Lessons from case studies of integrating mental health into primary health care in South Africa and Uganda

Abstract

BackgroundWhile decentralized and integrated primary mental healthcare forms the core of mental health policies in many low- and middle-income countries (LMICs), implementation remains a challenge. The aim of this study was to understand how the use of a common implementation framework could assist in the integration of mental health into primary healthcare in Ugandan and South African district demonstration sites. The foci and form of the services developed differed across the country sites depending on the service gaps and resources available. South Africa focused on reducing the service gap for common mental disorders and Uganda, for severe mental disorders.MethodA qualitative post-intervention process evaluation using focus group and individual interviews with key stakeholders was undertaken in both sites. The emergent data was analyzed using framework analysis.ResultsSensitization of district management authorities and the establishment of community collaborative multi-sectoral forums assisted in improving political will to strengthen mental health services in both countries. Task shifting using community health workers emerged as a promising strategy for improving access to services and help seeking behaviour in both countries. However, in Uganda, limited application of task shifting to identification and referral, as well as limited availability of psychotropic medication and specialist mental health personnel, resulted in a referral bottleneck. To varying degrees, community-based self-help groups showed potential for empowering service users and carers to become more self sufficient and less dependent on overstretched healthcare systems. They also showed potential for promoting social inclusion and addressing stigma, discrimination and human rights abuses of people with mental disorders in both country sites.ConclusionsA common implementation framework incorporating a community collaborative multi-sectoral, task shifting and self-help approach to integrating mental health into primary healthcare holds promise for closing the treatment gap for mental disorders in LMICs at district level. However, a minimum number of mental health specialists are still required to provide supervision of non-specialists as well as specialized referral treatment services.

Integrating mental health care services in primary health care clinics: a survey of primary health care nurses’ knowledge, attitudes and beliefs

“…These benefits are that if mental health services are integrated into general health care, the burden of mental health is reduced in the community; people are treated holistically; the treatment gap is reduced; access to mental health services is enhanced; there is respect for human dignity and good health outcomes. 22 Petersen et al 23 recommended that district management authorities should be educated on what integration entails so that they develop the political will-power to strengthen mental health services provision in PHC clinics. They also supported the implementation framework of task-shifting, where psychiatric trained nurses from the hospital are deployed to work in PHC clinics in order to improve mental health care services.…”

“…They also supported the implementation framework of task-shifting, where psychiatric trained nurses from the hospital are deployed to work in PHC clinics in order to improve mental health care services. 23 …”

Mental health policy implementation as an integral part of primary health care services in Oshana region, Namibia

“…In this study, 98% (49) of the participants (registered nurse) indicated that they had never been supervised in the area of mental health to enable them to implement the policy. According to Dreyer, [24] there is a trend in policy implementation of ignoring the policy implementer, and it is common to observe a gap between what is planned and what actually occurs as a result of a policy.…”

“…[1] As a result, programme implementers could choose one policy to implement in this case, while ignoring others which, in this case, are the mental health policy. [24] This study indicated that training of general health care workers would equip them with the skills needed to manage cases of mental illness appropriately. Accordingly, the detection and management of mental health problems should be improved so that people will be more willing to access care, care will be brought closer to the communities, there will be more human resources and there will likely be fewer patients.…”

Policy, power, stigma and silence: Exploring the complexities of a primary mental health care model in a rural South African setting

“…In resource-poor settings, the model focuses on improving the recognition and treatment of people with mental illnesses within primary health care clinics, alongside the treatment of more complicated cases at specialised centres. Other approaches include community collaborative models that feature multi-sectoral collaborations between health services, user and family groups, NGOs and multi-sectoral collaborative forums that draw on participation from social welfare sectors, as well as the general community (Petersen & Ssebunnya, 2011). Community collaborative approaches rely on task shifting and sharing strategies, which increases access to treatment for selected priority illnesses, such as psychotic disorders, or common mental disorders (CMD).…”