The Friendship Bench

Background

With a population of 13 million people Zimbabwe has only 13 psychiatrists and 2 clinical psychologists working in government facilities. However, the proportion of lay health workers at community level employed by the city health department (over 400 for Harare) can, through task-sharing, fill part of this treatment gap for CMD. The evidence-based Friendship Bench model offers one of the few feasible options to currently meet the enormous population mental health needs in Harare, and across Zimbabwe. We anticipate the Friendship Bench program to serve as a key element of a future and more comprehensive mental health care system evolving through the slow and arduous training of other health personnel to take on other duties. We are already piloting additions to the Friendship Bench to expand the services to those with more severe symptoms through training nurses to prescribe medication. Our group has been working to reduce the mental health treatment gap for several years. These efforts culminated with the testing of a model, the Friendship Bench (FB), suitable to the reality of Zimbabwe to treat CMD in primary care. This model was tested in a fully powered cluster RCT in Harare with excellent results. Currently, this is the only successful RCT of a psychological intervention delivered by Community Health Workers (CHW) in primary care clinics in Sub-Saharan Africa (SSA). A randomised controlled trial showed unequivocally that the Friendship Bench (FB) is the first effective psychological treatment programme in primary care to be tested so far in Sub-Saharan Africa. The results persuaded the government to scale-up the Friendship Bench to 72 clinics, in and around, Harare. Additional scaling-up has been planned for later this year. Up until now, there has not been an evaluation of the results of this scaling-up initiative.

Aims

To systematically identify and test promising implementation strategies to maximise the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) of the evidence=based friendship Bench programme in Zimbabwe. This study aims to evaluate the scaling-up so far but most importantly to identify the factors that have influenced the outcome of the implementation of the FB with a view to design an enhanced facilitation intervention to improve the implementation in clinics that have not performed so well. We will use two well-known implementation science frameworks (RE-AIM and CFIR) to guide our work. Whilst RE-AIM will provide us with a framework for the outcomes, CIFR will guide us through the process of exploring the ‘core’ factors that determine the success or failure of the implementation of the FB.

Project plan

To start with an evaluation of what has been achieved so far using all the data that has been routinely-collected during the scale-up effort. This was to be supplemented with additional data captured through a survey and other qualitative methods. The results would allow us to evaluate RE-AIM outcomes and classify clinics according to their implementation outcomes. Subsequently we aimed to conduct a workshop with the main stakeholders to discuss and agree on the CFIR framework to use for the second phase of exploration. The main aim of the second phase was to identify key or core variables deemed to be key predictors of the successful implementation of the FB.

In order to do this we aimed to focus on comparing low and high performing clinics to identify those factors that might explain implementation outcomes. During the second phase, most research was to be of a qualitative nature, through focus groups and semi-structured interviews, except for small surveys and the collection of additional economic data. At the end of this phase, we aimed to invite main stakeholders again to review our results and conclusions and to help us identify the components of an enhanced facilitation intervention that we aimed to test in those clinics whose implementation achievements fall into the lowest quartile. We conducted a hybrid type 3 study to ascertain if implementation outcomes improve four months after this facilitation took place in comparison with control clinics. The information generated in this study is vital to continue the successful expansion of the FB and to consolidate the implementation currently underway. It will additionally provide essential information for other neighbouring countries in terms of using implementation science methodology as well as learning about potential problems in the route to implementation as well as possible approaches to improve their implementation efforts.

Impact

The Friendship Bench project identified implementation barriers and enablers and developed an implementation blueprint that is informing national scale up. The project team is collaborating with the WHO FRIENDZ programme to reach one million people in Zimbabwe who need mental health care. This initiative combines the Friendship Bench and WHO’s mhGAP programme. The Zimbabwean Ministry of Health has a memorandum of understanding with the Friendship Bench to role out the programme in nationwide primary health care.

Publications and output

You can watch Professor Chibanda’s lecture discussing 10 years of implementation of the Friendship Bench.

This project has a related case study The Friendship Bench: Bridging Zimbabwe’s mental health treatment gap.

You may visit the project website for more information.

Principal investigators

Team members

Funding organisations

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