Twakena - Digital Mental Health

The World Health Organisation estimates that 1 in 4 people worldwide will be affected by a mental health issue at some point in their lives. Yet, the vast majority do not have access to the care that they need. Digital mental health is a validated model, but there are no robust service offerings in many low income settings, even where high mobile phone usage exists. 

Twakena is a digital mental health company connecting people with therapy services over their phones. 

We want to scale on a global level, bringing Twakena to urban centres. Beginning in Nairobi, Kenya, and with Mumbai, India identified as our second market for expansion, we will partner with local therapist networks, companies and organisations to design culturally relevant, affordable therapy services.

Kenya’s population is booming, slated to hit 66 million by 2030, and already 3.5 million people living in its capital, Nairobi. With World Health Organization estimates that 1 in 4 people have a mental health condition, that’s over 800,000 people in Nairobi alone needing support. 

Mental health has begun to enter the public consciousness, in 2018 Nairobi was shaken by a well publicized suicide that showed mental health issues can affect anyone. A Senior Manager at PWC in the city committed suicide by jumping out of a window at work. According to WHO, suicide is the second leading cause of death among youth in the 15-29 age bracket and close to 800,000 people commit suicide every year, which means one person every 40 seconds.

Mental health has been underserved in Kenya, with only an estimated 50-90 psychiatrists serving the entire country. As well as lack of supply, there are challenges in access, cost of services, and stigma in seeking appropriate services. Nairobi needs to find a way to provide its citizens with affordable access to quality mental health services. 

Twakena launched in Nairobi, Kenya, where 1 in 4 people will have a mental health condition at some point in their lives. It’s estimated that 5 out of 6 people here will not receive treatment. Our target population is urban, low-middle income individuals who don't have time or money for conventional therapy. 

Our pilot showed four roadblocks preventing people from accessing mental health services in the city.

• Supply: There are not enough psychiatrists available: (ratio 1:40,000)

• Access: Traffic in Nairobi is a nightmare. We’ve heard time and time again that clients are unlikely to travel to a therapist when their mental health is poor and they most need services. 

• Cost: High rent in Nairobi centre means high treatment fees that many can’t afford 

• Stigma: Clients are reluctant to have face-to- face therapy

A user-centric approach is our priority. We spoke with clients, therapists, therapy organizations, companies building employee wellness programmes, academic institutions, and NGOs to understand the needs, concerns, current workflows and pain points in seeking therapy and delivering services. 

We developed Twakena to provide a solution to these challenges. Through Twakena, clients can access affordable therapy services at a time that is convenient to them.

Twakena connects people to therapy services over their phones and computers. 

• Supply of Quality Therapists: Twakena is a digital model, the distance of client and therapist is no longer a hurdle. In-built feedback loops allow clients to rate therapists in every service, ensuring we can make sure quality is high and make changes as needed. 

• Access Anywhere: No need to travel, clients can access Twakena from wherever they are. 

• Low Cost: With Twakena, therapists don’t have to rent out space and can work from home, leading to lower operational costs and more affordable fees.  We will always have a tier of free service, ensuring anyone can access support. 

• Anonymity and Security: We want to normalise therapy, and we understand that privacy is key. Twakena is an anonymous and convenient way to begin discussions about mental health. Each client is prompted to choose a username at the beginning of their connection with Twakena. All messages are transmitted to and from all API endpoints through an SSL encrypted layer.. 

Three Service Offerings: 

1. Volunteer Peer-to-Peer Therapy: Certified, trained volunteers lend an empathetic ear whenever someone wants to talk. This service will always be free. 

2. Professional Practitioners: This tailored service offering matches clients to therapists with specific expertise that match their needs. Clients can book sessions online, and pay with mobile money. Therapists can monitor clients with wellness metrics. At this level, therapists have access to a range of tools including client tracking, client homework, and payment management. 

3. Organizations and Companies: Organizations and companies can partner with Twakena as part of employee/beneficiary wellness programs. An organizational dashboard offers aggregated qualitative and quantitative data for understanding of the impact of the program. As always, anonymity is key. 

Technology: We are making using of existing, cloud-based hosting technology, eliminating the need for a client to download a separate application. Currently Twakena is available on Facebook Messenger and Telegram, on your phone or computer. We decided to develop on these platforms to avoid requiring people to download a separate application to use Twakena. Instead, users can access our services easily on these platforms which they are already using. 

We are the only digital mental health provider built for the East African context. 

