Moving towards universal health coverage for mental disorders in Ethiopia

Background: People with mental disorders in low-income countries are at risk of being left behind during efforts to expand universal health coverage. Aims: To propose context-relevant strategies for moving towards universal health coverage for people with mental disorders in Ethiopia. Methods: We conducted a situational analysis to inform a SWOT analysis of coverage of mental health services and financial risk protection, health system characteristics and the macroeconomic and fiscal environment. In-depth interviews were conducted with five national experts on health financing and equity and analysed using a thematic approach. Findings from the situation analysis and qualitative study were used to develop recommended strategies for adequate, fair and sustainable financing of mental health care in Ethiopia. Results: Opportunities for improved financing of mental health care identified from the situation analysis included: a significant mental health burden with evidence from strong local epidemiological data; political commitment to address that burden; a health system with mechanisms for integrating mental health into primary care; and a favourable macro-fiscal environment for investment in human capabilities. Balanced against this were constraints of low current general government health expenditure, low numbers of mental health specialists, weak capacity to plan and implement mental health programmes and low population demand for mental health care. All key informants referred to the under-investment in mental health care in Ethiopia. Respondents emphasised opportunities afforded by positive rates of economic growth in the country and the expansion of community-based health insurance, as well as the need to ensure full implementation of existing task-sharing programmes for mental health care, integrate mental health into other priority programmes and strengthen advocacy to ensure mental health is given due attention. Conclusion: Expansion of public health insurance, leveraging resources from high-priority SDG-related programmes and implementing existing plans to support task-shared mental health care are key steps towards universal health coverage for mental disorders in Ethiopia. However, external donors also need to deliver on commitments to include mental health within development funding. Future researchers and planners can apply this approach to other countries of sub-Saharan Africa and identify common strategies for sustainable and equitable financing of mental health care

Developing a mental health care plan in a low resource setting: the theory of change approach

Abstract Background Scaling up mental healthcare through integration into primary care remains the main strategy to address the extensive unmet mental health need in low-income countries. For integrated care to achieve its goal, a clear understanding of the organisational processes that can promote and hinder the integration and delivery of mental health care is essential. Theory of Change (ToC), a method employed in the planning, implementation and evaluation of complex community initiatives, is an innovative approach that has the potential to assist in the development of a comprehensive mental health care plan (MHCP), which can inform the delivery of integrated care. We used the ToC approach to develop a MHCP in a rural district in Ethiopia. The work was part of a cross-country study, the Programme for Improving Mental Health Care (PRIME) which focuses on developing evidence on the integration of mental health in to primary care. Methods An iterative ToC development process was undertaken involving multiple workshops with stakeholders from diverse backgrounds that included representatives from the community, faith and traditional healers, community associations, non-governmental organisations, Zonal, Regional and Federal level government offices, higher education institutions, social work and mental health specialists (psychiatrists and psychiatric nurses). The objective of this study is to report the process of implementing the ToC approach in developing mental health care plan. Results A total of 46 persons participated in four ToC workshops. Four critical path dimensions were identified: community, health facility, administrative and higher level care organisation. The ToC participants were actively engaged in the process and the ToC encouraged strong commitment among participants. Key opportunities and barriers to implementation and how to overcome these were suggested. During the workshops, a map incorporating the key agreed outcomes and outcome indicators was developed and finalized later. Conclusions The ToC approach was found to be an important component in the development of the MHCP and to encourage broad political support for the integration of mental health services into primary care. The method may have broader applicability in planning complex health interventions in low resource settings

Recognition of depression by primary care clinicians in rural Ethiopia

BACKGROUND: Depression is a common health condition affecting up to a third of patients attending primary care, where most of the care for people with depression is provided. Adequate recognition of depression is the critical step in the path to effective care, particularly in low income countries. As part of the Programme for Improving Mental healthcare (PRIME), a project supporting the implementation of integrated mental healthcare in primary care, we evaluated the level of recognition of depression by clinicians working in primary care in rural Ethiopia prior to in service training. We hypothesised that the detection rate of depression will be under 10% and that detection would be affected by gender, education and severity of depression. METHODS: Cross-sectional survey in eight health centres serving a population of over 160,000 people. A validated version of the 9-item patient health questionnaire (PHQ-9) was administered as an indicator of probable depression. In addition, primary care clinicians completed a clinician encounter form. Participants were consecutive primary care attendees aged 18 years and above. RESULTS: A total of 1014 participants were assessed. Primary care clinicians diagnosed 13 attendees (1.3%) with depression. The PHQ9 prevalence of depression at a cut-off score of ten was 11.5% (n = 117), of whom 5% (n = 6/117) had received a diagnosis of depression by primary care clinicians. Attendees with higher PHQ scores and suicidality were significantly more likely to receive a diagnosis of depression by clinicians. Women (n = 9/13) and participants with higher educational attainment were more likely to be diagnosed with depression, albeit non-significantly. All cases diagnosed with depression by the clinicians had presented with psychological symptoms. CONCLUSION: Although not based on a gold standard diagnosis, over 98% of cases with PHQ-9 depression were undetected. Failure of recognition of depression may pose a serious threat to the scale up of mental healthcare in low income countries. Addressing this threat should be an urgent priority, and requires a better understanding of the nature of depression and its presentation in rural low-income primary care settings

Non-fatal suicidal behaviour in rural Ethiopia: a cross-sectional facility- and population-based study

Background: Injury related to self-harm is one of the leading causes of global disease burden. As a formative work for a programme to implement comprehensive mental healthcare in a rural district in Ethiopia, we determined the 12-month prevalence of non-fatal suicidal behaviour as well as factors associated with this behaviour to understand the potential burden of the behaviour in the district. Method: Population-based (n = 1485) and facility-based (n = 1014) cross-sectional surveys of adults, using standardised, interview-based measures for suicidality (items on suicide from the Composite International Diagnostic Interview), depressive symptoms (the Patient Health Questionnaire) and alcohol use disorders (Alcohol Use Disorder Investigation Test; AUDIT). Results: The overall 12-month prevalence of non-fatal suicidal behaviour, consisting of suicidal ideation, plan and attempt, was 7.9 % (95 % Confidence Interval (CI) = 6.8 % to 8.9 %). The prevalence was significantly higher in the facility sample (10.3 %) compared with the community sample (6.3 %). The 12-month prevalence of suicide attempt was 4.4 % (95 % CI = 3.6 % to 5.3 %), non-significantly higher among the facility sample (5.4 %) compared with the community sample (3.8 %). Over half of those with suicidal ideation (56.4 %) transitioned from suicidal ideation to suicide attempt. Younger age, harmful use of alcohol and higher depression scores were associated significantly with increased non-fatal suicidal behaviours. The only factor associated with transition from suicidal ideation to suicide attempt was high depression score. Only 10.5 % of the sample with suicidal ideation had received any treatment for their suicidal behaviour: 10.8 % of the community sample and 10.2 % of the facility sample. Although help seeking increased with progression from ideation to attempt, there was no statistically significant difference between the groups. Conclusion: Non-fatal suicidal behaviour is an important public health problem in this rural district. A more in-depth understanding of the context of the occurrence of the behaviour, improving access to care and targeting depression and alcohol use disorder are important next steps. The role of other psychosocial factors should also be explored to assist the provision of holistic care

Development of a scalable mental healthcare plan for a rural district in Ethiopia.

BACKGROUND: Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority. AIMS: To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia. METHOD: A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation). RESULTS: The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability. CONCLUSIONS: The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC