Innovation summary

Haiti suffers from the highest poverty levels and health morbidity indicators in the Western Hemisphere and, since the 2010 earthquake, continues to have very limited mental health services. Zanmi Lasante (ZL) is a local organization serving a catchment area of over 1.3 million people through 11 government hospitals and clinics in the Central Plateau and Lower Artibonite valley (also see: http://www.pih.org/country/haiti)

Following the 2010 Haiti earthquake, ZL, in partnership with its sister organization, Partners In Health (PIH), mounted a mental health response. Over the past six years ZL developed a community-based mental health system integrated into primary care services across this catchment area. ZL created and trained on curricula, materials, and protocols tailored to different providers (traditional healers, community health workers, psychologists and social workers, nurses, and physicians) across four care pathways: depression, epilepsy, psychotic disorders, and child and adolescent mental health problems. Care is given through a task-sharing model across different provider levels and integrated into primary care services at ZL. Alongside, the has team developed a system for sustained clinical supervision of providers and a sustainable Monitoring, Evaluation and Quality (MEQ) system for routine electronic mental health data collection. The goals of these initiatives are to demonstrate impact and outcomes and support continuous quality improvement initiatives to ensure patient safety1–3.

Impact summary

Between January- October 2016:

  • ZL enrolled 2,168 unique patients for mental health care across 11 facilities at 6,961 encounters
  • ZL trained 270 frontline providers, including psychologists, physicians, nurses, social workers, community health workers, and medicine trainees (residents)
  • A cost-effectiveness analysis has been completed and results are forthcoming 

 

Innovation should have as a main goal to improve people’s lives, and this is what we’re doing for people living in rural and poor areas in Haiti.4

 

- Eddy Eustache, or Père Eddy - Director of Mental Health for Zanmi Lasante

Innovation details

Zanmi Lasante has worked with the Haitian Ministry of Health (Ministère de la Santé Publique et de la Population--MSPP) in Haiti since 1987, creating and reinforcing a service delivery platform to deliver comprehensive HIV/TB care across 11 facilities serving a catchment area of over 1.3 million people in the Central Plateau and Lower Artibonite Valley. When Haiti was struck by a devastating earthquake in 2010, ZL collaborated with the MSPP to develop a model community based service for the nation and more formally expanded its own Mental Health Program1–3,5.   

ZL has methodically built up a comprehensive system of integrated mental health services encompassing interpersonal therapy (IPT) and other treatment modalities6. Historically, the problem with acute disaster responses in low-resource settings, and as they relate to mental health, has been that they have often tended to be carried out with insufficient attention to the key components necessary for sustainable delivery of care. The systems approach piloted by ZL in Haiti provides a comprehensive and innovative approach to implementation that could be replicated in other resource-limited settings, including other Partners In Health sites.

Key components of the work include: 

  • Developing or adapting and testing screening tools for depression, epilepsy/seizures, psychosis/bipolar, and child/adolescent developmental and behavioural disorders consistent with the WHO mhGAP Intervention Guide
  • Training providers (physicians, nurses, psychologists/social workers) across the continuum of care on curriculums, materials, and protocols iteratively developed across four priority disorder care pathways
  • Providing refresher trainings for all cadres of providers across all 11 sites, with a focus on patient safety and quality improvement
  • Integrating mental health curriculum within the residency program at the Hopital Universitaire de Mirebalais (HUM) and the Family Medicine residency program at the Hopital St. Nicholas of St Marc
  • Including community health workers &traditional healers in mental health screening, referral, and treatment tasks
  • Developing a system for sustained supervision, including Interpersonal Therapy (IPT) supervision and training with IPT world expert Helena Verdeli from Teachers College Columbia University
  • Developing a system for monitoring and evaluation and data collection
  • Deepening the data collection system to allow for the collection of patient-level data and tracking of symptoms and clinical outcomes over time in an electronic database, using data to drive quality improvement
  • Deepening the system for sustained supervision, with a focus on ensuring patient safety
  • Reducing stigma related to mental illness among providers, families and local communities
  • Working closely with the MSPP in implementation and advocacy

ZL is now working closely with the MSPP to build on this work and ensure quality is equitable across the system by:

  • Developing a plan to roll out a Psychiatry Residency program at HUM, in recognition of the importance of formal education and accreditation in attracting young providers to mental health work
  • Informing national mental health planning

 

Key drivers

Use of local personnel in a task-shared approach and focus on adaptation of materials to local context

  • A commitment to transfer knowledge and skills to existing institutions and local implementers and providers, and the reliance on Haitian personnel to assume clinical and management roles
  • Reliance on and continuous use of qualitative user feedback
  • Use of cultural psychological, ethnographic, and participatory methods in pathway and tools design7
  • Inclusion of community health workers and other staff across continuum of care.

Partnership across the PIH Network and with the MSPP

  • ZL and PIH are collaborative partners across all aspects of program implementation. They have been sister organizations for over 25 years, and have a deep and sustainable model of working together. Accompaniment is at the forefront of all of our work.
  • ZL/PIH also have a longstanding partnership with the MSPP and have developed trust and goodwill over almost thirty years in Haiti.1,5,8,9

Challenges

Current challenges for Mental Health Care in Haiti:

  • Stigma, leading to limited resources for mental health services and discrimination against people suffering from mental illness in the community
  • Need for financial support and buy-in from stakeholders
  • Very small number of mental health specialists and a weak system for formal education in mental health/psychiatry
  • Successful uptake by care providers can be affected by socio-economic and other barriers
  • Risk to patients and need for patient safety
  • Fidelity of data collected due to poor documentation and time consuming nature of data reporting and collection
  • Overburdening of providers due to shortage of human resources. Furthermore, sustained supervision, monitoring evaluation and quality improvement requires attention to detail and a robust team; human resource shortages can be a barrier to this
  • Need for political will - our work across partnerships requires careful consideration of stakeholder involvement, limitations, interests and capabilities 

 

Continuation

ZL’s approach serves as a strong model for the nation and there is hope that it can be shared outside of ZL’s catchment area. In September 2016, The Pan American Health Organization (PAHO) assessed the ZL health system to be “culturally adapted, acceptable and effective.”

