DfID’s Last Stand: A Belated but Welcome Theory of Change on Mental Health and Development

Abstract

This article critiques the new Theory of Change (ToC) on mental health published by the UK’s Department for International Development (DfID) in the last fortnight of its existence. The ToC offers development actors a framework for better support of beneficiaries with mental health conditions and psychosocial disabilities – given disappointingly scant attention by the sector to date. Yet, 70 per cent of mental disorders occur in low- and middle-income countries (LMICs), with a 22 per cent prevalence in fragile and conflict-affected states. Globally, mental ill-health is estimated to affect almost one billion people. Its intersectionality with poverty and physical health has been brought into sharp focus by the current COVID-19 pandemic which has magnified the underlying social and environmental stressors of mental health. DfID’s ToC provides a conceptual framework for improving mental health globally, with an overarching vision of the full and equal exercise of all human rights by those affected by mental health conditions and psychosocial disability. The framework incorporates a rights-based approach with user-participation embedded in five critical change pathways to outcomes. The article analyses the ToC, provides an overview, highlights gaps and comments upon how DfID might have improved clarity for development actors seeking to realise its vision.

Introduction

The UK government’s controversial decision to disband the Department for International Development (DfID) in June 2020 drew widespread condemnation (UK Government Spending Review, 2020). However, two weeks prior to its merger with the Foreign and Commonwealth Office, DfID published a new Theory of Change (ToC) on mental health for the international development sector – its last stand as a unitary body (DfID, 2020). Despite the importance of the topic, this went largely unnoticed. An estimated 971 million people globally – roughly 13 per cent of the world’s population – suffer from mental health conditions (Collaborative Paper, 2018). For almost three decades, mental disorders have accounted for over 14 per cent of years lived with disability (YLD), with more than a 10 per cent prevalence across all 195 countries (Collaborative Paper, 2018).¹ From 1990 to 2017, cases of depression worldwide increased by almost 50 per cent, from 172 million to 258 million (Liu et al., 2019), making it the leading cause of ill-health and disability worldwide (WHO, 2017). Further, contrary to the popular belief that mental disorders such as depression are a western construct, more than 70 per cent of them occur in low- and middle-income countries (LMICs) (Rathod et al., 2017).

The previous UN Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Dainius Pūras, lamented the fact that mental health continues to be one of the most neglected and underfunded development issues (Pūras, 2017: 10, 19). Although mental health was excluded from the Millennium Development Goals, the UN’s 2030 Agenda requires states to ‘ensure healthy lives and promote well-being for all at all ages’ through Sustainable Development Goal 3 (SDG3) (UN, 2015). This unhelpful loose phraseology has directed little funding to mental health per se, and total government health spending on it globally is woeful: under 2 per cent (WHO, 2018). For the last five years, the Special Rapporteur on the right to health – a psychiatrist – particularly focused on mental health, criticising the biomedical model for its paternalism, coerciveness, overdependence on pharmacological interventions and failure to respect human rights.² Calling for a paradigm shift towards a multisectoral, empowering rights-based approach favouring psychological and psychosocial treatment options,³ he also highlighted the negative impact of social determinants on health which cause inequities likely to have an adverse effect on mental health (Pūras, 2017: 15–16). Unfortunately, the much-heralded sea-change in mental health has largely failed to come to fruition, as evidenced by the need to extend the World Health Organization’s Comprehensive Mental Health Action Plan 2013–2020 by another decade (WHO, 2013). Can DfID’s document – An Approach and Theory of Change to Mental Health and Psychosocial Support – actually change anything?

DfID’s Five Pathways to Change

The ToC provides a conceptual framework for improving mental health globally. Its overarching vision is a world where those with mental health conditions and psychosocial disabilities can fully exercise all rights on an equal basis with others.⁴ Realising that vision would help states meet commitments under the SDGs, the UN Convention on the Rights of Persons with Disabilities (CRPD, 2007) – which a record 182 countries have ratified – and the WHO’s Mental Health Action Plan. A rights-based approach is embedded in five critical change pathways to outcomes (Figure 1). The first, central across each pathway, is the full and meaningful participation of those with lived experience of mental health conditions and psychosocial disabilities, also echoed in the second outcome (inclusivity and the exercise of the full rights’ spectrum). Such an inclusionary emphasis is essential. Until recently, the systemic disempowerment of psychiatric patients in all decisions affecting them was rarely questioned, leading to normalisation of coercion and other appalling human rights violations, as highlighted by the CRPD Committee (General Comment No.1 on Article 12, 2014). The ToC’s external working group itself comprised persons with lived experience of psychosocial disability, along with international development and humanitarian actors. Inclusion is also one of nine guiding principles within the ToC to ensure quality services, and one of three essential components of DfID’s suggested evaluative measurement system.

