Making it happen: Experiences and learnings from the implementation of the PRIME Project
In the field of Global Mental Health we know what needs to be done to treat a person with depression, psychosis, anxiety disorder or substance use disorder. As clinicians, we see miraculous changes taking place in the individuals when they are prescribed an anti-psychotic, a mood stabilizer or when they receive cognitive behavior therapy. We have also been quite successful to demonstrate the effect of these interventions in large community based trials across range of settings in different parts of the globe, though the efficacy of our interventions varies. Despite all this knowledge we are armed with, we hit a major roadblock when we try to take these interventions to scale and provide services at population level.
Global efforts to improve access to quality mental health care services at affordable costs have not yet produced significant results. This is certainly an uphill task which reminds me of the Penicillin story and we can draw few parallels from there. We all know how serendipity played an important role in discovery of penicillin in 1928 by Alexander Fleming. For the following 10 years, he worked with limited success to produce larger quantities of penicillin and test it for use as a surface antiseptic. Someone else (Chain and Florey) had to find a technique for developing greater quantities of penicillin, sufficient for testing in experiments in infected laboratory mice. Finally Heatley developed methods of producing penicillin in greater quantities, to enable them to test it on many mice and then human beings. It was quite a long journey from innovation to testing to scaling it up. There are similar challenges we face in Global Mental Health today while we attempt to translate evidence into practice. One of the most important things for us is to successfully integrate mental health services with existing platforms of care. The biggest challenge is to understand HOW we bring about this integration or mainstream mental health services with the existing services. Implementation of PRIME in Sehore district has provided us with some very valuable lessons.
Diamonds can adore your fingers only when they are fitted in a golden ring.
First of all it is important for us to make a paradigm shift from strict disease and intervention perspective to broader health system perspective. Countries across the globe differ in terms of their socio-economic development and sometimes within the countries as well there is marked heterogeneity. Evidence-based interventions remain the same, but they need to be modified and adapted to fit a particular ‘context’ in which they are implemented. As a result of this it becomes critical to design and implement enabling/support processes to ensure that the core clinical processes as suggested by the evidence-base are implemented well.Diamonds can adore your fingers only when they are fitted in a golden ring. Here, diamonds resemble the clinical processes while ring constitutes the enabling environment. Procurement and supply chain management of essential psychotropic drugs, having a dedicated space for delivery of psycho-social interventions and establishing information systems for regular reporting of key performance indicators are some of the enabling processes which are absolutely essential for delivery of core clinical processes such as pharmacological management or psycho-social interventions.
Human resource management
Another set of enabling processes relates to human resource management. We need to redefine the role of existing staff in public health care system and improve and sustain their competencies for basic clinical processes related to identification and diagnosis, management and follow-up care of priority mental disorders. We also need to be mindful of the fact that mental health programs are a low priority for senior officials and policy makers in the governments due to various reasons. As a result of this, it is very difficult to get immediate buy-in from the public health staff. In our experience we thought that getting a new dedicated human resource such as a mental health case manager could be good idea to introduce mental health interventions in the existing system. Presence of an additional human resource adequately trained in delivery of psycho-social interventions can ensure that true collaborative models of care are established and made functional in the new settings.
Lastly, it would be quite naïve for us to expect that just by disseminating results of the findings of our trials, these interventions will be integrated in the routine public health system. Researchers in the field of Global Mental Health will have to work with implementers in this field. Backbone organizations are a set of new generation of organizations that act in a mediating role between the policy, program development and the provider level of services and help supporting and financing the dissemination and implementation of evidence-based practices. The work of PRIME, especially in India, is very similar to that of a backbone organization and we are playing the role of a facilitator/catalyst to ensure that the enabling environment or support processes are in place and once this is achieved then work continuously with the existing delivery team to improve the quality of clinical services delivered.