Digital mental health is a validated model, and we have seen successful digital mental health companies grow across the globe, however our model organizes the mental health ecosystem in East Africa for the first time. Twakena aims to deliver additional functionality that provides tremendous value for both clients and therapists.

 Text Based Service over a chatbot: We want to connect existing therapist with a new channel for reaching their clients. Our discussions have shown that both therapists and clients are excited by the accessibility that Twakena brings.

Tools for Therapists: Therapists told us they wanted to be able to manage their clients inside Twakena. We have built tools for scheduling, client wellness metrics, therapists can even assign homework to clients. 

B2B tools for companies and organizations: Companies can view aggregated wellness metrics on their teams, and see reviews of therapists to understand the impact of employee wellness programs

Customized for scale: As we scale globally, our approach will be tailored to the markets we expand into.

Over time, we will build sophisticated Artificial Intelligence/Machine Learning models to help us analyse and generate insights about mental health that will both improve the overall product, and also feed back into the African mental health community. Robust data on mental health in East Africa is hard to get and we expect to spark new innovations through sharing insights with our community. 

We are mainly utilizing cloud-based hosting technology. We have launched on Facebook Messenger and Telegram, meaning our clients don’t have to download an additional app. 

1. User connects to Twakena over Facebook Messenger or Telegram, and is invited by the chatbot to choose a username 

2. User given the option to connect to a therapist volunteer, review bios of professional practitioners and book an appointment, or connect immediately to a therapist if it’s during office hours 

3. Message goes out to therapists asking them to “pick up” the conversation 4. User speaks to the therapist from 30-60 minutes 

5. At the end of the conversation, the client will be asked to rate the therapist, which helps us to monitor therapist quality as we grow, we plan to provide an SMS service through which we can access anyone in the country who has a phone, and will not be limited to connecting with people over data. 

Whilst we will explore voice/video calls in the future, as and when cultural context/user feedback calls for it, text-based therapy is a proven model, We aim to provide a method of communication that is easy to use, and eliminates barriers of seeking help, we’ve heard first hand of some of our clients expressing anxiety if they feel they need to make a phone call, let alone go see a person face-to-face. Text-based communication has been observed as being the most popular way of communicating on phones (with 80% of mobile phone activity being text based).

Our theory of change is simple. Connecting clients to therapists over a digital platform, will lead to improved mental health. 

Inputs: We provide the infrastructure needed to support mental health on both sides of the marketplace - clients and therapists. Clients can access quality, affordable mental healthcare, and therapists can access to the tools they need to best support their clients. 

Outputs: Thousands of conversations between therapists and clients

Outcomes: Clients' mental health improves

Impact: A strong, supportive, mental health ecosystem. Nairobi citizens living full, happy lives. 

We digitally track a number of wellness metrics for each of our clients on our internal dashboard, so we can see if/how their mental health is improving. We are frequently adding more metrics as necessary. Metrics include standardized measures such as PHQ-9 for depression rates, GAD-7 for anxiety, along with many more. These questions will be periodically asked to clients following sessions, and saved digitally. 

In other markets, digital mental wellness have proven to be highly-successful and impactful businesses. Examples include: Calm, Headspace, 7Cups, Betterhelp, and Talkspace. While the field is still maturing, studies have supported the efficacy of text-based therapy to improve client outcomes related to anxiety and depression [1].

 [1]https://www.talkspace.com/online-therapy/wp-content/uploads/2018/04/Talkspace-Depression_Anxiety-Large-Scale-Study.pdf 

2019: 1000 clients

2020: 25,000 clients

2021: 89,000 clients

In 2019 we are focusing on increasing the activity of existing users before pursuing aggressive acquisition. 

In 2020 we will focus on building out our Companies and Organizations service, which will see a rapid increase in number of clients through working with a targeted 9 companies and 2 NGOs (10,000 clients per NGO and 5000 across all companies). 

By year 3 we aim to have 7 NGO partners and 19 company partners allowing us to reach thousands more beneficiaries, as well as continuing to grow our core base of direct users. 

Over the next 5 years, we plan to be operational across Kenya, Uganda, Rwanda and India. These markets have relatively high mobile penetration, and a high utilization of mobile money, and do not have robust options to support mental health. 

Within the next year, we plan to run a pilot in Mumbai, India. Following the pilot, we will assess the viability of expanding into India, across different regions, and will factor in our team’s budget and capacity to expand into India. 

We will introduce a number of tools that help more effectively deliver therapy services to populations. Some key features we have planned: 

• Other technology channels integration e.g. 

