Dixon Chibanda: The Friendship Bench

This tran­script of an EA Global talk, which CEA has lightly ed­ited for clar­ity, is cross­posted from effec­tivealtru­ism.org. You can also watch the talk on YouTube here.

When peo­ple ex­pe­rience profoundly dam­ag­ing events, like war, in­va­sion, or mas­sacre, the psy­cholog­i­cal toll is vast. Which in­ter­ven­tions work best to help re­pair the dam­age? Dixon Chibanda pi­o­neered the Friend­ship Bench, where lo­cal grand­moth­ers sit with peo­ple and help them talk through their prob­lems. In this talk from EA Global 2018: Lon­don, Chibanda ex­plains his pro­gram, which has shown im­pres­sive re­sults in re­duc­ing de­pres­sion among par­ti­ci­pants.

The Talk

I come from Zim­babwe, a coun­try which is of­ten char­ac­ter­ized by sev­eral decades of psy­cholog­i­cal trauma, from the Rhode­sian Bush War, the farm in­va­sions, the mas­sacre of more than 20,000 peo­ple in Mata­bele­land, and so the Friend­ship Bench is in essence a pro­gram that was con­ceived as a re­sult of one such trau­matic piece of his­tory from our coun­try, which ac­tu­ally started on the 19th of May in 2005, when the Zim­bab­wean gov­ern­ment at the time, un­der the lead­er­ship of Robert Mu­gabe, em­barked on a cleanup op­er­a­tion which was called Oper­a­tion Mu­ram­bat­sv­ina, which liter­ally means “Re­mov­ing the filth.”

1530 Dixon Chibanda

And what Oper­a­tion Mu­ram­bat­sv­ina was all about was a sys­tem­atic de­struc­tion of build­ings, struc­tures that were la­beled by the gov­ern­ment as ille­gal, what­ever that meant at the time, and it re­sulted in over 700,000 peo­ple be­ing left home­less, and ac­cord­ing to the United Na­tions, over two mil­lion peo­ple were psy­cholog­i­cally af­fected as a re­sult of this op­er­a­tion. Dur­ing that time, I was study­ing for my Master’s in Public Health, and I was in­structed to carry out a sur­vey to es­tab­lish what the prevalence, or the mag­ni­tude of the psy­cholog­i­cal mor­bidity was, and when these re­sults were pre­sented to the au­thor­i­ties, I was then told, “You need to re­ally come up with some kind of in­ter­ven­tion.”

1530 Dixon Chibanda (1)

A whole lot of things were hap­pen­ing at the time, and of course in a coun­try where there were ab­solutely no re­sources, and most of the pro­fes­sion­als had left. I was in essence given a group of grand­moth­ers to work with, 14, to start a pro­gram, or pi­lot, some­thing that would even­tu­ally help thou­sands of peo­ple, and it was pretty de­press­ing ini­tially. And any­way, to cut a long story short, through an iter­a­tive pro­cess with these 14 grand­moth­ers, we gath­ered as much in­for­ma­tion as we could about pro­grams that had been de­vel­oped in the coun­try, out­side the coun­try, and we es­sen­tially through this iter­a­tive pro­cess tested differ­ent ap­proaches, which were rooted in cog­ni­tive be­hav­ioral ther­apy.

1530 Dixon Chibanda (TEST) (2)

And over a cou­ple of months, we man­aged to come up with a mean­ingful sort of in­ter­ven­tion, and over the years we de­vel­oped a se­ries of com­po­nents to this in­ter­ven­tion, which be­came known as the Friend­ship Bench, which in essence is psy­cholog­i­cal ther­apy which is de­liv­ered on a bench in the com­mu­nity by grand­moth­ers. And one of our most re­cent pub­li­ca­tions is a clini­cal trial of this in­ter­ven­tion, where we com­pared the Friend­ship Bench with usual care, through a cluster ran­dom­ized con­trol­led trial. And the cluster ran­dom­ized con­trol­led trial, which is pub­lished in the Jour­nal of the Amer­i­can Med­i­cal As­so­ci­a­tion ac­tu­ally showed that grand­moth­ers were more effec­tive at de­liv­er­ing and alle­vi­at­ing symp­toms of de­pres­sion and avert­ing suicides than usual care.

