Where to Launch Next: A Framework for Prioritizing Countries for Digital Depression Programs

Deciding where to launch a global health program is one of the most consequential decisions an NGO leader makes. Launch in the wrong context — insufficient digital infrastructure, hostile regulatory environment, existing well-resourced programs already serving the population — and you generate modest impact at high cost. Launch in the right context — large unmet need, viable delivery infrastructure, a regulatory environment that permits the model — and every dollar of organizational investment translates into substantially more impact.

For digital depression programs specifically, the decision involves a distinctive combination of factors that don’t apply to most other global health interventions. The technology-mediated delivery creates digital infrastructure requirements. The lay counselor model creates workforce requirements. The evidence-based content creates adaptation requirements. And the mental health context creates stigma and regulatory dimensions that don’t exist for bed net distribution or vaccination programs.

This post lays out the framework that Ambitious Impact developed for prioritizing countries for WHO Step-by-Step expansion, the ten countries that emerged from that analysis, and the practical considerations that should inform how organizations sequence geographic expansion in this space.

The Framework: What Matters for Country Prioritization

Country prioritization for digital depression programs requires assessment across five dimensions, each of which can be a constraint or an enabler depending on context.

1. Depression Burden

The most fundamental criterion is the size of the addressable problem. Countries with higher depression prevalence — whether due to conflict, poverty, displacement, or other structural factors — have more potential beneficiaries per unit of organizational investment. Depression burden is measured using Disability-Adjusted Life Years (DALYs) lost to depressive disorders, standardized by population.

High-burden contexts for depression include countries with significant conflict-affected populations (where depression rates are substantially elevated above non-conflict baselines), countries with high rates of poverty and economic precarity, and countries where structural factors — gender inequality, limited social support systems, rapid urbanization — contribute to elevated depression prevalence.

Burden alone doesn’t determine priority, but a context with low depression burden relative to other options should rarely be prioritized, regardless of how favorable other factors are. Impact per dollar is fundamentally constrained by addressable need.

2. Treatment Gap

Burden must be considered alongside existing provision. A country with high depression burden but well-developed, accessible mental health services represents a different opportunity — and a different level of additionality — than a country with comparable burden and near-zero existing provision.

The treatment gap — the proportion of people with depression who receive no treatment — provides a direct measure of unmet need. In most LMICs, the treatment gap is 75 percent or higher, but there is meaningful variation between countries. Countries where existing provision is genuinely scarce, and where a new program would be reaching populations with no current access to comparable care, represent higher-additionality opportunities than those where some provision exists, even if imperfect.

3. Digital Infrastructure

The WHO Step-by-Step model, as deployed by Kaya Guides, requires access to a smartphone and a WhatsApp account. This requirement is less restrictive than it might appear — WhatsApp penetration rates in many target countries are high, and smartphone ownership has expanded rapidly — but it is still a real constraint that varies significantly across and within countries.

Relevant metrics include: smartphone ownership rates (overall and by income quintile, gender, and urban/rural location), WhatsApp penetration and usage patterns, mobile data affordability and reliability, and electricity access for device charging. Programs that require continuous connectivity will be more constrained by infrastructure gaps than those that allow offline engagement or asynchronous delivery.

Digital infrastructure gaps are not static — they are closing rapidly in most LMICs — which means a context that is marginally below the threshold today may be viable within two to three years. Country prioritization should consider the trajectory of digital infrastructure development, not just the current state.

4. Regulatory Environment

Mental health is a regulated domain in virtually every country. The specific regulatory questions for a program like Step-by-Step include: What are the legal requirements for delivering psychological support? Can lay counselors legally conduct the support calls that are central to the guided self-help model? Are there requirements for clinical oversight or professional registration that would add cost or operational complexity? What are the data protection and privacy requirements for handling sensitive mental health information?

Regulatory environments for lay counselor delivery vary substantially. Some countries have explicit frameworks for community mental health worker roles that accommodate the Step-by-Step model. Others have no clear framework, creating legal ambiguity. A small number have restrictive requirements that would make lay counselor delivery of psychological support illegal or prohibitively complex.

