The Role of Microfinance in Supporting People with Mental Health Problems in their Recovery: A Case Study from Uganda
Special Articles / James Mugisha, Joshua Ssebunnya, Dorothy Kizza, Fred Kigozi / Community Work : Theories, Experiences & Challenges
Uganda is experiencing rapid growth and development.There are reported high changes in the gross national product (GDP percapita) and high rates of urbanisation across the country. One of the clear effects of modernisation and urbanisation are the reported weakening family systems.Families are becomingmore nucleated, yet,in the past,people with mental health problems could largely depend on the extended family systems for social supportin their recovery from mental health problems. This implies that people with mental health problems, especially in urban areas, grapple with challenges related to securing social support. The microfinance strategy, however, has potential in bridging this gap. It could provide alternative support services that were previously being provided by the extended family. In this chapter, the contribution of microfinance is organised under the following themes: supporting access to treatment, reduction in self-treatment, providing opportunities for leadership training, fighting social exclusion, opening doors for advocacy, and promotion of self-esteem and inclusiveness.The chapter ends with a focus on how mental health service delivery can be improved in the future.
Key words:Microfinance, social support mental health recovery
Social workers in both the developed and developing world are supposed to deliver interventions that help improve the resilience of individuals and families (Pulla, Chenoweth, Francis,&Bakaj, 2012). The intervention strategies adopted, however, should be contextualised to improve their level of effectiveness because of the diversities in our intervention communities.Africa today is still engulfed in a poverty context. However, within this poverty context there are also changes in social organisation at community level.Though regarded as largely communal in the past (Gyekye,1996; Ikuenobe; 2006), there are noticeable changes in culturalconstructs insocieties in Africa in general and Uganda in particular, wherebyfamilies are now becomingmore nucleated (Ankrah, 1993; Mugisha, 2012b).Asocial development approach that is culturally sensitive, however, requires the recognition of changes in family systems. Families are core to social development. This implies that social development approachesshould be dynamic to respond to the changing context. There is a need to recognise the changes in family systems if interventions in mental health are to improve their level of effectiveness. Within this changing context, the role of the family should be redefined owing to the fact that the family should not be regarded largely as the only source of social capital as it used to be inthe past (Banathy, 1996). This chapterfocuses on the changing family systems in Uganda and their implications in the design and delivery of mental health services in the country. First, it takes a critical look at the changing ways of social organisation (from communalism to individualism), by focusing on what ‘traditional’ Africa was in terms of social organisation in the past and what it is currently. Second, the author takes a look at how mental health services are organised in Uganda today. Third, the author illuminates how the microfinance strategy can bridge the gap in care and treatment for thosewith mental health problems within the changing family systems in the current mental health service delivery system. Insights are given on how the microfinance strategy can augment the weakening family systems in the delivery of mental health services.
Family Systems in Africa and the Changing Social Order
Africa is now experiencing rapid disintegration and destruction of traditional institutions due to modernisation (Weisner, Bradley & Kilbride, 1997). Several studies (e.g.;Ankrah, 1993; Chirwa,2002; Mathambo& Gibbs, 2009;Ntozi&Zirimenya, 1992) attest to the changing forms of social organisation in communities – from extended family systems to nuclear families. Effective service delivery systems in the community development field, however,require a clear understanding of the changing socio-cultural context in Africa (Banathy, 1996). The notion of community development requires family and community participation in service delivery. Community development here is reserved to mean measures in which people are enabled to recognise their own ability to deal with a problem(s) and use available resources for the betterment of their life (Republic of Tanzania, 1996). Within the community development agenda,families are the core of social work intervention and strength-based practice aims at strengthening the role of families (Pulla et al., 2012) in mental health care.Effective mental health service delivery, therefore, to some extent hinges on the role played by the family in supporting management and recovery from mental health problems. The thinking within community mental health should be that individuals and families have strength that can help them embark on the road to recovery (Francis, 2012).However, in this recovery process there is a critical role that is played by the family and community –social support. Social support from the extended family and the community is likely to dwindle when families get more nucleated.
