scholarly journals Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform

BJPsych Open ◽  
2019 ◽  
Vol 5 (5) ◽  
Author(s):  
Inge Petersen ◽  
André van Rensburg ◽  
Fred Kigozi ◽  
Maya Semrau ◽  
Charlotte Hanlon ◽  
...  
Keyword(s):  
Mental Health ◽  
Health System ◽  
Chronic Care ◽  
Mental Healthcare ◽  
Building Blocks ◽  
Scaling Up ◽  
Task Sharing ◽  
Middle Income ◽  
Middle Income Countries ◽  
System Building

Background There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs). Aims To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs. Method Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks. Results Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation. Conclusions Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important. Declaration of interest None.

scholarly journals Strengthening mental health systems in low- and middle-income countries: recommendations from the Emerald programme

BJPsych Open ◽  
2019 ◽  
Vol 5 (5) ◽  
Author(s):  
Maya Semrau ◽  
Atalay Alem ◽  
Jose L. Ayuso-Mateos ◽  
Dan Chisholm ◽  
Oye Gureje ◽  
...  
Keyword(s):  
Mental Health ◽  
Health System ◽  
Human Resource Development ◽  
Health Systems ◽  
Building Blocks ◽  
Health System Strengthening ◽  
Mental Health Systems ◽  
Middle Income ◽  
Middle Income Countries ◽  
Low And Middle Income

BackgroundThere is a large treatment gap for mental, neurological or substance use (MNS) disorders. The ‘Emerging mental health systems in low- and middle-income countries (LMICs)’ (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems.AimsTo provide a set of proposed recommendations for mental health system strengthening in LMICs.MethodThe Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012–2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening.ResultsThe proposed recommendations align closely with the World Health Organization's key health system strengthening ‘building blocks’ of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald.ConclusionsThese recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders.Declaration of interestNone.

scholarly journals Effective methods for knowledge transfer to strengthen mental health systems in low- and middle-income countries

BJPsych Open ◽  
2019 ◽  
Vol 5 (5) ◽  
Author(s):  
Jose L. Ayuso-Mateos ◽  
Maria Miret ◽  
Pilar Lopez-Garcia ◽  
Atalay Alem ◽  
Dan Chisholm ◽  
...  
Keyword(s):  
Mental Health ◽  
Knowledge Transfer ◽  
Health System ◽  
Health Systems ◽  
Mental Healthcare ◽  
Health System Strengthening ◽  
Mental Health Systems ◽  
Middle Income ◽  
Middle Income Countries ◽  
Low And Middle Income

Background The Emerald project's focus is on how to strengthen mental health systems in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). This was done by generating evidence and capacity to enhance health system performance in delivering mental healthcare. A common problem in scaling-up interventions and strengthening mental health programmes in LMICs is how to transfer research evidence, such as the data collected in the Emerald project, into practice. Aims To describe how core elements of Emerald were implemented and aligned with the ultimate goal of strengthening mental health systems, as well as their short-term impact on practices, policies and programmes in the six partner countries. Method We focused on the involvement of policy planners, managers, patients and carers. Results Over 5 years of collaboration, the Emerald consortium has provided evidence and tools for the improvement of mental healthcare in the six LMICs involved in the project. We found that the knowledge transfer efforts had an impact on mental health service delivery and policy planning at the sites and countries involved in the project. Conclusions This approach may be valid beyond the mental health context, and may be effective for any initiative that aims at implementing evidence-based health policies for health system strengthening.

scholarly journals Health system strengthening for mental health in low- and middle-income countries: introduction to the Emerald programme

BJPsych Open ◽  
2019 ◽  
Vol 5 (5) ◽  
Author(s):  
Graham Thornicroft ◽  
Maya Semrau
Keyword(s):  
Mental Health ◽  
Health System ◽  
Health Systems ◽  
Mental Healthcare ◽  
Research Programme ◽  
Health System Strengthening ◽  
Mental Health Systems ◽  
Middle Income ◽  
Middle Income Countries ◽  
Low And Middle Income

