Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries

Abstract

BackgroundLittle is known about how to tailor implementation of mental health services in low- and middle-income countries (LMICs) to the diverse settings encountered within and between countries. In this paper we compare the baseline context, challenges and opportunities in districts in five LMICs (Ethiopia, India, Nepal, South Africa and Uganda) participating in the PRogramme for Improving Mental health carE (PRIME). The purpose was to inform development and implementation of a comprehensive district plan to integrate mental health into primary care.MethodsA situation analysis tool was developed for the study, drawing on existing tools and expert consensus. Cross-sectional information obtained was largely in the public domain in all five districts.ResultsThe PRIME study districts face substantial contextual and health system challenges many of which are common across sites. Reliable information on existing treatment coverage for mental disorders was unavailable. Particularly in the low-income countries, many health service organisational requirements for mental health care were absent, including specialist mental health professionals to support the service and reliable supplies of medication. Across all sites, community mental health literacy was low and there were no models of multi-sectoral working or collaborations with traditional or religious healers. Nonetheless health system opportunities were apparent. In each district there was potential to apply existing models of care for tuberculosis and HIV or non-communicable disorders, which have established mechanisms for detection of drop-out from care, outreach and adherence support. The extensive networks of community-based health workers and volunteers in most districts provide further opportunities to expand mental health care.ConclusionsThe low level of baseline health system preparedness across sites underlines that interventions at the levels of health care organisation, health facility and community will all be essential for sustainable delivery of quality mental health care integrated into primary care.

Stakeholder analysis of the Programme for Improving Mental health carE (PRIME): baseline findings

“…Specifically, the Ministry of Social and Labour Affairs, the Ministry of Women and Children Affairs and the Ministry of Youth and Sport in Ethiopia; the National AIDS Control Organisation in India; the Ministry of Women, Children and Social Welfare, and the Ministry of Peace and Reconstruction in Nepal; the Department of Social Development in South Africa have been identified, and could be explored for strengthening collaborations. Although specialist mental health practitioners' (psychiatrists and psychologists) across PRIME countries were commonly believed to have high levels of support, general health practitioners (primary health care workers, community and voluntary health workers) were believed to have low-medium levels of support and interest due to being overburdened, which has also been widely documented [15,16,24,25]. This has important implications for integrating mental health into public health facilities, and creates opportunities for sensitising human resources for mental health, strategies of which are also well documented [20,24].…”

“…PRIME's research programme consists of three phases over a 6-year period: Inception Phase, Implementation Phase and Scaling Up Phase [14]. As part of the Inception Phase, formative research was conducted including literature reviews, a situation analysis of mental health systems [15], in-depth interviews and focus group discussions with stakeholders [16] and Theory of Change (ToC) workshops [17]. During the Inception Phase, the following systematic steps were followed in order to collect the cross-country data required for qualitative content analysis of stakeholder perceptions.…”

“…PRIME does this by advocating for evidence-based decision-making, and by promoting the uptake of its implementation research amongst knowledge users, including health and related sector policymakers and practitioners, through a dedicated 'Research Uptake Strategy' [14]. PRIME is piloting the scale-up of mental health services in one District in each country: Sodo in Ethiopia, Sehore in India, Chitwan in Nepal, Dr Kenneth Kaunda in South Africa and Kamuli in Uganda [15].…”

Incorporating services for common mental disorders and substance use disorders for people living with HIV along the HIV treatment cascade

“…The needed services (Table 1) are also required long-term, since CMDs and SUDs are chronic, relapsing medical conditions. Based on the need for continued engagement with the health care system, integration of services for CMDs and SUDs along the HIV treatment cascade provides for optional clinical outcomes, is cost-effective, and impacts epidemic control of HIV infection [94,95].…”

The role of mental health in primary prevention of sexual and gender-based violence

“…Research on the integration of mental health into primary care is growing (15–18) and these innovations should include attention to providing mental health services for SGBV survivors which is particularly challenging in resource-poor settings (19). Some studies have found using lay people to deliver CBT to SGBV survivors in extremely fragile settings to be effective in alleviating mental health symptoms (20–22).…”