Bas Hoefman, founder Text to Change

TTC believes that any successful communication depends on a thorough understanding of target audiences’ and participants. It researches participant information using mobile telephone data and once analyzed, combines this with other information for advocacy and behavioral change communication using a diverse set of mass-campaign channels including mobile phones, radio, and television, internet and news papers.

In the last 3 years TTC has carried out numerous successful SMS programs with various organizations with the aim to increase knowledge and improve the uptake of health services in Africa. TTC’s SMS programs have a response rate between 20 and 50 % and have shown remarkable figures in uptake of health services (+200%).

At present TTC is active in Uganda, Kenya, Tanzania and Namibia and is going to expand their operations to Madagascar, Ghana and Mali in 2010.

PC Tech’s Albert Mucunguzi & Richard Boateng spoke to Bas Hoefman, founder & director Text To Change.

1) PC TECH: Hello Mr. Bas Hoefman, you are welcome to PC TECH Magazine. Tell us little about yourself and some of the interesting projects you are currently working on.

BH: My name is Bas Hoefman I am the Founder and Director of Text to Change. I have a Bachelors degree in Marketing & Communication at the Hogeschool van Utrecht, the Netherlands. I also hold degrees in International Marketing and International Advertising. I have over 8 years of Marketing and Advertising experience in several areas. After graduating I worked for 4 years as a Marketing Manager Benelux and Central & Eastern Europe at ING Wholesale Banking Securities Services in Amsterdam. After learning about the enormous potential of Mobile telephony in Africa I decided to found Text to Change (TTC) Foundation, early 2007, together with 2 colleagues. With Text to Change we have presented successful programs in the field of HIV Prevention and Uptake of HIV Voluntary Counseling and Testing (HCT), Malaria, Family planning, Reproductive health and Child abuse, through interactive SMS Messaging in various countries in Africa.  Text to Change holds partnerships with organizations in both the public and private sector:  Aids Information Center, USAID, DED,  UNICEF, Family Health International, Zain, MTN,  Orange.

Text to Change projects

• Health Initiatives for the Private Sector (HIPS-USAID), August 2010 Uganda

o Workplace based SMS program among 25000 employees targeted from 8

companies:

•  Kinyara Sugar in Massindi;

•  Kakira Sugarworks in Jinja;

•  Kasesse Kobalt KCCL;

o Program focus: HIV/AIDS prevention, Malaria Family Planning, Medical Male

Circumcision (MMC), Multiple Sexual Partnerships.

o Response Rate: 37 %

o Uptake of health services at company clinics : + 200%

• ZAIN workplace based SMS program, Kenya, Madagascar

o Target Group: 500 Zain Employees in Kenya and Mdagascar

o Program focus: HIV/AIDS prevention and treatment

o Response Rate: 43%

o Uptake health services: + 10%

o Media: intranet , Email, internal communiqués

• Interactive Voice Response system (IVR), UNICEF Namibia (2010-2011)

o Target Group: Namibian citizens

o Program focus: opinion-polls about the Millennium Development Goals.

Upcoming projects:

• UNICEF Uganda (ANC/E-PMTCT) 2010 – 2012

• Warchild; SMS to fight Child abuse (2010-2011)

• Family Health International : Mobile for Reproductive Health (Kenya, Tanzania, Ghana

• UNICEF Facts for Life SMS program: Madagascar and Mali ( en2010)

• Health Child: HIV AIDS & Family planning 2010 (Jinja, Uganda)

• HIPS Workplace programs ( expansion to 8 companies in Uganda : e.g. Coca Cola, Nile Breweries)

• Budget Tracking program with Acode in Uganda (2010-2011)

• Zain workplace based SMS programs in Tanzania, Uganda, Madagascar

The Kawempe Home Care Initiative-Text to Change project started in April 2010.  The project aims at improving adherence to ARVs for the HIV infected population under care in Kawempe clinic using mobile phone message reminders.  

2) PC TECH: Impressive and congrats on your initiatives. However, why is mobile health increasingly gaining much attention in Uganda and other African countries?

BH: I think that more and more NGOs and development organizations are starting to realize that given the spectacularly growth of mobile telephony in Africa they can’t ignore mobile telephony anymore in their communication mix. Mobile telephony is booming in Africa. Uganda alone has over 10 million subscribers. This underlines the huge potential of Mobile telephony for Health. In Africa it is the fastest growing mean of communication in the world. A million users are being added every week.  TTC is driven by the belief that the cell phone is becoming more and more affordable and accessible, including at the poorest level and among youth, and therefore should be harnessed to carry forward the need for health and wellbeing communication.

Mobile telephony is the way to communicate to people on a personal level and due to its anonymity it is perfectly suitable for sending messages regarding stigmatized subjects such as, HIV/AIDS.  

3) PC TECH: So what has been key achievements of Text-to-change since it began?

BH:  Text to Change has had the advantage to having piloted its SMS Health campaigns in Uganda on a large scale 3 years ago (target audience: 15.000 mobile users). We knew it had potential and the only way to find out was to just do it large scale rather than first endlessly doing small scale pilots which unfortunately often is the case with a lot of  Mhealth initiatives.