As noted, urbanisation comes with acculturation (Kasenene, 1998),and, acculturation changes the existing cultural constructs in society. People have little dependence on members of their social organisations (Hofstede, 2001). Community members tend to live in nuclear or one-parent families with loose ties with extended family members (Hofstede, 2001). Around 24.6% of the total populations currently live in urban settings in sub-Saharan Africa (Keiser, Utzinger, Caldas de Castro, Smith, Tanner et al., 2004).For example, in 2006 the level of urbanisation in Uganda wasat 4.6 %.With urbanisation gaining ground in the country, individualism becomes a common form of social organisation.
Effective mental health service delivery should therefore be tailored to these changes in family systems in order to harness social capital. Social capital has been cited as a key factor in the promotion of mental health (De Silva, McKenzie, Harpham&Huttly, 2005). The focus in this chapter is on reciprocity and norms of cooperation whereby family/community members havea sense of obligation to help others, andreturn some assistance to those in need (De Silva et al., 2005).
It is common in Africa tofind family/community members sharing the burden of illness when a community member is afflicted. They also expect the same gesture in case they are tormented by disease.As noted above, social capital can be rotated around the norm of cooperation and sense of responsibility toeach other.This cooperation and sense of responsibility couldbe embraced into other forms of social organisation such as microfinance – as a form of social capital whereby organisations usecivic nets and engagement for community development (De Silva et al., 2005).Social capital is important in mental health since it lowers the risks associated with mental health problems and promotes recovery (Francis, 2012).
Berry in 1980 suggested that with increasing modernisation people in urban areas can live within two cultures (communalism and individualism). However, there is also a tendency to lean more on the dominant culture in the urban areas – individualism (Berry, 1980; Oswald 1999; Bhatia & Ram, 2001; Mugisha, 2012b).The changing forms of social capitaltherefore havemany implicationsforthe designers of community mental health programs in Uganda. Community approaches should be able to appreciate these changes in the family system and their implications for those with mental health problems.
Thefocus of the intervention models in mental health in urban areasshould be expanded from focusing only on traditional forms of social capital supporting management and recovery from mental health problems to other sources of social capital in the changing context.Microfinance can be one of the alternative forms of social capital in an urbanised context as a buffer to the weakening family systems.If microfinance is well expanded and effectively delivered, it can be one of the social development strategies at community level(Thabethe, Magezi&Nyuswa, 2012). Since the target of microfinance agencies is the poor, using microfinance is one of the ways of improving the wellbeing of those grappling with poverty in the community (Thabethe et al., 2012).
Organisation of Mental Health Services in Uganda
It is difficult to estimate the burden of mental health problems in Africa in general and Uganda in particular because of unreliable statistics and stigma (Kinyanda, 2006). However, there is a high magnitude of some mental health conditions. For example, in a study undertaken in northern Uganda (where there was civil strife), 49% of respondents were diagnosed with Post-Traumatic Stress Disorder (PTSD), 70% presented with symptoms of depression, and 59% with those of anxiety among the formerly abducted population (Pfeiffer &Elber, 2011). In a related study, over half (54%) of the respondents met symptom criteria for PTSD, and over two-thirds (67%) of respondents met symptom criteria for depression. Over half (58%) of respondents had experienced 8 or more of the 16 trauma events covered in the questionnaire (Roberts,Ocaka, Browne, Oyok, &Sondorp,2008).
The health service delivery system in Uganda, just like in other low income countries, still suffers from the colonial legacy. The delivery mechanisms are largely informed by the biological model, under whichmental health problemsare largely seenas a biological issue (Helman, 2007).As a result, mental health practice in Africa in general and Uganda in particular is dominated by practitioners trained in the biological model. The recruitment of health workers is also biased towards disciplines affiliated to the biological model.For exampleUganda has 22 Psychiatrists, 120 Psychiatric Clinical Officers (cadre with Diploma in Mental Health), 1400 Psychiatric Nurses registered with the nursing council, but some have been deployed to general services, 12 Clinical Psychologists and 6 Psychiatric Social Workers (BasicNeeds, 2008a). Because of the limited number of social workers in mental health units, the community/family role in the management of mental health conditions is not effectively undertaken.
In addition to the above, due to the inadequate mental health services in Uganda1 (Kigozi, Ssebunnya, Kizza, Cooper, &Ndyanabangi, 2010)civil society organisations have come up to support the delivery of mental health services. Their focus, however, has been largely on promotion of community mental health. Two of these organisations are:‘BasicNeeds Uganda’ and ‘Mental Health Uganda’. Unlike the health facilities that largely take the institutionalisation care approach, Non-Governmental Organisations take the community mental health care approach. Individual and familiesaregiven a central role in supporting management and recovery from mental health problems.They also aim at establishing a therapeutic relationship between the individual, family and other networks as a way of promoting recovery (Francis, 2012), and open up effective communication channels that aim at sharing information and experiences between the client and the therapist.The essence is to help people undertake self-determination, gaining greater power and control over their life situation (Pulla et al., 2012; Francis, 2012).
