Philanthropy Advisory Fellowship: Mental Health in Sub-Saharan Africa

by egastfriend21st Jul 201611 comments

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By Ashley Demming, Eric Gastfriend, Lori Holleran, and Danielle Wang.

 

This is the Executive Summary of the final report from a Philanthropy Advisory Fellowship project advising a family foundation on grantmaking opportunities and strategy. The full report (redacted for client confidentiality) is available here. This research was conducted on behalf of PAF client Child Relief International.

Mental Health in Sub-Saharan Africa Report

Executive Summary

Mental health, as defined by the World Health Organization, is “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community.” Although traditionally mental health has not been considered an immediate cause for concern in Sub-Saharan Africa, it is increasingly receiving more attention as the extent in which people suffer from various disorders has become apparent. As such, within this report, our team seeks to quantify and analyze the burden of mental health disorders in the region, focusing on total disability-adjusted life years (DALYs) from the 2013 Global Burden of Disease Study. Identifying depressive disorders as being the top contributor to total DALYs related to mental health in Sub-Saharan Africa, we dive into promising interventions such as Psychoeducation, Cognitive Behavioral Therapy, Module-Based Treatment, and Crisis Assistance and attempt to estimate their cost-effectiveness. To understand their potential impact, a cost-effectiveness comparison of mental health to sanitation is detailed. Based on research and interviews, we provide information on various organizations operating in Sub-Saharan Africa within the mental health field. Based on our analysis on not only the organizations but also on the mental health landscape in Sub-Saharan Africa as a whole, we provide three specific recommendations for investment consideration, the Alderman Foundation, AEGIS Foundation, and Network for Empowerment and Progressive Initiative, as these organizations show potential in leadership, scalability, cost-effectiveness of programs, and proven success. Finally, we then seek to hone in on current research opportunities related to depressive disorders and other similar mental health areas of concern. The research areas we recommend are: propranolol for PTSD, trace lithium for suicide, and computer-based CBT for anxiety/depression. 

The full report is available here.

11 comments, sorted by Highlighting new comments since Today at 7:29 PM
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Eric - this is so great! Coincidentally, CEA has also been working on a very similar report which was completed last week. It's here: https://drive.google.com/open?id=0B551Ijx9v_RoZWlUUFVTYWZ6aTVCUDRDLTViVHVyQVpPWVNn

I've shot you an email. We should definitely discuss our conclusions.

Very good report, James. I have a few comments:

  1. The DALYs calculated for mental health don't factor in the huge effect that mental health has on physical health. This may be laboursome to estimate, but should at least be considered. And you mentioned that people with MNS issues are often treated horrendously by their family/society, but that also hasn't been factored into the DALY cost estimate. An MNS disorder with a 0.4 DALY could really have a 0.9 DALY when you factor in mistreatment. I realize this is probably impossible to do, but it important to recognize that socialization side effects have huge impacts on DALYS.
  2. Sri Lanka pesticide ban cost per DALY: $1000 is pretty high. Eddleston estimated it at $2 per YLL using the actual costs of running Sri Lanka's pesticide regulation department. That figure doesn't even factor in savings in health care costs. Also, Sri Lanka and other countries have only banned a few HHPs. A total ban of HHPs could yield drastically different cost estimates. I should note that only a fraction of pesticides are classified as highly hazardous. A total HHP ban still leaves farmers with lots of choices to buy pesticides, in addition to non-chemical forms of pest control.
  3. No choice for donating to advocate for pesticide bans: Later this year, I expect that the Global Initiative for Pesticide Poisoning Prevention will begin our anti-HHP campaign. It takes a long time to do the initial steps of receiving charity status and input from all the experts in the field.
  4. Room for more funding for a program like StrongMinds doesn't make sense because it can be scaled up to LMIC around the world.
  5. I don't understand what the mental health charities have to do with children. Do StrongMinds and BasicNeeds treat children?

Re: DALY's for physical vs. mental health, in our full report we cite Vigo 2016 ( http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00505-2/abstract ) which lays out a strong argument for using a 2x adjustment for mental health DALY's. That's the approach we take in the paper.

Thanks Austen. This is really helpful feedback.

  1. Yes I agree. This is important but very hard to quantify. Of course the causal relationship goes both ways (poor physical health poor mental health) but it's probable that mental health disorders have worse downstream effects than most physical health problems (economic productivity, stigma, impact on carers, physical health). We tried to capture these qualitatively at the beginning of the report but could have been clearer that they weren't included in the cost-effectiveness calculations.

  2. Thanks - this is really interesting. The $1000 figure came from here: http://dcp-3.org/sites/default/files/resources/15.%20Self%20Harm%20Pesticide%20Ban.pdf but that excludes morbidity. I'll check out the Eddleston paper.

  3. This is exciting

  4. Agreed kind of. Room for more funding is a tricky one. In the long term, the treatment gap is so high that there's a LOT of room to scale. But we've also included StrongMinds forecast expenditure based on current plans as it may be relevant for short term ability to productively use more funding. In any case, conclusion is the same. The organisation can absorb more funding in the short term, and in the long term there's huge room to scale.

  5. Should have been more clear. Fit with key themes was evaluated as: Evidence generating] AND [Preventative child health OR Task-shifting model]

We'll be updating this before sharing it more widely. Would be great to chat more about pesticide bans if you're available?

Excellent paper! One important factor in LMIC mental health work is sustainability. Take helplines. Far as I know, they are locally funded in poor countries, yet there are very few of them. A foreign NGO or individual could have an extremely high impact founding a helpline in a location, turning the fundraising and operation over to the local community once it gets going, and then repeating the process in subsequent cities. Dependency on foreign donors is always a last resort. The absolute cost of running a helpline is less important than the ability of the local community to support it on their own once it's set up, although startup costs are major consideration.

Also, rather than trying to extrapolate the cost of running a helpline in Africa using Australian data, I think it would be more accurate to just call one up and ask them. Or call Befrienders International, they should know. I'm sure they'd be thrilled to hear from you!

I agree that helplines could have a very high impact. It's not mentioned in the paper, but we did look into it -- we weren't able to find an organization that we had enough confidence in to recommend. Could be an interesting challenge for an EA social entrepreneur or philanthropist to take on, though!

Thanks for sharing this information.

Have you shared this with GiveWell or Open Phil team? Especially considering that depression has such a negative impact on DALYs or QALYs (whichever you prefer), I think much of this research could be done outside of sub-Saharan Africa.

Also, where did you find the information regarding propranolol for PTSD? I remember reading about a couple studies done in Canada a couple years back that seemed promising, but concluded there was a lot more testing to be done.

Re: Propranolol, I spoke with Dr. Alain Brunet at McGill University, who conducted some of the studies you're referring to and was very helpful in explaining the science behind it and the potential.

If I remember correctly, participants were read stories and then asked to recall sad details. Not trying to be a downer, but the study's design is poorly related to PTSD.

"Brunet wondered if the drug could be used to reduce the emotional intensity of a given memory. He began administering propranolol to patients suffering from PTSD, then asking them to write down recollections of the traumatic event. When this process was repeated over the course of six sessions, as many as two-thirds of his patients were able to recall the event without displaying symptoms of traumatic stress." (http://publications.mcgill.ca/mcgillnews/2016/05/16/treating-trauma-on-a-city-wide-scale/)

Seems like the choice of participants and the method was ok, but the main downside is the lack of a control. You would expect a lot of improvement in PTSD symptoms over six sessions anyway.