F126 How is Tradition Hindering Health Literacy in Kenya, Tanzania and Malaysia? (Shamala Hinrichsen, Mariatheresa Samson Kadushi)
In developing countries, explanations for health problems or general human biology can be heavily influenced by traditional beliefs. Some communities still believe that during their period, women are cleansing of evil spirits or that if twins are born, that is a bad omen. The solution to these misconceptions is education. But to provide it, health education companies face infrastructure challenges and technology affordability issues.
Mariatheresa Samson Kadushi and Shamala Hinrichsen are two very different women. One lives and works in Tanzania, the other lives in Berlin, and works in Malaysia and Kenya. While being in different parts of the world, they have a lot in common: they are both entrepreneurs, women of color, and passionate about the same topic: bringing health education to the underserved populations.
Mariatheresa is the co-founder and CEO of Mobile Afya and Shamala runs Hanai. Both companies produce content about maternal health, sex education, domestic violence. Mobile Afya started adding content about adolescent health and first aid since Tanzania, where the company primarily operates, doesn’t have an active ambulance system. This means that when a traffic accident happens, the bystanders need to take care of the wounded.
“60% of healthcare information is global, 40% has to be localized,” says Shamala Hinrichsen. Her company Hanai is working primarily with indigenous communities in East Malaysia, which suffers from huge healthcare disparities compared to West Malaysian developed settings. The company provides health information through a smartphone app and is now expanding to Kenya, with a focus on reducing teen pregnancies and promoting second abstinence.
Mariatheresa Samson Kadushi.
Mobile Afya on the other hand is heavily focused on providing information through the USSD protocol on regular phones. Those are still prevalent in Africa. “Our goal is for any African with the mobile phone to be able to access basic health information in their own language. And we are a USSD application that works to provide and disseminate basic health needs information in local languages, starting with Swahili, which is the number one spoken language in Africa spoken in Eastern Africa and some parts of Southern Africa,” Mariatheresa Samson Kadushi explains.
It’s not access to mobile phones, access to the internet is still a hurdle to health education
According to a 2019 survey conducted by the Pew Research Center to assess the availability and accessibility of mobile phones in 11 different emerging market economies, the majority of people in these countries have access to mobile phones and more than 53% of them have access to a smartphone. This survey was conducted in middle-income countries as defined by the World Bank, including Mexico, Venezuela, and Colombia; South Africa and Kenya; India, Vietnam, and the Philippines; and Tunisia, Jordan, and Lebanon.
About 39.8% of the African population has Internet access, according to June 2019 statistics. This means 60% don’t have access. The challenge in Africa is the vast expanse of rural areas that can comprise anything from impenetrable jungles to endless deserts. In these regions, the growth of broadband Internet is not the only problem; many homes throughout Africa are not even connected to the electric grid.
But it’s not just about accessibility, adds Mariatheresa Samson Kadushi, internet is very expensive. Additionally, when searching for health information, many people face language barriers, because while French and English are official languages in some African countries, most people speak local languages. That’s one of the main value-added offers of Mobile Afya - the content is translated to Swahili.
Shamala Hinrichsen.
Statistic numbers about mobile and internet penetration are informative to a degree, but they don’t tell the story, warns Shamala Hinrichsen: “In Malaysia where we operate part of our business, the internet mobile penetration figures go up to 150%, because people have two phones. But again, that may be so in an urban area with a telecom tower. But let's move a kilometer, two kilometers, three kilometers away, and talk about people there. We need to question the network providers where are they building their towers, because this is quintessential to the development of a community altogether. There was a story recently of a Malaysian girl from one of the indigenous communities. She sat high up on a tree to finish her exam. She got up the tree with her notebook to finish her exams. That's the extent that people are going to. And it's year 2021,” Hinrichsen says critically.
Tradition and its impact on healthcare education
Both companies are trying to bring health information to the underserved populations. These usually don’t have a long history of formal education. In these environments education related to health is poor and therefore guided by traditional beliefs. Mariatheresa illustrates: “Before we had the biological understanding of what menstruation is, people thought it was something bad. In the normal context, if you bleed, something is wrong. So people decided, women’s bleeding could be the symptom of something evil. Women are cleansing of the evil spirits during their period. That is why during that time in the month, they are somewhere still removed from communities.”
Another example is the birth of twins. “In some parts of history, not only in Africa, if a woman had twins, that was interpreted as very wrong. People couldn’t understand how a woman can have more than one child at a time so if there are two that must be a very bad sign. And the children were killed because people believed twins were a bad omen,” Mariatheresa Samson Kadushi elaborates adding that it is her mission to fight misconceptions like that. “Misinformation comes from not knowing because people have to find a way of making sense of things. I have a personal rule. I think the only way to counter misinformation is through the provision of correct information.”
