Envisioning change: Learning from mental health advocacy and activism in LMICs

By Alma Ionescu, University College London (UCL)


Activism and advocacy are commonly misrepresented in popular discourse, often simply equated with street protests and depicted as loud, disturbing and violent. However, there’s much more to it than that. Broadly speaking, it is any effort towards changing the status quo in order to create positive change (for health, in this case). This means that the range of efforts it can encompass is extremely varied – from high-level actions, such as changing policy, to local level acts of solidarity that might go unseen to the outside eye. However, what all activist efforts have in common is a commitment to centre marginalised voices through an active act of renegotiating whose voices and experiences matter. Listening to these voices often exposes how power and politics operate across multiple levels and structures. This allows for a deep interrogation into the ways in which current systems and structures shape everyday lives and experiences; and sheds light on how better and health-enabling alternatives and environments can look like. As such, I believe  the quick dismissal of the value of activism has come with great detriment and has hindered our ability to consider the value it can bring to health policy and planning.

However, efforts of activism and advocacy are not without their challenges. When it comes to mental health specifically, multiple layers of complexity are added to complicate efforts aimed at trying to change the status quo. Mental health can be a nefarious topic, despite the fact that it touches and concerns every single life. What actually is mental health? What type of care should be provided? Who should be providing care? Where should care be given? Such questions and tensions underpin many conversations around visions for change. The challenges do not stop at that. Even in the presence of a clear vision and goal, the presence of stigma around mental health put a limit on who will be willing to listen and who will be willing to collaborate. Structural stigma, for example, is so deeply ingrained in the status quo that it requires active readiness from a range of stakeholders to create change, which is often lacking.

In light of the many challenges standing in the way of change, we wanted to better understand how activism and advocacy exist in practice. In our paper, published in Health Policy and Planning, we asked the question of what factors drive (or inhibit) mental health activism and advocacy efforts in low and middle-income countries (LMICs)?

The beauty of activism lies in its diversity and its ability to exist in many different ways. However, that also makes it harder to systematically understand it. Instead of trying to categorise efforts in (perhaps ill-fitting) boxes, we created a simple model that allows us to think about mental health activism and advocacy efforts all while allowing their individual features to be considered and included.

Our model, based on the analysis of the existing literature, suggests three dimensions to consider in order to better understand what drives mental health activism and advocacy: Legitimacy, Context, Timing.


The dimension of legitimacy asks about the various forms of legitimacy that are afforded to efforts for change. Are they perceived to be legitimate within the group? How do other outside actors perceive the legitimacy of the suggested means and claims? When and why do activists care about the legitimacy given by others, and how may they shape actions and behaviours to be legitimised by others?


The second dimension interrogates the importance of context and relationship to activism and advocacy. There is a growing understanding in the literature that our social, economic, political and historical views have a great impact on our mental health. In light of the intimate relationship between context and mental health, context also necessarily comes to play a role in determining solutions and the means used to pursue them. We differentiate between direct context (that directly pertains to health systems and provisions of care) and wider context (which form the broader socio-economic-politics contexts in which individuals live) as they may affect activism in different ways.


The last dimension – Timing – points our attention to critical junctures and how those may open (or close) windows of opportunity for advocacy and activism. This dimension points to the interconnected nature of the wider systems within which we operate, highlighting the interdependent nature of various actions aimed at improving current structures. In practice, this points our attention to wider momentum around mental health and how, and to what extent, other stakeholders might engage activists and advocates. It also highlights the agency of activists, and encourages us to look at the ways in which they might create that momentum themselves.


Ultimately, this paper tries to encourage researchers and practitioners in global (mental) health, and beyond, to re-envision what they understand by ‘change’ and points towards useful ways to start thinking about it. We hope this stimulates discussions about the various ways that health equity can be pursued and achieved.



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