[#WHD2017 Africa Blog Series] Inspiring African innovations: Inshuti Mu Buzima, Rwanda
This blog is part of our series celebrating World Health Day 2017. This year's theme is Depression: Let's Talk and we're showcasing inspiring innovations addressing depression across Africa.
MHIN Africa innovation on depression 2: Inshuti Mu Buzima: An expanded MESH model to address mental disorders in Rwanda (IMB)
IMB aims to integrate mental health services into primary care using community-based mentorship and enhanced supervision.
Tell us about your country’s context and the circumstances that inspired your innovation
Before the 1994 genocide in Rwanda, mental health care was limited to only one hospital in Kigali, Ndera. There were no local training programs in psychology or psychiatry and no national mental health policy. People with mental illness were often jailed or taken in by churches who rejected the biomedical causes of mental illness, and mental illness has historically been very stigmatized and misunderstood. Nearly one million people were killed during a period of 100 days of the genocide. Consequently, one-seventh of the country's population and 30% of children were left with no socio-economic resources or health system. The genocide increased the burden of mental disorders such as post-traumatic stress disorder, depression, somatoform disorder, psychosis and anxiety among victims, witnesses, perpetrators, and returning refugees1. To address the need for additional human resources, training programs for mental health nurse and clinical psychology graduate programs started at the University of Rwanda in 1998.
Rwanda’s first National Mental Health policy was developed in 1995. Today, it prioritizes decentralization and integration of mental health care into primary health care, and promotes a community-based health care approach. Within this framework, Inshuti Mu Buzima sought to implement the MOH’s policy starting in 2011.
What aspect of your project are you most excited about? How is the project innovative or unique?
Developed by IMB and the Rwanda Ministry of Health2, Mentoring and Enhanced Supervision at Health Centers - Mental Health (MESH MH) is a unique supervision model that decentralizes primary mental health care services into community health centers through task-shifting to general health nurses, involving a combination of hands on training, ongoing clinical mentorship, and quality improvement activities. General health center nurses receive an intensive, forty-hour training on how to identify and manage four major neuropsychiatric disorders: major depressive disorder, schizophrenia, bipolar disorder, and epilepsy. Community health workers also receive sensitization and training on these disorders. After the training, general nurses receive regular supervision by trained Rwandan mental health nurse mentors for two years, promoting sustainability of the model. A mental health supervision checklist is used to assist with clinical mentoring and ensure standardization of activities across a number of clinical domains. Quality of care is defined by the successful completion of checklist items during mental health clinical evaluations. During supervision visits, the nurse mentor discusses ways to identify issues in the system of care and “quality gaps”, formulate specific plans to improve patient care, improve referral pathways, and coordinate between services such as procuring mental health medication through supply chain3.
Have you noticed an impact ‘on the ground’? What is the best feedback you have received (from service users, team members, or otherwise)?
The impact of the MESH MH innovation is the successful integration of care packages for severe mental disorders and increased access to safe, effective, and quality mental health services in a primary health care setting in rural areas with limited resources. To date, 48 nurses at 19 health centers have been trained to provide mental health care, and 946 community health workers have been trained to identify mental health disorders, reduce stigma, and support patient care in the community. MESH MH Health Centers have performed 15,744 patient visits, and 2,239 unique patients have received care at health centers. MESH MH is currently being implemented at all 19 health centers in Burera district, which has a population of approximately 340,000.
Challenges and lessons through the implementation process were shared with government decision makers, who reviewed mental health essential medication list as result from this innovation.
The general health center nurses and patient experiences are very favorable thus far:
"The trainings taught me that mentally ill patients are not dangerous in any way. so, knowing that they are not dangerous and that it is an illness like other ordinary illnesses, I started to feel free to talk with them, in short I felt that a mentally ill patient is a patient like any other patient." – Nurse, mucaca Health Center
One patient from Mucaca Health Center was quoted as saying:
“It (community-based mental health care) cuts short the journey I used to make. Now there is no problem because I am getting the mediation from near my village.”
The MESH MH model includes medication management, psychoeducation, and community support. To further increase the effectiveness of the intervention and based on findings thus far, PIH/IMB is expanding treatment options to include psychotherapy for depression treatment in Burera, in collaboration with the MOH Mental Health Division. The therapeutic modality will be an adaptation of the World Health Organization Problem Management Plus (PM+) intervention4. PM+ will be integrated into the foundational MESH MH services already being provided. Given the success of MESH MH in Burera district, Inshuti Mu Buzima is currently exploring ways to scale the intervention to the other two districts (Kayonza and Kirehe), in which the organization does health systems strengthening work in Rwanda. In addition, the MOH Mental Health Division has expressed an interest in having the MESH MH interventions implemented in all district health care systems of Rwanda.
What is the one message about depression you want people to take away from your innovation?
Mental health disorders continue to pose substantial burden on families, communities and health systems. Depression has negatively affected the country economically, leading to many people suffering from loss of productivity at work and functional impairment in performing daily tasks. Treating depression is crucial to not only improve the lives of patients, but also to improve the wellbeing and productivity of a country.
- Bolton P, Neugebauer R, Ndogoni L. Prevalence of depression in rural Rwanda based on symptom and functional criteria. J Nerv Ment Dis. 2002 Sep;190(9):631–7.
- Republic of Rwanda Ministry of Health [Internet]. 2015 [cited 2017 Mar 25]. Available from: http://www.moh.gov.rw/index.php?id=2
- Smith SL, Misago CN, Osrow RA, Franke MF, Iyamuremye JD, Dusabeyezu JD, et al. Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol. BMJ Open. 2017 Feb 1;7(2):e014067.
- World Health Organization. Problem Management Plus (PM+): Individual psychological help for adults impaired by distress in communities exposed to adversity. (Generic field-trial version 1.0). [Internet]. Geneva, WHO; 2016 [cited 2017 Jan 18]. Available from: http://www.who.int/mental_health/emergencies/problem_management_plus/en/
For more African innovations featured in this series, please visit the [#WHD2017 Africa Blog Series].