Despite a lot of technical and cultural challenges it was a very successful project and above all we have learnt a lot from this. Besides that, due to the success of the Uganda programs we established the name Text to Change as a serious player in the field of Mobile Health in Africa.  Based on the results of our first program we have developed a state of the art platform with our local partners in Uganda.

–  Text to Change was the 1^st to have acquired a Zero rated Short code over 4 major networks in Uganda: MTN, Zain, UTL and Warid.

– TTC was the first to use SMS for health communication in private sector Workplace Programs in Africa:  TTC worked  with HIPS (Health Initiatives for the private sector project) a USAID funded program and carried out sms based workplace programs for Kakira Sugerworks, Kinyare Sugar and Kasesse Cobalt Company.

– TTC has proven that SMS is a simple and very successful way to transfer health information to the interest and needs target populations;

– TTC has reached over 200,000 people with Health communication via SMS and over 2000 people came directly for health services a a result of the messages they received from Text to Change on their phone.

–  Text to Change holds strong partnerships with both private sector, NGOS and CSOs: USAID, Zain ,  Unicef, Family Health International, IICD, the Dutch Ministry of foreign Affairs, the Deutscher Entwicklungsdients (DED) , War Child.

–   TTC has realized improvement in Uptake of health services varying from 35% to 200 % at partnering Clinics by using SMS.

– TTC has proven that SMS is a simple and very successful way to transfer health information to the interest and needs target populations.

– Text to Change Founding member of the Open Mobile Consortium, Mobile Health Alliance and preferred partner within Connect4Change Consortium;  

4) PC TECH: Considering these achievements, what do you think has been the key factors to the success of Text-to-Change?

BH: The key factor of the Text to Change success lies within the fact that we were determent to make it happen and never let loose of that thought. Staff working for TTC have strong backgrounds in development economics, econometrics, marketing and ICT. They come from both the private sector (banking, marketing and ICT) and from development agencies. Besides that the interactive incentive based concept were people receive questions on health and are enabled to send back their answers for free has proven to be a winner. Text to Change is simple in concept, yet powerful in delivery. It is well known that people learn through play. The Text to Change quiz entertains while also educating the youth in an accessible way.  When we started 3 years ago mHealth was still an untapped area and it really wasn’t easy to convince big donors, NGO’s and other development organizations of the huge potential mHealth had to offer for them. After the first pilot we did a whole range of relatively small scale (low budget) programs with various partners who have enabled us to gain experience and expertise. More importantly, we were able to show clear results in terms of high response rates and uptake in health services. That proof of concept was very important to bring the programs to scale. Furthermore, TTC offers the full package: Compiling the database, profiling, design messages, sending out messages and collecting/ analyzing data and reporting.  

5) PC TECH: Currently, what are key challenges and how are you addressing them?

BH: I think one of the biggest challenges for Text to Change and Mobile Health in general:  is who is going to pay for the programs after the pilot phase? In order for mHealth to become sustainable: Governments should be more involved. Now there is often a lack of real policies on E health and M Health resulting into many and similar pilots without a common target that are operating under the rader of the Government.

Another challenge I see is Local capacity: Because of the fact that M Health in Africa is rapidly growing I believe there will be a shortage of good quality programmers and program management. Our experience here in Africa in terms of the content of the messages is that NGOs find it difficult to translate their traditional health communication messages into SMS format. It is important to involve partners and programmers at very early stage in the projects as I believe that the knowledge and the skills are certainly there.

Another challenge is the creation of databases with telephone numbers and to find out who is behind the telephone number. Furthermore, it is also very common to share telephones so you never know for 100% sure who is behind a telephone number. We collect telephone numbers by communicating how to opt in to our services via mass media:  radio, posters and fliers. Especially the combination Radio and SMS has proven to be extremely powerful.  We also collect telephone numbers via peer educators and community health workers. The next step is to start profiling the database by simply asking people their age and gender and other demographics. This enables us to tailor our programs to specific target groups.  For example: We now preparing a program with UNICEF on prevention of mother to child transmission (PMTCT) whereby the challenge is to identify pregnant mothers.

It has become more and more common that people receive unsolicited messages on their phone about love, sex, dating etc. This is the reason that I believe in people voluntary opting in to our services rather then spamming large databases and cause a fatigue and spoil the market of sms marketing and m health.   Furthermore we always give people the option to opt out if people don’t want to receive the messages anymore.  

6) PC TECH: Do you think your target users will prefer voice calls over text messages? Further, what is the advantage of using text messages for health care information delivery?

BH: I really believe in the potential of IVR (Interactive Voice response messaging). As a matter of fact we have done a very successful IVR program with UNICEF in Namibia on the development goals. Although I think that Text message campaigns are equally effective and these two can compliment each other. One of the biggest advantages of the mobile phone for health communication is that you reach people in full anonymity; which is very important if you are dealing with sensitive health subjects such as HI/AIDS.

