Good question. I haven’t dug into this in depth, so consider this primarily my understanding of the story. I haven’t gone through an itemized breakdown of StrongMinds costs on a year by year basis to investigate this further.
It is a big drop from our previous costs. But I originally did the research in Spring 2021, when 2020 was the last full year. That was a year with unusually high costs. I didn’t use those costs because I assumed this was mostly a pandemic related aberration, but I wasn’t sure how long they’d keep the more expensive practices like teletherapy they started during COVID (programmes can be sticky). But they paused their expensive teletherapy programme this year because of cost concerns (p. 5).
So $63 is a big change from $170, but a smaller change from $109 -- their pre-COVID costs.
What else accounts for the drop though? I think “scale” seems like a plausible explanation. The first part of the story is fixed / overhead costs being spread over a larger number of people treated with variable (per person) costs remaining stable. StrongMinds spends at least $1 million on overhead costs (office, salaries, etc). The more people are treated, the lower the per person costs (all else equal). The second part of the story is that I think it’s plausible that variable costs (i.e., training and supporting the person delivering the therapy) are also decreasing. They’ve also shifted towards moving away from staff-centric delivery model to using more volunteers (e.g., community health workers), which likely depresses costs somewhat further. We discuss their scaling strategy and the complexities it introduces into our analysis a bit more around page 70 of the report.
Below I’ve attached StrongMinds most recent reporting about their number treated and cost per person treated, which gives a decent overall picture for how the costs and the number treated have changed over time.
They only include costs to the legal entity of StrongMinds. To my understanding, this includes a relatively generous stipend they provide to the community health workers and teachers that are “volunteering” to provide StrongMinds or grants StrongMinds makes to NGOs to support their delivery of StrongMinds programs.
Note that 61% of their partnership treatments are through these volunteer+ arrangements with community health workers and teachers. I’m not too worried about this since I’m pretty sure there aren’t meaningful additional costs to consider. these partnership treatments appear to be based on individual CHWs and teachers opting in. I also don’t think that the delivery of psychotherapy is meaningfully leading them to do less of their core health or educational work.
I’d be more concerned if these treatments were happening because a higher authority (say school administrators) was saying “Instead of teaching, you’ll be delivering therapy”. The costs to deliver therapy could then reasonably seen to include the teacher’s time and the decrease in teaching they’d do.
But what about the remaining 39% of partnerships (representing 24% of total treatments)? These are through NGOs. I think that 40% of these are delivered because StrongMinds is giving grants to these NGOs to deliver therapy in areas that StrongMinds can’t reach for various reasons. The other 60% of NGO cases appears to be instances where the NGO is paying StrongMinds to train it to deliver psychotherapy. The case for causally attributing these cases of treatment to StrongMinds seems more dubious here, and I haven’t gotten all the information I’d like, so to be conservative I assumed that none of these cases StrongMinds claims as its are attributable to it. This increases the costs by around 14%[1] because it’s reducing the total number treated by around 14%.
Some preemptive hedging: I think my approach so far is reasonable, but my world wouldn’t be rocked if I was later convinced this isn’t quite the way to think about incorporating costs in a situation with more decentralized delivery and more unclear causal attribution for treatment.
But 1.14 * 59 is 67 not 63! Indeed. The cost we report is lower than $67 because we include an offsetting 7.4% discount to the costs to harmonize the cost figures of StrongMinds (which are more stringent about who counts as treated—more than half of sessions completed are required) with Friendship Bench (who count anyone as treated as receiving at least 1 session). So 59 * (1 − 0.074) * 1.14 is $63. See page 69 of the report for the section where we discuss this.
Hi Nick,
Good question. I haven’t dug into this in depth, so consider this primarily my understanding of the story. I haven’t gone through an itemized breakdown of StrongMinds costs on a year by year basis to investigate this further.
It is a big drop from our previous costs. But I originally did the research in Spring 2021, when 2020 was the last full year. That was a year with unusually high costs. I didn’t use those costs because I assumed this was mostly a pandemic related aberration, but I wasn’t sure how long they’d keep the more expensive practices like teletherapy they started during COVID (programmes can be sticky). But they paused their expensive teletherapy programme this year because of cost concerns (p. 5).
So $63 is a big change from $170, but a smaller change from $109 -- their pre-COVID costs.
What else accounts for the drop though? I think “scale” seems like a plausible explanation. The first part of the story is fixed / overhead costs being spread over a larger number of people treated with variable (per person) costs remaining stable. StrongMinds spends at least $1 million on overhead costs (office, salaries, etc). The more people are treated, the lower the per person costs (all else equal). The second part of the story is that I think it’s plausible that variable costs (i.e., training and supporting the person delivering the therapy) are also decreasing. They’ve also shifted towards moving away from staff-centric delivery model to using more volunteers (e.g., community health workers), which likely depresses costs somewhat further. We discuss their scaling strategy and the complexities it introduces into our analysis a bit more around page 70 of the report.
Below I’ve attached StrongMinds most recent reporting about their number treated and cost per person treated, which gives a decent overall picture for how the costs and the number treated have changed over time.
Thanks yeah that’s a great graphic. Do they include government salaries and other NGO costs as part of their costs too?
They only include costs to the legal entity of StrongMinds. To my understanding, this includes a relatively generous stipend they provide to the community health workers and teachers that are “volunteering” to provide StrongMinds or grants StrongMinds makes to NGOs to support their delivery of StrongMinds programs.
Note that 61% of their partnership treatments are through these volunteer+ arrangements with community health workers and teachers. I’m not too worried about this since I’m pretty sure there aren’t meaningful additional costs to consider. these partnership treatments appear to be based on individual CHWs and teachers opting in. I also don’t think that the delivery of psychotherapy is meaningfully leading them to do less of their core health or educational work.
I’d be more concerned if these treatments were happening because a higher authority (say school administrators) was saying “Instead of teaching, you’ll be delivering therapy”. The costs to deliver therapy could then reasonably seen to include the teacher’s time and the decrease in teaching they’d do.
But what about the remaining 39% of partnerships (representing 24% of total treatments)? These are through NGOs. I think that 40% of these are delivered because StrongMinds is giving grants to these NGOs to deliver therapy in areas that StrongMinds can’t reach for various reasons. The other 60% of NGO cases appears to be instances where the NGO is paying StrongMinds to train it to deliver psychotherapy. The case for causally attributing these cases of treatment to StrongMinds seems more dubious here, and I haven’t gotten all the information I’d like, so to be conservative I assumed that none of these cases StrongMinds claims as its are attributable to it. This increases the costs by around 14%[1] because it’s reducing the total number treated by around 14%.
Some preemptive hedging: I think my approach so far is reasonable, but my world wouldn’t be rocked if I was later convinced this isn’t quite the way to think about incorporating costs in a situation with more decentralized delivery and more unclear causal attribution for treatment.
But 1.14 * 59 is 67 not 63! Indeed. The cost we report is lower than $67 because we include an offsetting 7.4% discount to the costs to harmonize the cost figures of StrongMinds (which are more stringent about who counts as treated—more than half of sessions completed are required) with Friendship Bench (who count anyone as treated as receiving at least 1 session). So 59 * (1 − 0.074) * 1.14 is $63. See page 69 of the report for the section where we discuss this.