At Shamiri, we are all about scale. We want to serve 1 million youth per year by 2027. And that means exponential growth. Here's how we are doing it.
Go big or go home.
At Shamiri, we are all about scale. We believe that we have a great idea—tiered lay-psychotherapy—that can have a real impact for young people across Africa and beyond. But we want to achieve impact at scale. And that means exponential growth.
But growth isn’t comfortable. It pushes us to build from scratch, to change and adapt, and to be quick to pivot when things aren’t working. To do this, we realized that we needed to build an organization with two strong arms: 1) a strong implementation arm that could execute service delivery at scale, and 2) a top-notch research and evidence arm that not only strengthens our evidence base but allows us to take advantage of analytics to spur growth.
Even though the work on what would become Shamiri started at Harvard University in 2019, it would be in 2021 when we would finally start implementing our model with 1,500 youths in Kenya. To catalyze exponential growth, we set for ourselves the lofty target of expanding our reach to 1 million youth by 2027.
So how did we get to 100k?
1. Implementing through Shamiri Hubs and Shamiri Partners.
An early realization for us was that for our solution to reach its full potential, we had to consider ways of implementing our program that did not directly involve us. Going to scale means that a solution escapes the orbit of our organization, and we realized that we had to think of helping others replicate our model.
To do this, we first started by setting up Shamiri Hubs. Shamiri Hubs are semi-autonomous hubs that are run by a full-time Hub Coordinator who is not a Shamiri staff member. Think of hubs as mini franchises. We train and support Hub Coordinators to set up Hubs which can host 10 Shamiri Supervisors and 100 Shamiri Fellows, thus serving up to 20,000 youths per year.
Over the past few years, we’ve set up hubs across Kenya, including in Dagoretti and Donholm in Nairobi County, Gatundu, Kiambu and Githunguri in Kiambu County, Kajiado in Narok County, as well as in Addis Ababa in nearby Ethiopia.
Additionally, we want other organizations to replicate our model. Since 2022, we’ve worked with community-based NGOs to implement the Shamiri model in areas where they have a footprint as Shamiri Partners. Borrowing from Mulago speak, we call these organizations “Doers.” Over the past two years, we’ve worked to identify organizations that aligned with our goals and mission, but that also have the capacity to implement. We now work with eight such organizations, all of whom have varying expertise and backgrounds. Some, like Activate Action in Homa Bay and Youth Café in Murang’a, are youth-led community-based organizations that have historically worked on supporting vulnerable youths, primarily those living with HIV and disabilities, in rural counties across Kenya. Others, like the Women Volunteers for Peace (WOVOP) in Kisumu and Tunaweza Empowerment Organization (TEO) in Migori, have historically worked on women empowerment programs, including supporting at-risk girls and young women through health promotion and anti-gender-based violence programming.
Though diverse, these organizations have shown that they can serve up to 10,000 youths a year and open up an interesting avenue for us to scale through partners.
2. Strengthening our model for scalability
We know that to achieve scale, a crucial first step is turning our model into something replicable. Going from replicable to scalable requires a model that meets the “4 enoughs” criteria. Our model must be:
- Good enough—consequential impact to matter in the lives of the people we work with;
- Big enough—sufficient scope to matter given the scale of the problem;
- Simple enough—easy enough that Shamiri Hubs and Shamiri Partners can implement our model well enough to achieve similar impact; and
- Cheap enough—affordable for our ultimate payer tobe able to pay for it.
Good Enough
We want to ensure that our model results in consequential impact that matters in the lives of the youth who we work with. To do this, we’ve over the years conducted rigorous evaluations to identify the effect size of our model and to ensure that we can demonstrate a case for lasting change.
In 2018, we completed a pilot RCT with 51 youths in Kibera where youths received either the Shamiri intervention or an active study-skills control intervention of equal dosage and duration. We found, in this pilot, that the Shamiri intervention led to significant reductions in depression (d = .32; p = .04) and anxiety (d = .54; p=.04) as well as improvements in academic performance (d = .32; p = .03) and perceived social support (d = .71; p = .03) in the Shamiri groups compared to the control group from baseline to the four-week endpoint. We published these findings in Behavior Therapy.
To overcome the limitations of this pilot RCT, we completed a large, substantially powered, and pre-registered replication study with 413 youths across diverse schools in Nairobi and Kiambu County in 2019 and 2020 (pre-Covid lockdowns). We found larger reductions in depression (d = .35; p = .01) and anxiety (d = .37; p = .04) symptoms in the Shamiri groups compared to the study-skills group from baseline to the four-week endpoint. Importantly, we also found that these significant reductions were maintained at two-week follow-up and extended to seven-month follow-up. Additionally, these effect sizes were generally similar to those reported in meta-analyses of traditional youth mental health interventions in the West. These findings were published in JAMA Psychiatry.