Partnership with the medical education sector in Haiti, particularly the residency at Mars and Klein Hospital, will ensure the integration of the curriculum and practical training for generalist practitioners – the future of the larger Haitian health system.

This work is also a model for mental health service integration across other low resource countries where PIH works.  Adaptation of the Haiti curriculum and materials to other PIH sites is underway, and could be further adapted for other NGOs working with different health systems and countries. 

 

Evaluation methods

The intervention was evaluated using quantitative, qualitative, systems, and cost data.

The primary clinical outcome was the Zanmi Lasante Depression Symptom Inventory (ZLDSI) score (depression-specific) and the primary functioning outcome was the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 Brief.

A qualitative evaluation titled “Recovery from Psychotic Disorders in Rural Haiti: The Perspectives of Persons with Lived Experience of Psychosis, Family Caregivers, Health Care Providers, and Community Leaders to Improve the System of Care” was conducted as part of a Master’s degree in the Department of Global Health and Social Medicine at Harvard Medical School.

A return on investment analysis was completed in collaboration with and using a framework provided by Dan Chisholm from the World Health Organization’s Department of Mental Health and Substance Abuse.

Facility assessments at each health center were conducted at baseline and the end of the 2015-2016 grant, through interviews with Medical Directors and providers, using a tool developed by the ZL Monitoring and Evaluation and the mental health team that incorporated elements from prior facility assessments in other clinical areas at ZL and the mhGAP Situation Analysis Toolkit for the Facility and Clinic level.

Cost of implementation

A cost-effectiveness analysis was completed and results are forthcoming. From preliminary findings, salaries of supervisors and frontline service providers was identified as a key cost driver. 

Impact details

Between January 2013 and December 2015 we recorded 10,835 patient visits for mental health.

Between January and October 2016, patient-level data collection revealed that  2,168 unique patients enrolled for mental health care across 11 facilities at 6,961 encounters. Of the 2,168 patients, 62% (1,354 patients) were female. Epilepsy patients made up the largest group, followed by patients with depression and then patients with a psychotic disorder. Other less common diagnoses included anxiety/OCD, brain disorders (delirium, other neurological, neurodevelopmental), personality disorders, conduct disorders, severe affective disorders, stress reaction/conversion, and substance use.

Analysis of patient outcomes is underway and results are forthcoming through journal articles and other channels.

Data from trainings revealed that 270 frontline providers were trained in depression, psychotic disorders, epilepsy and child and adolescent mental health. Providers included: psychologists, nurse and physician leaders, social workers, health center physicians, health center nurses, community health workers, hospital level nurses, and family medicine and emergency medicine trainees (residents).

References

  1. Belkin GS, Unützer J, Kessler RC, Verdeli H, Raviola GJ, Sachs K, et al. Scaling Up for the “Bottom Billion”: “5×5” Implementation of Community Mental Health Care in Low-Income Regions. Psychiatr Serv. 2011 Dec 1;62(12):1494–502.
  2. Raviola G, Severe J, Therosme T, Oswald C, Belkin G, Eustache E. The 2010 Haiti earthquake response. Psychiatr Clin North Am. 2013 Sep;36(3):431–50.
  3. Raviola G, Eustache E, Oswald C, Belkin GS. Mental health response in Haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions. Harv Rev Psychiatry. 2012 Feb;20(1):68–77.
  4. Friday L. Père Eddy, Haiti’s Patron Saint of Mental Health [Internet]. 2015 [cited 2017 Feb 7].
  5. Grelotti DJ, Lee AC, Fils-Aimé JR, Jean JS, Therosmé T, Petit-Homme H, et al. A Pilot Initiative to Deliver Community-based Psychiatric Services in Rural Haiti After the 2010 Earthquake. Ann Glob Health. 2015 Sep 1;81(5):718–24.
  6. Verdeli H, Therosme T, Eustache E, Hilaire OS, Joseph B, Sönmez CC, et al. Community Norms and Human Rights: Supervising Haitian Colleagues on Interpersonal Psychotherapy (IPT) With a Depressed and Abused Pregnant Woman. J Clin Psychol. 2016 Aug;72(8):847–55.
  7. Rasmussen A, Eustache E, Raviola G, Kaiser B, Grelotti DJ, Belkin GS. Development and validation of a Haitian Creole screening instrument for depression. Transcult Psychiatry. 2015 Feb;52(1):33–57.
  8. Legha RK, Solages M. Child and Adolescent Mental Health in Haiti: Developing Long-Term Mental Health Services After the 2010 Earthquake. Child Adolesc Psychiatr Clin N Am. 2015 Oct;24(4):731–49.
  9. Legha R, Eustache E, Therosme T, Boyd K, Reginald F-A, Hilaire G, et al. Taskshifting: translating theory into practice to build a community based mental health care system in rural Haiti. Intervention. 2015 Nov;13(3):248–67.
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