Department of Psychiatry and Mental Health, University of Cape Town Professors Lund and Joska have received funding from Prudential Africa for research on mental health workplace programmes in Africa.

The global economy has been devastated by the COVID-19 pandemic. In Africa it has led to both significant contraction of national economies, and more people living in poverty. The World Bank estimates that between 71 and 100 million people will be driven into extreme poverty in 2020, and Africa will be among the hardest hit regions.¹

The journey to recovery will be a long and difficult one for African economies and will be strongly dependent on the resilience and productivity of the workforce. Together with employers, government policy responses on the continent will need to consider mechanisms to stimulate and encourage investment in resilient and productive human resources. There is increasing global evidence that productivity in the workplace is profoundly influenced by mental health.

It is estimated that mental illnesses cost $2.5 trillion globally in 2010, and this cost will rise to over $6 trillion by 2030.³ Most of these costs are indirect and are due to productivity losses associated with mental illness. These losses include absenteeism (days out of work) and presenteeism (reduced productivity while physically present at work).^4,5 Adverse working conditions that involve poor communication and management practices, low autonomy, effort-reward imbalance, unclear tasks or organisational objectives, occupational uncertainty and lack of value and respect in the workplace are particularly associated with mental health problems.^6-8

Only a small proportion of the costs of mental illness are direct costs of providing mental health services. For example, in South Africa the annual cost of lost income due to mental illness is estimated at $3.6 billion (approximately 2.2% of GDP) and far outweighs direct spending on mental healthcare by the Department of Health (of around $59 million).⁹ At the society level, it costs more to not treat mental illness than to treat it.

Despite the massive economic costs of mental illness, African countries have historically under-invested in mental health. Most African countries spend less than 1% of their health budgets on mental health (approximately $0.10 per capita),¹⁰ leading to an enormous treatment gap – in Ethiopia, Ghana, Nigeria and South Africa more than 90% of people living with mental illness do not receive any form of evidence-based care.^11,12

In Table 1, we illustrate the mental health policy commitments and resources of several African countries. These are the markets in which Prudential Africa currently operates. What is clear is that despite high level policy commitments in most countries, allocation of appropriate budgets and human resources for mental health are sorely lacking. This becomes even more stark when compared to high-income countries, which spend approximately US$80 per capita on mental health (compared to US$0.10 in Africa) and employ 13.1 psychiatrists per 100,000 population.¹⁰

Table 1. Prudential Africa markets and mental health characteristics

* WHO (2017) Mental Health Atlas. Geneva: WHO

COVID-19 has had a further devastating impact on mental health, including elevated levels of health anxiety, social isolation, loss and the economic consequences of the pandemic.¹³ For example, in Ethiopia a survey in April 2020 found that the number of people experiencing depressive symptoms had tripled compared to pre-COVID-19 levels.¹⁴ In the workplace, new ways of working, including work from home arrangements, job insecurity and isolation are major threats to workforce mental health in the context of COVID-19.¹⁵

Why should African governments and employers invest in mental health?

There are a number of reasons for African governments and employers to invest in mental health.

• Investing in mental health pays off at the society level. A global return on investment (RoI) analysis showns that for every dollar invested in treatment for depression and anxiety there will be a $2-5 RoI over the 15 years of the Sustainable Development Goals (SDGs 2015-2030).¹⁶ This ranges from $2.3-3.0 when economic benefits alone are considered, and $3.3-5.7 when health returns are also considered.
• Workplace mental health programmes do not only lead to improved mental health and wellbeing. They also improve productivity. In an analysis of workplace mental health programmes in seven Canadian companies, median RoI was CA$1.62 over three years. This increased to CA$2.18 for companies with more long-term data, indicating that companies are more likely to yield greater returns as their mental health programmes mature.¹⁷
• There are important human rights reasons to invest in mental health: people have a right to gain access to mental healthcare that can improve their wellbeing and quality of life.¹⁸
• There is growing consensus from international development agencies, such as the World Bank that mental health is not only a health need but also a social and economic development priority.¹⁹

How should African governments and employers invest in mental health?

Governments

It is vital that African governments proceed with implementing the WHO Global Mental Health Action Plan (2013-2020, now extended to 2030), which has been endorsed  by most UN member states and provides a roadmap for key priorities and national investments in mental health.²⁰ As shown in Table 1, although many countries have endorsed the plan and have national mental health policies, none have allocated sufficient resources (minimum 5% of health budgets for low-income countries²) or developed adequate staffing.

In keeping with the SDGs, mental health needs to be included in national health insurance schemes, as part of universal health coverage. The WHO mhGAP programme provides a set of clinical and operational guidelines for scaling up mental health services in primary care and community settings, and has now been implemented in over 100 countries.

In response to COVID-19, African governments need to consider stimulus packages and improve the regulatory environment to incentivise employers to protect and promote the mental health of their workforce. For example, companies could receive tax incentives for establishing workplace mental health programmes according to key metrics of implementation, uptake and RoI. Stronger regulation is required for companies that pursue harmful and exploitative labour practices.

Employers

To build workforce resilience during and in the aftermath of COVID-19, employers should consider establishing workplace mental health programmes as a routine part of good business practice. Key components of such programmes include the following.