  • iOS/Android app - therapists can have extra support tools to work with their clients.. We can give more fine-grained control on features around privacy & safety for the clients who access the app

  • SMS integration - which will allow us to reach populations (especially low-income) who do not have ready access to network data or wifi. Our goal is to make mental health as accessible to as many as possible

• Increased dashboards and personnel/client management software to enable companies, and large NGOs to deliver their programs and react to actionable metrics

• Integrating leading assessment tools to help better ascertain a client’s level of depression or anxiety without having to rely on traditional questionnaires - an example is MIT’s NLP model for depression.  

• Tools to help in-person therapists better deliver their services, such as note-taking tools and assigning homework (like mood journals, meditation practices)

Financially, we are seeking $150,000 to scale. We need to build out our team, bringing on two more engineers and a psychology consultant. We have plans to develop enhanced desktop tools and a behavioural intervention system. As we scale, we will invest in marketing and outreach. 

Our model in part relies on the success of building strong partnerships. As with most partnerships, lead-time can be quite lengthy, so there has to be substantial investment up-front to attract and sign agreements with the partners we are looking to reach. 

Culturally, there is a need for more attention on the importance of mental health in Kenya. National awareness is growing, but stigma still exists. 

Another challenge as we scale into other markets in ensuring that our product fits the needs of every population. Our service offering must be culturally and technologically appropriate for each setting. 

Financing: We have a diversified revenue stream, with 3 customer segments able to generate revenue. We are seeking investment and philanthropic support to roll out Twakena to further populations  and to develop more tools. 

Partnerships: We’ve been fortunate to have engaged many partners at this point who are aligned with our vision. We are starting to secure MOUs - having signed with botha university and a counselling centre. We want to use our time wisely, we are targeting partnerships through which we can reach a large number of clients. 

Raising Awareness:  We are working with all players within the ecosystem to raise awareness of mental health, including private corporations, key influencers, and advocates. We will continue to organize efforts amongst all players. While we are fully prepared and able to scale Twakena and our product verticals without government assistance, we look forward to working with the government to scale our vision across the country. There are a few Senators within the government focused on implementing the drafted Mental Health Plan: https://healthservices.uonbi.ac.ke/sites/default/files/centraladmin/healthservices/Kenya%20Mental%20Health%20Policy.pdf

Fitting the needs of the population: We have a rigorous approach to product development currently and will adopt and continue to optimize that approach as we explore opportunities to scale. 

Full time: CTO and CEO

Part time: India Country Lead

Contractor: Fundraising Consultant

Advisory Board: Two members

Our team brings deep knowledge in tech, health and social enterprise. 

David Henia CTO

David believes in the power of technology for social impact. He previously worked as Lead Developer for Eneza, an education technology company in Nairobi. David holds an MSc in Computer Science from Keele University. 

Alex Royea, CEO

Alex brings experience from Silicon Valley, where he worked at LinkedIn and helped lead various mission-driven early-stage companies. Alex has a BS in Psychology and has been engaged with the growth of social minded companies in East Africa since 2016. 

Neha Muraka - India Country Lead

Neha is an entrepreneur, engineer, and machine learning specialist in Mumbai, India. She most recently ran a digital finance company to accept payments for online platforms. 

Advisory Board

Dr. Josephine Arasa

Dr. Arasa is the Chair of the Psychology Department at United States International University. She holds a PhD in Counseling Psychology and specializes in Neuro Psychological Assessment. 

Andy Bacon

Andy is a leader in the healthcare industry in Kenya and the UK. He served as CEO of Gertrude’s Children’s Hospital in Kenya for 8 years, was a leader in the UK’s NHS, and has a focus on global mental health. 

Contractor

Ani Cammack

Ani has 6 years in fundraising in growing social enterprises in the East African context. She has a strong interest in driving life improving solutions to low and middle income individuals. 

We identify partners who would either greatly benefit from the use of Twakena, or currently have some understanding of mental health. These partners are Universities, counseling centers, corporate clients, and (in the future) NGOs who provide mental health programming. Our current partners are as follows: 

United States International University - We have a standing MOU with USIU to provide Twakena as a tool through which Master’s and Doctorate students in Psychology can gain their required clinical hours to graduate.  We have built in a supervision tool, so more senior therapists can oversee conversations and troubleshoot. 

Rafiki Counseling Center - We are running a 2 month pilot with Rafiki to provide Twakena as a digital therapy solution to their individual clients. Twakena tracks therapy satisfaction ratings for Rafiki for the benefit of counselors and Rafiki leadership. 

Rotaract Group at University of Kenyatta - Rotaract act as Twakena Brand Ambassadors. They are marketing us on campus through flyers, posters, and Whatsapp groups. 

