Abwenzi Pa Za Umoyo: Integrating the MESH MH model in Malawi
To develop integrated mental health services in facilities and communities across Neno District, Malawi
Integration of an adapted Mentoring and Enhanced Supervision for Mental Health (MESH MH) model within healthcare settings with a focus on chronic care and maternal health
There are a limited number of public mental health workers and specialists in Malawi, as well as a high burden of mental health conditions. A study conducted in 2009 at a primary health care clinic in Zomba (a southern city in Malawi) found a 30% prevalence of depression in participants1. Furthermore, Malawi has one of the smallest government health expenditures in the world and as such, public funding for mental health services is very limited1-2.
To bridge this gap, Abwenzi Pa Za Umoyo (APZU) works in collaboration with the Ministry of Health in Malawi to integrate mental health services via depression case finding and treatment into the Integrated Chronic Care Clinic (IC3) for HIV services, primary care and maternal care.
The Mentorship and Enhanced Supervision at Health Centers for Mental Health (MESH MH) model is:
- Adapted from best practices in Malawi and Rwanda4-5
- Integrates core packages of services for severe mental disorders into a chronic care platform
- Provides training to general clinical officers and nurses under the supervision of Clinical Officers who hold a degree in mental health, allowing for a primary care model of mental health that can be scaled to health facilities across the district through care delivery by non-specialists
The mental health service delivery model uses existing staff, infrastructure, and patient tracking systems to lower costs and improve quality of care through learnings that care providers in the region have acquired over the past 10 years.
- As of June 2022, over 90% of the perinatal women at Partners In Health (PIH) facilities have been screened for depression and have access to group Problem Management Plus (PM+), antidepressant treatment (ADT), couple’s counselling, and other interventions
- Between July 2021- June 2022 the APZU Team: o Screened 17,973 people living with depression who attend IC3 in all facilities in Neno o Enrolled more than 700 people in mental health services
- The team has grown significantly from 2016, and currently provides care across 14 health facilities. They also provide crisis support such as psychological first aid and psychosocial support for communities outside of PIH-supported facilities for those who have been impacted by numerous natural disasters.
- From December 2017 to May 2018, approximately 92 (60%) clients were found to have an improvement in their mental health symptoms
- Three mental health training sessions for 41 staff members were conducted:
- Both the health centre staff and IC3 providers participated in the training sessions. An increase in knowledge capacity ranging from 29%-35% increase was found in pre- and post-test scores
- Three mental health training sessions for 41 staff members were conducted:
“The Mental Health Training equipped us with knowledge and skills to provide quality health care to mental health clients and proper documentation” McBrian Jamu, Lower Neno IC3 Officer
Christina Kaitano, is one of APZU’S clients, her daughter shared these remarks three months after the mother was put on medications treatment regimen, “My mother is a “person” again because of your medications.”
APZU launched its mental health program in 2016 to integrate mental health into its IC3 clinic in Neno District. The mental health clinic is incorporated into Neno District’s broader IC3 program, which utilizes two hospital-based teams supporting all health centers in the district. IC3 is a primary care delivery platform which leverages the pre-existing HIV clinics to deliver care to all patients with chronic disease, be it HIV and/or non-communicable diseases (NCDs), serving a catchment area of over 165,000 Malawians2, 6-8.
The clinic primarily treats patients living with mild to moderate mental health conditions and holds advanced mental health clinics once a week at the hospital for more complex patients who need a higher level of care including psychosis, schizophrenia, epilepsy and mood disorders. The APZU team conducts community visits for people living with epilepsy and mental health disorders who experience difficulties visiting health facilities and engage with communities through outreach and radio talks. The team has grown to include clinical officers, psychologists, program managers, monitoring and evaluation staff, who work across 14 facilities.
