Depression Defeated

Depression is the leading neuropsychiatric cause of the global burden of disease and known to increase the risk of suicide, increase health-care costs, and reduce economic productivity.

Mental, neurological, and substance use disorders now account for 1 in 10 years of lost health globally, while depression is the leading cause of disability worldwide. An astonishing 90% of people in low-income countries do not receive adequate treatment. Moreover, almost half of the world’s population lives in countries where, on average, there is one psychotherapist for 200,000 or more people. 

Strictly looking at depression, it affects 10-20% of the population globally – being particularly high in primary care settings. To be more exact, the largest study of primary care attendees showed that 24% had depression. However, studies from Africa have reported detection rates near 0%.  

79% of African countries spend less than 1% of their health budgets on mental health – Uganda is no exception. When mental health services and resources are available, they are often lacking, disintegrated, and out-of-the-way. Resources in low-income countries are highly centralized around more urban populaces.

Nearly 35% of Ugandans experience some form of mental illness, with depressive and anxiety disorders leading the pack. Nonetheless, estimates suggest that only 5-10% of those affected have access to services. The most recent assessment of the mental health system in Uganda found one national hospital, 27 community-based psychiatric inpatient units, one day-treatment facility, and no known community residential facilities. Uganda boasts a meager 50 psychiatrists for an estimated 48 million people. With regard to practicing mental health workers, there are 310, or 1.13 per 100,000 people with nearly ⅔ concentrated in Kampala, Uganda’s capital.

The center of Finemind’s efforts has been the Agago District in Uganda. It is an area that has suffered from years of civil war, genocide, refugee migration, humanitarian crisis and the AIDS epidemic, which has resulted in deep inter-generational trauma. In fact, the year the war ended, a study found that northern Uganda had the highest rate of post-traumatic stress (54%) and depression (67%) ever recorded among displaced and conflict-affected populations anywhere in the world. Even more shocking, it found that women were twice as likely to show symptoms of PTSD and four times as likely to have symptoms of depression. All these circumstances are linked in a vicious cycle with issues of poverty, poor education, inadequate healthcare and broken family structures. The people of Agago are continuing to face difficulties due to insufficient basic services and limited support. Finemind operates from the premise that rebuilding community-wide mental health will lead to greater agency in the community, i.e. stronger, more capable individuals and families and eventually prosperous, thriving communities.

Finemind offers free, widespread mental healthcare in Northern Uganda where the residents suffer from extensive intergenerational trauma and scant psychological resources. Finemind trains and monitors local community health workers (CHWs) with knowledge and skills to deliver streamlined and effective counseling, a method that has been documented through evidence-based research to be an effective approach. The peer-to-peer counseling is offered in progressive steps of treatment, known as “stepped care”. At each step, patients are counseled, evaluated and either discharged or referred to the next step where the treatment is intensified and more specialized. 

The technology we use is Kobo Toolbox and tablets for ease of data collection and analysis. We utilize Kobo Toolbox, a free toolkit for collecting and managing data. Counselors are provided tablets with Kobo Toolbox preinstalled. Kobo houses the proper surveys for data collection. Once counseling is completed and an internet connection has been made, data is uploaded to a secure server. Finemind then downloads and compiles the data. Monthly counselor reports are compiled and handed out to the counselors. The M&E team interfaces with the CHWs regularly to ensure accurate data entry and completion. Then, the data is reviewed, and Finemind’s data scientist analyzes month to month trends, averages, and other impact data. The server is checked often for data integrity and quality assurance.

Finemind’s solution consists of three essential pieces: task sharing, collaborative stepped care , and direct community involvement. 

Task sharing

• We train community members to deliver effective mental health services and equip them with the basic knowledge, skills, and competencies to offer streamlined and effective care. Evidence-based research shows that trained community health workers can effectively address common mental health disorders such as depression and anxiety. Services are available irrespective of the client’s socioeconomic status and location and are provided by community members who are trained and monitored by specialists. 

