The Friendship Bench
Friendship Bench - Ambuya Utano Lucia.

The Friendship Bench

Project type:
Program
Objectives:

To provide evidence-based mental health care to people with anxiety and depression in under-resourced settings.
Brief description:

Integrated mental health support into primary care for people with depression across Zimbabwe and beyond.
Project status:
Ongoing
Social:

Summary

Innovation summary

We believe that a community based approach to mental health is urgent as an estimated 450 million people worldwide suffer from mental illness, but very few have access to mental health services. 90% of people in Africa needing evidence based depression care do not get it because of the substantial treatment care gap according to the World Health Organisation. Exceeding sub-Saharan averages, Zimbabwe shows consistently high rates of suicide, (23.6 per 100,000).

Our mission is to get people out of depression by creating safe spaces and a sense of belonging in communities using problem-solving therapy and behaviour activation delivered by trained Lay Health Workers (affectionately known as grandmothers).

Impact summary

  • 14% of patients in Friendship Bench problem-solving group experienced symptoms of depression after 6 months compared to 50% patients in the control group. 48% of patients who received standard care still had symptoms of anxiety compared to 12% who received Friendship Bench (based on the GAD), and 12% of patients who received standard care still had suicidal thoughts compared to 2% who received Friendship Bench (based on SSQ).
  • Friendship Bench has been scaled-up to 72 clinics in the cities of Harare, Gweru and Chitungwiza (total population 1.8 million). To date, over 40 000 people have accessed treatment.
  • $1 million in funding from Grand Challenges Canada.

“When exposed to the right amount of stress, in the right place, at the right time without any support we will break. We are all vulnerable. Friendship Bench is that support, a safe space to find grounding and empathy before breaking point.”

Dixon Chibanda, Friendship Bench Founder, CEO

Innovation

Innovation details

In Zimbabwe, where 70% of the population lives below the poverty line, there is one mental health professional per 1.5 million people. In rural areas, where the majority of Zimbabwe’s 14.8 million people reside and access to primary health services is limited.

Friendship Bench has developed a research-anchored, consultative, community-based approach to mental health. Our work is rooted in over 10 years of research, developed, validated and showing clinically significant improvements in mental health outcomes in Zimbabwe. We achieve this by building the capacity of ordinary community members or community health workers affectionately known as “grandmothers” to enable them to intervene at a community level to promote, identify and care for those affected by the burden of mental illness. Our innovative model focuses on training community health workers to provide basic Cognitive Behavioral Therapy with an emphasis on Problem-Solving Therapy, combined with subsequent peer-led group support.

Key drivers

  • Our work is rooted in over 10 years of research, developed, validated and showing clinically significant improvements in mental health outcomes in Zimbabwe, and the foundation is a cluster randomised controlled trial published in the Journal of the American Medical Association (JAMA) showing the effectiveness of using community grandmothers to treat depression.
  • We have implemented a robust monitoring and evaluation framework that tracks the delivery, and quality of programming, as well as draws learning that further informs future programming.

Challenges

We had challenged with standardization of the delivery of our model across various geographies within and outside Zimbabwe. We have however

  • Developed a robust M&E framework to ensure standardisation of measuring metrics across Friendship Bench areas of implementation.
  • We have incorporated learning into our programming to ensure lessons learnt inform future programming.
  • We have developed Friendship Bench in a Box, a blueprint, which serves as a step-by-step toolkit for site set up and implementation, to ensure fidelity at scale.

Continuation

Friendship Bench Scale Strategy

Friendship Bench as the doer at scale

We have developed the ‘Hub and Spoke Model’ which provides us with a structured model of scaling through our implementation teams. The Hub and Spoke model is facilitating the decentralisation of the teams into their respective provinces. This will support our scale strategy as we expand from operating in six provinces to all 10 provinces in Zimbabwe.   

Capacitating others to be doers at scale

The Friendship Bench model continues to go through an iterative process to enable attaining of the scale status where we capacitate others to be doers at scale. We work with implementation partners locally and internationally to replicate our model, adapted to their own context. In Zimbabwe, we are working with six implementing partners where we train their members to deliver Problem Solving Therapy.

