The Friendship Bench: Bridging Zimbabwe’s mental health treatment gap

Globally, millions of people are suffering with mental health conditions and have no access to evidence-based interventions. The Friendship Bench (FB) is a successful programme that was developed in Zimbabwe in 2006 to bridge this gap. FB uses a task-shifting approach to support those dealing with “kufungisisa”, a term locally understood as an equivalent of anxiety and depression. Community health workers (CHWs) who are employed by health authorities, are trained to deliver basic counselling and problem-solving therapy to support clients. They offer one-to-one counselling sessions, which take place on wooden benches near community clinics, ensuring accessible mental health support. Clients who need a higher level of care are referred to health care professionals at primary or tertiary care level.

A quantitative survey was conducted in three cities in Zimbabwe (Harare, Gweru and Chitungwiza) to assess aspects that determine the programme’s quality and to identify barriers and enablers of success. Data was gathered through: Observations in 36 primary health clinics, interviews and focus group discussions (FGDs) with 152 key stakeholders, a stakeholder meeting to discuss preliminary results and foster knowledge exchange. Key stakeholders were the Harare, Gweru, Chitungwiza city health authorities, health care workers such as nurses, community health workers and their direct superiors, the district health promotion officers and service users.

Since 2016, City Health departments have overseen the Friendship Bench programme. Preliminary clinic visits were conducted to assess its performance and adoption and establish data collection methods. Findings revealed that smaller clinics achieved better reach and implementation outcomes with a higher uptake rate among screened clients compared to medium and large clinics. Adoption was measured by the presence of a functional bench and service availability.

Challenges included limited data on support sessions due to clients privacy concerns, low number of clients during visits and poor quality recordings. Process fidelity issues were noted, with some CHWs providing advice instead of using the problem-solving approach.

In general, programme effectiveness depended on the level of support received by the delivering agents and engagement from health authorities. Smaller clinics, where less differing demands were placed on delivering agents and their supervisors, provided better support and served as key entry points. Clients were only referred to larger clinics for advanced care needs. To strengthen implementation, integrating FB data into the existing health information system was recommended for ongoing monitoring, quality assurance, and referrals.

The findings were shared at a meeting with 50 key stakeholders, and through 25 focus group discussions and interviews with 152 stakeholders, enablers were identified on programme adaptability, strong design, effective communication, and proven evidence of impact. A supportive learning climate and internal leadership were deemed essential, alongside structured incentives, clear goals, and performance feedback. To address these needs, feasible strategies were identified. Champions were trained to advocate for the programme, an incentive and reward structure was introduced, and CHWs were integrated into clinical meetings to share insights. An implementation blueprint was developed to ensure applicability of recommendations. A participatory workshop refined implementation strategies, focusing on three core areas: sensitization and site preparedness, recruitment and training of staff, and programme implementation which included aspects such as community buy-in, client flow, monitoring and evaluation and stakeholder engagement.

 

The programme has been adopted in the National Strategic Plan and has been rolled out nationwide since 2022, in collaboration with the Ministry of Health and Child Care (MoHCC). This expansion has provided access to mental health support for 775,680 clients. This initiative is supported by WHO’s Special Initiative for Mental Health, with Zimbabwe selected as one of the participating countries.

 

This project was one of several Friendship Bench research initiatives conducted within the same time frame and results were aiming to influence policy. Insights from the project have been integrated in the Ministry of Health’s strategies for improving mental health care. The FB programme has also contributed to policy change leading to the inclusion of mental health support within HIV programmes.

Beyond Zimbabwe, the Friendship Bench model has been adapted for different populations with ongoing research in South Africa, Malawi and Vietnam. The programme is also being implemented in the US, Canada, Colombia and Tanzania, expanding its impact globally.

This research was funded by the UK Medical Research Council under the Global Alliance for Chronic Diseases (GACD) Mental Health Research Programme.

To access publications relating to this project, see GACD’s publications webpage (under Mental Health Research Programme publications, Project MH03).

For more information about this project, please contact Ricardo Araya, King’s College London, UK or Ruth Verhey, Friendship Bench, Zimbabwe.