SMS stands out as having several advantages: cost-effectiveness, scalability, convenience, broad reach and widespread popularity in the developing world. Moreover, all basic phones are able to receive SMS.

 7) PC TECH: Will you describe your service as being only accessible to those who are literate, especially in English? What about local languages – Any plans?

BH: Illiterate people, people in the rural areas, women and young Children will always be hard to reach. We have been using local languages, Luganda and Luwo, for our programs but we have seen that the response rates on our questions in English are much higher. One of the reasons is that the people that use mobile phones are familiar with the English language as the language of preference for the mobile phone companies is English.  The Local languages are often a spoken language rather than a written one. To overcome illiteracy we have been experimenting with Voice SMS were people receive a recorded spoken message.  We will definitely continue with using local languages as we believe we can’t exclude anyone for our programs.

8) PC TECH: There is always confusion between the following terminologies which are used interchangeably: mobile health and m-medicine? Can you briefly explain the differences?

BH: Mobile Health and m-medicine / telemedicine are confusing terminologies indeed. I believe that there is no clear distinction between them as there is a huge overlap and according to me everything could be under the umbrella of mHealth.  Telemedicine / m medicine at first was more focused on applications and mHealth more on the health communication side: campaigns and programs but now there is no clear distinction for me.

 9) PC TECH: If you had audience with African Head of States at the African Union, what will you say concerning mobile health?

BH: There have been around 30 ‘successful’ mHealth initiatives in Uganda and not one has been brought to a nationwide scale…? That is remarkable I would say. There is a firm need of evidence based evaluation of larger scale/ nationwide programs after the so called pilot phase. Only if you implement a program at a larger scale you are able to evaluate what works and what does not work and get the funding needed to implement a sustainable program. The biggest hype of Mobile Health in Africa is now over and by now policy makers should be convinced that you can’t ignore mobile telephony anymore and that it should become part of any Health communication strategy and/or data gathering program.

10) PC TECH: Concerning Text to Change, what should we expect in the near future?

BH: Text to Change will passionately continue with carrying out mHealth with our partners in Uganda and in other East and Southern African countries abd reach out to as many people with life saving health messages.  By the end of 2010 we are hoping to have expanded to Ghana, Mali and Madagascar. Our aim is to be in 10 countries in Africa by the end of 2010. Furthermore we are exploring the opportunities in Asia, Latin America and the Middle East. Besides sms wil offer IVR, Data and various other applications to our partners. It is our firm ambition to become a global platform of telephony based health services.

11) PC TECH: Mr. Bas Hoefman. Thanks for your time with us.

Text to Change (TTC) is a non profit organization, founded in 2007 in Amsterdam, the Nether lands. It uses state of the art mobile phone technology to collect and disseminate health information. TTC has been one of the pioneers in using mobile phones for health monitoring and advocacy in Uganda reaching out to the general public at a large scale. TTC works demand driven and sets up complete programs with local and international partners. The aim of TTC is to make life saving knowledge easily available to the general public and especially to community and family level caregivers. TTC is specialized in interactive and incentive based & interactive sms programs addressing a wide range of health issues such as HIV/AIDS, Malaria and Reproductive Health and Family planning. TTC believes that any successful communication depends on a thorough understanding of target audiences’ and participants. TTC researches participant information using mobile telephone data and once analyzed, combines this with other information for advocacy and behavioral change communication using a diverse set of mass-campaign channels including mobile phones, radio, and television, internet and news papers. In the last 3 years TTC has carried out numerous successful SMS programs with various organizations with the aim to increase knowledge and improve the uptake of health services in Africa. TTC’s sms programs have a response rate between 20 and 50 % and have shown remarkable figures in uptake of health services (+200%).   At present TTC is active in Uganda, Kenya, Tanzania and Namibia and is going to expand their operations to Madagascar, Ghana and Mali in 2010.

• Workplace programs aimed at informing employees about a healthy lifestyle and health

services available;

• “Mass” health communication sms programs campaign to make knowledge easily available

to the general public;

• Using SMS to monitor adherence to health services, especially VCT;

• Baseline survey followed up by mobile survey for high frequency monitoring (in conflict

areas and elsewhere);

• Supporting health workers to do their jobs, saving time and increasing the operational

efficiency of services by using Mobiles;

• Mobile survey aimed at enhancing transparency and creating public debate;

• Education tracking to improve teacher motivation and reduce absenteeism; Monitoring and evaluation of diseases and populations at risk;

• Citizen reporting on drug stock outs and absenteeism of health staff.

The proven TTC concept

Text to Change has a track record in carrying out health and educational related quizzes and surveys in Africa. To this end TTC has developed a well designed mobile platform to: send out multiple choice questions to assess knowledge of and increase the general health awareness levels, to encourage people to adopt positive behaviors and seek health services. To ensure loyalty, the programs include an incentive based approach. TTC has extensive experience with this form of “Edutainment” (Educational Entertainment) whereby people can win Airtime; Mobile

phones, T shirts etc.