Collaborative Stepped Care

• The goal of the ‘stepped-care-program’ is to identify and administer mental health care to a widespread population with varying needs via peer-to-peer counseling in progressive steps of treatment. At the first step, all patients receive psychoeducation. Then, those who need further intervention go on to receive antidepressant therapy and then interpersonal counseling sessions. After this, any patients who are a danger to themselves or others are referred to a specialist for individualized medication and treatment. In this way, large populations are able to efficiently receive the mental health treatment that fits their needs. At each step, patients are either discharged or referred to the next step, where treatments are incrementally intensified. While some individuals can be discharged after psycheducation, others are discharged after antidepressant therapy or interpersonal counseling, etc.

Community Involvement

• Finemind works with and for the community of Agago District. We consistently liaise with a community corps of representatives to make informed decisions. We also work closely with the local District Leaders and the District Health Office to ensure buy-in and to foster mutual aid.

Finemind's solution is targeted towards a population of adults aged 18 and older in Agago District, Northern Uganda, who are primarily daily wage laborers, farmers, women, and men, mothers, and fathers. These individuals are currently underserved in terms of access to quality mental health services. In fact, there is only one psychiatric nurse and one hospital in the entire district that provides in-patient mental health services for a population of 230,000 people. This means that access to mental health services is extremely limited, and mental illness is highly prevalent in the community.

Studies have shown that Agago District has the highest rates of PTSD (54%) and depression (67%) worldwide among affected populations, with women being 2X as likely to exhibit PTSD and 4X more likely to suffer from depression. Mental illness can have a significant impact on various aspects of life, including family well-being, education, health, and income.

Finemind's solution aims to increase mental health literacy, provide greater access to mental health services, and offer a locally-led mental health treatment option. The organization's ultimate goal is to uplift the overall well-being of the Agago society by focusing on mental health improvement. The solution has the potential to address depression within the community by providing access to quality mental health services and increasing awareness about mental health. Through this approach, Finemind hopes to improve the lives of those in the Agago community who are currently underserved in terms of mental health services.

Finemind's approach is rooted in cultural competency and community engagement. The organization partners with 16 health centers across 9 sub-counties in Uganda, and they prioritize building strong relationships with the in-charges before offering their mental health solutions. To ensure accountability and transparency, Finemind has a memorandum of understanding with the District Health Office and official contracts with each health center.

The team consists of 34 members, with 23 Ugandan community mental health workers who provide counseling. These workers are nurses, midwives, and health assistants who have a deep desire to support their community. They are all from the district and many have their own stories of survival, hiding, and trauma from the Lord’s Resistance Army regime.

Before launching mental health services, Finemind conducted a comprehensive needs assessment with over 60 people through surveys, interviews, and focus groups to identify the community's main needs. Mental health emerged as the top priority, with nearly 70% of respondents identifying it as the most critical issue. To address this need, Finemind adapted a successful peer-counseling program from India and incorporated Ugandan cultural, social, and economic values, including a focus on heritage, communal living, extended family structures, innovation, and entrepreneurship.

Finemind continues to engage a core group of community members for consultation, advice, and input to strengthen and expand their services. In response to community needs, they have introduced economic empowerment programs, nutrition and food security initiatives, social and emotional life skills programs for children, and expanded their counseling services to include trauma care. They also host regular awareness meetings and participate in radio shows to engage the community in dialogues around mental health and other relevant health issues.

2,000

We’re a small team with a big mission. Funding aside, we’re particularly curious about addressing a technical barrier that we believe will allow us to expand our work more efficiently. Our idea is to customize and scale our training of CHW via technology. We would like to innovate our training through interactive lessons designed specifically for the WhatsApp platform, through a partnership with Bean Voyage, a global leader in training methodologies and a feminist non-profit social enterprise on a mission to eradicate the gender gap in farming communities. The benefits of training through WhatsApp include customizable lessons, interaction, flexibility, convenience, accessibility and low cost. We see Solve as a vital partner in helping this program run successfully, which includes technical support, mentorship and troubleshooting. 

This innovation will extend our counseling services which have proven to be effective, by expanding our team of CHW, thereby impacting a much larger population in Uganda. Future CHW candidates face significant barriers that prevent them from attending in-person training, such as lack of time, mobility and transport, and loss of income. WhatsApp will afford us the possibility to train more CHW faster.

