Mental Health Innovation in Africa Blog Series: From PRIME TO ASSET

During the last year we have wound up the large Programme for Improving Mental health carE (PRIME)¹ consortium after 8 years of work. PRIME was a DFID-funded research programme consortium that worked in 5 countries (Ethiopia, India, Nepal, South Africa and Uganda), in a partnership between researchers, ministries of health and non-governmental organisations (NGOs). A very exciting aspect of PRIME was that it was led from a southern research institution – the University of Cape Town².

The focus of PRIME’s work was on integrating mental health into primary care in low resource settings. We set up district demonstration sites in each country, working closely with local stakeholders to develop district mental health care plans. We then implemented these plans and evaluated them using a variety of different study designs^3-5 including case studies, repeat facility detection surveys, repeat community surveys and cohort studies. We learnt an enormous amount through this process and have published our findings in over 100 peer reviewed-journal articles, supporting 20 PhD students in the process.

I’m often asked what happens at the end of a project like PRIME. Where does all that experience go? And who benefits? What has been encouraging about PRIME is that we have worked closely with ministries of health from the outset and so our findings have been translated into policy and practice in various ways in all the PRIME countries and been disseminated in several other countries. In addition, our findings have been taken up in key tools that support other countries to integrate mental health into primary care and scale up services. For example, the WHO mhGAP Operations Manual, launched last year, has drawn substantially on PRIME methods and experiences, and will support the implementation of mhGAP in over 100 countries.

But what is perhaps equally important is to ensure that we remain aware of what we were not able to achieve – the unanswered questions that lie at the edges of any research endeavor. One of our key take-home messages from PRIME was that ministries of health in LMICs are unlikely to see substantial improvements in detection or care for people living with mental, neurological or substance use (MNS) conditions in primary care without substantial investment in strengthening health systems. This means drawing on the lessons of the emerging field of implementation science to strengthen the ‘building blocks’ of healthcare delivery systems, including assessment processes, referral pathways, training and supervision and routine health management information systems. Many of these challenges are not unique to mental health but are experienced in a variety of different healthcare delivery platforms in LMIC.

This is where a follow-on project called “HeAlth System StrEngThening in sub-Saharan Africa (ASSET)” comes in. ASSET is being led by Martin Prince at King’s College London’s Global Health Institute and is developing and evaluating interventions to strengthen health systems for surgery, primary care, maternal care and palliative care in Ethiopia, Sierra Leone, South Africa and Zimbabwe.

In the South African ASSET site in Cape Town, we are drawing on lessons from PRIME and the Africa Focus on Intervention Research for Mental health (AFFIRM)⁶ collaboration to strengthen detection and care for perinatal women with depression, anxiety or exposure to domestic violence. ASSET’s health system strengthening intervention aims to improve the referral pathway for antenatal women in Midwife Obstetric Units (MOUs) by standardising empathic enquiry at first antenatal bookings, and formalising referral pathways and care within the existing public health platform. We are working with the Western Cape Department of Health to train and supervise community health workers to deliver brief structured problem-solving therapy counseling sessions to perinatal women in need.

In short, the implementation science journey continues. We are making use of some of the tools we developed and used in PRIME, such as Theory of Change workshops⁷ and situation analysis methods⁸, and taking this one step further to deliver a health system strengthening intervention at scale across the whole of the Cape Town metropolitan area. As with PRIME, a highlight of this work is close collaboration with the many dedicated health workers and health service managers who deliver care to people living in adverse and very challenging circumstances – they are an inspiration!

References

1. Lund C et al (2012). PRIME: A Programme to Reduce the Treatment Gap for Mental Disorders in Five Low- and Middle-Income Countries. PLOS Medicine, 9(12), e1001359. Retrieved from [Link]
2. Breuer et al (2019). Partnerships in a Global Mental Health Research Programme---the Example of PRIME. Global Social Welfare, 6(3), 159–175. Retrieved from [Link]
3. Jordans M J et al (2019). Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal. British Journal of Psychiatry, 215(2), 485–493. Retrieved from [Link]
4. Petersen, I et al (2019). Evaluation of a collaborative care model for integrated primary care of common mental disorders comorbid with chronic conditions in South Africa. BMC Psychiatry, 19(1), 107. Retrieved from [Link]
5. Nakku J E M et al (2019). Evaluation of the impacts of a district-level mental health care plan on contact coverage, detection and individual outcomes in rural Uganda: a mixed methods approach. International Journal of Mental Health Systems, 13(1), 63. Retrieved from [Link]
6. Lund C et al (2015). Generating evidence to narrow the treatment gap for mental disorders in sub-Saharan Africa: rationale, overview and methods of AFFIRM. Epidemiology and Psychiatric Sciences, 24(3), 233–240. Retrieved from [Link]
7. Breuer E et al (2014). Using workshops to develop theories of change in five low and middle income countries: lessons from the programme for improving mental health care (PRIME). International Journal of Mental Health Systems, 8(1), 15. Retrieved from [Link]
8. Hanlon C et al (2014). Challenges and Opportunities for Implementing Integrated Mental Health Care: A District Level Situation Analysis from Five Low- and Middle-Income Countries. PLOS ONE, 9(2), e88437. Retrieved from [Link]

More Resources:

• About the Mental Health in Africa: Innovation and Investment Conference taking place on the 20th of November at Wellcome Trust, London, UK [Link]
• Tickets and booking can be accessed [Here]

Photo Credit: Primary Health Care Clinic in Ethiopia. © Programme for Improving Mental Health Care, 2015