To ensure our work is adaptable to different contexts, we initially conduct a situational analysis which is a two-step approach that includes submission of a Suitability Checklist by the interested party which is reviewed by the Friendship Bench team.  We conduct a Theory of Change workshop that underpisn the path we take to integrate Friendship Bench into existing programming and context. During the ToC we invite other key stakeholders identified as critical during the situational analysis to build consensus and identify assumptions, barriers, and define indicators that inform us of the feasibility, acceptability and fidelity of the programme.

Friendship Bench in A Box – Catalyst for scale and fidelity 

We are well positioned to take the Friendship Bench deeper (impact) and wider (reach), strengthening our national reach as well as taking the work globally. We have developed a proof of concept for our scale model, named: Friendship Bench in a Box, a blueprint, which serves as a step-by-step toolkit for site set up and implementation. This is aimed at strengthening the delivery model and ensuring fidelity of the Friendship Bench model as we scale across and beyond Zimbabwe, through strengthening others to be doers at scale.

Partners

We have six implementation partners in Zimbabwe.

 

Current and past international partners implementing our work include:

Other collaborators / project associates

Funders

Impact

Evaluation methods

The Friendship Bench’s Monitoring and Evaluation system is made up of key components that make it effective and efficient for purposes of monitoring and evaluating the work that the organisation does. The key components are described below.

  • Organisational Structure for M&E - there are clearly defined roles and responsibilities pertaining to how to collect, analyse and report information against key performance indicators. The organogram articulates reporting lines for both the Programming and M&E team members.
  • Funded M&E Plan & work plan -  the M&E plan is the reference point for the rationale behind how the project is monitored and evaluated. It consists of the following:
    • Logical Framework which is the key planning tool for the Friendship bench model, feeding off the Theory of Change(ToC) development process. The logical framework captures the cause-effect model of the FB model, the Key Performance Indicators (KPIs), data sources for the KPIs and key assumptions and risks associated in the implementation of the project.
    • Results Framework - this shows in graphical format the immediate and intermediate result areas for the Friendship Bench project. It defines the measurement parameters for the project.
    • Indicator dictionary - as part of the M&E plan the indicator dictionary provides in detail the operational definition for each key performance indicator that is tracked under the Friendship bench model.
  • Periodic Surveys & Evaluations/Research - Friendship bench is anchored in evidence, and evidence is  produced on a periodic basis in order to:
    • Answer Questions: through life of implementation the Friendship bench has produced well over 25 research manuscripts that feed into the knowledge base of the organisation that then informs implementation and program redesigns.
    • Question Answers: ongoing evaluations are conducted by the organisation’s M&E unit in order to determine why things are or aren't working. This is done in order to feed into the iterative program development process at Friendship Bench.
    • Friendship Bench in conducting periodic surveys and evaluations/research is guided by the OECD evaluation criterion consisting of:
      • Impact
      • Relevance
      • Sustainability
      • Coherence
      • Effectiveness
      • Efficiency

These form the backbone of any evaluation study carried out by the organisation , in order to determine or gauge the worth of the work that we do.

  • Technology for Impact - technology is leveraged upon for timely data and information processing across the data value chain.A relational database management system is in place to house and allow for the extraction of key data points to inform impact reporting. A pilot has been conducted with Grandmothers equipped and trained with smartphones/tablets in order to conduct PST sessions and upload to the FB server which has significantly reduced time lag between data collection and reporting.

Cost of implementation

The Friendship Bench model defines innovation units as the total number of bench sessions conducted by lay health workers as they service the clientele that seeks mental health services from the organisation.

2019 to 2022 Total expenditure $3,219,100/Total reach for period 183,395  =  cost of innovation USD 17.55

Impact details

The Friendship Bench since 2016 has reached a total of 268,536 clients through providing mental health services. The table below portrays reach per year.

Year Reach
2016 28,291
2017 11,081
2018 6,799
2019 4,353
2020 15,741
2021 53,798
2022 109,503
2023 15,687
Regional (from 2018) 23,283
Total 268,536

References