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programme for improving mental health care Evidence on scaling-up mental health services for development
Rehabilitation in health systems: learning from current initiatives
What can we learn from PRIME?
(Programme for Improving Mental Health Care)
On behalf of PRIME consortium:
Dr Dan Chisholm
Department of Mental Health and Substance Abuse
World Health Organization
programme for improving mental health care
What is PRIME ?
• PRIME is a DfID-funded international mental health services research consortium focused on scaling up treatment programmes for priority mental disorders in primary and maternal health care contexts in low resource settings. It is a partnership between • Leading academic institutions in five LMIC, and
• Ministries of Health in each country, plus
• Cross-country partners (academia, NGOs, WHO)
South Africa
Ethiopia
Uganda
India
Nepal
• PRIME can offer relevant insights for the rehabilitation community in terms of its approach to: 1. district-level service development
2. programme evaluation
3. health system strengthening
supported by
programme for improving mental health care
PRIME Annual meeting; India, Feb 2015
programme for improving mental health care
Mental health system context in LMIC
Low priority
Many misconceptions
Under-resourced
Weak governance
Large treatment gap
Inequitable access / coverage
Fragmented, inefficient service delivery
Poor monitoring and surveillance
programme for improving mental health care
Rehabilitation system context in LMIC !
Low priority
Many misconceptions
Under-resourced
Weak governance
Large treatment gap
Inequitable access / coverage
Fragmented, inefficient service delivery
Poor monitoring and surveillance
programme for improving mental health care
PRIME approach to scale up
1. A focus on (WHO mhGAP) priority conditions, for which intervention (cost-)effectiveness evidence exists: depression, alcohol use disorders, schizophrenia, epilepsy
2. A focus not so much on “what works” but “how it works” (translational / implementation science)
3. Partnership (local government & community partners)
4. Robust methodological framework: Theory of Change
5. Multi-level development and evaluation plan
programme for improving mental health care
A phased approach
year 1 year 4 year 6
formative
phase
implementation
phase
scaling-up
phase
year 2 year 3 year 5 year 0
Men
tal h
ealth
cov
erag
e
Time
programme for improving mental health care
Formative phase
• Defining the health care plan:
1. Situational analysis / resource mapping
2. Formative studies with key stakeholders: • Focus group discussions and interviews with personnel in
the districts: health managers, doctors/nurses, CHWs
• Theory of Change workshops
3. Service planning / costing of the packages of care
4. Map the components of care into a matrix
programme for improving mental health care
Building blocks of a mental health plan
Source: Lund et al (2012). PRIME: A Programme to Reduce the Treatment Gap for Mental Disorders in Five Low- and Middle-Income Countries. PLoS Medicine, 9(12).
programme for improving mental health care
Mental health care plans: Functional matrix
Awareness Detection Recovery Treatment Enabling
Healthcare organisation
Specialist MH services
Health Facility
Community
Programme management,
HMIS, Capacity Building
Engage and mobilise district
stakeholders
Provide psychotropic medication and basic
psychosocial interventions
Build capacity of facility staff
to deliver facility level
packages
Ensure continuing
care
Detect/carry out screening
and assessment for priority disorders
Increase awareness of service users and providers
Provision of specialist care
to complex cases
Ensure specialist MH
care interfaces with PHC
Provision of case reviews for complex
cases
Provide basic psychosocial interventions
and peer support
Build capacity of community
to support mental health
care
Promote rehabilitation
& recovery
Improve case detection in
the community
Improve awareness
and decrease stigma
programme for improving mental health care
Resource planning … reality checking
Human resource needs of scale up (e.g. FTE workers per 100,000 population)
Health service costs of scale up (e.g. US$ or LCU per capita population)
Source: Chisholm, et al (2016). Estimating the cost of implementing district mental healthcare plans in five low- and middle-income countries: the PRIME study. British Journal of Psychiatry. 208(s56): s71 – s78. doi: 10.1192/bjp.bp.114.153866.
programme for improving mental health care
Implementation of Mental Health Care Plan
• Before-after evaluations • Non-randomized controlled trials.
Economic evaluation of resource inputs and outcomes
Revision of Mental Health Care Plan Scaling up mental health services
Process and outcome evaluation
Economic evaluation
Evidence on the impact of scaling up on coverage and
utilisation of mental health care
Case studies at the level
of individual AHUs
• Analysis of routine health information
system data
• Surveys, document review,
interviews, observation
Implementation and scale up phases
programme for improving mental health care
PRIME evaluation: Study designs
Source: De Silva, et al (2016). Evaluation of district mental healthcare plans: the PRIME consortium methodology. British Journal of Psychiatry. 208)s56): s63 – s70 doi: 10.1192/bjp.bp.114.153858.
programme for improving mental health care
Challenges with implementation
• Low priority given to mental health in national / local government
• Tangible, ongoing financial commitment from certain Ministries of Health
• Detecting certain disorders in the primary care context (depression, alcohol use disorders)
• Maintaining common evaluative methods while being respectful of country differences
programme for improving mental health care
Capacity building, research uptake and stakeholder engagement
• Capacity-building
• Service providers: Detection, treatment, management and referral using adapted mhGAP guidelines
• Researchers: PhD studentship programme
• Research uptake and stakeholder engagement:
• Stakeholder analysis / research uptake strategy
• Website: http://www.prime.uct.ac.za/
• MoH and local NGOs
programme for improving mental health care
Policy successes
1. Ethiopia: National mental health strategy; rapid scaling up of WHO mhGAP training and services across regions
2. India: Mental health plan in Madhya Pradesh; SOHAM: scaling up across all 51 districts in the state
3. Nepal: Mental Health in the Training Curriculum; expanded service scale-up following earthquake
4. South Africa: National Mental Health Policy and Action Plan; integration of mental health into PHC reform
5. Uganda: MoH implementing mhGAP in 2 other districts, in parallel with PRIME site
programme for improving mental health care
Outcomes and legacy
• Increased uptake of findings to influence policy and practice in the study countries
• Improved mental health, social and economic outcomes
• Sustainable research capacity
• Sustainable partnerships for future collaborations