The focus of Basis Needs Uganda2 and Mental Health Uganda3 is to promote the role of the individual and family in mental health management and recovery from a holistic perspective. Both agencies take the perspective that a person has biological, social, economic and psychological needs. Moreover, all these needs have to be addressed, if that person is to function effectively. Microfinance could be one of the holistic strategies in social development; its benefits to the communities can be social, economic and psychological (Thabethe et al., 2011). The strategy can also lead to development of sustainable livelihoods among the poor (Bateman, 2011).
Microfinance entails the provision of financial services to the poor such as loans, savings, insurance, and training. The strategy involves small amounts – hence ‘micro’ – of savings, credit, insurance and money transfer services (Uganda Bureau of Statistics, 2010).Microfinance has been one of the key strategies in social development in the developing nations for over 30 years (Bateman, 2011).The thinking was that with so many of the poor in the developing world, the microfinance strategy should be able to help them establish or expand simple income-generating projects.There were hopes (until today) that this strategy will enable the poor communities the world over to escape poverty on an unprecedented scale (Bateman, 2011). This strategy, however, has been recently applied in mental health in Uganda. Microfinancehas played vital roles in the following areas:
Supporting Access toTreatment
The social development approach in social work entails empowerment of individuals, families and the general community.Families and communities have been instrumental in supporting people in Uganda to access treatment. However, in the recent past, the role of the family and community has started to diminish, largely due to development of individualistic cultural constructs among urban families.
Recovery from mental health problems requires addressingbottlenecks to access to drugs and adherence to treatment guidelines. Here two issues should be addressed, especially in a context of weakening family support: the cost of transport to treatment centres and the cost of drugs.
Most health centres in Uganda are far from service users. It therefore becomes difficult for the poor to meet the cost of transport. In the past some of the transport costs could be borne by the family/community.Experience from the private sector agencies seems to indicate, however, that once people with mental health problems are involved in income-generating activities, they are likely to afford the cost of transport to health facilities for their appointments with the health staff. For example, the BasicNeeds project in Sembule district (one of the districtsin central Uganda) helped people with mental health problems to embark on gardening, cow and cattle rearing as a way of boosting their income. Such savings were drawn upon to meet transport costs to the health facilities.
Many of our people cannot afford transport costs and this means that they cannot come for review. One way to help is to enable them embark on income-generating activities in both rural and urban areas. (Psychiatrist, Butabika National Referral and Teaching Hospital, personal communication, April, 2013)
From the remarks above, we see a diminishing role of the family in supporting people to access medical care. However, this gap is bridged by a social development approach that empowers families to embark on income generation as one way of generating income to meet their transport needs.
The other view is that, as people organise into groups, it is easy for service providers to target them and the cost of transport goes down when one targets a group as compared to targeting individuals.‘It is easy to meet them as a group than making individual visits. So the group approach becomes more ideal for community work’ (personalcommunication,nurse in community mental health, ButabikaNational Referral and Teaching Hospital, April, 2013). People with mental health problemsorganise around microcredit groups and become easy to reach with mental health services. A mutual aid system develops when they are working together with shared goals and objectives.
In addition to transport-related barriers to seeking treatment are the frequent drug shortages in the government health system in Uganda. The cost of drugs is always beyond the reach of most Ugandans. Because most of the psychiatric drugs are normally expensive, patients can no longer entirely rely on the family systems for help. From a strength-based perspective, the most feasible alternative is to make the poor attain independence and be empowered to become purchasers of medical goods.BasicNeeds Uganda experience indicates that the poor withmental health problems can embark on income-generating activities as a way of meeting the associated costs of treatment and work towards full recovery (BasicNeeds, 2008a).The project through a holistic model combines improving access to treatment and poverty alleviation. The same approach is currently undertaken by Mental Health Ugandain its study project area. The poor have been involved in income-generating activities of their choice; this directly impacts on their ability to contribute to the cost of treatment including purchase of drugs.Evidence from a related project suggests an improvement in seeking family planning services as a result of improvement in income (Institute for Health Sector Development, 2004).