Summary This paper gives an overview of the Emerald (Emerging mental health systems in low- and middle-income countries) programme and introduces the subsequent seven papers in this BJPsych Open thematic series. The aims of the Emerald research programme were to improve mental health outcomes in six low- and middle-income countries (LMICs), namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda, by building capacity and by generating evidence to enhance health system strengthening in these six countries. The longer-term aim is to improve mental healthcare, and so contribute to a reduction in the large treatment gap that exists for mental disorders. This series includes papers describing the following components of the Emerald programme: (a) capacity building; (b) mental health financing; (c) integrated care (d) mental health information systems; and (e) knowledge transfer. We also include a cross-cutting paper with recommendations from the Emerald programme as a whole. The inclusion of clear mental-health-related targets and indicators within the United Nations Sustainable Development Goals now intensifies the need for strong evidence about both how to provide effective treatments, and how to deliver these treatments within robust health systems.

scholarly journals Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: a cross-country qualitative study

2017 ◽  
Vol 27 (1) ◽  
pp. 29-39 ◽  
Author(s):  
H. Lempp ◽  
S. Abayneh ◽  
D. Gurung ◽  
L. Kola ◽  
J. Abdulmalik ◽  
...  
Keyword(s):  
Mental Health ◽  
Health System ◽  
Mental Health System ◽  
Service User ◽  
Health System Strengthening ◽  
Service Users ◽  
Middle Income ◽  
Middle Income Countries ◽  
Cross Country ◽  
Caregiver Involvement

Aims.The aims of this paper are to: (i) explore the experiences of involvement of mental health service users, their caregivers, mental health centre heads and policy makers in mental health system strengthening in three low- and middle-income countries (LMICs) (Ethiopia, Nepal and Nigeria); (ii) analyse the potential benefits and barriers of such involvement; and (iii) identify strategies required to achieve greater service user and caregiver participation.Methods.A cross-country qualitative study was conducted, interviewing 83 stakeholders of mental health services.Results.Our analysis showed that service user and caregiver involvement in the health system strengthening process was an alien concept for most participants. They reported very limited access to direct participation. Stigma and poverty were described as the main barriers for involvement. Several strategies were identified by participants to overcome existing hurdles to facilitate service user and caregiver involvement in the mental health system strengthening process, such as support to access treatment, mental health promotion and empowerment of service users. This study suggests that capacity building for service users, and strengthening of user groups would equip them to contribute meaningfully to policy development from informed perspectives.Conclusion.Involvement of service users and their caregivers in mental health decision-making is still in its infancy in LMICs. Effective strategies are required to overcome existing barriers, for example making funding more widely available for Ph.D. studies in participatory research with service users and caregivers to develop, implement and evaluate approaches to involvement that are locally and culturally acceptable in LMICs.

scholarly journals Next steps for meeting the needs of people with severe mental illness in low- and middle-income countries

2016 ◽  
Vol 26 (4) ◽  
pp. 348-354 ◽  
Author(s):  
C. Hanlon
Keyword(s):  
Mental Health ◽  
Health Care ◽  
Mental Illness ◽  
Human Rights ◽  
Mental Health Care ◽  
Severe Mental Illness ◽  
Mental Health Professionals ◽  
Task Sharing ◽  
Middle Income ◽  
Middle Income Countries

The explicit inclusion of mental health within the Sustainable Development Goals is a welcome development, borne out of powerful advocacy using public health, economic and human rights arguments. As funding comes on line for scale-up of evidence-based mental health care by task-sharing with primary care, it is time to take stock about care for people affected by severe mental illness (SMI). The existing evidence base for task shared care for SMI provides an imperative to get started, but is skewed towards relatively more affluent and urban populations in middle-income countries where specialist mental health professionals provide most of the care. Randomised, controlled trials and rigorous implementation research on task shared service models are underway which will go some way to improving understanding of the quality, safety, effectiveness and acceptability of more widely generalisable care for people with SMI. A sub-group of people with SMI have more complex and long-term needs for care, with a high risk of homelessness, imprisonment and human rights violations as family and social supports become overwhelmed. Case studies from non-governmental organisations provide examples of holistic approaches to rehabilitation, recovery and empowerment of people with SMI, but rigorous comparative studies are needed to identify the most efficient, effective and scalable approaches to care. Health system constraints are emerging as the over-riding barriers to successful task-sharing, highlighting a need to develop and evaluate chronic care models for people with SMI that succeed in reducing premature mortality, improving wellbeing and achieving better social outcomes. Addressing these evidence gaps is essential if task-sharing mental health care is going to deliver on its promise of promoting recovery for the full range of people affected by SMI.

