Mining for more: An innovative investment in maternal mental health

According to Miranda Wolpert, director of mental health at research funder Wellcome, we are “on the cusp of a revolution in mental health science.” Innovations in treatment and prevention are emerging all the time. Data is improving. Awareness is higher than ever. And, with poor mental health now seen as an economic risk, not just a social one, investors of all stripes are pricking up their ears. “It’s a very, very exciting sector,” said Jules Chappell, CEO of Kokoro, a U.K.-based nonprofit that aims to mobilize capital for mental health around the world. There are “highly investable” areas, including in low- and middle-income countries, such as software for clinical staff. Meanwhile, many peer support and community-based interventions have proven successful. A decade from now, Chappell predicted, mental health will be “in an utterly different place,” boosted by both private markets and development aid. But she also believes waiting for that moment isn’t an option. Nearly 1 billion people suffer from poor mental health, yet governments spend an average of just 2% of health budgets on addressing this. Globally, the financing gap in domestic spending is more than $200 billion. “It can sometimes feel utterly overwhelming,” Chappell said, “but that is zero reason not to dive into it.” An inflection point In September 2024, Kokoro, Wellcome, African Venture Philanthropy Alliance, Clinton Global Initiative, and McKinsey Health Institute unveiled the Coalition for Mental Health Investment in a bid to catalyze the investment required to meet the scale of global need within a generation. That launch is indicative of a wider momentum. “We’re really at this inflection point where mental health is going from this extremely, extremely neglected area to a slightly less neglected area,” said Julia Greenland, managing director for Africa at Healthy Brains Global Initiative. Some governments are beginning to prioritize the issue, she added — Kenya, where she is based, will host a mental health conference in 2025. Regional and international donors are showing interest: Melinda French Gates’ recent $250 million call for grantees targets both mental and physical health, and the African Venture Philanthropy Alliance told Devex it has recently created a pooled fund for health that aims to also attract investment into mental health. Entering this field may require a different approach. While investing in physical health often means backing infrastructure, that’s “almost exactly what you don’t want within mental health,” said Chappell, referring to the push to deinstitutionalize treatment of serious mental illness. In fact, community-based, demedicalized approaches using existing touch points can address less severe issues effectively and cheaply — with experts warning against conflating mental health and wellbeing services with psychiatric care. “Generally in East and southern Africa, there is a phenomenal primary health care system and structure,” said Alexandra Plowright, head of community health and well-being at mining firm Anglo American. People get help at clinics but also in nonclinical settings such as churches, mothers’ groups, and traditional healers. The key is figuring out how to embed mental health provision within that, she said. Language is another consideration. In Africa, for example, discussing mental health is not necessarily new; it is just done differently, said Greenland. She highlighted one study that identified “acute loss of hope” among girls who had dropped out of school — something that might elsewhere be described as a symptom of depression. While the growing use of Western or English-language terminology is not always helpful, Greenland acknowledged that it can be less stigmatizing: in Kiswahili, for example, the only way to describe mental health problems is to refer to “madness.” Outcomes-based approaches Perhaps the biggest issue for mental health interventions anywhere is knowing if they’ve worked. Programs often focus on the number of available therapists or counseling sessions provided, said Greenland, “but there’s very little measurement, and therefore very little management, of whether or not people’s mental health has actually improved.” That’s where outcomes-based approaches fit in, according to Healthy Brains Global Initiative, which specializes in this field. From January 2025, it will pilot a yearlong project, funded by Anglo American and delivered by the nonprofit Right to Care, to integrate mental health support into existing maternal and immunization pathways in South Africa’s Limpopo province. Plowright told Devex it aims to improve the well-being of 2,000 mothers, resulting in increased uptake of immunization for their children. Limpopo is in South Africa’s “platinum belt,” where mining companies including Anglo American are present. The province is marked by poverty and “harmful masculinity,” said Plowright. Teenage pregnancy rates are high, and 31% of pregnant women in Limpopo experience antenatal depression, but standard approaches to mental health have not succeeded, according to the project partners. So, the project has selected indicators based on what Limpopo women have said matters to them — for example, whether they “know what to expect during pregnancy,” or “enjoy caring for their baby.” Right to Care will work on improving these, for example, by providing informational material for existing maternal care providers to use, at clinics or in women’s homes. But it also has the flexibility to change its approach if needed. Scaling and sustainability Paying for outcomes ensures efficiency and scalability, said Plowright — once you have a proof of concept, it’s easy to get other funders on board. She did not disclose the budget, but described this kind of intervention as “extremely low-cost.” If successful, it will be scaled across all Anglo American’s community health and well-being programs in southern and East Africa. Material will be open access so that others can replicate it too. Whether other companies would fund this work is another question. Anglo American has had to work hard to build credibility in the health care sector, Plowright explained. Sustainability is “a core work stream” in the business; firms without a similar commitment may find it difficult to sustain internal buy-in and could prompt suspicion among local communities about their motives, she said. And, while South Africa has significant experience of outcomes-based approaches, with the government taking over as funder in some cases, that makes it something of an outlier in the world, Greenland said. Many governments are simply not set up to fund and manage work in this way. Outcomes financing, also known as payment by results, is not without its critics. Greenland acknowledged that the temptation for “cream-skimming” — selecting less-vulnerable beneficiaries so that success is more likely — can be a risk with this kind of setup. “That needs to be mitigated in the program design,” she said. Her colleague Richard Johnson, CEO of HBGI, argued that issues only arise with poor design or lack of capacity, adding that defining the “right mixture of inputs, outputs, and outcomes” and ensuring good performance management makes this approach far preferable to the alternative, which often results in waste. “When you tie the hands of the service provider to a very rigid delivery model that you have prescribed in Washington or in Geneva, you're going to fail, because you're not taking account of the local context,” Johnson said. A ‘golden thread’ across the SDGs Connecting mental health interventions with physical health outcomes is not new. Integrating mental health and psychosocial services into HIV and tuberculosis programs, for example, has long been shown to help patients stick to treatment and improve quality of life. Now, many experts want to see more integration of mental and physical care. “There are so many vertical programs that deal with one disease area, whether that’s prevention or whether it is curative, because that’s the way that health systems have been set up the world over,” said Anglo American’s Plowright. Rather than creating another “vertical” requiring its own pot of funding, mental health should be integrated across existing verticals, she said. Kokoro’s Chappell described mental health as “a kind of golden thread” across the Sustainable Development Goals. Many of the funders within the Future Mental Health Collective, which Kokoro co-facilitates, address mental health as part of existing work in areas such as gender or early childhood. Climate action, another issue that affects almost everything else, offers a model for all those pushing for mental health investment: Chappell hopes that CEOs everywhere will one day be able to talk about their organization’s contribution to the “people crisis.” Some major concerns persist. HBGI’s Greenland emphasized the need to invest in solutions that also work for the most marginalized. Digital technology, for instance, won’t help the teenager who goes online using a shared device with limited access to data. It’s also easier — and more profitable — to invest in, for example, an application that connects users to a therapist, than to address the underlying causes such as reducing poverty. The question, said Greenland, was “whether just scaling treatment indefinitely is the answer, or if there’s a more fundamental public health approach that needs to be taken.” Visit Accelerating Action — a series highlighting pathways for funding NCD prevention and control, spotlighting innovative financing models and cross-sector collaborations. This content is produced in partnership as part of our Accelerating Action series. To learn more about this series, click here.