Figure 1:

DfID’s Five Pathways to Change

[Image omitted. See PDF.]

The document’s proposed second pathway is securing the full enjoyment and exercise of human rights for those with psychosocial disabilities. Somewhat unnecessarily, the ToC repeats its first pathway and its inclusionary principle in pathway two. Interestingly, it recommends innovative practices to prevent and end coercion to assist ‘the long-term process of de-institutionalisation’ (DfID, 2020: 11). Gradual withdrawal from coercive psychiatric practices such as compulsory hospitalisation and enforced medical treatment (often more traumatising than symptoms) contradicts the CRPD Committee’s call for an outright and immediate ban. Nonetheless, this would be a step in the right direction, as I have argued elsewhere (Davidson, 2020).

‘Advancing’ leadership and governance for mental health at all levels and across sectors is the ToC’s third pathway. What this might mean lacks clarity and detail, but the need for integrating mental health into policies and plans is mentioned. Critical change pathway four is the promotion of well-being for all and the provision of quality services and interventions. An elision of these two different and very broad pathways is curious. States have a duty under SDG3 to ‘promote well-being’, yet globally its achievement lacks focus, with SDG targets and indicators largely silent (UN, 2015). DfID missed its opportunity to make a meaningful contribution here. It might have adopted and/or expanded upon the World Health Organization’s 2005 definition: ‘[h]ealth promotion is the process of enabling people to increase control over their health and its determinants, and thereby improve their health’ (Bangkok Charter for Health Promotion in a Globalized World, 2005). Although it has not been spelt out, it does appear that DfID sees promotion of mental health as tied to action on social determinants. This can be surmised from its reference to the WHO’s Mental Health Action Plan (DfID, 2020: 5),⁵ and its discussion of outcome three, where it advocates for ‘[s]upporting [the] integration of mental health into global and national frameworks and sectors – including SDG national plans to address social determinants of mental health and provide a comprehensive strategy to promote mental health’ (DfID, 2020: 12). DfID could also have provided useful clear and concrete examples of well-being promotion.

The ToC’s fifth and final critical change pathway is the prioritisation of mental health and psychosocial support (MHPSS) in fragile and conflict-affected situations (FCAS), where mental conditions affect an estimated 22 per cent of the population at any one time (Charlson et al., 2019). Since conflict can overwhelm state capacity for even basic service provision, planned incorporation of mental health into national and community level emergency preparedness, response and recovery systems is vital. Notably, DfID emphasises the need for strategic plans and programmes to promote the well-being of humanitarian staff – both local and international – often at high risk of suffering first-hand and/or secondary trauma. This requirement was conspicuously absent from the UN Inter-Agency Standing Committee Reference Group’s 2017 mental health Framework. Sadly, such trauma may be compounded by the widespread culture of bullying and abuse in the development and humanitarian sectors, recently exposed by whistle-blowers (Guardian, 2018).

Weaknesses

There is nothing particularly new about DfID’s ToC approach. Mental health support and treatments must be evidence- and rights-based, affordable, provided by properly trained staff and fully integrated into health and social care systems across the life-course. Community-based rehabilitative approaches must be developed and/or expanded, and the number of qualified service personnel increased. Stigma must be combated. MHPSS must be coordinated, integrated, accountable and culturally appropriate, engaging with the community, including vulnerable groups. Sufficient political will is recognised as essential. National mental health policies, strategies and legislative amendments must outlaw discrimination and meaningfully protect rights in the health, social welfare, employment, education and criminal justice sectors. This is pretty basic stuff and hardly a panacea.