1530 Dixon Chibanda (4)

And usual care in­cluded nurses trained in men­tal health, psy­chol­o­gists, and also the use of Prozac, so grand­moth­ers were pretty effec­tive at do­ing their job. And to ac­tu­ally illus­trate what we’ve achieved over the past cou­ple of years and where we’re go­ing, we di­vided the Friend­ship Bench into three main com­po­nents. The first part was the re­search and de­vel­op­ment, which was re­ally the for­ma­tive phase of Friend­ship Bench, where in the ab­sence of re­sources we had to come up with an in­ter­ven­tion which was sim­ple, cheap, but was ad­dress­ing a huge prob­lem, and apart from that we needed an in­ter­ven­tion that would ad­dress a di­verse pop­u­la­tion.

And we man­aged to kind of achieve that, look­ing at Zim­babwe as an iso­lated coun­try, but re­ally when you’re think­ing of an in­ter­ven­tion that is likely to be scaled up it has to be repli­cated, and so we were think­ing of the next stage, which is repli­ca­tion. Can the Friend­ship Bench in its cur­rent state be repli­cated in places out­side of Zim­babwe? And if it can be repli­cated then it can re­ally go to scale? So we started the pro­cess of repli­ca­tion in Malawi, in New York City, in Zanz­ibar and Botswana, and the model seemed to be quite in­tact in terms of its repli­ca­bil­ity in differ­ent set­tings, differ­ent cul­tural set­tings, and so we’re kind of con­fi­dent that this re­ally can go to scale.

1530 Dixon Chibanda (5)

Now, one of the things that we ob­served while we were run­ning the Friend­ship Bench is that not all young peo­ple were com­fortable sit­ting on a bench with grand­moth­ers, and also we re­al­ized that some peo­ple preferred to com­mu­ni­cate a lot more us­ing digi­tal tech­nol­ogy, mo­bile phones with the grand­moth­ers. So we teamed up a cou­ple of years back with folks from Philips, with Robin and oth­ers, and we came up with an in­ter­ven­tion which sup­ports Friend­ship Bench called Inuka. Inuka is a Swahili word which means “Arise,” and the ra­tio­nale be­hind it is, if Friend­ship Bench can be scaled up, Inuka as a digi­tal plat­form could en­hance that scal­ing-up pro­cess, and so in essence Inuka be­comes a digi­tal plat­form. This is in ad­di­tion to the ex­ist­ing Friend­ship Bench, which has been run­ning since 2006. It’s an app which can be down­loaded, and it’s re­ally based on the same prin­ci­ples of the Friend­ship Bench.

1530 Dixon Chibanda (6)

And the idea is with this ap­proach of hav­ing these grand­moth­ers, for in­stance, in Zim­babwe who de­liver an in­ter­ven­tion on a park bench in the com­mu­nity, and at the mo­ment we are op­er­at­ing in more than 70 com­mu­ni­ties in the coun­try, and ob­vi­ously we also have com­mu­ni­ties out­side of Zim­babwe. With that kind of in­ter­ven­tion, which is then sup­ported us­ing digi­tal plat­forms, we are able to reach out to more peo­ple. We are able to provide a lot more sup­port to the grand­moth­ers via these digi­tal plat­forms, and this has been re­flected in the work that we’ve been do­ing in New York City, for in­stance, in Zanz­ibar, where there’s a need for that digi­tal plat­form. At the mo­ment, some of that digi­tal com­mu­ni­ca­tion is fa­cil­i­tated through What­sApp, you know, through Skype, and so Inuka comes in as some­thing that could effec­tively take over that role and en­able strength­ened com­mu­ni­ca­tion to re­ally en­hance our reach and im­pact.

1530 Dixon Chibanda (TEST)

I’d like to share some of the Sus­tain­able Devel­op­ment Goals which speci­fi­cally fo­cus on men­tal health, just to high­light why an in­ter­ven­tion like Friend­ship Bench is im­por­tant. So if you look at tar­get 3.4, 3.5, and 3.8, they all touch on men­tal health, and there’s this grow­ing need when you look at the global bur­den of men­tal, neu­rolog­i­cal and sub­stance use di­s­or­ders, there’s a real need to scale up in­ter­ven­tions that truly re­duce that treat­ment gap for men­tal, neu­rolog­i­cal and sub­stance use di­s­or­ders. We can­not train enough psy­chi­a­trists or clini­cal psy­chol­o­gists, that is com­mon knowl­edge. How­ever, through task-shift­ing we can make a huge differ­ence in a very short space of time, but the challenge is find­ing task-shift­ing in­ter­ven­tions which are re­ally solidly rooted in ev­i­dence, which are based in em­piri­cal ob­ser­va­tion.