In the same vein,microfinance programs can offer opportunities for both income generation and health insurance. BasicNeeds Ugandais currently piloting the drug bank strategy at KamwokyaChristianCaring Community in Kampala (the capital city of Uganda and Sembabuledistrict).People with mental health problems are being helped to save money and later on draw upon it to purchase drugs in case of need (each person contributes USD 1.5 per month).There have been challenges with this scheme but it is currently under revision. This is indicated the remarks below:
Regular monthly cash contribution to the drug bank by people with mental disorders does not hinder patients’ access to drugs. Health workers and respondents confirmed that they can always negotiate for credit or free treatment during times when a client has a genuine problem with their finances [and therefore cannot meet the monthlycontribution to the drug bank]. (BasicNeeds, 2008a,p.19)
The strategy of using drug banks also promotes gender equity and is usefulin reducing the much reported gender-related barriers in accessing medical care in Uganda. Women in Africa largely depend on ‘out of pocket donations’ (Institute for Health Sector Development, 2004) from their spouses for meeting their medical care needs. Engaging women with mental health problems in health insurance schemes such as this one may be one of the ways of promoting their treatment-seeking behaviour for mental health care.
While this model has been more successful in urban areas, it was still quite a challenge to effectively implement it in rural areas due to rural poverty:
For instance, patients in rural communities will easily contribute during the harvest season but drop off treatment during the drought because they have nothing to sell. (BasicNeeds, 2008a)
Similarly, this scheme in urban communities also has challenges because people are quite mobile. It becomes difficult to keep them in the scheme because they frequently change their place of residence(BasicNeeds, 2008a). Despite these few challenges, this strategy needs to be supported and be up-scaled to other areas in the country, given the fact that there are largely no government-led health insurance schemes in Uganda. Health insurance as a community development strategy can help the poor improve their health indices. It makes the cost of medical care affordable to the communities.
Self-treatment (where no qualified provider is consulted) with pharmaceutical drugs is one of the main forms of health care treatment in Africa (Institute for Health Sector Development (2004). One of the ways of reducing self-treatment and the associated risks is making sure that the poor can relatively afford the cost of drugs. Community health insurance through micro-credit could be one of the ways to tackle self-treatment and the associated risks, as explained above. As the poor pull resources together (the notion of mutual aid), they are likely to be able to afford the cost of drugs. They could work towards improved access to psychiatric drugs as a group objective. The group can be formed using an economic model (capital investment) to meet social goals.
There are other skills that may come along with participation in income-generating activities. Some of the people with mental health problems through participation in group activities have become group leaders and have gained leadership skills. Yet, before joining such groups they havesometimes been regarded as deficient in this area by both their families and the general community.
As people work within groups, their leadership qualities are identified and supported by the project. Some of them become facilitators in the groups while others become group advocates and other things of that nature. (Personal communication,BasicNeeds Ugandaofficial, May 2013)
Elsewhere, in Sri Lanka, similar findings are reported on ahorticulture project that supports people with mental health problems as indicated below:
… most people complained that they are sick and they cannot work. However, gradually they learn that they can work and take responsibilities.
The project also contributed to develop different life skills such as working in a group, thinking about different solutions, cooking, money management, and sharing skills with others, with people with mental health problems. (BasicNeeds, 2008b, p.11)
Fighting Social Exclusion
Social work aims at promoting people’s ability to maximise their own capabilities and life options, including participation in productive activities.People with mental health problems suffer two forms of stigma:self-stigma whereby they largely make no attempt to get involved in income-generating activities, and community stigma whereby the community ‘locks’ them out of employment/production. However, when they engage successfully in income generation activities the attitudes of those with mental health problems towards themselves and thoseof the community towards a person with mental health problems change positively. Within this vein BasicNeeds (2009) noted that removing stigma is essential in breaking the cycle of illness and poverty for people with mental disorders. The project helps families to join Self-Help Groups (SHGs) and engage in collective economic activity and many are able to access micro-financing loans from government economic development programs.