Furthermore, unfortunately the document is scant on methods to achieve the proposed outcomes. How can quality services and support be guaranteed in struggling LMICs or FCAS with inadequate national and district budgets? Regular and continued monitoring and evaluation is fundamental for significant change, but assessing the degree to which DfID’s five outcomes are met will be imprecise and subjective. The ToC recommends measuring the reach of broader development interventions to those with psychosocial disabilities, without defining such interventions or explaining how ‘reach’ might be measured. The Washington Group Questions referred to provide little help.⁶ The same can be said for the UN SDG indicators (UN, 2015): only a paltry three out of twenty-seven reference mental health, despite thirty-six major changes to the indicator framework approved within a Comprehensive Review in March 2020. Evaluating progress and holding governments accountable in these circumstances is extremely difficult.

The various barriers to change identified within the ToC also warrant comment. Some are merely the inverse of the output, with no indication as to how they will be overcome. For example, ‘lack of … political will’ is acknowledged as a barrier to ‘political will for mental health at all levels; decision makers responsive and held to account’. It would have been helpful had DfID provided some pointers for development actors on how they might improve governmental appetite for increased spending on mental health – such as by, for example, funding pilot interventions to create a firm and sustainable evidence base from which to advocate for an increased mental health spend. Furthermore, the interrelationship of the barriers identified by DfID is noteworthy. For example, in LMICs the common dual barriers of inadequate sustainable resources and the scale of social determinants such as poverty and inequality result in multiple obstacles, such as ‘lack of … health care and services and skilled workforce’ and ‘data and information’; ‘poor quality of limited services’; and ‘poor integration of physical and mental healthcare and comorbidities’.

Intersectionality, Social Determinants and COVID-19

To achieve DfID’s vision and measure impact effectively, the document urges NGOs to advocate for and create programmes to ‘address structural conditions and root causes’ of mental ill-health. Yet, the ToC self-admittedly only ‘touches on’ how mental health is inextricably linked to other developmental goals – regrettable, given its clear intersectionality. Initiatives, policies, programmes and legislation must address broad determinants to enable radical improvement in mental health interventions, as recognised by the Global Declaration on Universal Health Coverage (Political Declaration of the High-Level Meeting on Universal Health Coverage, 2019). The strong association between mental health and poverty, inequality and poor physical health is obvious; ‘multidirectional pathways’ can produce a cycle of disadvantage leading to psychosocial disability and vice versa.⁷ Neglect of underlying social and economic determinants reduces all healthcare service impact. The interconnection has become painfully apparent during the current COVID-19 pandemic, with the novel coronavirus compounding and complicating the disease burden among the poor. For example, UK research revealed that people with hypertension, diabetes and obesity are at higher risk of poor virus outcomes (The Health Foundation, 2020; Public Health England, 2020: chapter 8), and COVID-19 mortality rates from the most deprived areas of England are over double those of the least deprived areas, for both men and women (Public Health England, 2020: chapter 3).

In LMICs, there are huge disparities between rich and poor, and accordingly, viral risk exposure. Those living in poverty have a much greater likelihood of sharing small living spaces with more people, including in crowded informal settlements, rendering social-distancing impossible. Soap and hand-sanitisers are important weapons against COVID-19, yet 33 per cent of those in rural India have no access to soap after toilet use, and even in urban areas almost 14 per cent of the population does not have both bathroom and toilet within the household premises (Government of India, National Sample Survey Office, 2018: 38). Lingam and Sapkal (2020: 177) identified poverty as a key pandemic mortality factor spanning three differentials: exposure, vulnerability and consequences.⁸ The latter includes not only genetic predisposition to virus susceptibility, but also neglect of pre-existing health conditions and of related needs (such as nutritional intake). These may arise not only from poverty, but also from mental health fluctuation, or from gender-based violence which has increased globally during lockdowns – often the cause of poor mental health.⁹ Thus, the pandemic continues to impact adversely upon mental health worldwide. Direct impact arises from increased stress and anxiety about infection and risk, trauma resulting from contraction of the illness, or the inability to provide comfort in death to loved ones, as well as depression resulting from grief or socialisation restrictions. Indirect impact on mental health emanates from uncertainty and economic strain. Accordingly, the global mental health reach of the coronavirus pandemic will be significant for years after it is brought under control, magnifying the acute need for a multisectoral approach (COVID-19 Disability Rights Monitor 2020; WHO News Release, 2020).¹⁰

