From Skepticism to Scale: Lessons from Friendship Bench with Dr. Dixon Chibanda

This transcript was generated by AI and may contain typos and inaccuracies.

Amie Vaccaro: Welcome to High Impact Growth, a podcast from Dimagi about the role of technology in creating a world where everyone has access to the services they need to thrive. I'm Amie Vaccaro, Senior Director of Marketing at Dimagi and your co-host, along with Jonathan Jackson, Dimagi's CEO and co-founder. Today we speak with Dr. Dixon Chibanda, CEO of Friendship Bench. If you've not heard of Friendship Bench, you are in for a treat. And if you have, today you will get a behind-the-scenes look at how this incredible program and intervention has achieved such incredible resonance and scale.

Friendship Bench has developed a way to offer evidence-based, accessible and scalable, community-based psychological interventions to people in need. By training grandmothers across Zimbabwe to deliver therapy on park benches in their communities, Friendship Bench has served 100,000 people last year and expects to reach 200,000 this year. Today, the organization's CEO shares his keys to success and how he's working towards the goal of becoming completely digital. Trigger warning that we will be speaking about suicide today.

Welcome to High Impact Growth. So I am so excited for today's conversation. We have Dr. Dixon Chibanda here, CEO of Friendship Bench, and I'm joined as always by Jonathan Jackson, Dimagi's CEO and co-founder. Welcome, Dr. Chibanda. Great to have you. You've got a really, really powerful story, and I've been watching your TED Talks and I'm really motivated and inspired by them. I would love to hear from the audience a bit about your background story and how you got into the work of Friendship Bench.

There's never really a single starting point when it comes to developing something like the Friendship Bench. I think it's a process, you know, and the beginning of that process is considered to be, I guess, my childhood influence that I had from my grandmother. I always say that I grew up with very strong women around me. I think getting into psychiatry or mental health, you know, whichever way you want to look at it, was triggered by a series of events. We started off with the loss or the death of a close friend and took his own life.

And I think I was attending oil in terms of just understanding how people who may be seemingly looking like they are doing well, striving, happy, energetic, and the next minute they're not doing well and, you know, they take their own lives, you know. So I was like an eye opener for me. And when I came back to Zimbabwe, I think just deciding to work in psychiatry also led to its own new understanding of mental health, particularly the death of Erica. One of my patients, Erica had been under my care for a while when she took her own life.

That was really the turning point that made me realize that I need to do something. The journey began, I think the death of Erica was a point where I had to make a decision and I kind of realized that I needed to move away from working in a hospital as a psychiatrist and find a way of working in the community, make my services a lot more accessible. And I think that's where the journey of Friendship Dance really starts. And it has inspired so many people, the story that you shared in your TED Talk and what you're now doing with Friendship Dance.

For our listeners who aren't as familiar with your specific model, could you share what that model is, how you have created this amazing ability for grandmothers and communities to support mental health and what you're currently doing today in Zimbabwe and scaling up? In very simple terms, a low intensity ecological therapy or folk therapy that is provided by trained community grandmothers in Zimbabwe and beyond. In a nutshell, what we do is we equip these grandmothers with basic skill in cognitive behavioral therapy.

We then allocate each grandmother a wooden bench in that community. We facilitate referrals to that wooden bench through social media and through other existing organizations in the community, police stations, school. And people go to the bench, the grandmothers screen everyone who comes to the bench using locally validated screening tools, which enable the grandmothers to establish whether someone is a case or not. By case, we mean do they have enough symptoms to warrant receiving a structured therapy or do they just need reassurance?

Nobody stands away from the bench. It's just that people receive different things depending on what your score is on the validated screening tool. And if there are anything from four to six sessions, people are then invited to join a support community. And in the support groups, they use the skills that they have learned from the bench with the grandmother. They use those skills to connect to the problem solved around bigger issues. That's what we do. Friendship day. You know, we empower grandmothers to be the therapist.