I be­lieve that the Friend­ship Bench is one such in­ter­ven­tion which can con­tribute sig­nifi­cantly to re­duc­ing that treat­ment gap. I’ll get on to why I think grand­moth­ers are also a crit­i­cal role, or the el­derly pop­u­la­tion in the world, a lit­tle bit later. Just to give you a few ex­am­ples from two very differ­ent lo­ca­tions: Zim­babwe and New York City.

1530 Dixon Chibanda (7)

Here we have the old­est grad­u­ate from Zim­babwe, she’s 84 years old, and the lady on the right is from New York City, her name is Skip, and the com­mon thing that re­ally unites or brings these peo­ple to­gether are the lived ex­pe­riences which they bring on the bench. This is some­thing that we’ve found to be re­ally pow­er­ful, where or the sto­ries that peo­ple bring to the bench are rooted in CBT prin­ci­ples, and em­piri­cal ob­ser­va­tion, be­cause the whole thing is about mea­sure­ment.

If we can’t mea­sure what we’re do­ing then we re­ally don’t know if it’s work­ing, and so by bring­ing in and in­ject­ing some­thing like CBT and the use of val­i­dated screen­ing tools, while you give sto­ries, you’re able to tell how a per­son is im­prov­ing, what kind of progress that per­son is mak­ing. And so what has es­sen­tially hap­pened over the years is some­thing that started off as a strongly CBT-based in­ter­ven­tion has re­ally be­come more of CBT through sto­ry­tel­ling, CBT through the use of ev­i­dence-based tools which are val­i­dated within a lo­cal con­text.

1530 Dixon Chibanda (8)

This is a pic­ture that I of­ten like to use to illus­trate the power of us­ing or­di­nary peo­ple in com­mu­ni­ties. This is a pic­ture of the very first grand­mother who worked on the Friend­ship Bench in Zim­babwe. Her name is Grand­mother Jack, and Grand­mother Jack was the first per­son who started do­ing this work, and she gave hope to all of us be­cause she was re­ally ded­i­cated in what she did, and she would per­sis­tently be there ev­ery morn­ing see­ing her clients. It was some­thing that we ex­pected of her to do, you know, and one morn­ing when she didn’t come to work, we kind of all knew what had hap­pened to Grand­mother Jack.

But what re­ally illus­trates the Grand­mother Jack story is that if you think of the world’s el­derly, the pop­u­la­tion of el­derly peo­ple in the world to­day, you know, if you look at 65 and above, it’s es­ti­mated by the World Health Or­ga­ni­za­tion and the UN that there are over 600 mil­lion peo­ple aged 65 and above, and then within an­other 15 years it’s go­ing to be over a billion peo­ple aged over 65, and the older one gets, the richer the lived ex­pe­rience is.

And what we are learn­ing from the Friend­ship Bench is that if we can take those lived ex­pe­riences and in­ject a fair dose of ev­i­dence-based talk ther­apy, they re­ally can reach out to thou­sands of peo­ple ad­dress­ing the global bur­den of de­pres­sion, for in­stance, and con­tribute sig­nifi­cantly to avert­ing suicides. This is what we have seen in Zim­babwe, we’ve seen this in Malawi, we are see­ing this in New York City, we are see­ing it in Zanz­ibar, and more re­cently in Botswana. So this is what I re­ally wanted to share with you about the work that we’re do­ing in Zim­babwe, and why I think that this kind of work can make a differ­ence, and this kind of work is re­ally what’s go­ing to con­tribute sig­nifi­cantly to­wards nar­row­ing or re­duc­ing the treat­ment gap for men­tal, neu­rolog­i­cal, and sub­stance use di­s­or­der on a global scale.

If any­one is in­ter­ested in learn­ing a lit­tle bit more about the Friend­ship Bench, you can look up my TED Talk, which goes into more de­tail of how the Friend­ship Bench ac­tu­ally works.

Questions

Ques­tion: On the bench, what does a per­son ex­pe­rience? What is the na­ture of the ex­pe­rience as peo­ple ac­tu­ally have it?