Conclusion

DfID’s ToC contains chapters entitled ‘The Challenge’ and ‘The Opportunity Is Now’, echoing previous calls to action. It is described as a tool for development actors to ‘maximise aid portfolios to strengthen their contribution to mental health and wellbeing’. It is striking that DfID only set out such strategic guidance ‘for the first time’ five years into the SDGs. In the current global health crisis which has so starkly exposed the fragility of mental health and underscored the interrelation between mental and physical health, and between health and its social determinants, the ToC for use by development and humanitarian sectors has come not a moment too soon. I suggest that two outputs within the document are key to achieving the quality services and community interventions it commends. These are scaling up an integrated approach to mental health and social care across services – an output under pathway four – combined with the utilisation of community-based and empowering participatory approaches, as delineated in critical care pathway two (respect for human rights). Following the government’s recent volte face on its foreign aid spending commitment of £15bn (reduced to £10bn), regrettably the UK’s global contribution to transformative mental health as espoused by DfID’s ToC will now be considerably lessened.

Footnote

1 This was an age-standardised figure.

2 Reports from the Special Rapporteur, www.ohchr.org/EN/Issues/Health/Pages/AnnualReports.aspx (accessed 2 December 2020).

3 The biomedical model emphasises brain disease and pharmacological treatments targeted at presumed biological abnormality. For a critique from a service-user’s perspective and some examples of effective, empowering and inclusive care without coercion, see Lehmann (2019: 263–7), in Davidson (2019).

4 DfID defines the term ‘psychosocial disability’ in Annex A of the ToC: ‘Used to describe the experience of people with participation restrictions associated with mental health problems and conditions’. It is considered less stigmatising due to its focus on the functional impact of mental health difficulties.

5 The promotion of mental health through action on social determinants is one of the Plan’s five key objectives.

6 The Washington Group on Disability Statistics (New York, 4–6 June 2001) has developed both short and extended sets of standard functioning questions.

7 This phrase was coined by Patel et al. (2018).

8 Differential exposure results from increased low-paid frontline work (e.g. in transport, delivery services, nursing and cleaning services). Differential vulnerability arises from biological and/or social disadvantages that result in morbidities involving immune system compromise, or which create constraints in adhering to lockdown requirements, such as mask-wearing.

9 A Tunisian study, for example, found women who had experienced previous domestic abuse were at increased risk of violence during lockdown: Sediri et al. (2020). See also Raj et al. (2020).

10 For the impact of the pandemic on mental health in LMICs generally, see, for example, Kumar et al. (2020). For three country case studies, see: Newby et al. (2020) (Australia); Jaguga and Kwobah (2020) (Kenya); Kim et al. (2020) (South Africa).

Works Cited

The Bangkok Charter for Health Promotion in a Globalized World (11 August 2005) , www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/ (accessed 4 January 2021).

Charlson, F., van Ommeren, M., Flaxman, A., Cornett, J., Whiteford, H. and Saxena, S. (2019), ‘New WHO Prevalence Estimates of Mental Disorders in Conflict Settings: A Systematic Review and Meta-Analysis’, The Lancet, 394:10194, 240–8, doi: 10.1016/S0140–6736(19)30934–1.

Collaborative Paper (2018), ‘Global, Regional, and National Incidence, Prevalence, and Years Lived with Disability for 354 Diseases and Injuries for 195 Countries and Territories, 1990–2017: A Systematic Analysis for the Global Burden of Disease Study 2017’, The Lancet, 392:10161, 1789–1858, www.ncbi.nlm.nih.gov/pmc/articles/PMC6227754/pdf/main.pdf (accessed 4 January 2021).

Committee on the Rights of Persons with Disabilities, General Comment No.1 on Article 12 (2014), ‘Equal Recognition Before the Law’, UN Doc. CRPD/C/GC/1, www.ohchr.org/en/hrbodies/crpd/pages/gc.aspx (accessed 4 December 2020).

Convention on the Rights of Persons with Disabilities (2007), UN General Assembly, UN Doc. A/RES/61/106, 24 January, www.un.org/en/development/desa/population/migration/generalassembly/docs/globalcompact/A_RES_61_106.pdf (accessed 4 December 2020).

