elected as representatives of the company. We wanted to make sure our staff had more of a voice as we grew, so that’s an element that we’re now incorporating into our governance systems. That’s all from just one hour with a Rippleworks expert. 

Sanne Breimer: You’re mostly funded by grants?

Nneka Mobisson: Yes. We’ve been very intentional about not taking venture capital. Imo has an MBA in corporate finance. I have an MBA, too, and I used to work for a consulting firm, so I’m very interested in the private sector, and the role of the private sector. Imo and I are completely aligned on our belief in for-profit. What’s happened in the last few weeks in the development world, and the global health space in particular, is an indication of why for-profit social enterprises should have gotten a lot more support than they have to this date.

I think we have the most wonderful partners and the most amazing funders, and I’m so grateful that our funders took a risk to fund us. In the early days, funders told us what we were trying to do was too risky. We were working in chronic disease, and we were working in digital before COVID. At that time, no one cared about chronic disease, and if you look at global health funding historically, it’s been very verticalized, and very siloed. Chronic disease was not sexy because that’s what was happening in the Western world. Then, everyone was saying digital can’t work for health in Africa. As friends have told us many times, if you’d done this in America, you would be a unicorn today because we saw this wave ahead of other folks, maybe even a little bit too early.

We started leveraging AI when COVID hit. It wasn’t when ChatGPT came out. Our belief was that there would be ways to unlock non-dilutive capital to help us test and understand what it’s like to do this work in an environment that’s not been supportive historically. We thought it would be much less risky to focus on non-dilutive capital and it would allow us the flexibility to really learn. 

What that’s done, without question, is it made us much slower than we would have been if we’d had the right kind of dilutive capital. What it’s also done is allowed us to focus on impact. A lot of investment firms come to us and ask why we’re doing one thing rather than another. Or they tell us that direct-to-consumer does not work for health in Africa. Our response is: How do you know that? Where are the analogs? 

We’re working in a lot of uncharted territory right now. We need to have the humility to say we don’t know what we don’t know. That’s a big reason why we have focused on non-dilutive capital, but without question, I think we’re getting to a point where sooner rather than later, we’ll need to focus on raising dilutive capital.

Sanne Breimer: What role does trust play in your relationship with funders? How can a funder cultivate trust, and what bold shifts are needed in the funding landscape to truly center the voices of those closest to the problem?

Imo Etuk: Trust is at the center of everything. They always say you bet on the jockey, not the horse. You have to have trust in the people who are delivering the solution. You have to have trust and believe that they are able to execute. This trust is what allows you to give funders the confidence to add more fuel to that fire so they can actually grow the business and have more impact.

Trust is at the center of everything … Trust is what allows you to give funders the confidence to add more fuel to that fire.

– Imo Etuk

If that seed of trust is not there, then there’s no follow-on funding, and there’s no introduction to other funders to help build an ecosystem around the team and help them have the impact they say they’re going to have.

Sanne Breimer: Was there ever a case where you had to convince a funder, or an instance where you had to work extra hard to build trust or build a relationship? Do you think any bold shifts are needed in this landscape?

Nneka Mobisson: Some of our current funders have been with us for years. These folks were very clear in the early days that even though they got it, they didn’t think their board was ready for chronic disease. But they kept talking to us, and they kept an open space for conversation. They listened. It’s the same way we’ve built an entire trust-building framework to engage the people that we serve at mDoc. They didn’t fund us for a couple of years, but they created a space for us to meet. They always made time for us.

Finally, they decided to try it with a funding structure that allowed them to mitigate risk from their end. For instance, initially, they did not directly fund us. It made sense. Eventually, they were just blown away by how invested we are, and how much we were able to achieve with so little, and they said, this is real. They continued to support us. 

Trust is built through partnership and dialogue. It’s a safe space to talk about where you’re struggling, where you’re winning, and what you need, and it’s a bilateral dialogue. I don’t think that we have that with everybody. I think that sometimes, people develop opinions and then run off with them because of an assumption or because of a bias. I’m going to be very direct: there’s no question about the bias that Imo and I have experienced over the last several years.

