Making complex interventions work in low resource settings: developing and applying a design focused implementation approach to deliver mental health through primary care in India

Abstract Background Globally, there is a large treatment gap for people with mental disorders, and this gap is especially extreme in Low and Middle Income Countries. This gap can be potentially bridged by integrating evidenced based mental health interventions into primary care, but there is little knowledge about how to do this well, especially in countries with weak health systems. Research into the best implementation approaches is a priority, but in order to do so, it is first necessary to adapt implementation science principles and tools for mental health services in low resource settings. Results The frameworks that have been used to implement evidence-based behavioral health and health care interventions in High Income Countries do not directly apply to contexts where resources and processes for service delivery and support do not exist. We propose an implementation approach for low resource settings, called design-focused implementation, emphasizing the design of delivery systems using systematic design methods as precursor to implementation in severely resource constrained environments. This approach draws from existing literature in design thinking, quality implementation, improvement science and evaluation and we describe its use in creating the processes, organizations and the enabling environment for integration of mental health service delivery into primary care in India. Conclusions Design-focused implementation will be useful for guiding research and practice in closing the implementation gap for a wide variety of complex interventions in low resource settings

Service user involvement for mental health system strengthening in India: a qualitative study

Background - There is a wide recognition that involvement of service users and their caregivers in health system policy and planning processes can strengthen health systems; however, most evidence and experience has come from high-income countries. This study aimed to explore baseline experiences, barriers and facilitators to service user-caregiver involvement in the emerging mental health system in India, and stakeholders’ perspectives on how greater involvement could be achieved. Methods - A qualitative study was conducted in Sehore district of Madhya Pradesh, India. In-depth interviews (n = 27) and a focus group discussion were conducted among service users, caregivers and their representatives at district, state and national levels and policy makers, service providers and mental health researchers. The topic guide explored the baseline situation in India, barriers and facilitators to service user and caregiver involvement in the following aspects of mental health systems: policy-making and planning, service development, monitoring and quality control, as well as research. Framework analysis was employed. Results - Respondents spoke of the limited involvement of service users and caregivers in the current Indian mental health system. The major reported barriers to this involvement were (1) unmet treatment and economic needs arising from low access to mental health services coupled with the high burden of illness, (2) pervasive stigmatising attitudes operating at the level of service user, caregiver, community, healthcare provider and healthcare administrators, and (3) entrenched power differentials between service providers and service users. Respondents prioritised greater involvement of service users in the planning of their own individual-level mental health care before considering involvement at the mental health system level. A stepwise progression was endorsed, starting from needs assessment, through empowerment and organization of service users and caregivers, leading finally to meaningful involvement. Conclusions - Societal and system level barriers need to be addressed in order to facilitate the involvement of service users and caregivers to strengthen the Indian mental health system. Shifting from a largely ‘provider-centric’ to a more ‘user-centric’ model of mental health care may be a fundamental first step to sustainable user involvement at the system level

COVID-19 Policies and Women in Informal Work in India - A REBUILD Scoping Report

The COVID-19 pandemic has wrought a global socio-economic crisis, with profound implications for the wellbeing of individuals, households and communities. It has further deepened existing social inequalities, heightened the risks for genderbased violence (GBV), and limited the access to health services, including sexual and reproductive health among marginalized groups. As countries move to mitigate the health threats of the COVID-19 pandemic, immediate policy action has often led to large economic and social costs that are majorly borne by vulnerable and low-income populations, among whom women are the most affected. So far, immediate, state-led policy responses focused on COVID-19 clinical management, quarantine guidelines, mobility restrictions and lockdowns, protective and promotive social safety, and economic stimulus packages

Making complex interventions work in low resource settings: developing and applying a design focused implementation approach to deliver mental health through primary care in India

Abstract Background Globally, there is a large treatment gap for people with mental disorders, and this gap is especially extreme in Low and Middle Income Countries. This gap can be potentially bridged by integrating evidenced based mental health interventions into primary care, but there is little knowledge about how to do this well, especially in countries with weak health systems. Research into the best implementation approaches is a priority, but in order to do so, it is first necessary to adapt implementation science principles and tools for mental health services in low resource settings. Results The frameworks that have been used to implement evidence-based behavioral health and health care interventions in High Income Countries do not directly apply to contexts where resources and processes for service delivery and support do not exist. We propose an implementation approach for low resource settings, called design-focused implementation, emphasizing the design of delivery systems using systematic design methods as precursor to implementation in severely resource constrained environments. This approach draws from existing literature in design thinking, quality implementation, improvement science and evaluation and we describe its use in creating the processes, organizations and the enabling environment for integration of mental health service delivery into primary care in India. Conclusions Design-focused implementation will be useful for guiding research and practice in closing the implementation gap for a wide variety of complex interventions in low resource settings

India’s Policy Response to COVID-19 and the Gendered Impact on Urban Informal Workers in Delhi NCR: Thematic Brief 5: Policy Responses and Impact on Sexual and Reproductive Health