COVID-19 Disability Rights Monitor 2020 (2020), Disability Rights during the Pandemic. A Global Report on Findings of the COVID-19 Disability Rights Monitor, https://covid-drm.org/assets/documents/Disability-Rights-During-the-Pandemic-report-web.pdf (accessed 4 January 2021).

Davidson, L. (ed.) (2019), The Routledge Handbook on International Development, Mental Health and Wellbeing (Abingdon: Routledge).

Davidson, L. (2020), ‘A Key, Not a Straitjacket: The Case for Interim Mental Health Legislation Pending Complete Prohibition of Coercion on the Basis of Psychosocial Disability in Accordance with the CRPD’, Harvard Health and Human Rights Journal, 22:1, 163–78, www.hhrjournal.org/2020/06/a-key-not-a-straitjacket-the-case-for-interim-mental-health-legislation-pending-complete-prohibition-of-psychiatric-coercion-in-accordance-with-the-convention-on-the-rights-of-persons-with-disabilit/ (accessed 4 December 2020).

Department for International Development (2020), An Approach and Theory of Change to Mental Health and Psychosocial Support, 19 August, www.gov.uk/government/publications/an-approach-and-theory-of-change-to-mental-health-and-psychosocial-support (accessed 4 December 2020).

Government of India (2018), Report 584: National Sample Survey Office Report on Drinking Water, Sanitation, Hygiene, and Housing Condition: NSS 76th Round, July 2018–December 2018, mospi.nic.in/recent-reports (accessed 4 January 2021).

Guardian (2018), ‘#MeToo Strikes Aid Sector as Sexual Exploitation Allegations Proliferate’, 12 February, by P. Beaumont and R. Radcliffe, www.theguardian.com/global-development/2018/feb/12/metoo-strikes-aid-sector-as-sexual-exploitation-allegations-proliferate (accessed 4 January 2021).

The Health Foundation (December 2020), Build Back Fairer: The COVID-19 Marmot Review – The Pandemic, Socioeconomic and Health Inequalities in England, www.health.org.uk/publications/build-back-fairer-the-covid-19-marmot-review (accessed 4 January 2021).

Jaguga, F. and Kwobah, E. (2020), ‘Mental Health Response to the COVID-19 Pandemic in Kenya: A Review’, International Journal of Mental Health Systems, 14:68, 2892, doi: http://dx.doi.org/10.1186/s13033–020–00400–8.

Kim, A. W., Nyengerai, T. and Mendenhall, E. (2020), ‘Evaluating the Mental Health Impacts of the COVID-19 Pandemic in Urban South Africa: Perceived Risk of COVID-19 Infection and Childhood Trauma Predict Adult Depressive Symptoms’, 16 June, preprint, doi: 10.1101/2020.06.13.20130120.

Kumar, S. K., Oyetunji, T. P., Prakash, A. J., Ogunmola, O. A., Tripathy, S., Lawal, M. M., Sanusi, Z. K. and Arafat, S. M. Y. (2020), ‘Mental Health Research in the Lower-Middle-Income Countries of Africa and Asia during the COVID-19 Pandemic: A Scoping Review’, Neurology, Psychiatry and Brain Research, 38, 54–64, doi: 10.1016/j.npbr.2020.10.003.

Lehmann, P. (2019), ‘ Paradigm shift: Treatment alternatives to psychiatric drugs, with particular reference to low- and middle-income countries’, in L. Davidson (ed.), The Routledge Handbook on International Development, Mental Health and Wellbeing (Abingdon: Routledge), chapter17, 263–67.

Lingam, L. and Sapkal, R. S. (2020), ‘COVID-19, Physical Distancing and Social Inequalities: Are We All Really in This Together?’, The International Journal of Community and Social Development, 2:2, 173–90, doi: 10.1177/2516602620937932.

Liu, Q., Hairong, H., Yang, J., Xiojie, F., Zhao, F. and Lyu, J. (2019), ‘Changes in the Global Burden of Depression from 1990 to 2017: Findings from the Global Burden of Disease Study’, Journal of Psychiatric Research, July 2020, 126: 134–40, doi: 10.1016/j.jpsychires.2019.08.002.