Funders need to do more honest reflection on that bias. It may come in the form of an individual, or the direct program officer you’re working with, who then translates information in a way that is wrong and unhelpful. You have to look at your processes and your systems and understand where they’re institutionalized, or where the infrastructure is set up so that bias expands as it gets further into the funding organization. 

Trust is also recognizing where you need to improve. For instance, we had someone tell us that we are not great at communicating. They told us, you have all this evidence, and you’ve done all this work, but you’re not good at communicating it. There are other folks who are getting funding who haven’t done the work, or who are saying their work is based on evidence that’s in published papers, and they’re getting funding. You guys are really bad at communication. We recognized that they are correct. We own it. We’ve been saying it.

Trust is also recognizing where you need to improve.

– Nneka Mobisson

We have about 100 blogs that have not gone onto our website because Imo and I will not approve them. We are hiring 95% local folks, many of whom, unfortunately, have been failed by the education systems in which they’re working. They were not taught how to write, and Imo and I are so busy being in the business, not on the business as we should be, that we don’t have time to sit down and fix the blog or fix the white paper. It doesn’t get published because we know funders are looking at our website, and we know that they will not support us if they see something that’s poorly written, with extra spaces and spelling mistakes in it, despite our infrastructural support and leveraging AI to write better papers.

In that instance, it wasn’t very helpful advice, and we did not get follow-on funding. An example of something that would have been helpful or supportive would have been if they’d asked, how can we support you with communications? 

For example, a current funder was so delighted by all the data that we were demonstrating through a research grant on our AI work, they wanted to know when we were going to publish it. We told them we would love to publish it, but our team is working 20 hours a day. Who’s going to write it? Their response was to send a writer to us in literally 24 hours. 

Trust develops from recognizing intention, and recognizing the authenticity, the ethos, and the principles by which we’re trying to live and implement our work. Then it grows through supporting us in being the best versions of ourselves and the company we can be, so that we can truly deliver the best impact, rather than judging and interpreting. 

Sanne Breimer: What type of support did you receive from Rippleworks? If I understand correctly, it’s capacity building and expert office hours.

Nneka Mobisson: Yes, it was capacity building, expert office hours, and two longer projects that we had around product management and sales.

Sanne Breimer: How does Rippleworks’ process of deciding what capacity-building support to provide differ from what you’ve experienced before?

Nneka Mobisson: They’re very intentional and thoughtful. They came to us and said, tell us what you need. It’s an open space. Look at our website and look at other projects if you need ideas. We’re a learning organization, so we took that. We have a laundry list of what we need, so both times we had three or four different projects on the table, and over time, we worked with them to decide on the best project. They respect what we see our own needs to be and they also recognize that we’re on a journey, so our needs vary over time. Just being accessible to us over time has made a world of difference.

Initially, it was product management. Then later on we were uncovering that it was sales and there were other areas as well, but they had more expertise in that arena, so that’s why we got support there.

Sanne Breimer: Do you identify any gaps in this model?

Nneka Mobisson: Yes. For instance, I’ve desperately needed support on clinical operations. We have lifestyle coaching, but there’s an entire clinical component missing. I am desperate for support in structuring that component, in understanding what clinical operations, coaching, and education look like at both an organizational and operations level, and in integrating that into the broader fabric of the organization. I have not gotten that support even though I’ve voiced that need a lot.

I wanted to write a blog about how all I want for Christmas is the ability to teleport into organizations for one or two weeks and see how they do things. The Eisenhower Fellowship does this, and I wish Rippleworks offered that. As CTO—who also functions as the CFO [chief financial officer], COO [chief operating officer], and CTO [chief technology officer]—Imo keeps saying, I just want to be a better CTO. Imagine if he could teleport into a company, for even one week, to see their practices, their habits, and their routines. As CEO, I’d love to see a very successful digital company that is doing both coaching and clinical. Imo and I are studying online, trying to figure out and dissect how an organization is set up. 