In 2022, we conducted trials aimed at investigating the pathways of scaling the Shamiri model to reach as many youths as possible. We wondered if Shamiri Partners and Shamiri Hubs could implement with similar fidelity and efficacy. To do this, we completed two single-arm large-scale naturalistic dissemination trials with N=3,226 and N=757 youths across diverse secondary schools in both urban, peri-urban, and rural settings in Kenya. In both trials, youths completed the Shamiri model either through Shamiri Hubs or through Shamiri Partners. Findings from both trials indicated that there were no significant differences in the effects between the two implementation models on mental health and wellbeing outcomes as well as in fidelity scores. These results demonstrated that the Shamiri model can be effective when directly implemented by organizations other than the Shamiri Institute, and in the varied urban, peri-urban, and rural contexts that characterize Kenya’s youth population distribution. Findings from these trials have been submitted to a peer-reviewed journal and will be published in the near future.
Big Enough
Big enough means understanding the full scope of our model to address the scale of the problem. Whereas we want all youth to have access to Shamiri programming, we are cognizant that there are constraints such as geography, availability of resources, and socio-economic considerations that may limit this. We’ve worked to get a general sense of the scope of where it is needed and where it could work. Additionally, we’ve worked to get a deeper sense of where our model works based on multiple replications across different regions, settings, countries, and other socio-demographic variables. Currently, we anticipate that up to 4 million youths in Kenya can benefit from our programming. We are realizing that our model works best for female youths and younger youths. We are working with IDInsight to complete analyses on whether school type, Shamiri Fellows, and Shamiri Supervisors characteristics affect impact.
Simple Enough
We want to generate evidence that other Doers could implement our model with similar fidelity and efficacy. We started in 2022 by working with organizations like the Africa Mental Health Research and Training Foundation (AMHRT) and Psychiatric Disability Organization, which had prior experience and programming in mental health. From this, we realized it is crucial to offer customer support and guidance to implementing partners throughout the process. This allowed us to be able to expand our work to other organizations which didn’t necessarily have a background or experience in running mental health programming.
Cheap Enough
Over the past two years, we’ve worked hard to develop a full sense of our costs, including our cost-effectiveness and our cost to deliver. In 2021, our cost per student was $40/year. The biggest drivers were our cost-of-service delivery, particularly costs around compensating our providers and running group sessions. We were able to reduce this cost per student to $15 in 2022 and $11 in 2023. This year, we’ve reduced it to $7/student, as can be seen in the chart below. Our hope is to get this to $5/year in the coming two years.
With regards to cost-effectiveness, we’ve used data from our previous RCTs and estimated cost-effectiveness using Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guidelines for economic evaluations. What we found was that per dollar spent, there was an average 0.31 to 0.94-point reduction in anxiety and 0.27 to 0.84 depending on the criteria used to measure clinically significant outcomes. Our cost per clinically meaningful improvement varied due to various definitions and assumptions but was as low as $61.88 for a clinically meaningful improvement in anxiety and $75. These findings were published in BMC Health Services Research.
Nonetheless, we are in the process of conducting more robust cost-effectiveness analyses, including a GiveWell style cost-effectiveness analysis using their funding benchmark of 10x the effectiveness of cash transfers. Internationally, we estimate that our weighted cost-effectiveness relative to a cash transfer could be 27.37 for depression and 22.97 for anxiety. We are currently collaborating with a third party, the Happier Lives Institute, towards updating cost-effectiveness estimates using actual cost per student calculations from 2023 ($11.12 per student) and 2024 ($7.48 per student).
What Next?
We are buoyed by having reached 100k youth per year this year, and are committed to growing to serve 1 million by 2027. To do so, we are excited about:
- Working with the government: We want to partner with the government to scale our impact. We are excited that this partnership will not only pave the way for a national adoption of our mental health intervention across Kenyan schools, resulting in improvements in youth mental health and wellbeing, but that this partnership will also accelerate and create jobs for young people across Kenya as Shamiri Fellows and Supervisors.
- Unlocking tech: Finally, we believe that tech can extend our reach, lower transaction costs, and drive new efficiencies. That is why we are building a tech studio that will allow us to take advantage of best-in-class tech as well as build our own bespoke tech to support scaling. We are currently working on tech that will allow us to scale effectively, support real-time analytics and learnings, and allow us to leverage the power of AI to improve our care.
- Further strengthening our evidence base: We are currently testing new interventions, including art-literacy interventions like Pre-Texts, mindfulness, and life skills interventions. To better strengthen our case for impact, we are also conducting randomized control trials with “treatment-as-usual” control groups rather than active control groups and finding ways to account for “spillover” effects which happen when youths in our trials share program information with their friends in the control group. Additionally, we are conducting long-term follow-up studies to test if mental health, academic, social, and character-strength outcomes, along with related health outcomes (e.g., sleep quality, heart-rate variability, activity levels measured via wearables, HIV risk behaviors, alcohol, and substance use) differ between the intervention and control groups at a 3–4-year follow-up.
Shamiri means “thrive.” We want to build a future where young people can thrive by amplifying our impact at scale. We are on the pathway towards exponential growth, but we still have a long way to go. As we celebrate these milestones, we are excited about what the future holds for all of us.
