A reflection on mental health, the silence we inherited, and the work that comes next.
I don’t know where to start! That was my answer.
A friend, and a colleague I respect deeply in this industry, looked at me across the table and asked what I thought of mental health, and whether it was a topic I wanted to explore through my organization. I had walked in carrying a story I had not planned to tell. A few weeks before, a parent had shared in our school’s WhatsApp group that a friend’s daughter had taken her own life. The girl was young. She was not unwell in any of the ways we have been taught to recognize. The people who had loved her had no warning, no pattern to point at, no language ready for what had just happened to them.
It turned out my friend knew this family. So I told her about the girl first, before I answered her question, and I told her about the conversation I sat my own children down for the next morning. Because of where I have spent my career, in reproductive health, I do not believe in withholding hard topics from children when they are old enough to ask hard questions. I asked them what they understood about suicide. I asked them whether they had ever felt close to a place they could not return from on their own. I listened more than I spoke.
Then I answered her. I told her I would love to do more in this space, but I did not know where to start. And as soon as the words were out, I wondered whether that was a strategic thing for someone in my position to say. Strategic people are supposed to walk in with a thesis, an entry point, a positioning statement. I think the truth, especially in mental health, is that the people who pretend to know exactly where to start are the ones we should be most cautious about.
What follows is not a strategy memo. It is me thinking out loud, on the page, about a problem I am no longer able to set down.
What I grew up believing
When I was growing up, suicide existed. It was almost certainly underreported, but the more important fact is that it was almost never discussed. There was an embarrassment around it, a shame that landed on the family of the person who had died. People did not say the word out loud. They said “she passed” or “he was sick for a long time,” and the rest was implied through silence. What that silence taught a generation of us is that mental anguish is a private failure. That feeling unwell in your mind is something you manage in the dark, on your own, until you cannot anymore. That asking for help is the same as admitting to a flaw in character. We have moved less far from that than we like to believe.
What the numbers actually say
The World Health Organization estimates that close to one billion people globally live with a mental health condition. In low- and middle-income countries, between seventy and eighty five percent of those who need care do not receive it. Across much of sub-Saharan Africa, there are fewer than one psychiatrist per one hundred thousand people, with some countries reporting extremely limited specialist capacity. Suicide remains among the leading causes of death for young people aged fifteen to twenty-nine globally, with growing concern about rising mental distress among adolescent girls and young women in several contexts.
The treatment gap is the headline. The gap underneath the gap is harder to capture in a statistic. It is the distance between the language we use for mental distress and the languages people speak at home. It is the distance between formal services and the people who would never walk into them. It is the distance between a clinical diagnosis and a young woman who simply could not see a way through her week.
What has already been tried
It would be unfair, and inaccurate, to pretend that nothing has been done.
The WHO’s mhGAP programme has spent more than a decade translating specialist mental health knowledge into protocols that non-specialists, including primary care nurses and community workers, can use. The Friendship Bench in Zimbabwe, designed by Dixon Chibanda, trained grandmothers to deliver problem-solving therapy on wooden benches outside clinics, and produced outcomes for depression and anxiety that rivalled clinical care. StrongMinds in Uganda has scaled group interpersonal therapy through lay counsellors. BasicNeeds has worked across Africa and Asia to integrate mental health with livelihoods and rights. The Lancet Commission on Global Mental Health put serious intellectual weight behind reframing mental health as a development priority rather than a niche specialty.
These are real efforts, designed by serious people, and many of them work. But they sit inside a global ecosystem that still treats mental health as a vertical, a side programme, a thing that earns a paragraph in a national health plan and less than two percent of the health budget. They have not been brought to the scale the problem demands. And they are not yet woven into the systems that touch most people’s lives most often: schools, workplaces, primary care, social protection, faith communities, and families.
Where the real gaps are
If you spend any time looking honestly at this field, three gaps come into view. The first is a workforce gap. There will never be enough psychiatrists in Africa and Asia to meet the need through specialist care alone. This is not a temporary shortage. It is a structural reality. It means any serious mental health response has to be built around task-shifting, lay providers, and trusted community figures, with specialists held in reserve for the most acute cases.
The second is a systems gap. Mental health is treated as a thing that lives in clinics, when in fact it shows up in classrooms, in employment offices, in police stations, in maternal health visits, in refugee camps, and in almost every social service interaction a person has. The systems that touch people are not equipped to recognize mental distress, let alone respond to it. Teachers are not trained. Frontline health workers are not trained. Managers are not trained. Parents, like me, are mostly not trained.