Building resilience: Employers can promote mental wellness in the workplace through supportive environments that create opportunities for career growth and innovation; involving employees in decision-making; and recognising and rewarding employee contributions. Examples include the “job demand-control-support model”, which encompas strategies such as establishing clear workplace roles, allowing workers some control over their workload, and creating a supportive environment.²¹ The use of interventions to reduce effort-reward imbalance shows promise in diverse occupational settings.²²

Mainstreaming mental health: Employers should create awareness about mental health and common problems like depression, anxiety and alcohol and other substance misuse. For example, awareness campaigns about mental health, including Mental Health First Aid,²³ and the use of personal story telling to reduce stigma, especially by company leadership have been shown to be particularly powerful.¹⁷ This is a relatively inexpensive intervention that can promote a culture of employees seeking help early, before situations reach a crisis point. 

Minimising shame and discrimination by reducing stigma against mental illness. This is key because people with depression and low education are known to have high levels of self-stigma, which in return reduces their own ability to seek treatment.²⁴ There are different approaches to reducing stigma in the workplace, including raising education and mental health literacy among employees and supervisors,²⁵ and personal contact with people with lived experience of mental illness.²⁶

Focusing on interpersonal relations: Managing conflict and effective communication in the workplace is essential. There is evidence that group-based stress education in emergency personnel, which included conflict management, communication and relaxation training, showed a significant reduction in depressive symptoms.²⁷ Clear communication from management also improves depression outcomes in managing organisational change, for example in company mergers.²³

Strengthening systems: Screening, detection and care pathways for people with mental health problems should be established in the workplace. While there is a debate regarding who to screen and which tools to use, there is evidence that a two-stage process of screening and referral to telephone and care management intervention in the workplace reduced depression, and increased job retention and number of hours worked.²⁸

Effective delivery of employee and family assistance programmes (EFAP): Counselling (including peer counselling and digital platforms) and specialist mental health care should be made available, where needed.²³ For persons with confirmed clinical depression, referral to appropriate providers is key, and strategies such as reducing or removing co-payments from medical insurance are workplace approaches which may facilitate this. People with sub-clinical, or low-grade depression, may benefit from psychoeducation, internet-based or computer-based treatments.²⁹

Mental health scorecard: alongside the design of effective workplace mental health programmes, it is vital to collect accurate indicators of the costs, process and outcomes of implementing these programmes. These indicators include programme implementation, uptake, performance measures and RoI, with adaptation of programmes according to data results in real time.¹⁷ Key indicators are: (A) costs of mental health programmes, (B) costs of additional benefits such as EFAP utilisation, (C) savings from reductions in short-term disability claims, (D) cost reduction in long-term disability claims, and (E) presenteeism-related savings. RoI can be calculated utilising the formula: RoI = (C+D+E)/(A+B).¹⁷

To conclude, we believe that there are compelling reasons for governments and employers to invest in the mental health of their workforce on the African continent. From the available evidence, these investments are likely to strengthen the capacity of African economies to recover from COVID-19 and move forward on a more sustainable and resilient development path – in short they have the potential to super-charge the African economic recovery. This article also illustrates how Prudential Africa is putting in place progressive measures to protect and promote the mental health of its employees. We strongly encourage other employers and governments to take up the challenge, to document programmes and their outcomes, and to share best practice on the continent.

Prudential Africa, which operates in eight African countries, has demonstrated that it is possible for employers to address mental wellness by committing to the following actions:

• Each business will host a ‘Mental Wellness Day’ this year to check-in with every employee on the cause and effect of stress factors in the workplace and what we can do to support one another better. 
• Confidential counselling will be made available to everyone in Prudential Africa.
• All managers will receive professional training to help them create the best environment to work in, to identify stress and other mental wellness issues and equip them with the resources needed to provide support.
• Every employee will benefit from an enhanced performance management and objective setting process for 2021, to ensure all colleagues know what is expected of them and feel supported to succeed at Prudential Africa.
• Prudential Africa has communicated to its employees that mental and physical wellness are equally important and the same is true when they are not well enough to work. Managers are as supportive if employees need time off to recover for mental health issues as for physical illness.
• Every employee is entitled to an additional day of leave for important life events such as: taking his/her children to their first day of school, getting married, or a significant birthday. Local HR teams work with all employees to figure out what’s right for their business.
• Each business will increase teambuilding and community engagement activities to strengthen the bonds between staff and enable mutual support. 

“We recognised that Prudential Africa is not alone in dealing with mental wellness in the workplace, yet it is an unmet need. Our employees identified it as an important concern for them, indicating that a mindful and supportive working environment can do much to address their work-life balance, anxiety and stress. COVID-19 and this year’s “new normal” of working from home, virtual meetings and less frequent checking in with one another have affected our staff. Hence we see this as a timeous opportunity to use our brand, digital platforms and existing relationships across eight African markets to open dialogue with our employees and other stakeholders. This will lead to improved productivity which is a vital contributor to Africa’s economic recovery from the pandemic,”

says Dr Matt Lilley, CEO of Africa Prudential.

About Prudential Africa

Prudential has insurance operations in eight countries in Africa: Cameroon, Cote d’Ivoire, Ghana, Kenya, Togo, Uganda, Zambia and Nigeria.  With approximately 1,000,000 customers, Prudential Africa works with over 10,000 agents and six exclusive bank partnerships, with access to over 600 branches, to bring value-added insurance solutions to its customers.

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