Project Everest

Using Hubs to Provide Health Services in Malawi

Josh Marshall
Josh Marshall | Dec 20, 2017 | in Health Consulting

Throughout the past month, the Malawi Health team have been working towards testing a pre-diagnostic application for assessing patients, in the hope of reducing the extensive travel times, wait times and short consultation times that impact the local health system. Although much of this process has involved the development of a research protocol to enable future teams to test the accuracy, efficiency and usability of this technologies, the team has also been developing ideas on how to create a sustainable business using this technology. Whilst the final product is still a long way off for future health projects in Malawi, the current team thought it was important to develop an initial model as an end goal to work towards. Through much discussion, the team has developed an idea around selling the product to health care centres, rather than to individuals, and using local ‘hubs’ as a form of delivery to patients.


Through much empathising by both the current and previous teams, barriers including health illiteracy, long travel times to health care centres and heavily congested clinics, resulting in  extensive wait times and short consultations in clinics, were identified. In reality, this often looks like an upwards of a two hour walk to the clinic, two hours in a congested waiting room and a consultation that is less than five minutes, meaning it is difficult for a clinician to deliver care in an appropriate manner. A major cause of this congestion is created by health illiteracy, with many patients travelling to clinics afflicted by illnesses they could treat themselves in their homes. This pre-diagnostic tool has the potential to remove these patients from the clinics, which would alleviate congestion issues.


Although a need had been identified, the team were still struggling to understand how a sustainable business could be developed around this product. Currently pre-diagnostic tools are being used throughout the developed world, with these applications being offered for free, and revenue created from click-throughs to other health services. In Malawi, this model will not work for several reasons. Firstly, internet penetration currently sits at 9.4% as of 2016, considerably lower than areas like the UK that have 94% penetration (, 2016). Secondly, a revenue stream that revolves around recommending individuals to certain health centres is not relevant when travel times are already so long, and when individuals do not have choice of what clinic to visit, especially in rural areas. The issue of health illiteracy also means that treatments need to be provided by the application, as simply providing a user with their illness is of no benefit to those without the capability to act upon this information. This reduces the potential amount of applications that could be used.


With these issues in mind, the team began ideating upon how to create a revenue stream for a potential product. When considering who to sell the product to, the team understood that selling to individuals may not be sustainable in the current state, as internet penetration, although increasing, is still quite low. Additional to this, these applications are only available in English, which creates somewhat of a barrier as although it is the national language of Malawi, many individuals, particularly in rural areas, still use tribal languages and do not have English levels high enough to use such an application. Deciding that selling the application to individuals was not sustainable, the team instead began to focus on other ways to create revenue streams from the application.


Clinics were then identified as a potentially important customer for this product, particularly as they have greater funds than individuals in this space. In order to differentiate the product from those available for free in the market, the team developed a model around creating a separate application using the API of Your.MD, which is the current application the team is looking to use in testing. Creating a separate application allows for tailoring to local conditions, as well as differentiating the product from those applications already available on the market. This allows the application to be sold to clinics. In terms of a revenue stream, this can be sold on a subscription basis to clinics, who then gain access to using the product. In addition, the team came up with with the idea of using hubs, which are further explained below, as a method of delivering the application for patients to use. Revenue from the hubs will be gained through a one off setup payment, creating a secondary revenue stream.


The hubs are an essential aspect of this model, in that they allow patients greater access to the application and healthcare services. The product could simply be set up at clinics, and although this would identify which patients need treatment and which do not, this does not alleviate the long travel times faced by many patients in rural areas, which is a central issue in the local healthcare system. However, using hubs reduces this. The hubs revolve around setting up a smartphone or tablet at an area designated by either the clinic or PE, and then having individuals travel to this hub to use the application on this smart device. The hubs would be at specific locations, for example where individuals only have to travel half an hour instead of two hours. Individuals would be employed to work at these locations, who speak both English and the local language Chichewa, and who have been trained in using the application. They do not necessarily have to have medical training, as the application provides the diagnosis and treatment, not them. This method also removes the language barrier that many patients will have when using an application that is in English. In terms of ensuring power to the devices, the team is looking to work with the Energy team in Malawi, who are working with solar.


Having individuals travel to hubs rather than clinics has several advantages. Firstly, it can greatly reduce travel times since individuals can travel to a location that is closer than a clinic. This is an important consideration in understanding the necessity of the hubs rather than just using the application at the clinics. Reducing the need to travel long distances when ill is important in terms of ensuring that individuals can regain health. If they do not need to walk long distances, then they can spend more time resting and recovering and have a better chance of regaining their health faster. Creating time to recover from a minor illness will allow for a swift recovery, whereas taking a day for travel can cause prolonged recovery time. Also, if an individual walked two hours to a clinic, only to use the application and be told they do not need to see a clinician, they may still want to see a clinician anyway after they travelled such a long distance. This would not alleviate congestion within the clinic, and would not allow the application to have its desired effect.


Secondly, the application can identify whether or not an individual actually needs to go to a clinic by providing likely illnesses and recommended treatment. This will help alleviate congestion in clinics, as less people will need to go to clinics to have basic symptoms identified and treated. This has the potential to reduce waiting times in clinics as well as increase patient time spent with a clinician, which will improve efficiency and quality of services, specifically for those with more serious illnesses. Long term, it also has the potential to improve health literacy, as patients begin to understand basic symptoms more readily without depending on a clinicians diagnosis.


While the team feels this is a viable end-product to consider in the future, we also understand that there is a considerable amount of work left before such an endpoint is reached. Specifically, the application still needs to be tested in terms of its accuracy, efficiency and usability in the Malawian health environment. This will allow opinions on how the application needs to evolve to be created, and also understand how it can operate within the Malawi context. Although this process and several others need to be completed before this final product can actually be used, the team has found it a rewarding experience to develop this idea, especially in allowing them to visualise an end state of what their work could look like.



Statista. (2016). Percentage of population using the internet in Malawi from 2000 to 2016. Retrieved from:

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