New mental healthcare blueprint for African and Asian countries launched at WHO
The PRogramme for Improving Mental health carE (PRIME) today publishes district mental healthcare plans from five low- and middle-income countries (Ethiopia, India, Nepal, South Africa and Uganda) in a supplement to the British Journal of Psychiatry, which is currently being launched at the WHO mhGAP Forum meeting in Geneva just before World Mental Health Day on the 10 October. Led from the University of Cape Town in South Africa and funded by UKAID, the research is the culmination of more than three years of work, and collaboration between a range of academic institutions, non-governmental organisations, Ministries of Health, and the World Health Organization.
Developed in the inception phase of PRIME, the plans set out packages of mental healthcare that policy makers can use to provide care for people living with mental illness, and in so doing, narrow the mental health treatment gap in low and middle-income countries. The plans focused on the four mental disorders that contribute to the greatest overall burden of disease: alcohol abuse, depression (including maternal depression), psychosis (notably schizophrenia) and epilepsy (the latter covered by Ethiopia, Nepal and Uganda only).
PRIME CEO Prof Crick Lund said: "For the first time we now have a blueprint for an integrated model of mental health service delivery for primary care in PRIME countries, and we know how much this will cost."
Emphasising the importance of PRIME’s Ministry of Health partnership, PRIME Ethiopia lead researcher Dr Abebaw Fekadu added: "An important feature of the work in Ethiopia is continued interaction with the wider national Ministry of Health strategic plan for mental health, which envisages major scale up of mental health services in the coming years."
The PRIME mental healthcare plans were piloted in 5 Districts from each country. Based on the pilot in the Kamuli district of Uganda, Ministry of Health partner, Dr Sheila Ndyanabangi, said: "The experience revealed that primary healthcare workers require thorough mental health training and frequent ongoing supervision for mental healthcare."
Lead researcher in India, Dr Rahul Shidhaye, added: "The piloting experience revealed that mental health service delivery can be strengthened with strong facilitation by an external resource team and that additional human resources are essential to establish true collaborative models of care. Enabling packages also need to be installed as a foundation prior to the implementation of service delivery packages."
The core features of the mental healthcare plans are intended to enhance detection of the priority mental illnesses, and identify culturally appropriate treatment and recovery in the respective PRIME countries. Highlighting the unique features to the Nepal plan being piloted in the Chitwan district, lead investigator Dr Mark Jordans said: "We developed a Community Informant Detection Tool for use by lay community informants to detect alcohol use disorders, depression, epilepsy and psychosis, using locally validated case vignettes. Focused psychological treatments are being provided by community counsellors, who operate in conjunction with primary health care workers. We also developed a tool to assess competency of general primary healthcare workers in delivering psychological treatments and basic mental healthcare: the ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale."
The supplement includes a series of papers from each of the PRIME countries (see Fekadu et al for Ethiopia, Shidhaye et al for India, Jordans et al for Nepal, Petersen et al for South Africa and Kigozi et al for Uganda). Across the five countries, the supplement also covers the details of how PRIME is planning and evaluating mental health services using the Theory of Change (ToC) tool (see Breuer et al); the commonalities, variances and evidence gaps across countries (see Hanlon et al); estimating the economic cost of implementing the mental healthcare plans (see Chisholm et al) and evaluating the research methods used by PRIME (see De Silva et al).
The next stage of PRIME’s research will evaluate how the mental healthcare plans have been implemented, and document lessons learnt. This will include assessing changes in detection rates for priority mental disorders, changes in treatment coverage for these disorders in the district populations, and the clinical, social and economic outcomes for service users who receive care for alcohol use disorder, depression, psychosis or epilepsy. Further research is needed on the scaling up of such treatment packages for larger populations, and the implementation of treatment packages for other priority disorders, for example disorders of childhood and adolescence. Regarding the scale-up of the mental healthcare plans, lead South African researcher, Prof Inge Petersen, said: "The plan leverages resources and systems availed by integrated chronic care, which strengthens the potential for future scale-up."
The PRIME consortium shares its findings in order to stimulate engagement from a range of local, national and international agencies, who wish to commit themselves to narrowing the enormous treatment gap for mental healthcare in low- and middle-income countries.