Thank you so much for sharing that. I think that sounds so simple, but I'm also sure that it took so much to even get to that point. I'm curious to hear a little bit about the journey to kind of figuring out a model that works and how the kind of scaling has been over the last handful of years. Often when I talk about friendship day, folks think it was smooth and I knew exactly what to do. Now, there's been a lot of mess, a lot of mistakes, and we continue to make a lot of mistakes.

But one of the things that we do, which I always encourage my team to do, is if we're going to fail, let's fail fast and go back to the drawing board and focus on what needs to be improved. So that's really our sort of approach to the work we do at Friendship Bench. Go in, try out things, and we use rigorous methods to evaluate what we do. We have over 100 peer-reviewed scientific publications about the work that we do at Friendship Bench. So that actually reflects the journey. Anyone who wants to understand where we're coming from and the mistakes we've made can read our publications.

But in a nutshell, when we started the journey from the 14 grandmothers, I like to use the 14 grandmothers as the starting point of Friendship Bench because we're just 14 grandmothers in one community in Harare. Everything that we did was predominantly manual data collection. I remember us running around trying to find a stationary bookstore where they had the cheapest notepads, the cheapest pens. Everything had to be the cheapest. And of course, that also compromised our quality sometimes.

That was the beginning, really, the four or two years of Friendship Bench. Really going out there, getting the material that the grandmothers needed in order for them to collect that data, and then bringing that data together, trying to understand how best to put all of that in an Excel sheet, and then try to transfer that to another software package to analyze that. You're working with just 14 grandmothers and you can manage to bring together all that data that is collected by the 14 grandmothers.

But as the numbers increase, at the moment we are working with more than 2,000 across Zimbabwe alone. It didn't take much to realize that the methods that we were using were not going to work. As we were scaling, as we were seeing more and more people, last year Friendship Bench reached over 100,000 people. Talk to your grandmother. This year we're expecting more than 200,000. So that journey has really been marked by a lot of lessons which have prompted us to start thinking on how best to collect data, how best to support the grandmother, how best to ensure fidelity at scale.

We're moving toward using a lot of technological platforms to help with the data collection, help with the analysis, and help ensuring fidelity. So we've come a long way and we're hoping that by the end of 2024 we will be completely digital in the way we collect data, the way we analyze data, and the way we run most of the support that we provide to the grandmothers. Yeah, and we're really excited to be partnering with you on that journey and trying to make sure CommCare can meet the needs of supporting those grandmothers and the D'Ebony side.

Going back to those 14 grandmothers, though, Dixon, I'm curious, when did you know this was going to work? We have these ideas and these nuggets, maybe this intervention could solve this problem, but what was it in that first cohort of 14 grandmothers that you saw and you're like, this has something here, this is definitely the nugget of an intervention that I can scale? The stories, because when I first started with the 14 grandmothers, we would meet every week. Initially we met twice a week.

And it was really more like an opportunity for us to deep breathe, for me to hear from the grandmothers the challenges that they were facing, people who were coming to the bench to get services, learn about the different stories that were coming to the bench and the different issues people were facing. That was really the first sort of realization from the stories that, wow, this is powerful. If people can bring these kind of stories and feel comfortable to open up to these grandmothers and then walk away from the bench feeling a lot better, there must be something in this, could probably be taken to scale.

Of course, my intention back then was never to take Friendship Bench to scale. I didn't think I had the capacity to do that. But I think once others got a lot more familiar with what I was doing and encouraged me to really start thinking about how best to expand it, that's when the idea really sort of emerged. When we got that first big grant from Grand Challenges Canada, I think that was the beginning of going big. Because for a long time initially while Friendship Bench was running, particularly with the 14 grandmothers, I supported the 14 grandmothers.

I didn't see that as a burden. I felt it was my way of ensuring that in my own small way, avoiding another incident like the one that I had with Erica, because people could now go directly to a grandmother in their community and talk about the issues that they were affecting. And then grandmother would be there to provide therapy, but also provide guidance. But of course, as it became bigger, I needed to then start thinking of how to support the initiative as it grew from 14 grandmothers to 52 grandmothers.

