Hamza Asumah MD, MBA, MPH
The 80% Nobody Is Building For
In Africa, 97% of people lack formal insurance coverage, with pharmacies serving as the primary interface for 80 percent of patients. That means virtually every patient in your target market is:
- Paying cash out of pocket
- Navigating fragmented care across multiple providers
- Making healthcare decisions in the context of extreme budget constraints
- Operating in environments with low institutional trust
And yet, most healthtech products are designed as if patients have insurance, trust doctors implicitly, and follow linear care pathways.
This isn’t a corner case. This is the market.
The Trust Deficit
In the informal sector, high poverty rates and lack of synergy between service providers hinders fee payment even with subsidies, while members resist paying “hidden” transaction fees. Patients aren’t resistant to healthcare—they’re rationally skeptical of systems that have consistently failed them.
Consider what “trust” means when:
- Counterfeit drugs are rampant
- Diagnostic results may be falsified to generate more business
- Providers often demand payment before treatment
- Health records are lost when you switch facilities
- There’s no legal recourse when things go wrong
Your UX problem isn’t teaching patients to use your app. It’s earning trust in an environment where trust is survival-calibrated.
UX Principles for Cash-Pay Markets
1. Price Transparency at Every Step
Mobile-friendly, chat-based interfaces allow users to quickly get personalized information like cost estimates in an accessible manner, supporting transparency around complex topics like pricing or treatments.
Show pricing before asking for any commitment. Not “contact us for pricing”—actual prices, upfront. If costs vary, show ranges and explain why.
Example: M-TIBA in Kenya shows exact costs before patients commit to services, with transparent breakdowns. The platform uses mobile technology to facilitate inclusive healthcare with flexible payment options that make it easier to meet program needs.
2. Offline-First Architecture
Technology must be offline-first, with USSD, SMS, and asynchronous synchronization accommodating intermittent connectivity in peri-urban and rural areas.
Your product shouldn’t require constant internet access. Use:
- USSD for feature phones
- SMS for notifications and confirmations
- Local data storage with background sync
- Progressive Web Apps that work offline
3. Zero Assumed Literacy (Health or Digital)
To achieve true inclusivity, it is essential to design accessible healthcare products that cater to diverse users including those with disabilities, non-native speakers, and varying levels of digital literacy.
Design for:
- Visual navigation over text-heavy interfaces
- Voice options where possible
- Multiple language support (not just official languages)
- Icons and symbols that don’t require health literacy
4. Minimize Upfront Data Collection
Every field you ask users to fill in is friction. Every piece of personal information requested increases skepticism.
Good: Let users explore pricing, see provider options, book appointments before asking for full registration.
Bad: Requiring full medical history before showing what services cost.
Pricing That Reflects Reality
The affordability challenge: Patients are making trade-offs between healthcare, food, transport, and school fees. A consultation that costs $5 may represent 2 days of income.
Effective pricing strategies:
- Pay-as-you-go: Match payment to service consumption. M-TIBA’s wallet model lets patients pay small amounts into health savings, then draw down as needed.
- Transparent add-ons: Base service priced low, additional services clearly optional. Let patients choose their own bundle.
- Group discounts: Family plans that reduce per-person cost. Several telemedicine platforms offer household subscriptions.
- Value-based tiers: Not “basic/premium” but “consultation only” vs “consultation + tests” vs “full care package.”
Distribution Strategies That Work
Distribution and trust remain the ultimate moat, with startups not bypassing pharmacies but co-opting them. The informal patient isn’t sitting at home waiting for your app. They’re already going somewhere for healthcare.
Successful distribution channels:
1. Community Pharmacies
They’re trusted, accessible, and where patients already go. Today’s African consumers increasingly view pharmacies as comprehensive health hubs, expecting services beyond medication dispensing including screenings, immunizations, and chronic disease management.
Strategy: Don’t compete with pharmacies—enable them. Provide inventory management, patient management, or teleconsultation services that make the pharmacy more valuable to patients.
2. Community Health Workers
Kenya committed to supplying every Community Health Promoter with essential health commodity kits containing blood pressure monitors, glucometers, malaria test kits, and other tools.
CHWs are trusted, embedded in communities, and already doing house-to-house health education. Your product should make their job easier, not replace them.
3. Faith-Based Networks
Churches, mosques, and temples have existing trust networks and gathering points. Health messaging through religious leaders often has higher credibility than government campaigns.
4. Employer Networks
Informal sector employers (markets, transport associations, trade unions) sometimes organize group health benefits. Easier to negotiate with aggregators than individual patients.
5. Mobile Money Integration
Mobile money applications with flexible payment options make it easier to meet program needs, with educating users about mobile money processes being crucial.
M-PESA, MTN Mobile Money, Airtel Money—these are payment rails patients already trust and use daily. Direct bank transfers or credit cards are non-starters for most informal patients.
The Product Categories That Fit
What works for cash-pay, fragmented care:
Telemedicine with medication delivery: Consultation + immediate fulfillment. Patients don’t trust referrals to “go to this pharmacy.” They want one transaction.
Chronic disease management: Diabetes and hypertension care is recurring revenue, and patients are motivated to engage. Several successful models combine telemonitoring, medication delivery, and periodic in-person check-ins.
Diagnostics with clear results: Patients will pay for tests if they trust the accuracy and understand what results mean. Portable ultrasound, rapid malaria tests, and blood sugar monitoring have all found product-market fit.
Preventive care subscriptions: Annual check-ups, vaccinations, family planning. When packaged as yearly or monthly subscriptions, the per-visit cost feels more manageable.
What struggles:
Complex care coordination: Referrals between providers rarely work when patients pay cash and have no continuity of care.
Long-term treatment adherence: When patients face daily trade-offs between medication and other needs, adherence suffers without continuous support.
Preventive services with unclear value: Hard to monetize health education or preventive screenings when patients are focused on acute needs.
Real Examples of Good Design
Babyl Rwanda: Built for cash-pay before insurance expansion. USSD interface, phone-based consultations, partnered with pharmacies for medication delivery, tiered pricing with free basic tier.
MyQura Nigeria: Digital care marketplace connecting patients needing ongoing support with verified caregivers, running on a subscription model covering tele-consultations, home care, and ongoing support. Designed for families managing chronic illness or post-surgery recovery—cash-pay market with clear value proposition.
Labtracka Nigeria: Online test booking platform where customers can order tests with samples collected at home or designated labs, with results uploaded where users can access them once available. Transparent pricing, home service option, choice between cost and convenience.
The Fragmented Care Problem
Patients see multiple providers, keep no unified records, and often restart from scratch at each visit. Your product needs to work within this fragmentation, not require fixing it first.
Practical approaches:
- Assume no medical history available. Design intake processes that work even when patients can’t remember drug names or previous diagnoses.
- Patient-held records. Give patients control of their data. WhatsApp-based record storage, SMS summaries, or physical cards they can carry.
- Provider-agnostic design. Don’t require patients to return to the same provider or facility. Design for one-time transactions that deliver value independently.
What Success Looks Like
You’ve designed well for informal patients when:
- A patient can understand value and complete a transaction within 3 minutes on a feature phone
- Pricing is transparent before any data is shared
- The service works offline or on unstable connectivity
- Trust is built through transparency, not marketing claims
- Payment integrates with how people already move money
- The product fits into existing care-seeking behavior rather than demanding new patterns
The informal patient isn’t a downmarket version of insured patients. They’re the actual market, with distinct needs, constraints, and behaviors.
Design for them first, and you’ll build something that works for everyone.
Dr. Hamza Asumah 
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