Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low-and middle-income countries

BACKGROUND: Little 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. METHODS: A 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. RESULTS: The 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. CONCLUSIONS: The 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

Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries.

BACKGROUND: Little 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. METHODS: A 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. RESULTS: The 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. CONCLUSIONS: The 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

The context of mental health care scale-up across PRIME districts.

<p>MNS disorders = Mental, neurological and substance use disorders; URTI = Upper Respiratory Tract Infection; LRTI = Lower Respiratory Tract Infection; STIs = Sexually transmitted Diseases; HIV = Human Immunodeficiency Virus; AIDS = Acquired Immunodeficiency Syndrome; NCDs = Non-Communicable Disorders.</p

Community context for scaling up mental health care in districts in PRIME study countries.

<p>DOTS = Directly Observed Treatment – Short-course; NGO = Non-governmental organization, FBO = faith-based organisation, CBO = Community-based organization.</p

Health service organisation to support mental health care in PRIME districts.

<p>PHC = primary health care; Health Management Information System; MNS disorders = mental, neurological and substance use disorders; Community Health Workers; HIV = Human immunodeficiency virus; TB = tuberculosis; SMD = severe mental disorders.</p

Baseline mental health care in PRIME districts.

<p>PHC = Primary health care; MNS disorders = Mental, neurological and substance use disorders; NGO = non-governmental organisation; SMD = severe mental disorders; HIV = human immunodeficiency virus.</p

General and primary health care context for integrating mental health care in PRIME districts.

1<p>In Nepal, doctors and psychotropic medications are only available at the highest level of primary care, which is not locally accessible for the majority of the population and differs from the definition of PHC in the other country settings.</p>2<p>World Health Organisation's Essential Drug List.</p

Requirements for integrating mental health into primary health care [14]–[17].

<p>Requirements for integrating mental health into primary health care <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0088437#pone.0088437-Hanlon1" target="_blank">[14]</a>–<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0088437#pone.0088437-World3" target="_blank">[17]</a>.</p