Regulatory risk is not always a hard constraint — ambiguous environments can sometimes be navigated through engagement with regulatory authorities, and regulatory frameworks evolve. But organizations should enter new country contexts with a clear-eyed assessment of regulatory risk and a strategy for managing it, rather than discovering barriers after operational investment has been made.

5. Operational Feasibility

Even in contexts that score well on burden, treatment gap, digital infrastructure, and regulatory environment, operational realities can constrain program viability. Relevant factors include: the organization’s existing presence or partnerships in the country, the availability of local staff with the language skills and cultural competence to manage the program, the ability to recruit and train lay counselors from the target community, the stability of the operating environment (political, security, economic), and the availability of referral pathways for participants who need more intensive support than the program provides.

Operational feasibility considerations often argue for sequencing expansion in ways that allow organizational learning to compound. A second country that is culturally and operationally similar to the founding context is lower-risk than a second country that requires entirely new languages, counselor recruitment channels, and partnership relationships. The learning from context A reduces the cost and risk of entering context B when they share relevant features.

The Ten Priority Countries

Applying this framework, Ambitious Impact’s research identified ten countries as priority targets for WHO Step-by-Step expansion: Pakistan, China, Nigeria, Bangladesh, Indonesia, Egypt, Brazil, Tajikistan, Ethiopia, and Malaysia.

Each country has a distinctive profile that explains its ranking. A brief analysis of the key factors for each:

Pakistan scores highly on depression burden (elevated by conflict exposure, poverty, and high rates of gender-based adversity), treatment gap (mental health infrastructure is extremely limited, particularly outside major urban centers), and digital infrastructure (rapidly expanding smartphone penetration and high WhatsApp usage). The program has already been tested in a Pakistani RCT, reducing cultural adaptation requirements. Regulatory environment for lay counselors is manageable.

China presents a different profile: middle-income country with strong digital infrastructure, high WhatsApp-equivalent penetration (though regulatory complexity around foreign apps requires consideration), substantial depression burden driven by rapid urbanization and social isolation, and a significant treatment gap despite relatively better economic resources than other priority countries. A Chinese-language RCT of Step-by-Step has been completed, providing a head start on cultural adaptation.

Nigeria is the largest country in Sub-Saharan Africa by population, with a very large absolute depression burden, near-zero specialist mental health infrastructure, rapidly growing smartphone penetration, and a population that is predominantly young — a demographic that is both at elevated depression risk and particularly likely to engage with digital delivery.

Bangladesh combines high depression burden (driven by poverty, climate vulnerability, and demographic pressure), a large addressable population, growing smartphone penetration, and limited existing mental health provision. Geographic density — one of the world’s most densely populated countries — creates favorable economics for lay counselor recruitment and supervision.

Indonesia has the fourth-largest population in the world, high WhatsApp penetration, significant depression burden, and a growing digital health ecosystem that creates potential for partnership and integration with existing programs. Linguistic diversity (hundreds of regional languages) creates adaptation complexity that should be factored into sequencing decisions.

Egypt benefits from a completed Arabic-language RCT of Step-by-Step, making it one of the best-evidenced contexts for program deployment. Depression burden is significant, WhatsApp penetration is very high, and the urban population’s familiarity with digital tools supports engagement. An Egyptian-language program is effectively ready for deployment, reducing the adaptation investment required.

Brazil represents the largest opportunity in Latin America — a country with substantial depression burden, Portuguese-language adaptation requirements, high smartphone penetration, and significant geographic variation in mental health provision (urban areas have some access; rural and peri-urban areas have much less). Brazil’s regulatory environment is complex but navigable.

Tajikistan may surprise as a priority given its relatively small population, but it scores highly on the combination of very limited mental health infrastructure, high depression burden in a post-Soviet context with significant economic precarity, and a regulatory environment shaped by the Soviet healthcare legacy that includes community health worker roles compatible with lay counselor delivery.