And it just kept growing, growing, growing. Unfortunately, there were people out there who were watching. That's wonderful. And we'll dig into how that scaling process has been, what role technology can play. I'm just curious, in that initial cohort of 14 or that next cohort of 50, when a grandmother hears about this concept, you're talking to potential grandmothers who could play this role to provide this amazing support. How confident is a grandmother that this will work, that she can fulfill this role?

I'm curious, when you enroll these women who are providing this amazing service, does it resonate immediately? Does it take some time for you to explain, like, yes, this can work? Yes, this is something that is going to help your community dramatically? Or did it just kind of click naturally? Was there a lot of belief that it made a lot of sense? Yeah, I mean, the first 14 grandmothers, that was the most difficult, you know, because when I started interacting with the first 14, I was using a lot of frameworks to develop in the Western world, conceptualize what we were to try to understand, what conditions we would be treating and all of that.

I hadn't realized, for instance, with the first 14 grandmothers until much later, storytelling can be healing in itself. I didn't know back then that you actually embed elements of CBT within storytelling. I didn't understand the importance of using local indigenous idioms of distress to navigate through therapy. You know, all of those things were still new. So I think the greatest barrier was with the 14 grandmothers. After that, I think because all the new grandmothers that come to Friendship Beach are actually told about the importance of storytelling, which they immediately resonate with, and the importance of using the wisdom that they hold as the elders in our communities, as the gatekeepers, as the custodians of local wisdom, culture and knowledge.

And they all kind of resonate with that entry point. And so we hardly have problems recruiting people to provide therapy, particularly elderly people. The problem that we face is we can't take everyone that wants to do this work. You know, I wish I would take everybody that comes forward to offer their services. And so we're in a good position at the moment when it comes to interest to do this work. And I think it's largely because the work that we do in a very different way, in a non-clinical way, the way it is framed.

You know, we often talk about creating space for people to share their stories. You know, that is the first thing that we do at the Friendship Beach. You know, the fact that we don't focus on a diagnosis, you know, like we're not really interested if you're schizophrenia, or if you're bipolar, or you're suffering from major depression, you know, the point is your story. Because regardless of what condition you have, you have a story. And that's what we leverage on the bench, that story and how to use that story to help you become a better person, to cope better with the challenges, the adversities that you might be facing as a human being.

You know, one of the things that I have learned personally from the grandmothers is really the importance of being comfortable with being vulnerable. It's something that I didn't learn from medical school, from training as a psychiatrist, but it was from the grandmothers. You know, and that's so powerful when we are comfortable with being vulnerable. We enable ourselves to be a vehicle for therapy, you know, and we are able to share our own personal stories as well. So I think you've mentioned Erica a few times and how that was an impetus for making sure that there was access at the community level, coming up with this new model and in your TED Talk, there's a very powerful explanation of why that was incredibly compelling.

And this model is just so compelling when you hear it right now. I'm curious, the initial reaction you got as you tried to collaborate with local health departments, the government, with other experts in mental health, as this model came up, as you kind of validated that first set of 14 and tried to figure out how this could improve, what was the initial reaction to the model and how did you build partnerships to keep scaling this up, as you mentioned? The initial reaction naturally was, you know, build with skepticism.

This was something new. Here I was trying to do what doctors, psychiatrists, psychologists do with a bunch of grandmothers who have very little education. So there was quite a bit of skepticism and I must be honest on that. Me having a little bit of skepticism myself about it, I wasn't sure it was going to work, you know, particularly when I first started interacting with the 14 grandmothers. The reason why I carried on or persisted was largely because I was trying to remove myself from the hospital because of the death of Erica.

My presence at the hospital where I worked kept reminding me of Erica's death and having these flashbacks that I had had about her. Certainly when I was running on a Thursday morning, you know, I'd sit in this consultation room where I had sat on numerous occasions with Erica and always gave me these flashbacks. I wanted to remove myself and so these 14 grandmothers was my way of running away, to be quite honest, you know. I wanted to distance myself from Erica's death because I hadn't really come to terms with it.

And interestingly, I truly opened up about Erica's death was with the 14 grandmothers and I think in itself created a very strong bond. Well, it sounds powerful and parallel to the intervention design itself in terms of the power of storytelling, the ability for it to heal. And, you know, as you scale interventions, there's often a lot of pressure from the donor community to scale quickly, to have this big vision for scale. You mentioned that that wasn't necessarily what you set out to do initially was, you know, reach 2000 or get to multiple countries.