Dixon: Sure. So, the Friend­ship Bench model con­sists of two crit­i­cal com­po­nents. The first com­po­nent is the prepa­ra­tion of the grand­moth­ers, so in essence what we do is we first train train­ers. The train­ers then train the grand­moth­ers, and the train­ers that train the grand­moth­ers end up su­per­vis­ing the grand­moth­ers once the grand­moth­ers are in the field. And the ac­tual CBT com­po­nent con­sists of three steps, very sim­ple steps, which are rooted in be­hav­ior ac­ti­va­tion, ac­tivity schedul­ing, and in prob­lem-solv­ing ther­apy.

The first com­po­nent is called “Open­ing the mind,” in Shona it’s called “Ku­vhura pfungwa.” The sec­ond com­po­nent is up­lift­ing, and the third com­po­nent is kusim­bisa, and how it es­sen­tially works is peo­ple are referred to the bench from ev­ery­where, from schools, from the po­lice sta­tion, from the clinics, from homes, and some peo­ple just self-re­fer. Some are referred through ra­dio talk sta­tions, and when they come to the bench the first thing that hap­pens is they are screened. They are screened us­ing a lo­cally-val­i­dated screen­ing tool. I think here in the UK with IAPT you use PHQ-9. We also use the PHQ-9, but we also have a very spe­cific lo­cally-val­i­dated tool called the SSQ, which is broader.

And screen­ing tools are crit­i­cal, be­cause if you don’t use screen­ing tools in this kind of work, it’s difficult to have struc­ture. So the screen­ing tools in­form the grand­moth­ers whether they are deal­ing with a se­vere case, a mod­er­ate case, a case that needs to be referred to the next level, and so once they es­tab­lish that this is a case, they then provide the talk ther­apy, which is re­ally con­sist­ing of those three steps, and nor­mally it’s over a se­ries of about four ses­sions.

Ques­tion: Can you de­scribe each of those three steps in a lit­tle bit more de­tail?

Dixon: Open­ing the mind es­sen­tially is the sto­ry­tel­ling part, where the grand­mother listens to the sto­ries. So you know, clas­si­cally peo­ple who come to the bench have a whole lot of prob­lems. A whole lot of is­sues, ev­ery­thing is just kind of go­ing wrong in their lives, and peo­ple will of­ten pre­sent with a num­ber of prob­lems, not just one prob­lem. A per­son may pre­sent with be­ing HIV pos­i­tive, un­em­ployed, hav­ing no place to stay, hav­ing chil­dren who are not at school, you know, just a whole lot of prob­lems, and what we’ve also re­al­ized is when peo­ple pre­sent with these kind of prob­lems, they get into a kind of learned hel­pless­ness, where they can’t re­ally figure out which prob­lem to start work­ing on.

An in­ter­est­ing thing is, we thought this phe­nomenon was spe­cific to Zim­babwe, but we see ex­actly the same thing in New York City when we look at the cases that they are deal­ing with in the Bronx and in Har­lem. It’s pretty much the same, peo­ple with all these prob­lems and just not know­ing where to start, and sit­ting on the bench and hav­ing some­body say to you, “Tell me your story,” is just such an amaz­ing way of open­ing up, and re­al­iz­ing that there’s ac­tu­ally some­one who can listen to you, some­one who can help you. So that’s re­ally the first stage, open­ing up the mind through open­ing up and tel­ling those sto­ries, as painful as they are.

And one of the other things which we also en­courage on the Friend­ship Bench, which is re­ally not in-keep­ing with your usual psy­chother­apy or CBT ther­apy is that the ther­a­pist be­comes al­most in­volved. And this is some­thing that I was never trained to do as a psy­chi­a­trist, you know? You always keep your dis­tance, but we’ve learned from the grand­moth­ers that it’s crit­i­cally im­por­tant to show your weak­nesses too as a hu­man be­ing, by shar­ing your own lived ex­pe­rience, but within a very struc­tured way, and by do­ing that you re­ally es­tab­lish strong rap­port with the client.

So any­way, so the client talks about their story, and while they’re do­ing that the grand­mother sim­ply lists the prob­lems that are high­lighted. That’s all she does, and she listens with a lot of em­pa­thy, with a lot of ap­pro­pri­ate phys­i­cal ges­ture where called for, and af­ter all of that has hap­pened the grand­mother sim­ply sum­ma­rizes what she hears. And that par­tic­u­lar com­po­nent is also very pow­er­ful, be­cause when some­body tells you their story and you are able to ac­cu­rately sum­ma­rize what they’ve told you, that’s a sign that you’ve been listen­ing, and that’s a sign for that per­son who’s tel­ling their story that, “I’ve got some­one who’s on my side.”