Our great differentiator is our innovative approach to mental healthcare, which includes training community health workers, using stepped care to tailor treatment to each patient's needs, providing counseling at health facilities and community gathering places, running public awareness campaigns, and collaborating with local health authorities and non-profit organizations. This approach allows us to expand our reach, improve the quality of our services, reduce stigma around mental health, and build a more sustainable model for the future. By demonstrating the effectiveness of this approach, Finemind can inspire other organizations and governments to adopt similar models of care.

We’re particularly excited about our push for integration of mental health care within primary care, which will allow practitioners to offer whole-person care. This has the potential to change the market by increasing the demand for mental health services and incentivizing health facilities to provide such services. This could lead to greater investment in mental health infrastructure, increased access to care for those in need, and ultimately improved mental health outcomes for individuals and communities.

Currently, we’re working with five health centers to directly send depression and trauma data to the Ministry of Health to inform legislation. This type of effort can lead to policy change and capacity building in health facilities to provide mental health services. This could set a precedent for other countries and organizations to prioritize mental health in their healthcare systems and policies.

Overall, Finemind's approach has the potential to catalyze positive impacts in the mental health space by inspiring others, changing the market, and leading to policy changes and capacity building.

In 5-years time, our ultimate goal is to see 150,000 people recover from depression.

The program's one-year goals are centered around three key outcomes: increasing household income, improving community resilience, and reducing stigma.

The goal of a 50% increase in household income is based on the understanding that improved mental health and productivity can lead to better economic outcomes for individuals and their families. With better mental health and increased coping skills, individuals may be better equipped to pursue and maintain employment or entrepreneurship opportunities, which can ultimately contribute to increased household income.

We intend to achieve this goal by

• Fostering entrepreneurship and small business development through training and mentorship

• Offering financial literacy and management training to help community members better manage their money and investments

The goal of a 70% increase in community resilience recognizes the importance of building strong and resilient communities in the face of adversity. Mental health is a critical component of resilience, as individuals who are better able to cope with stressors and challenges may be better equipped to support their families and communities during times of hardship.

We intend to achieve this goal by

• Providing trauma-focused counseling and other mental health services to individuals affected by trauma

• Offering community-wide mental health education and training to help community members build their coping skills

• Facilitating community-building activities, such as cultural events, volunteer opportunities, and support groups

The goal of a 60% reduction in stigma is based on the understanding that stigma around mental health can be a significant barrier to individuals seeking support and treatment. By reducing stigma, individuals may feel more comfortable accessing mental health services and engaging in conversations about mental health, ultimately leading to improved overall community well-being.

We intend to achieve this goal by

• Running public awareness campaigns to educate community members about mental health and reduce stigma

• Foster dialogue and communication around mental health through community meetings, forums, and other events

In the long term, the program aims to train a large number of community health workers to provide counseling sessions, with the goal of successfully treating a significant number of citizens. This would not only improve the mental health of individuals but could also potentially have positive impacts on families, communities, and the broader society.

The indicators used to measure progress toward impact include:

1. Increase in the abilities of health workers to offer consistent, appropriate, and timely mental health services: To ensure the quality of our CHW services, we have a dedicated team of 23 CHWs. Continuing education and supervision are crucial to ensuring their services are of high quality, acceptable, and effective.

2. Improvement in the quality of mental health care in Agago District: We follow a stepped-care approach in our treatment of patients. A patient starts with psychoeducation, then receives additional advising from doctors, engages in interpersonal counseling if needed, and/or is referred to a mental health specialist if the symptom severity doesn't improve. On average, a CHW provides 20 counseling sessions per month.

3. Successful treatment of patients via depression care management: Recovery is achieved when a patient scores PHQ < 5 for two consecutive sessions. On average, a patient requires 4 sessions to recover, each session lasting 30-45 minutes.

4. Increase in mental health awareness via awareness campaigns: We utilize edutainment to mobilize community members to attend mental health awareness events. Stigmatization limits the accessibility of services and inhibits those who suffer from mental illness from seeking services. The goal of these events will be to increase mental health understanding and literacy, thereby assisting with stigma reduction.

In the near future, we intend to use these indicators to measure impact

1. Household income: Finemind will conduct regular surveys with the community and collect data on their income levels before and after the intervention. We will also expand access to economic opportunities, such as microfinance programs and vocational training, to further increase their income levels.

