Every year, 100 million people worldwide are pushed into extreme poverty. The reason is their lack of protection against the financial dangers that arise in the event of illness. Dr. Julius Emmrich and Dr. Samuel Knauss are both physicians and researchers at Charité – Universitätsmedizin Berlin as well as associate membersof the Einstein Center Digital Future (ECDF). Within the framework of the Berlin Institute of Health’s‘Digital Clinician Scientist’ program,the two physicians are investigating how mobile technologies can be used to protect people in developing countries from impoverishment caused by medical expenses.

Both of you are originally neurology specialists. How did you come up with the idea of a research project in the field of digital health care?

Knauss: Neurological diseases cause the greatest burden of disease worldwide. At the same time, treatment is cost-intensive and access to expert care is often difficult. This is precisely why we, as neurologists, are devoting our energies to issues of global health.

Emmrich: We have been involved in development cooperation for several years while pursuing our studies and residencies. Together with similarly motivated colleagues, I founded the medical aid organization “Ärzte für Madagascar” (Doctors for Madagascar) in 2011 in order to improve health care there, especially for the socially disadvantaged sections of the population. The association supports existing health facilities by providing medical equipment, as well as training for specialists. In the course of our work, we came to realize that access to health care is highly dependent on income and that a large part of the population lives with the threat of medical impoverishment. At the same time, we were observing the rapid digital change taking place in Africa: Over the last decade, the number of mobile phone users in sub-Saharan Africa has quadrupled; and in many regions mobile money – that is, the use of mobile phones to make payments – has become an everyday practice for a large part of the population. We detect in these developments an immense potential for reaching patients directly and offering them protection against medical impoverishment.

In countries where medium and low incomes predominate, less than ten percent of the population is covered by health insurance. What impact does this have?

Emmrich: Due to a lack of access to health insurance and bank services, patients are forced to pay for treatment out of their own pockets – with money that, in many cases, they either don’t have or can’t come up with as quickly as necessary. As a result, people often suffer great financial hardship – or have to forgo life-saving treatment. In sub-Saharan Africa alone, 1.6% of the population is driven into extreme poverty each year by high and unpredictable health expenses.

Which means could be used to help protect people against medical impoverishment?

Knauss: In Europe, it took decades to establish functioning health care systems – the first health insurance system in Germany emerged as early as the late 19th century. Development was more or less steady. In Africa, by contrast, we are currently witnessing a leap forward in development with new paths being opened up quickly and efficiently by rapid digitalization. In recent years, large sections of the population have gained access to general financial services for the first time, and this, in turn, is paving the way for affordable health care.

In Madagascar, you are implementation partners of the national health insurance fund. How did this cooperation come about? How has the tool you developed been accepted among the population and the doctors on the ground?

Emmrich: We have been working closely with Madagascar’s Ministry of Health for several years – precisely to protect the population from impoverishment through expenses caused by medical treatment. Together we came up with the idea of trying to find a way to take advantage of the rapid spread of mobile payment systems in order to reach patients directly – using a medium that is already integrated into people’s everyday lives. With the support of the charitable Else Kröner-Fresenius Stiftung (EKFS), the Berlin Institute of Health, and Charité – Universitätsmedizin Berlin, we were able to achieve our goal by developing the mobile health savings book mTOMADY (the Madagascan word for ‘healthy’). This has been available to the population of the capital Antananarivo since late 2018. Acceptance of the health savings book is high because it provides people with a safe way to save money for their health care and also to receive money for this purpose from friends and families – some of whom live in completely different parts of the country. For the hospitals, billing has become more transparent and cost-efficient. 

Knauss: In our accompanying research project, we are now investigating the actual benefits of the health savings book and the resulting costs, both at individual and national levels. Needless to say, these findings are something that interests Madagascar’s Ministry of Health too. If the health savings book proves its worth, the Ministry is interested in integrating our solution into the national health insurance fund, thereby giving all 25 million Madagascans access to affordable health care.

Both of you have been selected as Digital Clinician Scientists. The program enables you to spend half of your residency in research. What does this mean for your research work?

Knauss: By exempting us from clinical activities for 50% of the time, the DCS program gives us the latitude to successfully implement this research project. The program is specially designed for digital research projects and is therefore unique in Germany. The research leave enables us to pool our medical expertise, digital skills and practical experience in development cooperation in order to advance the research project in the best possible way.

What is the current state of your research project and what are your plans for the next six months?

Emmrich: Over the next three years, we will be conducting a cluster-randomized study in more than 60 public health care facilities in Antananarivo. The results of the design study, which we conducted prior to this, provided us with information on how best to use the savings book and how information could be packaged for, and communicated to, patients. Initially, we implemented the tool in a small number of health centers to test and adapt the software. In the pilot project, we are concentrating on the target group of pregnant women and young mothers, because they are especially disadvantaged and often not prepared for the unexpectedly high costs of pregnancy and giving birth. Over the coming six months, our main focus will be on spending a lot of time on the ground in Madagascar to plan together with the local team the implementation of the project. In addition, we are also preparing our software to enable the reach of this project to be extended nationally.

You are associate members of the Einstein Center Digital Future (ECDF). What do you hope to gain from this cooperation?

Knauss: We can only solve the really big problems by working together. From the experience we’ve gained from our own project we can say with certainty that a wide variety of perspectives and experiences makes it possible to rethink and evaluate content.

Emmrich: We hope our membership will enable us to benefit from precisely this variety of perspectives. We look forward to exchanging ideas with our colleagues and introducing the subject of digitalization research in a global context as a means of promoting equal opportunities and reducing pover