…we combine treatment interventions with directed attention to reducing poverty and social stigma…BasicNeeds’position is that social acceptance starts when a person starts working, earning, or contributing to household chores. The experience feels complete when the family and community fully include the person as a valued member. BasicNeeds relies heavily on community-based workers and SHGs to foster positive social interactions between users [psychiatric users], their families, and their communities. We have witnessed this positive interplay in many communities where the success of SHGs’ business enterprises has led to SHG members training other community members…. (BasicNeeds, 2009,p.5)
Finding Alternative Sources of Social Support
There is no doubt that people with mental health problemsneed social support during recovery. For example, people with mental health problems need peer-support and counselling.This (peer support and counselling) may not be easy to find withinfamilies and communities, more especially in urban areas. The alternativeisformal community groups (such as microfinance groups) where people with mental health problems can get involved in peer support and counselling activities. Apersonal communication with an anthropologist at Makerere Universityis instructive here:‘The meaning of social support is only changing form, we are moving away[in Uganda] from families to formal groups and associations.’ The BasicNeeds and Mental Health Uganda model ofdelivery of mental health services has ingrained peer support and counselling within the income-generating activities of the group. From a community development perspective, formal systems can be used to augment family systems as alternatives are being sought to rejuvenate family systems.
Opening Door for Advocacy
Uganda is currently using the group approach to delivery social services. Many people in Uganda have been organised into groups for easy reach by government programs. The same approach is being pursued by the civil society organisations.The microfinance sector is growingat a rate of 75% in terms of geographical coverage (Uganda Bureau of Statistics[UBOS], 2010). However, many people with mental health problems due to stigma are currently excluded from such groups. ‘As community members organise for microfinance, those with mental health problems are looked at as dysfunctional and risky’ (Personal communication, Psychiatrist Butabika, May, 2013).However, it is people’s right to participate in production even when they have mental health problems. In order to promote activism, best practices in this strategy should be documented to build evidence that can influence policy and the planning of the microfinance sector in Uganda in a manner that does not discriminate against people with mental health problems. Social organisation models and skills need to be employed to mobilise people with mental health problems and the general community to advocate for their rights (i.e. the rights of people with mental health problems). This will enable them to embark on the road to investment. Some advocacy has been undertaken by BasicNeeds as indicated below:
As users recover, they develop new aspirations and begin to advocate for their human rights. The changes reconnect them with their families and communities who benefit as well. The process is self-sustaining as the increased capacities, skills and confidence motivate adherence to treatment and desire to work. Self-development of individuals is backed by the strength and opportunities they gain from membership in SHGs. The SHGs, and the burgeoning user movement that they fuel, provide a collective voice with regard to entitlements and human rights. (BasicNeeds, 2009,p.12)In Kenya, Uganda, Tanzania, Ghana, Lao PDR and Sri Lanka, district governments are now explicitly including mental health in annual plans and budgets. Overall there is a growing recognition that it is the government’s responsibility, not Basic Needs’, to sustain mental health services. Basic Needs has trained primary health care personnel who are now eager to treat people with mental health problems or epilepsy. All programme health professionals work collaboratively with community basedworkers, who are essential in mobilizing affected individuals and their families to participate.Community-based workers also support participants in accessing services, provide follow-up services, and facilitate SHGs.(BasicNeeds, 2009, p.8)
While such efforts by BasicNeeds Uganda are commendable, they are still in their infancyand need to be supported and up-scaled in the whole country in order to build a national platform for advocacy for people with mental health problems.
Self-Esteem and Inclusiveness
Increased participation in productive activities will consequently improve the self-esteemof people withmental health problems. It will also be one sure way of fighting both felt and community stigma. People with mental health problems should be empowered to overcome stigma so that they are able to effectively participate in group activities. On the other hand, the community should be sensitised to appreciate the implications of community stigma forthose that have mental health problems. A deliberate public/mental health policy in this direction is desirable.
The experience of BasicNeeds elsewhereis instructive here:
Working in a group contributed to decrease fear about society and to improve interactive social skills …when they attend Horticulture therapy activities they feel happy and confident about themselves through seeing results of their activities such as harvest of different cultivations. Acceptance and appreciation of volunteers and staff of these results also improved their self-esteem. (BasicNeeds, 2008b, p.11)
Looking at the Future
There is no doubt today that due to urbanisation and globalisation there are changes in social organisation in Uganda and these changes are likely to continue. Amidst these changes the Institute for Health Sector Development (2004) looks at microcredit as one of the sustainable ways of targeting families affected by poverty. It would be easier to organise funding for institutions that are offering microcredit from donor agencies than for funding agencies to target the families directly. For long term financing of activities meant for people with mental health problems, this strategy is highly desirable and defendable. However, this strategy has to beanchored in the core principles of community development. Individual and family empowerment should be the core target of the microfinance strategy.