2. Community resilience: Finemind will use a community resilience scale to measure progress in this area. The scale will measure the community's ability to cope with adversity, adapt to change, and thrive in the face of challenges. We will collect this data at the beginning and end of the intervention, and periodically during the intervention, to track progress.

3. Reduction in stigma: Finemind will use a stigma scale to measure the reduction in stigma around mental health in the communities it serves. It will measure attitudes toward mental illness and willingness to seek help for mental health issues. We will collect this data at the beginning and end of the intervention, and periodically during the intervention, to track progress.

Finemind's theory of change is centered around the belief that rebuilding community-wide mental health in the Agago District will lead to stronger individuals and families and eventually, prosperous and thriving communities. Our approach aims to address the critical need in Uganda's mental health landscape, where over one-third of the population suffers from mental illness, and less than half of those who could benefit from mental health assistance actually seek treatment.

To achieve our goals, we provide peer mental health counseling, reduce stigma via awareness campaigns, support social and emotional learning of children, empower women and men economically, and advocate for primary care integration. These activities are expected to yield specific outputs such as an increased number of counseling sessions provided, patients enrolled in counseling, and successfully discharged, CHWs trained to provide counseling, and women receiving economic empowerment.

Our outcomes include strengthened mental health services, increased awareness and knowledge of mental health, and empowered citizens who seek care, continue to use services, and recover. We will measure progress toward our ultimate outcome of seeing 150,000 citizens recovered from depression by 2028 by monitoring improved clinical outcomes for those with depression and trauma, improved symptom severity, and increased household income and community resilience.

Abel Otoma underscored the value of Finemind’s intervention, “I am a counselor working with Finemind. You find that these stressing conditions were not fully addressed by the government and other partners that have been working around. Finemind comes in to bridge the gap that we have seen. This approach that Finemind is using has been lacking in the healthcare system.” 

In fact, a recent impact evaluation showed that our team of CHW has treated nearly 10% of the adult population of Agago over the last 3 years. Our work has shown an almost 5.5-point decrease in depression symptom severity scores for our patients as evidenced by the PHQ-9 Depression Screening Tool (-4 points is considered a clinically significant reduction).

Through our efforts, Finemind hopes to empower individuals and communities to thrive and address the critical need for mental health services in Uganda.

Our core technology is tablets and Kobo Toolbox. Simply put, our program would be impossible without the use of these two tools. Kobo is a brilliant software tool that stores, collects, and aggregates patient data, both qualitative and quantitative. Each time a counselor interfaces with a patient, Kobo guides the counselor to ask relevant questions for impact measurement from the PHQ-9 Depression Screening Tool and other relevant bio-data. These questions are designed to capture a holistic view of the patient's mental health and track their progress over time.

With Kobo, data is collected digitally, reducing the need for paper forms and manual data entry. This saves time and resources, and eliminates errors that can occur when transcribing data from paper forms. Additionally, Kobo offers a range of features that allow for more efficient data collection, such as skip logic, which guides the counselor to ask relevant questions based on previous answers, reducing the time needed to collect data. Kobo also has built-in data validation rules, which prevent incorrect or incomplete data from being entered, ensuring high data quality.

Moreover, Kobo Toolbox provides real-time data access to our M&E team, enabling them to quickly review and analyze patient data. This allows us to monitor patient progress and identify any issues that may arise, allowing us to intervene in a timely manner. Kobo Toolbox also enables us to generate reports quickly and easily, allowing us to communicate our results to stakeholders and partners. Finemind’s M&E team cleans the data, compiles weekly targets, and aggregates monthly reports for patient follow-ups. Bimonthly, the results are evaluated via Tableau for prior mentioned outputs and outcomes and shared more broadly with stakeholders and district officials.

This same analysis informs our team of what is working, where we require additional resources, and other necessary modifications. For example, suppose we notice that patients in a particular village are dropping out of counseling at a higher rate than patients in other villages. In that case, we might deploy additional community health workers to that village to provide more support to patients. In fact, this analysis is the single most important thing in evidencing our intervention as effective and garnering financial and collaborative support from prospective partners. 

