Reason for the visit

In our prior research, we designated Friendship Bench (‘FB’) as a ‘promising’ charity: we think it may be as, or more, cost-effective than the other options we’ve examined so far. We haven’t conducted an in-person site visit, and seeing as FB runs on-the-ground programmes, we thought this could be a useful way to better understand the programme and the people in it – in a way that reading studies and reports does not. We don’t expect site visits can, or should, be decisive for evaluation purposes (they are ‘anecdata’), but they can nevertheless be informative. What’s more, when enough donor money is at stake, checking for ourselves that the programme is operating as expected, seems appropriate due diligence.

About this document

This is written as my (Michael’s) personal reflections and primarily for internal purposes. Even though I am the Research Director, what I say does not necessarily represent the collective, considered views of HLI.

Overview of the visit

• 9:00-10:30 am: Arrival and briefing
  • I, Dr Michael Plant, accompanied by my partner, Jasmine, arrived at the Friendship Bench (‘FB’) offices in Harare. The FB office is a secured facility typical of buildings outside the poorest areas, enclosed by a 6-foot wall topped with barbed wire. We were welcomed by the leadership team and the approximately 30 office staff. The leadership team provided a detailed briefing on their programme, during which I posed numerous questions to better understand their operations.
• 10:30-11:30 am: Travel to health centre
  • We travelled to a local health centre (a ‘polyclinic’) on dusty, potholed roads, passing through various neighbourhoods with corrugated tin shacks, street sellers, and, coincidentally, the president’s residence (which had walls, wires, and armed guards).
• 11:30 am-1:30 pm: Meeting grandmothers and clients 
  • At the health centre, we met with several ‘grandmothers’, the lay therapists FB uses (many of whom are genuinely  grandmothers), and their clients (the people receiving therapy). The session began with a warm Zimbabwean welcome of singing, dancing, and clapping. We observed a group check-in, where participants shared how they were doing that week. Subsequently, we had private conversations with a few grandmothers and clients, facilitated by FB staff. These personal stories highlighted the significant impact of the Friendship Bench programme on their lives (see more on these stories below).
  • I asked what had been happening in their lives before they came across FB, what their experience had been with it, and how things had been since. 
  • The clients were visibly emotional sharing their stories, and I felt honoured and grateful that they did so. With their permission, I took notes of what they said, which I will state in more depth later.
• 1:30-2:30 pm: Return to FB offices
• 3:00-3:15 pm: Debrief with leadership team
  • We had a debrief with the leadership team, addressing remaining questions and reflecting on the visit.
• 3:15 pm: Departure

Reflections and insights

The visit was profoundly inspiring and confirmed the value of the Friendship Bench programme. Although it did not provide a definitive answer to the question of cost-effectiveness, it demonstrated the tangible positive impact on the participants. Meeting the clients and grandmothers in person was particularly moving and provided insights that cannot be fully appreciated through reports or data alone.

Personal stories and impact

After hearing briefly about the clients and the programme, I spoke to two past clients in depth who became ‘grandmothers’ themselves. They spoke some English, but their first language was Shona. The FB staff were bilingual and acted as translators.

Betty

Before encountering Friendship Bench, Betty was in a state of deep distress, feeling suicidal and overwhelmed by her circumstances. When she started attending sessions with the grandmothers, she found a compassionate ear and practical support. Over time, her mental health significantly improved. Betty spoke about how the sessions provided her with tools to manage her emotions and a community where she felt understood. Joining a support group became a critical part of her recovery process. Through this group, she learned to crochet, an activity that not only brought her joy but also provided a source of income. Betty also improved her relationship with her four children, fostering open communication and support.

Charlotte

Charlotte’s life before Friendship Bench was marked by the struggles associated with her mental health condition. She was diagnosed but had not found a path to effective treatment or peace. Friendship Bench introduced her to a supportive network where she felt heard and valued. Through the regular sessions with the grandmothers, Charlotte began to see improvements in her mental wellbeing. She appreciated the holistic approach of the programme, which addressed her psychological needs and encouraged her participation in income-generating activities. Charlotte became involved in crocheting and raising chickens, initiatives that provided her with financial stability and a renewed sense of purpose.

Key questions and reassurances

Session attendance discrepancy

In practice, clients attend an average of two sessions, compared to the six sessions in the Randomised Control Trials (RCTs). The staff attributed this to a sense of obligation in the trials, whereas, in real-life settings, clients attend sessions as needed. They believe that transportation costs also play a significant role in attendance rates.

Effectiveness of short-session therapy

I questioned the effectiveness of 1-2 sessions, and the answer was three-fold:

1) The grandmothers act as ‘social prescribers’, initiating further support by getting people to go and talk to others to get help.

2) They also run support groups they called ‘CKTs’  for those who have been to therapy sessions. In these groups, people come together to talk and brainstorm ways to engage in income-generating activities such as crocheting bags and raising chickens.

3) FB staff talked about ‘non-sessions’, where grandmothers would meet people in the community, e.g. at church or collecting water, and provide support, but not record it as a session.

Cost efficiency

How do the costs work, and how could they be so low, at around $20 per person? The programme operates at a low cost due to the part-time nature of the grandmothers and their integration within existing health centres. The grandmothers are paid approximately $1 per session, with a structured pay scale based on the number of sessions conducted. 

The professionalism and dedication of the FB staff were evident. The central office team was knowledgeable, research-focused, and highly engaged in their mission.

Possible implications and research topics

Some specific areas for the HLI research team to look into.

• Investigate reasons for low session attendance: Further research is needed to understand why clients do not attend more sessions and how peer-support groups impact their mental health. 
• Long-term impact tracking: Implementing long-term tracking of clients’ progress could provide deeper insights into the sustained impact of the programme.
• Programme adaptation and scaling: As the programme scales, it is essential to monitor and adapt its implementation to maintain effectiveness and fidelity to the original model.

The visit reinforced the value of the Friendship Bench programme and its approach to community mental health. Continued support and research will be crucial in enhancing its impact and ensuring its sustainability.

Author: Dr Michael Plant

10 April 2024