This mission can refer to general health information, or more serious preventative actions such as informing pregnant women, when they should visit a doctor, what signs they should recognize as dangerous. Many times the challenge is that the doctor is six or more hours away. But even if it is so, there’s a difference if a woman is aware she needs to be seen by a doctor or not. As mentioned by Shamala, in rural areas what ends up happening is that less experienced young doctors are forced to perform demanding procedures in unsuitable circumstances. “How can a 25-year old doctor in a rural area, without electricity, without ultrasound and proper tools to do a C-section in an unsterile environment? But they have to do it. And then we wonder why women die in childbirth?”
How to raise funds for something that’s not very profitable?
Both companies are doing important work for the advancement of public health. While they are for-profit entities, they are not easy to run. Because they are providing health information, content needs to be approved by health ministries and the approval process can be several months long. They are constantly faced with delays at the speed of their application approvals.
“We are dealing with governments and health ministries. Getting approval on content is a decision made by an individual in these institutions. And those individuals can decide ‘I'm not going to read this today. I'm going to read it in six weeks.’ And then it's six months later and the document is not read yet. This does not even concern healthcare infrastructure, but the infrastructure for enabling people. Another barrier would be that somebody decides to ask for $200 in order to read your application. How do I respond to this email where somebody says, I need $200? I'm trying to save lives, but now I have to give $200 to do that? No university education teaches you how to respond to that,” Shamala Hinrichsen says.
Both companies also don’t offer solutions that would be highly profitable from the viewpoint of investors. But also, the fact that both founders are women, plays a role. Both companies operate in environments where women have a very traditional role and face many biases due to their business ambitions, on top of the generally existent bias towards women entrepreneurs in the VC world.
Shamala Hinrichsen lives in Germany, but has built part of her career in San Francisco. Despite gender disparities being addressed in these countries much more than in the developing world, challenges persist: “I am also a woman of color. That definitely stands out more than the challenge of being just a woman, which alone is enough. But especially in a European setting and even to a certain extent American setting it can at times happen that I'm the only person of color in the room. And when I'm speaking about technology, my voice is much quieter, it's not quite as respected as other voices in that room. And the people that I choose to serve are then also not the biggest economies in terms of making money. Why should someone invest in a woman of color? Who's interested in serving women of color who don't actually have much more money? It is a very controversial statement, but I'll put it out there because that is a daily part of my reality.”
Mariatheresa believes things will improve with the rising impact of the work women like them are doing.“ You're told that if you want something to move, just put a man on the front, because they'll be respected more. They're going to make things a little faster. People are not going to be looking down on you. Government officials look down on you and they think - she's just a woman. What is she going to do? We were told to put a man on the front. And I have said no to that. I said I'm not going to do it. We're going to go forward as women because we are a team of female founders. And we are going to achieve our goals as such no matter how long it will take. But we are not going to bow down to not having our own identity and our name up on the front.”
As advice to other female founders potentially in a similar position, they advise entrepreneurs to check VC portfolios before applying for funding. That is a good indicator of what kinds of companies the VC supports. Unfortunately, at the moment, the chances for support are still higher if the VC is a woman. But those are, again, a minority.
Tune in for the full discussion.
Some questions addressed:
Mariatheresa and Shamala, you are both on a mission to increase health literacy. Mariatheresa, you work primarily in Tanzania with your company Mobile Afya, and Shamala your company Hanai is present in Malaysia and Kenya, and is bringing health information to rural and marginalized settings. For starters can you both explain the scale of your operations and the type of health information you are providing? Shamala you go first.
Before we continue, can we briefly outline healthcare systems and healthcare accessibility in Kenya, Tanzania, and Malaysia?
Mariatheresa, you started Mobile Afya among other things to educate women about their health, pregnancies, family planning, and prevent unwanted pregnancies. Can you take us through your journey so far? How is Mobile Afya evolving/expanding?
A huge challenge both of you are facing is basically undermining tradition with science. Can you mention a few misconceptions about women’s health and how you are addressing them?
You are both working in public health but run for-profit organizations. What are your business models?
Mariathesa, when we had an interview two years ago, you mentioned the difficult position female entrepreneurs are in Africa. Can you briefly elaborate and how you’re tackling the challenges?
Shamala to which extent does the situation differ in your case and the environment you work in?
When we think about digital health apps we generally consider smartphone apps. However, in Africa a lot of innovative solutions are based on the USSD protocol so basically the SMS version of apps where you type in a specific code to a regular mobile phone and receive an answer. Briefly: are you still developing that further? Is there a visible evolution of smartphones taking over?
Shamala, you on the other hand offer your solution only through a smartphone app. How accessible does that make your solution? To which extent do people in rural and underserved populations own smartphones?
You both work with public institutions and healthcare regulators. How does that affect the speed of your development and change you want to see?
What are your hopes for next five to ten years?