APZU has implemented the World Health Organization’s, Group PM+ psychological intervention to treat perinatal depression at Nsambe Health Center. The team adapted group PM+ training manuals and trained lay mental health counselors to screen mothers for depression at routine antenatal visits. APZU's mental health team developed this forward-looking intervention to reach more people, given the small number of mental health care providers. As of June 2022, over 90% of the women at Nsambe Health Center have been screened and have access to group PM+, relevant depression medication, couple counseling, family counseling and other interventions. APZU continues to expand mental health services beyond the facilities; they have offered Psychological First Aid (PFA) and depression/acute stress/trauma screenings to two additional districts in Malawi, which are Chikwawa and Phalombe, to care for survivors of the Tropical Cyclones Ana and Freddy that hit Malawi in 2022 and 2023, respectively.
Team is conducting a randomized controlled trial funded by the National Institute of Mental Health with the Malawi Ministry of Health on a care model for depression with group PM+ and antidepressant medication, integrated into a chronic care clinic for HIV and other conditions. The intervention is called the Integrated Chronic Care Clinics Depression Model (IC3D), which leverages best practices identified from the literature and WHO guidelines. The team is also completing research projects on active case findings, referrals, and linkage to care for clients with mental health conditions in the Advanced Mental Health Clinic, coordinating with local pharmacies to prescribe psychiatric and anti-epileptic medication.
Training and Mentorship
The mental health clinical officers support the primary care delivery at all health centers through mentorship at IC3, traveling out to health centers with the multidisciplinary IC3 team on a regular basis. Mentorship is conducted using the Mentoring and Enhanced Supervision at Health Facilities for Mental Health (MESH MH) checklist at least twice per month per mentee and initial results show progress in the clinical teams’ skills. To supplement the mentorship approach, APZU conducts mental health trainings for health providers in the Neno District to enhance the knowledge capacity of health providers on the management of common mental disorders and how to handle psychiatric emergencies.
The team is implementing the Common Elements Treatment Approach (CETA), focusing on people who experienced gender-based violence, substance abuse and other related mental health problems. They have created a draft curriculum for their Adolescent Mental Health Program and community awareness initiatives on common mental health disorders.
- The model is integrated into the pre-existing public health care system infrastructure in Malawi. The Ministry Of Health (MOH) HIV clinics were shifted to the IC3 model under the leadership of the District Health Officer, and clinic staff are comprised of both MOH and PIH staff
- The data systems at IC3 are utilizing the national M&E system, and IC3 is piloting several additional data collection systems for the national NCD Unit for the MOH
- This public sector integration, coupled with the MOH’s ongoing support, bolsters the program’s sustainability
Strong relationships with partner NGOs
- PIH is an international non-governmental organization that has almost 30 years of global health experience delivering community-based services in resource-poor settings across the world. PIH also provides technical support to its sister organization APZU in Neno.
- Since 2007, APZU has been supporting public health delivery systems in one district with a goal of delivering world-class health outcomes and scaling innovative care delivery platforms, all in close collaboration with the Ministry of Health
- PIH’s technical expertise, coupled with APZU’s broad based and sustained presence in Malawi, are additional key drivers for successful MESH-MH implementation
Pre-existing health system limitations:
- There is a gap of pre-existing health system capacity for the delivery of chronic disease services, including mental health, in Malawi.
- Thus, the model depends on an approach of leveraging expertise from the HIV care system, task-shifting, and a mentorship approach to allow progressive decentralization to the primary care level.
Strain on resources:
- Mentorship and supervision coverage is time intensive and requires ongoing relationship-building and patience; however, the significant time mentors spend with mentees strengthens the skills of the nurses and builds capacity for service delivery
- Given Malawi’s substantial limitations in health care personnel, it can be challenging to ensure that those trained are able to dedicate the time to supporting additional directives. Providers are often very busy with many demanding elements of their job, thus integrating initial supervisory and mentorship tasks can be challenging. Furthermore, transfers of trained and mentored staff continue to create a gap.
- Malawi has in the past had adverse conditions during the rainy seasons with resulting cyclones that have significantly affected the country. There have been increased times of crisis as a result that have affected both our patients and our team as well as the ability to reach them and administer care.
The Neno District will continue to identify mental illness in the community and provide mental health care through IC3 and the advanced mental health clinics. Additionally, the team in Neno hopes to expand the program to do depression screenings in the IC3 program for all patients with chronic illness. The goal is to make sure that Neno clinicians and nurses especially at IC3, inpatient wards, general outpatient departments, and in the health centres are able to identify and provide services to their patients living with mental illness. Ultimately, we expect to reduce the burden of severe mental disorders in Neno District and see most of our clients effectively attaining full social and occupational functioning state.
