Challenges to peer support in low- and middle-income countries during COVID-19

BACKGROUND: A recent editorial urged those working in global mental health to “change the conversation” on coronavirus disease (Covid-19) by putting more focus on the needs of people with severe mental health conditions. UPSIDES (Using Peer Support In Developing Empowering mental health Services) is a six-country consortium carrying out implementation research on peer support for people with severe mental health conditions in high- (Germany, Israel), lower middle- (India) and low-income (Tanzania, Uganda) settings. This commentary briefly outlines some of the key challenges faced by UPSIDES sites in low- and middle-income countries as a result of Covid-19, sharing early lessons that may also apply to other services seeking to address the needs of people with severe mental health conditions in similar contexts. CHALLENGES AND LESSONS LEARNED: The key take-away from experiences in India, Tanzania and Uganda is that inequalities in terms of access to mobile technologies, as well as to secure employment and benefits, put peer support workers in particularly vulnerable situations precisely when they and their peers are also at their most isolated. Establishing more resilient peer support services requires attention to the already precarious situation of people with severe mental health conditions in low-resource settings, even before a crisis like Covid-19 occurs. While it is essential to maintain contact with peer support workers and peers to whatever extent is possible remotely, alternatives to face-to-face delivery of psychosocial interventions are not always straightforward to implement and can make it more difficult to observe individuals’ reactions, talk about emotional issues and offer appropriate support. CONCLUSIONS: In environments where mental health care was already heavily medicalized and mostly limited to medications issued by psychiatric institutions, Covid-19 threatens burgeoning efforts to pursue a more holistic and person-centered model of care for people with severe mental health conditions. As countries emerge from lockdown, those working in global mental health will need to redouble their efforts not only to make up for lost time and help individuals cope with the added stressors of Covid-19 in their communities, but also to regain lost ground in mental health care reform and in broader conversations about mental health in low-resource settings.