The platform offers a range of data collection tools, such as surveys, questionnaires, and interviews, that can be tailored to fit the specific needs of Finemind's program. This customization capability allows Finemind to collect the data it needs to effectively measure the impact of its mental health interventions, which may differ from other mental health programs. The use of technology enables us to track progress, measure impact, and continuously improve our program, ultimately leading to better mental health outcomes for the people of Agago District.

Finemind is committed to promoting diversity, equity, and inclusivity in all aspects of our work. Our approach centers around ensuring that our programs are designed and implemented with local input and expertise. We recognize that the people most impacted by the challenges we aim to address are also the most knowledgeable about the context and solutions that will work best for their communities. For this reason, we have intentionally built an amazing team of Ugandans to lead our programs and impact.

In addition to having a local team, we actively seek out input and feedback from community members to guide our decision-making and the development of new initiatives. We understand that each community has its unique strengths, challenges, and perspectives. Therefore, we approach each new program with a mindset of cultural humility, recognizing that we have much to learn from the communities we serve. By centering community input and expertise, we can create programs that are tailored to the specific needs and assets of each community.

Furthermore, we are committed to promoting equity by ensuring that our programs are accessible and inclusive to all members of the community. We recognize that there are many structural barriers to accessing mental health services, such as poverty, stigma, and discrimination. To address these barriers, we actively work to reduce stigma through our awareness campaigns, prioritize economic empowerment activities for women and men, and integrate our programs into existing health systems to promote access to care.

In summary, Finemind's approach to incorporating diversity, equity, and inclusivity into our work centers around building a local team, actively seeking community input, promoting cultural humility, and working to reduce structural barriers to mental health services. We are committed to building programs that are accessible, inclusive, and tailored to the unique needs of each community.

As a 501c3, non-profit organization, Finemind's focus is on achieving its mission rather than generating profit. This means that the organization aims to generate revenue to support its programs and services, rather than to provide a return on investment for shareholders.

To fund its operations, Finemind primarily relies on philanthropic capital from individuals and foundations. This includes donations and grants from people and organizations that support the organization's mission and work. These funds are used to cover the costs of the organization's programs, including the salaries of staff members, materials and supplies, and other expenses.

In addition to philanthropic capital, Finemind is exploring building a more sustainable support system from corporations. This could involve partnering with businesses to provide mental health services to their employees or licensing the organization's curriculum to other organizations. By generating revenue from these activities, Finemind can diversify its funding sources and become less reliant on philanthropic capital.

Overall, Finemind's business model is focused on achieving its mission of improving mental health in underserved communities, while generating revenue to support its operations and expand its impact.

Finemind has two strategies for achieving financial sustainability. First, our long-term goal is to integrate mental health care into primary care in all health facilities in Uganda. We plan to work closely with the Ministry of Health to pass policy and legislation that will provide consistent budgetary financing for our efforts. This will allow us to continue providing our services without relying solely on philanthropic capital.

Our second strategy is to expand our earned revenue arm by licensing our mental health curriculum to other organizations. This would involve selling the rights to use our curriculum to non-profit organizations, schools, or government agencies that could then provide mental health services in their own communities. By doing so, we would generate additional revenue while also expanding our impact beyond the communities we currently serve.

Finemind has been successful in achieving financial sustainability through a combination of philanthropic funding and earned revenue. Our operating budget has steadily increased over the past few years, with $17,471 in 2020, $87,619 in 2021, $121,959 in 2022, and a projected budget of $200,000 for 2023. We have received generous support from a range of donors, including Rotary International ($64,800), the Charles Engelhard Foundation ($35,000), the Kathryn McQuade Foundation ($22,000), and the Acceleration Portfolio of the Dovetail Impact Foundation ($15,000), among others.

We have also been successful in generating earned revenue by providing a six-month trial project to a community-based organization in Western Uganda. The project included a six-day training, biweekly monitoring, minimal administrative costs, a mid-project visit, and a final project visit, for which we were paid $4,000.

While we have not yet received financial support from the Ugandan Ministry of Health, we are working closely with them to advance our goal of integrating mental health care within primary care facilities. We have substantial backing from key personnel in the Ministry, and we are hopeful that this partnership will lead to more consistent budgetary financing in the future.