There are continued arguments from various scholars against microcredit (Stewart,Stewart, van Rooyen, Dickson, Majoro, & De Wet, 2010).Quite a number of scientists have argued that the strategy isbedevilled by lack of standardisation and no clear strategy to assess its impact. In addition to this criticism, quite a number of studies have indicated limited impact of microfinance organisations on the targeted communities (Stewart et al., 2010; Rooyen et al., 2012). While these arguments may hold water given the scale and nature of some of the microfinance organisations (which are sometimes not based on robust foundations and ethical practice), it will still be unethical and a violation of the rights of people with mental health problems if they are not given the opportunity tobe part of this development process, regardless of its shortcomings. One of the government policies in Uganda isto support microfinance institutionsacross the countryto grow and contribute to poverty reduction (UBOS, 2010). Keeping people with mental health problems in a slumber is not only inhuman, but also a violation of their rights to contribute to their own development and that of their country (BasicNeeds, 2008a). As noted above, such a policy also re-enforces stigma and social exclusion. From a human rights perspective, the arguments that people with mental health problems are ‘risky material’should not be entertained. Society still has a duty to ensure that they access effective treatment and care through sound policies and programs. Uganda has enacted quite a number of laws and policies that promote the engagement of people living with HIV and AIDS in production without stigma (e.g. the HIV and AIDS work policy). A similar approach could be undertaken specifically for people with mental health problems. As the country tries to improve the microfinance strategy, people with mental health problems should be given their due space and opportunity to grow and be part of this development strategy.
There are doubts as to whether microfinance organisations improve access to health in low income countries. One of the limitations in assessing the impact of microfinance could be the methodologies used in this assessment.It will also be important that a participatory process is undertaken to develop home-grown tools to assess the impact of microcredit on people with mental health problems.
It would be important that government supports and evaluates the business plans for microfinance organisations. Microfinance institutions need to come up with robust development strategies and sound operational methods. This might require a lot of resources, given the fact that there is a plethora of microfinance organisations countrywide. A phased approach to this endeavour is, however, more feasible, guided by the notion of best practices.
The other view is that holistic development requires developing people in all sectors of life. Developing capacities of those that have mental health problems to participate in economic production and be able to meet their health needs is a contribution to the holistic development model (also see BasicNeeds, 2008a).Microfinance needs to be seen as one of the special development packages meant to fight rural poverty in Uganda since its major focus is the poor(Thabethe et al., 2011). It also has a lot of gender development connotations because the primary target of microfinance is poor women (Thabetheet al., 2011). It could be seen as one of the bottom-up approaches to fighting rural poverty since it is community driven and holistic (Thabetheet al., 2011). Its limitations, however, need to be seriously addressed.
This chapter delves into the changing forms of social organisation in Uganda –from communalism to individualism. It also dwells on how microfinance can be used to bridge the gaps left by changing forms of social organisation.In this vein, caution is expressedthat planning and delivery of mental health services should move away from the out-dated colonial/dogmatic approach to delivery of mental health services to more dynamic people-centred approaches.The health systems have to become more innovative in the delivery of mental health services. Linking people with mental health problems to microfinance institutions can be one of the innovations.
The planning of mental health delivery systems should appreciate the changing meaning of relatedness in Uganda and how this changing meaning influences the availability of social capital from family/community systems.Therefore concepts, relatedness and social capital require both theoretical and technical modification; and this should influence the design of social service delivery systems in Uganda today and Africa in general(see Lin, 1999). Functionally, microfinance could provide opportunities for social capital. However, the shortcoming of the microfinance strategy in poverty alleviationneeds to be addressed. The strategies to be adopted to improve the effectiveness of the microfinance strategy forpeople with mental health problems are beyond the focus of this chapter.
Funding: This document is an output from the EMERALD Research Programme Consortium, funded by the European Community’s Seventh Framework Programme (FP7/2007-2013) under the Emerald grant agreement n° 305968. The authors alone are responsible for the views expressed in this publication and these views do not necessarily represent the decisions, policy or views of the World Health Organization or any of the funders.
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