The Evolution of Friendship Bench: Two Decades of Community-Led Mental Health Care in Zimbabwe

Over the past two decades, the Friendship Bench has evolved from a small-scale research initiative into a nationally embedded, government-owned model for delivering accessible mental health care in Zimbabwe. Its trajectory reflects a deliberate progression in program delivery, from proof of concept to real-world validation, to structured scale-up and ultimately to system integration through phased technical assistance and government transition.

The model was initially developed and tested in urban primary health care clinics, where trained grandmothers (lay health workers) delivered structured problem-solving therapy on wooden benches. This simple, culturally grounded approach created a trusted and non-stigmatizing space for care. Evidence from a randomized controlled trial (RCT) demonstrated significant reductions in depression and anxiety, establishing the model as both effective and feasible in low-resource settings. The program then transitioned into a learning and adaptation phase, applying implementation science frameworks such as the Consolidated Framework for Implementation Research (CFIR) and Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) to evaluate delivery under routine conditions.

This phase was instrumental in shaping scalable delivery defining supervision systems, standardising training, strengthening referral pathways and embedding monitoring and evaluation into routine practice, while also strengthening the documentation and reporting of impact.

With a defined implementation framework in place, the Friendship Bench moved into national scale, expanding from urban clinics into rural and hard to reach communities across all ten provinces in Zimbabwe, reaching over 1 million people to date. Over the past three years, program delivery has evolved from direct implementation to a phased technical assistance model, with the central program increasingly focused on building government capacity to lead delivery. This approach supports systems strengthening through structured mentorship, supervision, quality assurance and integration within existing health system functions, ensuring that scale is both sustainable and locally owned.

Digital innovation has further strengthened program delivery. The integration of routine data collection and reporting into national platforms such as DHIS2 has improved visibility, accountability and data driven decision making. In addition, digital service delivery models including WhatsApp based support and a call centre have expanded access to care. Together, these systems have enhanced the program’s ability to monitor performance, document outcomes and continuously refine implementation at scale.

While grandmothers or community health workers remain the backbone of delivery, the cadre has expanded to include grandfathers, youth facilitators, people with lived experience (expert clients) and peer supporters embedded within different health programmes. This diversification has increased reach and contextual relevance. The program has also broadened its target populations moving beyond predominantly women to more intentional engagement of men, adolescents and young people through the Youth Friendship Bench, alongside tailored approaches for key and special populations. The success of the model lies in its ability to combine simplicity with rigor delivering culturally resonant, human-centred care through trusted community members supported by strong evidence, structured implementation and robust systems.

Strategic partnerships have underpinned each phase of growth. Collaboration with government particularly the Ministry of Health and Child Care and the Ministry of Local Government, the World Health Organization, implementing partners within HIV and TB programming, academic institutions and funders has enabled both expansion and integration. Embedding the Friendship Bench within broader primary health care and disease specific platforms has strengthened efficiency, extended reach and reinforced its role within the national health system.

A defining milestone occurred in October 2023 with the formalisation of the transition from Friendship Bench-led implementation to government ownership. The model is now being integrated into Zimbabwe’s public health system, supported by structured frameworks for handover, capacity building, supervision and quality assurance.

Through a phased, province-by-province approach, the program is shifting from direct service delivery to the provision of technical assistance supporting planning, capacity building, supervision and quality assurance within government systems. This transition anchors the Friendship Bench within national structures, ensuring sustainability while maintaining fidelity to the model.

Looking ahead, the focus is on deepening systems integration, strengthening quality and fidelity within government-led delivery and leveraging digital innovation to enhance performance and impact. Continued investment in government ownership, technical assistance, partnerships and adaptive delivery will be critical to sustaining gains and expanding reach. The Friendship Bench stands as a compelling example of how locally developed, evidence-driven models can evolve into scalable, system-integrated solutions for mental health care.

Charmaine Chitiyo

Friendship Bench Zimbabwe Programs Manager