Neno is the only district in Malawi using MH-MESH. Working closely with the national and district Ministry of Health, APZU hope that the pilot programs and lessons in Neno can inform future work for national scale up for improving access to mental health services in Malawi.
- Counselors and community health workers administer PHQ-9 questionnaire as a primary tool for screening, diagnosing, monitoring and measuring the severity of depression. The team uses CommCare as their digital platform of Electronic Medical Records (EMR), and each client has a mastercard to record the data on each of their visits.
- APZU uses the Mentorship and Enhanced Supervision at Health Centers for Mental Health (MESH MH) model to improve quality of services across facilities. Through the MESH MH model, mental health clinicians travel to each facility to mentor fellow clinicians. Mental health clinical officers currently conduct mentorship sessions every month, the results of which are filled out on checklist programmed into a tablet for monitoring and evaluation purposes.
Cost of implementation
The program’s treatment approach combines counselling and support with a number of psychotropics such as haloperidol and risperidone. We prioritized the more costly medications for those who need it based on side effects, and we use small doses that can help our patients get better while preventing more unwanted side effects. The delivery model utilizes existing chronic care infrastructure and resources to maximize efficiency. A cost-effectiveness analysis of the IC3 model, including the mental health program, is underway.
Sample annual program costs include (not inclusive of full program costs):
- Psychotropic medication at the IC3 in Upper and Lower Neno: $12,157
- Mental health training: $530
- Government partnership activities and World Mental Health Day: $530
- Currently IC3 is providing treatment for 181 clients with mental illness and 680 registered clients with epilepsy
- Among all active mental health clients receiving treatment at the centres, approximately 50% from the Upper Neno district (December 2017 to May 2018) and 71% from the Lower Neno district (December 2017 to May 2018) were found to have recovered from their mental health symptoms since their admission to the clinic
- Almost 90% of the mental health clients and approximately 80% of the epilepsy clients have had clinic visits in the preceding 3 months. This indicator is also used by the Malawi Ministry of Health to indicate retention in care
- Some clients struggle with poor compliance to treatment, while others have neurological disorders which can result in restricted help-seeking. In response, monthly home visits are also conducted to check in on clients and keep them in care
- More than 900 people with mental health conditions were treated in more than 1500 visits made by the APZU team between July 2019 - June 2022
- The team developed a mechanism to screen all perinatal women at Nsambe Health Center for depression As of June 2022, over 90% of the women have been screened and have access to group PM+, anti-depressants, couple counselling, family counselling, and other interventions
- APZU provided psychosocial support to people living with mental health conditions, and linked them to medical care and the Program on Social and Economic Rights (POSER)
- Udedi M (2014) The Prevalence of Depression among patients and its detection by Primary Health Care Workers at Matawale Health Centre (Zomba). Malawi Med J, 26(2):34–7.
- Udedi M (2016) Improving Access to Mental Health Services in Malawi. African Institute for Development Policy.
- Mental Health Innovation Network (2017) Inshuti Mu Buzima: An expanded MESH model to address mental disorders in Rwanda. [Link]
- Anatole M et al. (2013) Nurse mentorship to improve the quality of health care delivery in rural Rwanda. Nurs Outlook, 61(3):137–44.
- Kachimanga C et al. (2017) Novel approaches to screening for noncommunicable diseases: Lessons from Neno, Malawi. Malawi Med J J Med Assoc Malawi, 29(2):78–83.
- Partners In Health (2018) Malawi. [Link]
- Government of Malawi. Malawi AIDS Response Progress Report (2015). [Link]
- Cundale K et al. (2017) Reframing non-communicable diseases and injuries for the poorest Malawians: the Malawi National NCDI Poverty Commission. Malawi Med J J Med Assoc Malawi, 29(2):194–7.
- Wroe EB et al. (2015) Leveraging HIV platforms to work toward comprehensive primary care in rural Malawi: the Integrated Chronic Care Clinic. Healthc Amst Neth, 3(4):270–6.