The third is a conversation gap. Even if we built the workforce and re-engineered the systems, we would still be left with the silence I grew up inside. The shame. The suspicion that something is wrong with you if you cannot manage on your own. The belief that the people in your life would think less of you if they knew. This gap is cultural, and it does not close from the top.
Why a human-centered approach is not optional
A great deal of what has been tried in mental health, across Africa and Asia and elsewhere, has fallen short for a single reason. It was designed without enough listening. Programmes get built around a clinical category, a screening tool validated in another context, a manual translated into a local language but not adapted to a local logic. They are launched with the assumption that if we hold a community sensitization meeting and put up a poster, people will walk in. Most of the time, people do not. And when we ask why, we discover that the architecture of the programme: who delivers it, where it is delivered, what it is called, how it is paid for, was decided in a room that did not include the people the programme was meant to serve.
A human-centered approach starts in a different place. It begins with the question of what mental distress actually looks like in this community, in this school, in this workplace, and in this family. It asks who people already turn to when they are unwell, and whether those people, the aunt, the pastor, the form teacher, the WhatsApp group, the grandmother on the bench, can be supported rather than replaced. It treats stigma not as a target to be reduced through messaging but as a design constraint to be engineered around.
Designed this way, mental health programmes look less like clinics and more like seams in everyday life. A maternal health visit that includes a real conversation about how a mother is sleeping and feeling. A school where teachers are supported to notice the child who has gone quiet. A workplace where managers can name what they are seeing without reaching for a referral form. A WhatsApp group where a parent can share the news of a death by suicide and receive something other than silence.
Why mental health has to be an intersectoral conversation
This is where I find myself returning to my reproductive health background. We learned, slowly and at significant cost, that reproductive health could not be solved as a vertical. The most consequential work happened where reproductive health intersected with education, with adolescent development, with gender, with livelihoods, with rights, and with the way young people moved through the systems around them. The technical interventions were necessary but not sufficient. The integration was where the change actually lived.
Mental health is the same shape of problem. Treating it as a stand-alone health issue makes it harder, not easier, to reach the people who need it. The integration points are everywhere if we are willing to look. Adolescent girls’ programmes that already operate across Africa and Asia are a natural home. Primary care platforms, where pregnant women and new mothers are already showing up, are a natural home. School systems are a natural home. Workplace wellness, in formal sectors and increasingly in informal ones, is a natural home. Social protection programmes, faith institutions, and community-based organizations are all natural homes.
An intersectoral approach does not mean adding mental health to everyone’s job. It means recognizing that mental health is already in everyone’s work, often unrecognized, and helping the systems around it become competent at noticing and responding. It means designing partnerships across ministries, across sectors, and across the artificial boundary between health and not-health.
So what, for Orpesi
This is the question we ask ourselves at Orpesi about everything we work on. So what. Why does it matter that we, specifically, take this on. What do we add that is not already being added.
What I have come to believe, over the last few weeks of thinking about this, is that the gap in mental health is not primarily a knowledge gap. The evidence base is real. The models exist. The policy frameworks are written. The gap is a translation gap. It is the distance between what is known in academic and donor circles and what is actually built and sustained inside organizations on the ground.
That is the work Orpesi was set up to do. Designing programmes that fit the contexts they will run in. Strengthening the institutions that will carry those programmes after the funding cycle ends. Turning what has been learned into what others can act on. We do not need to become a mental health implementer. We need to help the organizations we already work with, in adolescent health, in education, in livelihoods, in social protection, in primary care, recognize the mental health that is already inside their work and respond to it well.
The call to action is therefore not for Orpesi alone. It is for funders, for governments, for INGOs, and for the locally led organizations that already serve the communities where mental distress is rising. Stop treating mental health as a separate problem awaiting a separate solution. Bring it into the work you are already doing, the people you already trust, the systems you already hold. Do that with the discipline of listening first, designing with people rather than for them, and staying long enough to see whether what was built actually held.
Where I am starting
I told my friend I did not know where to start. I think I was wrong about that, in a small way. The starting place was the conversation we were having. The starting place was the conversation I had with my children. The starting place is every WhatsApp group, every staff meeting, every school assembly, every clinic waiting room where someone has the chance to break the silence and chooses to.
I do not believe Orpesi will solve mental health. I do not believe anyone will. But I do believe that if we apply the way we already work, listening hard, designing with rather than for, building institutions that can carry what is started, and translating what is learned into what others can use, to a problem this big and this human, we will be useful. And that, in the end, is a strategic thing to say.