But Friendship Bench is on this amazing path right now. And as you mentioned, over 100 studies showing the efficacy and lots of support. What challenges have you hit? One of the main challenges that we are facing currently or we've been facing for a while is how to exactly manage big data. You know, how do we ensure fidelity and how do we effectively support the grandmothers or anyone for that matter who is delivering at the Friendship Bench wherever they may be. To address those challenges, firstly with big data, particularly remote areas, you know, like rural parts of Zimbabwe where connectivity is not always guaranteed.

This partnership with Comair has really been a game changer because we are now able to actually load data from the remotest parts of Zimbabwe. As I speak right now, we are using Comair, I think, with around 80% of the grandmothers and we hope that by the end of the year it will be 100%. What that has enabled us is actually be able to upload data when we need it. Also, the good thing I think with Comair is that it can also work offline. You know, you don't have to have internet.

And so the data can be uploaded when they get into Wi-Fi range, which is great for us. And it's user friendly. You know, the pilots that we have run so far have been very encouraging. That was one of my worries that the grandmothers might not be able to manage this whole idea of collecting data using a tablet or a smartphone. It's worked amazingly well. It's a sustainable model that we could use because it ends up being much cheaper for Friendship Bench and the government. Ultimately, the end game at Friendship Bench is to hand over Friendship Bench to the government.

So it becomes a program which is run through the government of Zimbabwe. And we've made some interesting steps towards that. One of them is the integration in the national strategic for health. And I think that is a big win for Friendship Bench because we are now sort of officially endorsed by the government. And through the work that we're doing with World Health Organization as well, we are using these different government forms, provincial, district and at primary health care level, the visibility of Friendship Bench because in line with our vision of having a Friendship Bench within walking distance, we see the integration of compare as a vehicle towards reaching a lot more people.

I think impact for us at Friendship Bench is a measurable variable. You cannot talk about impact if you cannot measure. And this is where bringing in comcare has been extremely helpful because we can now track. We can say baseline, this is what we saw. Six weeks, this is what happens. And at six months and 12 months, just looking at the data that is coming in through these different sites where we have it present. Can you give us an example of how the grandmothers are using comcare?

One of the examples comes from a place called Guanda, which is very remote. And so the grandmothers in Guanda have these tablets. You know, where we have comcare, the grandmothers have been trained on how to use these devices. And what they do is when they see a client, they will actually enter the date on that client base. And some of the information that we collect at baseline include the age, the presenting problem, the gender, where the person lives, the problem that they presented with.

And most importantly, what the baseline score is, whether it's with the SSQ, which is the measure that we use to establish caseness. By caseness, I am referring to a person meeting criteria for a particular condition, whether it's anxiety, depression or PTSD. And so all of that is entered. So the grandmothers are now able to enter that data on this device as opposed to writing it down in a book. Because in the past, we would write physically in a book to an Excel sheet, which is then shared with our SIE team.

With comcare, this information goes immediately to our SIE team. And they are able to then follow up after six weeks to see what has happened with this client. One of the examples is clearly around making the data collection simpler for the grandmothers. They don't have to spend a lot of time writing in a book, which sometimes gets lost. And we don't have to worry about stationery. We don't have to worry about pens and all those kinds of things. And also we are able to see when that data is uploaded, whether there's a problem within specific areas where we are collecting data with comcare.

We might zero in on an area because they have a lot of red flags. And that can enable us to figure out how best to intervene or what is happening in that area. For instance, this is just an example. We had floods in Zimbabwe, I think two years ago. And people who were affected by those floods had extremely high rates of common mental disorders. And now using comcare, we would be able to pick up that kind of data without our whole team going there to carry out a survey. We can just look at the data as it comes in and learn from that data.

And it will enable us to effectively and efficiently allocate resources in areas that need more of our intervention. So yeah, the comcare platform is a game changer. Thank you so much, Dr. Chibanda. And I love hearing about your endgame of handing over Friendship Bench to the government of Zimbabwe. I see so many organizations grappling with that challenge of how do you keep a program running over time. Can you share a bit about how you're approaching handing over Friendship Bench to the government?

