This research explored the history, effectiveness and feasibility of primary-level health
workers (PHWs) in delivering care for mental, neurological and substance use (MNS)
disorders in India, to better inform the organisation and delivery of mental health
services at primary care and community levels.
This thesis examined evidence for the effectiveness of PHWs in mental healthcare in
low- and middle-income countries (LMICs) (Cochrane review – 38 included studies),
and then focused on India. Seventeen oral history interviews described the
experiences of integrating mental healthcare into primary care and 72 case-studies
explored government and non-governmental models of PHW-delivered mental
healthcare initiatives and their human resources.
PHWs can be effective in delivering care for MNS disorders in LMICs. The case studies
identified heterogeneous collaborative care models in India, most of which were
delivered through community- rather than government- primary care. Other models
(training and referral) which have less evidence for effectiveness were more
widespread, and included the government model which was perceived as having
‘failed’. A new model was identified: community outreach services which were
specialist-led but PHW-delivered.
LHWs and care managers seemed more feasible and appropriate care managers than
PHC doctors across models and provided more holistic psychosocial support.
Specialists were valuable for PHWs’ and care managers’ training and ongoing support.
Barriers to mental health care integration are discussed.
Future research priorities are to assess whether variations of collaborative models are
similarly effective to those described in HICs and whether these are feasible and
effective if implemented at scale. Priorities for improving the DMHP would be to
consider deploying care managers and LHWs and reorient as well as incentivise
specialists to support them. Better inter-sectoral collaborations, health system
strengthening and technical support at central- and state-government levels may
improve leadership, implementation and evaluation of mental healthcare integration
into primary care across India