And re­ally, that’s why we call it “open­ing up the mind,” be­cause most of these peo­ple have never re­ally talked about their prob­lems to any­one in such a set­ting, and so when that hap­pens the grand­mother then sum­ma­rizes, and af­ter sum­ma­riz­ing asks the client to se­lect a prob­lem to work on, so like your tra­di­tional PST, you know, and then it goes on from there, where they brain­storm to come up with a solu­tion, and es­sen­tially come up with a very spe­cific, mea­surable, achiev­able, re­al­is­tic and timely solu­tion that they fo­cus on. Very, very prac­ti­cal, but with a very strong dose of emo­tions and hu­man con­tact.

Ques­tion: It strikes me that this is also sort of an in­struc­tion man­ual for how to be a good friend.

Dixon: Well, that’s why it’s called “Friend­ship Bench!”

Ques­tion: So, you’ve kind of re­counted now to your client, “Here’s what I heard from you,” and then up­lift­ing is this kind of brain­storm­ing?

Dixon: Yeah.

Ques­tion: Choos­ing a par­tic­u­lar thing to sort of fo­cus on first, brain­storm­ing solu­tions to that. What is the strength­en­ing phase?

Dixon: So, the strength­en­ing phase is es­sen­tially the part where you then start to clearly iden­tify a sin­gle prob­lem and break it down in terms of what hap­pens, but a crit­i­cal com­po­nent of the strength­en­ing phase is some­thing that we call “The holy cow mo­ment.” And we call it “the holy cow mo­ment” be­cause it’s one of those stages in ther­apy where the ther­a­pist is in­ter­act­ing with the client and you’ve listed all these prob­lems, and I used to strug­gle with that, you know? So you list all these prob­lems, you know, “I’m suffer­ing from HIV, my neigh­bor is not talk­ing to me, my hus­band is abu­sive, I have a preg­nant teenage daugh­ter,” and with my mind as a med­i­cal doc­tor and psy­chi­a­trist, when I hear HIV, the first thing I think of, “We’ve got to put this per­son on med­i­ca­tion. We have to make sure that the CD4 count and the viral load is all in place.”

And then when you ac­tu­ally dis­cuss with the client, and the client iden­ti­fies a prob­lem to fo­cus on which just doesn’t fit with you and your think­ing as a psy­chi­a­trist, that’s what we call the “The holy mo­ment,” and we strug­gled a lot with the holy mo­ments with the grand­moth­ers as well, be­cause ini­tially they would pri­ori­tize cer­tain things, but we also re­al­ized that han­dling that “holy cow mo­ment,” where a client se­lects some­thing that seems re­ally ridicu­lous to fo­cus on, is crit­i­cal. And what we es­sen­tially do is we en­courage the grand­moth­ers to deal with the “holy cow mo­ment” as it comes, so if a client chooses to fo­cus for in­stance on some­thing which seems triv­ial, fo­cus on it, be­cause what we’ve learned over the years is by fo­cus­ing on that which seems triv­ial to us, we ac­tu­ally are open­ing up av­enues to treat all the other prob­lems that seem mas­sive.

So that be­comes the strength­en­ing com­po­nent, where the client re­al­izes that, “Re­gard­less of the prob­lem that I’ve se­lected to fo­cus on, this per­son is still pre­pared to work with me.” And once that is done, the third stage which is the strength­en­ing, kusim­bisa, is in essence the home­work. Be­cause the beauty of what we do on the Friend­ship Bench, which is differ­ent from your tra­di­tional ther­apy, is your first ses­sion, the fo­cus is to make sure that you walk away from there with a solu­tion. We don’t be­lieve in tel­ling peo­ple to come back for three, four ses­sions be­fore a prob­lem is solved. You know, peo­ple in Africa are very mo­bile, they’re con­stantly mov­ing, and if a per­son spends an hour and a half with you and you can’t solve your prob­lem, they’re pretty much not go­ing to come back.

So we re­ally do em­pha­size on mak­ing sure that they go home with some­thing tan­gible that they can work on, that’s the strength­en­ing, and then part of the strength­en­ing in­volves the grand­mother call­ing up on the client, ei­ther by send­ing an SMS, or send­ing a What­sApp mes­sage, and just to touch base, to see how the client is do­ing, and this strength­en­ing car­ries on be­cause they will meet some­times out­side, when they are in the mar­ket­place or in the com­mu­nity, and she can do a five minute strength­en­ing. “So how is it go­ing? How are things?” You know, that kind of stuff, and so that car­ries on.