So with regards to the endgame of getting it embedded within the government of Zimbabwe, it's simply based on the understanding that sustainability ideally is to be delivered by a government. Yes, non-governmental organizations can also deliver to scale. But at Friendship Bench, we believe that the ultimate doer at scale is the government. And if we equip the government with the skills that they need to do Friendship Bench, and we empower the government at all the different levels from primary, secondary, tertiary level with doing Friendship Bench, then they will continue to do it.

And part of our strategy towards achieving this has been to partner with the World Health Organization. So with WHO, because WHO, as you know, works closely with governments globally, and we have recently partnered with the World Health Organization through an initiative we call FRIENDS. And essentially FRIENDS is about going deep for fidelity at scale within Friendship Bench. And what that essentially means is we have a presence in 10 provinces. And what we need to do is strengthen the work we're doing in those provinces.

But we also need to strengthen the referral pathways because the grandmothers are not going to have the skills or the capacity to manage everybody that comes to the Friendship Bench. We have people who come to the Friendship Bench who are extremely suicidal or who are psychotic or who need medication for that matter. And the grandmothers cannot manage any of those. And so with the World Health Organization, we are able to reach from the grandmothers to the next level, be it a mental health nurse or a doctor at the district level in the province.

And that doctor then assesses the red flag and establishes what can be done. So now our focus is not just to strengthen Friendship Bench as we go deep, but to also strengthen the different referral pathways or points in the referral to ensure that when somebody comes to Friendship Bench, they get good quality services all the way to the top if they end up being admitted, for instance, in a hospital. So that's one of the ways that we are really moving towards ensuring that Friendship Bench is embedded and is largely about ensuring that the referral pathways are strengthened and that there is buy-in for Friendship Bench all the way to the top.

And for us to be able to do all of that, you know, what I've just shared, you need data. And that's where CommCare comes in. You have to be able to collect data consistently and you have to use that data to inform you of what needs to happen next. Dr. Jibanda, you shared so many rich learnings and insights from your journey throughout this conversation. I'm curious, what advice do you have for other individuals or organizations who are looking to implement community-based interventions for mental health support?

All right. The advice I would give to other organizations or individuals that are looking to implement community-based interventions for mental health is build the evidence. That's number one. Number two, understand who is the doer at scale. Number three, be very clear with your story because most folks that will look at an initiative like Friendship Bench, first and foremost, interested in the story. What is the story behind the work that you do? And at least this is what I have learned.

People get attracted to the story and then they want to see the evidence. And then they also want to see what is your scale strategy. Who is the doer at scale? Going back to the evidence, that is critical because if you have, ideally, the gold standard would be evidence showing effectiveness of an intervention through a randomized controlled trial. That's the gold standard. Nowadays, you have all sorts of other ways of showing that something works. You have implementation hybrid trials, for instance.

You can also start off with a very simple before and after evaluation, like a cohort study, a prospective cohort study. The important thing is to build the evidence systematically. Always try to publish what you are doing. Let the world see that what you're doing is driven by rigorous research. It's evidence driven. And then my other point on understanding the doer at scale. That is a process which should be carried out right from the beginning by engaging critical stakeholders.

Understanding the gatekeepers who are likely to influence policy. How can you influence policy? One of the strategies that I used with Friendship Bench to get attention was to focus on integrating Friendship Bench in existing so-called sexy public health programs like HIV. If you can show that integrating Friendship Bench in HIV, you improve HIV outcomes, policymakers love you. If you can ensure that by integrating Friendship Bench in maternal and child health, you improve outcomes for mothers and babies, they love that.

If you can integrate Friendship Bench in communicable diseases such as diabetes and hypertension and show that you improve outcomes, they all love it. Being strategic about it is important because then they begin to see the need for the intervention going beyond mental health. Friendship Bench is not just about mental health. Friendship Bench improves diverse public health issues or programs. That is important. The story of course. What is your story? I guess at Friendship Bench I am considered to be the chief storyteller.