We have four customer segments:

1. B2C: Individual clients using peer-to-peer volunteer service. 

Impact: Access to free therapy from a network of trained volunteers. A great starting point to begin conversations on mental health and tackling stigma. 

Revenue: $0

2. B2C: Individual clients paying for professional therapy 

Impact: Clients build long term relationships with therapists, leading to improved mental health. 

Revenue: % commission on every session

3. B2B: Companies pay on behalf of their employees for an employee wellness program. There are a number of companies in Nairobi who already pay for face-to-face therapy for their employees, though utilization is low for reasons of stigma and employees not wanting to leave work, or see the in-person therapist at the office. 

Impact: Allows us to reach thousands of lower income beneficiaries who otherwise couldn’t afford to pay for professional therapy. Clients again can build long term relationships with their therapists leading to improved mental health. 

Revenue: Monthly  licence fee + cost per user + optional add-on services

4. NGOs offering mental health programs

Impact: We can reach thousands of lower income beneficiaries who otherwise couldn’t afford to pay for professional therapy. As above, long term relationships with one therapist leads to improved mental health. 

Revenue: Monthly licence fee + cost per user + optional add-on services

Of our four customer segments, three generate revenue. 

1. B2C model:  we take a percentage from digital payments made from clients to professionals

1. B2B model:  licensing fee + % commission per user + Optional add-on services (wellness assessments, therapist forums, push notifications). This mostly is delivered through employee wellness packages where the company pays the license fee, and they pay for the therapy session per employee.

1. NGO model: NGO with mental health beneficiaries (such as International Rescue Committee) pay a license fee that is tiered based on the number of beneficiaries and the number of practitioners who use Twakena. 

We are seeking grant funding to support the development of programs designed to reach low income individuals. An example is working with the International Rescue Committee who currently has a large mental health program in refugee camps, but have not digitized their treatment. This will require grant funding to ensure that the refugee camps have the relevant infrastructure in place to support the roll out of Twakena. 

We’re a small team in Nairobi focusing on building our capacity. We’re seeking support in getting the right business partners, team members and advisors, relevant to the markets we’re targeting. We would love support from Solve in the following areas: 

Monitoring and Evaluation - We’re looking for support in Identifying the right impact metrics and tracking them well. Through Solve, we would love to be connected to people who can support us in the development of metrics to ensure we’re fully capturing our impact, and learning from the data. 

Technology - we want to use AI to measure depression / wellness metrics in a non-intrusive way to our users. We’ve even identified a PhD project from MIT that can help us implement this. The goal is to reduce extra cognitive load to a user who’s already dealing with a lot with extra questions around how they’re doing, but still track this information over time. Our challenge is we don’t have any AI/ML dedicated members on staff at the moment to help us implement this and other ideas to help us innovate.

Legal - We’re looking at expansion into new markets where we’ll have to deal with different legal entities to get registered. On top of that: mental health is regulated differently in different markets. Some markets like Kenya have few organised bodies and understandings on requirements for mental health practitioners beyond the strictly medical fields.Through Solve we hope to be connected to partners working in these markets already.

We want to partner with NGOs working with thousands of low income individuals who offer mental health programs or are looking to provide their beneficiaries with mental health programs. For example, the International Rescue Committee who work with thousands of people in refugee camps. 

We want to work with companies with large numbers of employees, who otherwise couldn’t pay for therapy services, for example, businesses like Uber. These businesses have insurance packages provided to their staff, and Twakena can form part of this bundle. We want to talk to insurance companies who can offer Twakena as part of their insurance packages. 

We want to work with NGOs supporting women’s health. We've spoken to several organisations who work to support maternal health, but don’t currently have the infrastructure to support mental health as well. We see a gap in service for women with post-natal depression and we are keen to bring Twakena to support this population.

As mentioned earlier, we’ve wanted to get into using AI to measure depression / wellness metrics in a non-intrusive way to our users. We’ve even identified a PhD NLP project from MIT that can help us implement this. The goal is to reduce extra cognitive load to a user who’s already dealing with a lot with extra questions around how they’re doing, but still track this information over time. Our challenge is we don’t have any AI/ML dedicated members on staff at the moment to help us implement this + other ideas to help us innovate. 

Our ideal AI use case is for helping either measure wellness with reduced cognitive load to the client, or to help perform more menial tasks on platform. We do not want to have people speaking to an AI bot for therapy, except in therapy-support situations e.g. helping people focus on tasks/assignments from their therapy sessions.