Ethiopia has one of the largest absolute populations in Sub-Saharan Africa, very limited mental health provision, and a rapidly expanding digital infrastructure — still with significant gaps, particularly in rural areas, but improving. The Ethiopian context is higher-complexity than some other priority countries, but the scale of unmet need justifies the operational investment.

Malaysia is an upper-middle-income country with strong digital infrastructure, high WhatsApp penetration, and — despite relatively better economic development — a significant mental health treatment gap driven partly by stigma and partly by the concentration of specialist services in major urban centers. The economic profile makes Malaysia suitable for a model with slightly higher per-participant cost than the lowest-income contexts.

Sequencing Expansion: Practical Considerations

Having a list of priority countries doesn’t answer the sequencing question: which to enter first, and in what order? Several principles should guide this decision for organizations in Kaya’s position.

Sequence for learning, not just impact. Earlier expansions should be chosen partly for their learning value — what will operating in this context teach us that will make subsequent expansions more efficient? Countries that share features with later priorities (language family, regulatory framework type, digital infrastructure profile) are valuable early entries because the learning compounds.

Minimize the number of simultaneous unknowns. Every new country entry involves multiple new unknowns — counselor recruitment, cultural adaptation, regulatory navigation, partnership development. Entering a new country that differs from the founding context on all of these dimensions simultaneously creates high operational risk. Sequencing to minimize the number of new unknowns per entry — choosing contexts that share language, or regulatory framework, or partnership network — reduces risk and improves the odds of a successful first cohort.

Build the referral pathway before scaling. The absence of referral infrastructure — clear pathways for participants who need more intensive support — is a safety and quality risk. Before scaling to significant participant volumes in a new context, organizations should invest in establishing at least basic referral relationships with whatever higher-level services exist, even if imperfect.

Consider the funding implications of geographic choice. Some contexts are more legible to specific funders than others. An organization that relies heavily on funders based in the UK may find that expansion to South Asia is more fundable than expansion to Latin America, not because of any difference in impact potential but because of funder familiarity and existing portfolio logic. Geographic sequencing should account for the funding implications of each choice, particularly for early-stage organizations where funding constraints are binding.

Don’t let the priority list become a constraint. The ten-country list is a starting point derived from the best available evidence, not a fixed mandate. If a compelling partnership opportunity, regulatory opening, or funding relationship creates a strong case for entering a country not on the list, the framework should inform — not override — that decision. The goal is maximum impact, and sometimes the path to maximum impact deviates from any pre-specified plan.

The Competitive Landscape

Country prioritization decisions should also consider the competitive landscape — whether other organizations are working effectively in the same space in the target context. The goal of NGO country selection should not be to compete with existing high-quality programs, but to extend provision to populations not currently being served.

In mental health in LMICs, the competitive landscape is generally sparse — most contexts have too little provision of any kind for “competition” to be a meaningful concern. But as the field develops and more organizations scale digital mental health programs, this will change. Maintaining awareness of what is being built in target contexts, and positioning expansion to be additive rather than duplicative, will become increasingly important.

Conclusion

Country prioritization for digital depression programs is a multi-dimensional analytical exercise that rewards rigor. The combination of depression burden, treatment gap, digital infrastructure, regulatory environment, and operational feasibility creates a complex decision space — but one that can be navigated systematically using available data.

The ten countries identified in the Ambitious Impact analysis represent a strong starting point for organizations working in this space. They are not equally ready for program launch — each has a distinctive profile of opportunities and challenges — and the sequencing decision should be made with as much care as the initial selection.

The ultimate measure of a country prioritization framework is not its analytical elegance but its impact: whether the populations in the countries selected are better served as a result of the decisions made. At $97 per DALY averted, each person reached in a well-chosen, well-executed country expansion represents exceptional value. The framework exists to maximize how many of those people can be reached.

To learn more about Kaya Guides’ expansion strategy and how to support the scaling of WHO Step-by-Step globally, visit besidehealth.org.