Ques­tion: Is it val­i­dated that grand­moth­ers in par­tic­u­lar are the right peo­ple to be do­ing this, ver­sus any other group of peo­ple?

Dixon: So, for Zim­babwe cer­tainly grand­moth­ers are the best. We have con­sis­tently found that grand­moth­ers are re­li­able. You know, they are rooted in their com­mu­ni­ties and they have this wealth of wis­dom which is very cul­turally ap­pro­pri­ate. They are very good with us­ing ap­pro­pri­ate proverbs to ac­tu­ally get through a prob­lem, and they’re just… they give very good hugs as well, you know? So for Zim­babwe cer­tainly, we cer­tainly love the idea of grand­moth­ers, but we are also work­ing with young peo­ple. If you go to New York City, they don’t have that many grand­moth­ers. New York City I guess has a very di­verse group of peo­ple work­ing on the bench, from about 24 years old all the way up to like 56, so that’s what works for New York City.

I’m strongly in fa­vor of work­ing with grand­moth­ers for the sim­ple fact that we find them to be more re­li­able, but I think this model can be used for any­one. Any­one can de­liver this model, and the grand­moth­ers that we’re work­ing with, as I in­di­cated in my pre­sen­ta­tion ear­lier on, in essence I was given grand­moth­ers. I guess the city health de­part­ment thought that grand­moth­ers are not so im­por­tant, so try and come up with a solu­tion with grand­moth­ers, and the nurses and other men­tal health pro­fes­sion­als were busy do­ing other things. So it’s not that I chose them. They are what I had to work with, which was a bless­ing in dis­guise, ac­tu­ally.

Ques­tion: Who funds your or­ga­ni­za­tion? Are you look­ing to ex­pand, are you look­ing to start some­thing in the UK? What could you do with more fund­ing? All of that has been asked.

Dixon: So, I mean ob­vi­ously we would love a lot of fund­ing. We run a trust called the Friend­ship Bench Trust. So ini­tially when we started Friend­ship Bench, as I in­di­cated in my pre­sen­ta­tion, was re­ally my the­sis, my field­work for my Master’s in Public Health. That’s re­ally how it started, and it just car­ried on since 2006. It has grown, and we are now a Trust, a reg­istered Trust in Zim­babwe. We are hop­ing at some stage to be reg­istered here in the UK, be­cause I’m kind of af­fili­ated to the Lon­don School of Hy­giene and Trop­i­cal Medicine, so that’s the idea.

Most of our work has been funded by re­search agen­cies like the Wel­l­come Trust, NIH, MRC. This is why our work is heav­ily re­search-based, but we also do re­al­ize that as we think of scal­ing up the Friend­ship Bench, we re­ally need to move to a differ­ent kind of fun­der, be­cause most of these re­search or­ga­ni­za­tions or fun­ders do not fund scal­ing up of pro­grams, and I think the Friend­ship Bench has ac­quired quite a lot of ev­i­dence to jus­tify tak­ing that next step, which is scal­ing up. Yeah.

Ques­tion: For those that are in­ter­ested in kind of go­ing a lit­tle bit deeper into the sub­ject mat­ter, are there any self-train­ing ma­te­ri­als that peo­ple could ac­cess some­where on­line?

Dixon: If you go to the Friend­ship Bench web­site, we do have a man­ual that is available that we use. We have a fa­cil­i­ta­tors’ man­ual, and we have a train­ing man­ual for the de­liv­er­ing agents, but we also have the Inuka plat­form, which offers the train­ing of guides as I in­di­cated ear­lier on. You’ve got Friend­ship Bench, which was the origi­nal pro­gram which started in Zim­babwe, and now we have a digi­tal com­po­nent which is re­ally based on what we’ve done in Zim­babwe, and for Inuka we ac­tu­ally hope­fully wanted the gains to run smoothly. At the mo­ment we are test­ing Inuka. Inuka has been tested, pi­loted in Zim­babwe, in Kenya, and we’ve done some work in In­dia, so at the mo­ment we are ac­tu­ally run­ning a pi­lot in Kenya, but we would love to have guides on Inuka once it starts to run.

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