[#WHD2017 Africa Blog Series] Inspiring African innovations: PRIME South Africa

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 10: PRIME South Africa

PRIME South Africa is one of five countries where PRIME aims to develop, implement, evaluate and scale up district mental health care plans.

Tell us about your country’s context and the circumstances that inspired your innovation

South Africa has a high burden of chronic illness, and some of these conditions have a high comorbidity with mental disorders, indicating a need to integrate mental health care into chronic care. South Africa also has a high treatment gap for depression with only one in four people with a common mental disorder receiving treatment of any kind. PRIME in South Africa developed a district mental health care plan that foregrounded the integration of mental health with care for chronic conditions in Dr Kenneth Kaunda District in North West Province following an intensive formative phase which included a situational analysis, qualitative interviews with service users and service providers, and theory of change workshops. The collaborative, stepped care plan was piloted and refined before implementation.

What aspect of your project are you most excited about? How is the project innovative or unique?

Within a resource-constrained primary health care setting, the PRIME-SA collaborative stepped care model integrates care for common mental disorders including depression into chronic care. Primary health care practitioners identify common mental disorders, including depression using an integrated set of chronic care guidelines, called Adult Primary Care (APC). Referral pathways for depression within a collaborative stepped up model have been strengthened. These include a psychosocial intervention using evidence-based practices that can be delivered by non-professional mental health care workers under the supervision of professional psychological practitioners; as well as referral for specialist care for more severe and treatment resistant conditions. The mental health care plan has been adopted by the Dr Kenneth Kaunda District and seeks to enhance access to psychosocial services for depression in the chronic care platform. The training is informed by adult learning theories and experiential learning. Identifying an existing suitable cadre of health worker to provide the intervention has been challenging, and is an ongoing process for scale up. Currently, existing HIV counsellors at the implementation site have been identified as a suitable cadre of worker to be trained to assume this role.

Have you noticed an impact ‘on the ground’? What is the best feedback you have received (from service users, team members, or otherwise)?

Service users who have benefitted from the programme for both depression and psychosis have provided positive feedback on the impact the interventions have had on their mental health including daily functioning, self-esteem and interpersonal relations. In collaboration with the primary health care facilities where the programme is based, the programme has facilitated a voluntary feedback loop between service users and service providers for service users who have benefitted from the intervention to provide feedback on the effect of the psychosocial intervention sessions on their functioning. The feedback serves as validation of service provider efforts to detect and refer patients with depression and demonstrates the value of the detection and referral for depression to service providers.

A photo essay and a short documentary have also showcased a sample of patients who have benefitted from the psychosocial intervention for depression and the psychosocial rehabilitation for psychosis.

Preliminary results from a facility detection survey in the implementation site (following a year of embedding the plan) indicate an improvement in detection and awareness of common mental disorders including depression and alcohol use disorders. Results at 3 month follow-up from a cohort study of patients with depressive symptoms indicate clinically and statistically significantly improved depression scores for patients exposed to the collaborative care model for depression compared to those who were not exposed. In the twenty scale up facilities, more than 2000 patients were referred to the counsellor for depression over a two year period. Close to 1500 have received two or more counselling sessions.

Policy makers are positive about PRIME in South Africa, and are collaborating with technical support partners funded by Centre for Disease Control to scale up the PRIME model through the Mental health Integration Project (MhINT) in two additional districts in two different provinces from where PRIME has been working. We have received interest from foreign countries who are interested in the collaborative care plan and the training package for care for depression. PRIME-SA has provided training support for a group of health workers in Kabwe, Zambia to integrate mental health as part of non-communicable disease care into the HIV care platform in Zambia. Based on formative interviews in Zambia, PRIME-SA assisted with the adaptation of resource materials to the local socio-cultural context that was modelled on the PRIME-SA psychosocial training for task sharing of depression counselling.

What’s next?

In-country scale up of services for depression to unreached clinics in the implementation site as well as the two MhINT districts. Extending services for depression in the maternal and child health platform in implementation site. In-country technical support in country for scale up services.

What is the one message about depression you want people to take away from your innovation?

In the context of rising multi-morbidity, managing depression in primary care settings through task sharing is possible and important to reduce chronic physical condition onsets; improve health outcomes; and reduce health care utilization/costs.

For more African innovations featured in this series, please visit the [#WHD2017 Africa Blog Series].