Newby, J. M., O’Moore, K., Tang, S., Christensen, H. and Faasse, K. (2020), ‘Acute Mental Health Responses during the COVID-19 Pandemic in Australia’, PlosOne, 28 July, doi: 10.1371/journal.pone.0236562.

Patel, V., Saxena, S., Lund, C. et al. (2018), ‘The Lancet Commission on Global Mental Health and Sustainable Development’, The Lancet, 392:10157, 1553–98, doi: 10.1016/S0140–6736(18)31612-X.

Political Declaration of the High-Level Meeting on Universal Health Coverage (2019), 10 October, UN Doc. A/RES/74/2, undocs.org/en/A/RES/74/2 (accessed 4 December 2020).

Public Health England (August 2020), ‘Disparities in the Risk and Outcomes of COVID-19’, Chapter 8, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf (accessed 4 January 2021).

Pūras, D. (2017), Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc. A/HRC/35/21, https://ap.ohchr.org/documents/dpage_e.aspx?si=A/HRC/35/21 (accessed 4 December 2020).

Raj, A., Johns, N. E., Barker, K. M. and Silverman, J. G. (2020), ‘Time from COVID-19 Shutdown, Gender-Based Violence Exposure, and Mental Health Outcomes among a State Representative Sample of California Residents’, EClinicalMedicine, 26:100520, doi: 10.1016/j.eclinm.2020.100520 (accessed 4 January 2021).

Rathod, S., Pinninti, N., Irfan, M., Gorczynski, P., Rathod, P., Gega, L. and Naeem, F. (2017), ‘Mental Health Service Provision in Low- and Middle-Income Countries’, Health Services Insights, 10: 1178632917694350, doi: 10.1177/1178632917694350 (accessed 4 January 2021).

Sediri, S., Zgueb, Y., Ouanes, S., Ouali, U., Bourgou, S., Jomli, R. and Nacef, F. (2020), ‘Women’s Mental Health: Acute Impact of COVID-19 Pandemic on Domestic Violence’, Archives of Women’s Mental Health, 3540, 17 October, doi: 10.1007/s00737–020–01082–4 (accessed 4 January 2021).

United Kingdom Government Spending Review 2020 (25 November 2020), www.gov.uk/government/publications/spending-review-2020-documents (accessed 4 December 2020).

United Nations (2015), ‘The UN 2030 Agenda for Sustainable Development’, 25 September, sdgs.un.org/goals (accessed 4 December 2020).

United Nations Inter-Agency Standing Committee Reference Group (2017), ‘A Common Monitoring and Evaluation Framework for Mental Health and Psychosocial Support (MHPSS) in Emergency Settings’, www.who.int/mental_health/emergencies/IASC_MHPSS_M_E_30.03.2017.pdf?ua=1 (accessed 4 December 2020).

United Nations (2020), ‘Global Indicator Framework for the Sustainable Development Goals and Targets of the 2030 Agenda for Sustainable Development’ (after review), UN Doc. A/RES/71/313, unstats.un.org/sdgs/indicators/Global%20Indicator%20Framework%20after%202020%20review_Eng.pdf (accessed 4 December 2020).

The Washington Group on Disability Statistics (New York, 4–6 June 2001) has developed both short and extended sets of standard functioning questions , www.washingtongroup-disability.com/about/ (accessed 4 December 2020).

World Health Organization (2013), Comprehensive Mental Health Action Plan 2013–2020 (Geneva: WHO), www.who.int/publications/i/item/9789241506021 (accessed 4 December 2020).

World Health Organization (2017), Depression and other Common Mental Disorders: Global Health Estimates (Geneva: WHO), www.who.int/mental_health/management/depression/prevalence_global_health_estimates/en/ (accessed 4 January 2021).

World Health Organization (2018), Mental Health Atlas 2017 (Geneva: WHO), apps.who.int/iris/bitstream/handle/10665/272735/9789241514019-eng.pdf?ua=1 (accessed 4 January 2021).

World Health Organization News Release (2020), ‘COVID-19 Disrupting Mental Health Services in Most Countries, WHO Survey’, 5 October, /www.who.int/news/item/05–10–2020-covid-19-disrupting-mental-health-services-in-most-countries-who-survey (accessed 4 January 2021).