The importance of youth mental health is being increasingly recognised as a key determinant of population health outcomes. Might cash transfer programmes, the dominant social protection tool across the African continent, act as a tool to improve mental health among this demographic?
This is the first blog of the CHANCES-6 series.
Mental health conditions are the leading contributor to the global disease burden for young people with the onset of an individual’s first mental disorder occuring before the age of 25 for more than half (62.5%) of the population. The knock-on effects of not addressing mental health challenges at a young age can lead to problems later in life including poor health outcomes and poor socio-economic outcomes, including lower likelihood of completing education and finding employment.
What are the challenges faced in addressing mental illness on the continent?
African governments often focus resources on combatting communicable diseases such as HIV/AIDS, malaria, and tuberculosis. These are seen as more urgent priorities that are directly related to one’s physical health rather than mental illnesses that are sometimes perceived to be a “white man’s disease” or a problem for high-income countries. This is despite evidence showing that every $1 invested in school-based interventions that address anxiety, depression and suicide returns over $65 in low and middle-income countries over 80 years. Most African governments allocate less than 1% of their health budgets towards improving mental health and there is often no budget specifically allocated to child and adolescent mental health. This has resulted in the global average of 9 mental health professionals per 100,000 people being ten times higher than the African average resulting in treatment gaps for mental health disorders thought to be as high as 90 percent. The COVID-19 pandemic has only added pressure to health and social care systems already working at capacity while the increase in youth mental health problems may be viewed as another pandemic in the making.
A lack of awareness of what mental illness is and how to support those living in poverty with mental illness is a major barrier across the continent.
There is little bandwidth among those that are poor to pay attention to symptoms of poor mental health in oneself or others. This is the case despite a greater prevalence of mental health conditions in households living in poverty. Mental disorders, at times, being the product of poor social and economic environments with high levels of violence and crime. Many African languages do not have a word for depression and this can make it difficult for individuals to articulate feelings related to their mental wellbeing.
Going forward, attention must be paid towards clinical definitions of mental health being more inclusive when it comes to African languages and cultures.
Stigma and discrimination with respect to mental health and poverty are still widespread across the globe and this continues to be a difficult obstacle to overcome in Africa where mental illness can at times be attributed to “demon spirits”. A large-scale study of popular attitudes towards people with mental illness in Nigeria found stigma to be widespread, with most people indicating that they would not tolerate basic social interactions with someone with a mental illness. Shame and stigma experienced by those in poverty can lead to social exclusion and a lack of agency. This can lead to a vicious downward spiral of worsening mental health and entrenched poverty.
With a vast array of barriers impeding the tackling of a breadth of mental health challenges faced on the continent, universal social interventions have been posited as a means to prevent the onset of mental illness.
What did the Chances-6 Research programme find with regards to youth mental health and life chances?
CHANCES-6, led by the Care Policy and Evaluation Centre at LSE, is a large research programme covering six low- and middle-income countries in Africa and Latin America. It seeks to explore the relationships between poverty, mental health, and future life chances of economically deprived young people.
Cash transfers, both conditional and unconditional, are a well-evidenced and effective social protection tool that provide recipients the means to improve their livelihoods. To date, most of the benefits of these programmes have been traced to reducing food insecurity and restoring dignity to families and communities struggling to break free of the poverty cycle.
A systematic review and meta-analysis conducted on cash transfer programmes which included studies from Uganda, Kenya, Liberia, Malawi, and South Africa suggested that cash transfers are associated with small positive effects on mental health in the majority (85%) of studies. The meta-analysis found no effect on depressive symptoms among children and young people.
Research focused on receipt of South Africa’s child support grant, the largest social protection program in Africa, found no improvements in the psychological wellbeing of adolescents and young adults. The grant, which provides unconditional cash transfers to children living in households below a poverty threshold, also did not appear to improve education or employment outcomes indicating limited efficacy in addressing the social determinants of young people’s mental health.
These findings highlight the need for policymakers to fund targeted interventions to prevent mental illness by improving their social and environmental determinants of health and support those already living with mental illnesses.
Where might the key levers and opportunities be?
Lost human capital from mental health conditions is estimated to cost over $17bn in Sub-Saharan Africa every year. However, a number of place-based approaches tailored to local contexts have been effective in tackling the onset of mental illness across the continent. In Kenya, the Shamiri Institute has developed a youth-led and oriented grassroots model to deliver mental health interventions. Randomised controlled trials have shown the model to be effective in reducing symptoms of depression and anxiety. The Friendship Bench approach trains lay health workers to recognize mental illness using a locally validated assessment tool and offer evidence-based problem-solving therapy in primary care settings. Given the increased community ownership of cash transfer programmes across the continent, localised models could be combined community-led mental health interventions.
There has been an explosion of growth in digital connectivity across the globe. As of 2020, 28% of the Sub-Saharan African population was connected to the mobile internet, more than double the rate in 2014, with young people making up a significant proportion. Improved coverage could provide another avenue to facilitate delivery of cash transfer programmes in a way that could allow them to be combined with digital mental health interventions. Global investment in mobile mental health interventions is expected to hit $500m in 2022. Last year, Panda launched a mobile application for mental health support in South Africa that gives users access to online resources to help them manage their mental health. Their provision also includes 1 to 1 support with a registered professional however, no formal evaluation of this exists to date. Facilitators of cash transfer programmes would be well placed to leverage innovation in this space to positively impact mental health as a universal social protection measure.
Place-based innovation alongside increasing access to digital connectivity could provide meaningful levers to design and implement effective mental health interventions through cash transfer programmes going forward.
The views expressed in this post are those of the authors and in no way reflect those of the Global Health at LSE Blog or the London School of Economics and Political Science.