With the immediate impact of the pandemic on the healthcare sector, medical centres across the country were burdened by the need to respond to the emergency health contours, resulting in tremendous pressure on hospitals. An oxygen crisis, particularly in NCR, created a greater chasm between the Centre and certain states like Delhi; with the country’s judiciary stepping in at both the High Court and Supreme Court levels to mediate. In the face of rising COVID-19 fatalities, the discussion around Sexual and Reproductive Health and Rights (SRHR) receded into the background. In both waves, issues such as disrupted supply of over the counter (OTC) medicines, restricted footfall at chemists and general stores, fear of COVID-19, and limited access to non-COVID-19 healthcare further impacted SRH services across the country, with reports of a dip in institutional deliveries even in urban centres like Delhi emerging during this time. Not only were OTCs difficult to find within India but the country also limited the export of 26 pharmaceutical ingredients and medicines during this time. One among these was progesterone, which is used in contraceptive pills and IUDs

India’s Policy Response to Covid-19 and the Gendered Impact on Urban Informal Workers in Delhi NCR: Introductory Brief

A year into the pandemic, the devastating impacts have disrupted social and economic infrastructure and have furthermarginalized millions of people. In many ways, the epicentre of the pandemic was felt among the urban informal workers in the country, particularly women. Already existing at the edge of precarity with respect to livelihood, social security, and shelter - all of which lay on the spectrum of informality - the humanitarian crisis brought about by the pandemic further widened the fault lines of their pre-existing social and economic vulnerabilities. As the government urged people to stay at home and the economic cogwheels of the country came to a grinding halt, India witnessed one of the worst recessions since independence, with the economy shrinking by a historic 7.3% in the first year of COVID. Overnight, urban informal workers across the country lost their jobs and incomes. As a result of the loss in livelihood and income, it is estimated that about 400 million people, working in the informal economy in India, were at the “risk of falling deeper into poverty”. During this period, the number of people living below the minimum wage threshold of Rs 375 per day had increased by 230 million

India’s Policy Response to COVID-19 and the Gendered Impact on Urban Informal Workers in Delhi NCR: Thematic Brief 1: Pandemic and the Urban Governance Structures

The report published by Center for Policy Research on urban governance during the pandemic looked at the jurisdictional coverage of various actors in the ecosystem in certain regions in the country, including Delhi, pointing out the need for resilient infrastructures and greater authority for local governance. It also highlighted the disproportionate impact on vulnerable populations like street vendors and migrant workers, delineating the need for special provisions addressing current and future challenges. The pandemic changed the contours of service delivery across the country, with structures rearranging themselves for an unprecedented crisis response. This section details a few key actors that played a role in the deployment of the Delhi NCR’s COVID-19 responses

India’s Policy Response to COVID-19 and the Gendered Impact on Urban Informal Workers in Delhi NCR: Thematic Brief 2: Policy Responses and Impact on Economic Well-Being

The pandemic-induced lockdown had a severe impact on the employment rate in the country, with most studies indicating that urban women being the worst affected. A report by the Centre for Monitoring Indian Economy (CMIE) noted that while urban women were the most affected during the 1st wave, accounting for 39% of the total job loss, the impact on employment was more on urban men in the 2nd wave. Though the focus on social security measures for ensuring the economic well-being of migrant workers was more during the 1st wave, as per the KIIs, several experts alluded that the monetary needs were much higher in the 2nd wave. However, much of the government’s as well as CSOs’ resources were allocated towards addressing the immediate health concerns due to the high numbers of infection, especially in Delhi NCR. Since the onset of the pandemic, the household bank deposits to GDP ratio have been declining while the debt to GDP ratio has been increasing, confirming a deep financial impact of the pandemic. Different studies have also commented on the low savings and financial insecurity among informal workers having led to accrued indebtedness during this period. For casual workers requiring ICU hospitalization, the annual wage fell short for 90% of workers and for hospital isolation, the costs were unaffordable for 48% of workers. Among self-employed workers, about 66% and 27% workers’ annual wages could not meet ICU hospitalization and home isolation respectively. Multiple factors added to the economic vulnerability of urban informal workers since the onset of the pandemic leading to food insecurity, poor access to safe living and healthcare. Due to this broad ranging impact, access to liquid cash was the need of the hour for millions of urban informal workers. This section, therefore, squarely focusses on economic well being in terms of access to cash either through employment or as welfare transfers from the government

India’s Policy Response to COVID-19 and the Gendered Impact on Urban Informal Workers in Delhi NCR: Thematic Brief 3: Policy Responses and the Impact on Food Security

The lockdown and subsequent labour exodus disrupted the supply chain of essential commodities, with grain markets being closed and oil and rice mills operating at limited strength in many cities. This also impacted the transport of goods to wholesalers and retailers. In June 2020, the food supply situation was further complicated by a cyclone in eastern India. At this time, the Delhi government submitted in court that it had deposited money with the Food Corporation of India for release of grains, rice and other essentials, but noted that there was a “glitch in the supply chain” as ration had to be diverted by the FCI to meet the needs of states impacted by the cyclone. The impact was also seen in access to rations owing to loss of income, and curtailed supply chains leading to a spike in food inflation. Researchers have also commented on the relationship between food insecurity and poor mental health of women. A researcher, who was also helping with the Hunger Helpline Centre in Delhi NCT, mentioned during a KII. There was a palpable sense of increased mental stress noticed among women as they felt a larger sense of responsibility towards ensuring there is enough food for everyone in the household. Furthermore, various studies have also noted that gender norms often play a role in the distribution of food within a household, with women often eating the least, last and which gets significantly worse during times of economic hardships and other public crises. This also has a severe impact on their health and nutrition