I sell Friendship Bench. Everybody sells Friendship Bench I guess. That's a very nice way of putting it. You have to sell your product. You have to make your product interesting. I am constantly telling the Friendship Bench story. When you combine all of those together and you also tell the story. Telling the story is not necessarily just peer reviewed scientific publication. Telling the story often is about non-scientific publications. Writing opinion editorials, presenting non-scientific forms such as TED for instance.

We have leveraged my TED Talk extensively at Friendship Bench. A lot of people who have ended up funding us, it was because they watched the TED Talk. Not so much because they looked at the publication. This is how it works. They look at the TED Talk and think this is a compelling story. How much evidence does this have? They do their own research and say they have published quite a lot extensively about this issue. How are they intending to scale? They are intending to scale through government.

Where is the evidence? They have a national strategic plan where Friendship Bench is included. Then they get in touch. Can we talk and try and see how we can help you? It's just really being very systematic and deliberate. Love that. Thank you so much for that crystal clear advice. Do you have any last words for our audience? What I'd like to say is that everyone, wherever you are, you are capable of contributing towards the well-being of your community. We all have this inherent ability to reach out and support one another.

The main reason why people find it difficult to do so is because, to a large extent, human suffering, particularly psychological, emotional suffering, has been medicalized. When things are medicalized, people keep a distance because they are worried that they will make a mistake. They are worried that they are not the expert. The entry point really is ultimately about storytelling. Regardless of what a diagnosis a person has, they have a story. I think ultimately what we all can learn to do is create that space for people within our communities to tell their stories, to feel comfortable to tell their stories.

When people are comfortable to share their stories, that's when healing actually begins. Thank you to Dr. Chibanda for joining us today. There is so much rich insight in what we heard. Here are my takeaways. Dr. Chibanda summed it up really nicely at the end with a three-part formula for creating a scaled intervention that applies beyond mental health, really to any intervention. First, build the evidence. Try things and test them rigorously. Know that you'll have learnings and iterate along the way.

Friendship Bench has amassed over 100 peer-reviewed scientific publications about their work. Second, understand who is the doer at scale. In Friendship Bench's case, and likely in many cases it's the government. As Dr. Chibanda says, sustainability is best delivered by a government. Because of this, the Friendship Bench team has been thoughtful about engaging government stakeholders, as well as the World Health Organization, building in referral pathways all the way to the top of the health system, and considering how to integrate the Friendship Bench program into the bigger picture, making it about more than just mental health but overall improved health outcomes.

Third, be clear with your story. This is what attracts people. Then they want to see the evidence. As a founder or entrepreneur, you need to be ready to be constantly telling your story, and do so in creative ways. It can be both in scientific publications but also in non-scientific platforms as well. Dr. Chibanda shares how his TED Talk has attracted funders and been leveraged extensively by the organization. Beyond that three-part framework, I'm taking away the tremendous, healing power of both storytelling and vulnerability.

Dr. Chibanda took one of his hardest and darkest moments when he lost a patient to suicide, and used that to guide him to take his career in an entirely new direction, moving him out of the hospital setting and into the community. This is particularly informative to me as I lost my own brother to suicide seven years ago, and continue to work to find ways to let that grief and tragedy guide me and my work. I also heard Dr. Chibanda's incredible resilience. You will always get skepticism on a new idea that goes against conventional norms, but he's an example of the power of pushing through.

And lastly, Dr. Chibanda highlights the foundational role of digitization in enabling all of this great work. To scale a program for sustainability, you have to be able to collect the data and use that data to inform what needs to happen next. Dr. Chibanda is partnering with Domangi and using CommCare to go completely digital in how they collect and analyze data and support their incredible grandmothers to deliver high-impact therapy to people in need on park benches across Zimbabwe.

That's our show. Please like, rate, review, subscribe, and share this episode if you found it useful. It really helps us grow our impact. And write to us at podcast at domangi.com with any ideas, comments, or feedback. This show is executive produced by myself. Danielle Sheldon is our producer. Sarah Strauss is our editor. And cover art is by Sudanshi Khan.