Another area where we desperately need support is behavioral science. There’s so much in this work that’s behavioral science, and we’ve highlighted this so many times, but we haven’t gotten that support. People naturally do what’s easier for them, and tend to focus on sales and marketing. We respect that because we need help there, too. We always say we need help in everything. We’re learning.

It would also help if Rippleworks fostered more opportunities for peer learning, where [the many organizations in their portfolio] can learn from each other. There’s the platform by which we learn from Rippleworks, and having seen that view of all of us, they are able to make linkages. 

For instance, we created the review system I was talking about earlier because one of our funders connected us with their grantee in India, and we had a lot of bilateral exchanges. Also, one of our first grants, back in 2016 or 2017, was for $8,000, and it was given just to learn. They told us to choose an organization in Africa and they gave us $8,000 to engage in bilateral learning. We found a consortium in western Kenya that was working on chronic disease in communities and leveraging financial incentives to drive behavior change. The funder facilitated 12 months of learning collaboratives for us to continuously exchange ideas, and that learning fostered trust. One of the professors there was from Purdue University, which has now led to us partnering with Purdue on evaluations of our work and so much more today.

Sanne Breimer: You also participated in expert office hours. Can you share an example of something that you were able to take from that experience that was immediately useful for you?

Nneka Mobisson: Recently, I was looking for, and I still am, organizational structure support and organizational design. We still need that. We now have 68 people at mDoc. We’re trying to be for-profit, but I don’t think we’re structured in a way that’s set up for us to be for-profit. They set up expert office hours, but this is not a one-hour conversation; it’s a full-blown project. The conversation was not helpful in terms of organizational structure. However, it was helpful for other reasons. 

One of the key things was that point about staff delegates. We’d had some issues with salaries and people feeling salaries were inequitable for people outside of Nigeria versus in Nigeria. It was perfect timing to learn that if we have staff representation at the governance level, it will help address some of these issues early on. That was an instant, gratifying insight.

Sanne Breimer: Do you have any other ideas about things that would have made these expert sessions more useful?

Nneka Mobisson: No, because they give guidance and tell us what to prepare beforehand. As an organization, we internally prepare, and thanks to Imo’s days in finance and my days in consulting, we know how to maximize learning opportunities. We have learning support from Google, and we come together as a team and determine what we’re trying to get from that one hour.

Sanne Breimer: Nigeria is where you’re based and where most of mDoc is working, but you mentioned some expansion to other African countries. Can you share more about that?

Nneka Mobisson: We’ve had so many people call us and ask, why aren’t you doing this in other countries, or outside of Africa? This is important everywhere. This year, we’re focusing on South Africa. Over the next several months, we’re going to be testing whether this is feasible to do in the US, as well.

Sanne Breimer: How would you describe your target audience?

Nneka Mobisson: They’re very low-income. They make less than $2 a day, and 73% of them can only access healthcare at public facilities. That’s our proxy for income, but we recognize that to be sustainable, we need to have a cross-subsidization model. That’s where we provide the same quality of service, but leverage tiered subscription models or premium pricing. We’ve had so many people from middle-income and upper-income communities tell us that they want our service, or ask why it’s not available for them. One question we’re going to be looking into is whether our focus is low-income, or if it’s the masses, or if it’s serving the vulnerable, the neglected, the marginalized. Low-income is our core, but if being able to serve more of them means repurposing this platform and serving more middle-income and upper-income people, we will do that as well. 

Sanne Breimer: Thank you very much.

Sanne Breimer (she/her) is a freelance journalism trainer, project manager and adviser for international media organizations including SembraMedia, Thomson Reuters Foundation (TRF), European Journalism Centre, Thibi, and the Asia-Pacific Broadcasting Union (ABU). She founded Inclusive Journalism, aiming to educate (primarily) Western journalists about media representation and decolonisation through a weekly newsletter, online courses and retreats. Sanne works remotely and divides her time between Europe and South East Asia. Before moving into training, Sanne worked at a managerial level in national public broadcasting in the Netherlands for almost 13 years, focusing on radio, digital media and innovation. She is Dutch with Frisian roots.

* This interview has been edited and condensed.

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