Dr. Kwame McKenzie is Medical Director at the Centre for Addiction and Mental Health (CAMH) and Professor, Department of Psychiatry, at the University of Toronto. Dr. McKenzie is an international expert on the social causes of mental illness, suicide and the development of effective, equitable health systems. As a physician, psychiatrist, researcher and policy advisor, Dr. McKenzie has worked to identify the causes of mental illness, particularly in cross-cultural health, for over two decades.
Today is Bell Let’s Talk Day. This landmark anti-stigma campaign, run by phone and media company Bell, gets Canadians talking about mental health. But it is more than that. They donate money to mental health for every call made today using their network and for every tweet using #BellLetsTalk.
So far, they have donated over $60 million to community mental health initiatives and hospitals in Canada. It is a truly momentous initiative.
But on such a great day in Canada, it is hard not to reflect on the global situation. Many low- and middle-income countries can only dream of that sort of money coming into mental health. The money that has been given away by Bell is more than the budget for mental health services. For instance, $60 million dollars is, in unadjusted terms, about 30 times the annual mental health budget of a country like Kenya, which has 40 million people.
That sort of money could go a long way in a low- or middle-income country.
The sheer scale of the need for mental health services and the lack of funding can make people disheartened. It could be argued that local mental health budgets are too small. Building on the fabulous work done by Grand Challenges Canada to identify low-cost innovations and solutions at proof of concept, it is also essential to develop pathways for these great ideas to be implemented at scale.
Indeed, how to make sure that ideas for mental health innovations are scaled up and sustained in resource-poor countries is something that has bugged me whenever I have gone to international meetings.
I think I had at the back of my mind some form of magical thinking. I thought that perhaps somewhere, if we looked hard enough, we could identify initiatives in low-income countries that have been taken up and we could learn from them.
Perhaps, we would be able to land on an innovative technique, like the positive deviance work that came from the charity Save the Children.
If you do not know the story, it is a good one. Two people working for them in Vietnam in the 1990s were trying to work out how to deal with a problem of 64% malnourishment in children. But when they looked deeper, they found that there were other similarly poor children in the community who were not malnourished – the positive deviants. They further investigated the well-nourished children and found they were doing a few things that staved off problems. They and their parents were using uncommon but successful strategies to stave off malnourishment. The parents were getting their children to eat foods that were considered culturally inappropriate for children, like sweet potato greens and shellfish. They got their children to wash their hands before meals – which was less common in malnourished kids. And, finally, their kids ate twice as many meals in the day – 4 as opposed to 2. Because of these behaviours, the well-nourished kids had a better balanced diet than the kids eating traditional foods and were less likely to get infections.
But the thing that seemed to make the difference was what was done with the knowledge. Instead of simply telling parents to change the diet of their children, feed them more often and wash their hands, they designed a program of behavioural change. They developed feeding sessions. But to enter, a parent with a malnourished kid had to bring along one of the atypical foods. They attended the session with their child, learned to cook the foods and learned about hand washing. The new behaviours stuck and the rest is history.
The level of malnutrition decreased by 85% in two years. But more than that, the results were sustained and transferred to younger siblings who had not attended the classes. The positive deviance approach has been applied in nutrition programs in at least 40 different countries, with good results.
Grand Challenges Canada is funding Trang Nguyen Thi Thu, who is carrying on the tradition in Vietnam of using positive deviance as an innovation – but this time in mental health. This is great but we may need a slightly different approach to the larger problem, which is how to scale up. In Toronto, I was lucky to be part of a group led by Sean Kidd that developed a more involved approach, but one that may be more applicable to mental health.
We asked why certain community-run mental health services for marginalized populations in Toronto, Canada, succeeded, while others failed. What was it about the leadership, the way that they were set up and how they were run that predicted success and sustainability? What lessons could be learned by people thinking of funding initiatives and people who are thinking of setting up initiatives? We identified groups using a Delphi method and then undertook qualitative case studies.
Though the organizations that were studied varied widely in the problems that they addressed, their organizational structure and in their specific activities, there was a remarkable degree of similarity between them in the core components that were crucial to their effectiveness and success. The five most important factors were:
- The person or people leading the group were the right people to deal with that specific problem.
- Early in their development, they aligned around a specific problem and organized a constituency, partners and an organizational structure.
- They offered an innovative approach.
- They kept their operations focused, though they were nimble to change with the times and needs of their constituency and partners.
- They were as much a community in themselves as a service to the community.
For more depth, please have a look at the website.
But could this approach work internationally? We have now teamed up with Grand Challenges Canada and Ashoka to find out. If we can find people who have succeeded in mental health service development and up-scaling in low- and middle-income countries and they can let us know the secrets of their success, we will be in business. If we can talk to them, we may be able to have as much of an impact as Bell.
For more information about the Bell Let’s Talk campaign, click here. On Twitter, use hashtag #BellLetsTalk. We encourage you to post your questions and comments about this blog on our Facebook page Grand Challenges Canada and on Twitter @gchallenges. You can follow the author at @CAMHnews or @kwame_mckenzie.