scholarly journals Mental health system governance in Nigeria: challenges, opportunities and strategies for improvement

2016 ◽  
Vol 3 ◽  
Author(s):  
J. Abdulmalik ◽  
L. Kola ◽  
O. Gureje
Keyword(s):  
Mental Health ◽  
Health Care ◽  
Health Policy ◽  
Health System ◽  
Health Systems ◽  
Mental Health System ◽  
Middle Income ◽  
Middle Income Countries ◽  
Health System Governance ◽  
Low And Middle Income

IntroductionA health systems approach to understanding efforts for improving health care services is gaining traction globally. A component of this approach focuses on health system governance (HSG), which can make or mar the successful implementation of health care interventions. Very few studies have explored HSG in low- and middle-income countries, including Nigeria. Studies focusing on mental health system governance, are even more of a rarity. This study evaluates the mental HSG of Nigeria with a view to understanding the challenges, opportunities and strategies for strengthening it.MethodologyThis study was conducted as part of the project, Emerging Mental Health Systems in Low and Middle Income Countries (Emerald). A multi-method study design was utilized to evaluate the mental HSG status of Nigeria. A situational analysis of the health policy and legal environment in the country was performed. Subsequently, 30 key informant interviews were conducted at national, state and district levels to explore the country's mental HSG.ResultsThe existing policy, legislative and institutional framework for HSG in Nigeria reveals a complete exclusion of mental health in key health sector documents. The revised mental health policy is however promising. Using the Siddiqi framework categories, we identified pragmatic strategies for mental health system strengthening that include a consideration of existing challenges and opportunities within the system.ConclusionThe identified strategies provide a template for the subsequent activities of the Emerald Programme (and other interventions), towards strengthening the mental health system of Nigeria.

scholarly journals Cost of scaling up mental healthcare in low-and middle-income countries

2007 ◽  
Vol 191 (6) ◽  
pp. 528-535 ◽  
Author(s):  
Dan Chisholm ◽  
Crick Lund ◽  
Shekhar Saxena
Keyword(s):  
Low Income ◽  
Scale Up ◽  
Mental Healthcare ◽  
Scaling Up ◽  
Psychosocial Treatment ◽  
Economic Evaluations ◽  
Middle Income ◽  
Middle Income Countries ◽  
Per Capita ◽  
Low And Middle Income

BackgroundNo systematic attempt has been made to calculate the costs of scaling up mental health services in low-and middle-income countries.AimsTo estimate the expenditures needed to scale up the delivery of an essential mental healthcare package over a 10-year period (2006–2015).MethodA core package was defined, comprising pharmacological and/or psychosocial treatment of schizophrenia, bipolar disorder, depression and hazardous alcohol use. Current service levels in 12 selected low-and middle-income countries were established using the WHO–AIMS assessment tool. Target-level resource needs were derived from published need assessments and economic evaluations.ResultsThe cost per capita of providing the core package attarget coverage levels (in US dollars) ranged from $1.85 to $2.60 per year in low-income countries and $3.20 to $6.25 per year in lower-middle-income countries, an additional annual investment of $0.18–0.55 per capita.ConclusionsAlthough significant new resources need to be invested, the absolute amount is not large when considered at the population level and against other health investment strategies.

scholarly journals Planning and evaluating mental health services in low- and middle-income countries using theory of change

2016 ◽  
Vol 208 (s56) ◽  
pp. s55-s62 ◽  
Author(s):  
Erica Breuer ◽  
Mary J. De Silva ◽  
Rahul Shidaye ◽  
Inge Petersen ◽  
Juliet Nakku ◽  
...  
Keyword(s):  
Mental Health ◽  
Mental Healthcare ◽  
Theory Of Change ◽  
Middle Income ◽  
Middle Income Countries ◽  
Three Stages ◽  
Practical Guidance ◽  
Cross Country ◽  
Participatory Method ◽  
Country Specific

BackgroundThere is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings.AimsTo describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME).MethodToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13–22) stakeholders per workshop; and (c) review and refinement of the cross-country ToC by 18 PRIME consortium members.ResultsOne cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts.ConclusionsToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation.

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