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Barriers to Improvement of Mental Health Services in Low-Income and Middle-Income Countries
Category: Key Publications & Readings
Audience: Implementing agencies, Governments, Donors
A comprehensive review of barriers to mental health service development through a qualitative survey of international mental health experts and leaders, that includes a reflection on the need to accompany, or precede, investment in PHC with development of community mental health services (page 85, first paragraph).
Full reference: Saraceno, B., van Ommeren, M., Batniji, R., Cohen, A., Gureje, O., Mahoney, J., … Underhill, C. (2007). Barriers to improvement of mental health services in low-income and middle-income countries. The Lancet, 370(9593), 1164–1174.
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Service User and Caregiver Involvement in Mental Health System Strengthening in Low- and Middle-Income Countries: Systematic Review
Category: Key Publications & Readings
Audience: Implementing agencies, Governments, Donors
A systematic review that examines service user and caregiver involvement in mental health system strengthening, as well as models of best practice for evaluation of capacity-building activities that facilitate their greater participation.
Full reference: Semrau M., Lempp H., Keynejad R., Evans-Lacko S., Mugisha J., Raja S., … Hanlon C. (2016). Service user and caregiver involvement in mental health system strengthening in low- and middle-income countries: Systematic review. BMC Health Services Research, 16(1).
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The Contemporary Refugee Crisis: An Overview of Mental Health Challenges
Category: Key Publications & Readings
Audience: Implementing agencies, Governments, Donors
The paper refers the reader to the specialized literature on vulnerable sub-populations (child soldiers, unaccompanied minors, children and youth, single or widowed women) and specific geographical situations around the world, that advocates for a stronger system of services through engaging and supporting communities that have temporarily lost their equilibrium as a consequence of overwhelming circumstances.
Full reference: Silove, D., Ventevogel, P., & Rees, S. (2017). The contemporary refugee crisis: An overview of mental health challenges. World Psychiatry, 16(2), 130–139.
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Integrating Mental Health Care into Primary Care: The Case of One Rural District in Rwanda
Category: Key Publications & Readings
Audience: Implementing agencies, Governments, Donors
This case study (a) describes a model to integrate mental health care into primary care, embedded within an existing public sector healthcare strengthening program that emphasizes generalist nurse supervision and health system quality improvement methods (b) highlights how mental health care and clinical supervision within a government health system was supported by an international health care delivery organization, rather than developing a parallel system of care (c) Provides examples of challenges and solutions to initial system and human resource barriers to mental health integration into primary care in resource-limited settings.
Full reference: Smith, S. L., Kayiteshonga, Y., Misago, C. N., Iyamuremye, J. D., Dusabeyezu, J. D. A., Mohand, A. A., ... & Dushimiyimana, D. (2017). Integrating mental health care into primary care: The case of one rural district in Rwanda. Intervention, 15(2), 136-150.
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Mental Health Treatment Outcomes in a Humanitarian Emergency: A Pilot Model for the Integration of Mental Health into Primary Care in Habilla, Darfur
Category: Key Publications & Readings
Audience: Implementing agencies, Governments, Donors
A study that aims to describe the characteristics of patients first attending mental health services and their outcomes and functionality after treatment.
Full reference: Souza, R., Yasuda, S., & Cristofani, S. (2009). Mental health treatment outcomes in a humanitarian emergency: A pilot model for the integration of mental health into primary care in Habilla, Darfur. International Journal of Mental Health Systems, 3(1), 17.
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WHO mhGAP Evidence Resource Center
Category: Key Publications & Readings
Audience: Implementing agencies, Governments, Donors
The mhGAP Evidence Resource Centre contains the background material, process documents, and the evidence profiles and recommendations in electronic format for mhGAP guidelines for mental, neurological, and substance use (MNS) disorders. The Centre is organized around the mhGAP priority conditions.
Access here.
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WHO mhGAP Newsletters
Category: Key Publications & Readings
Audience: Implementing agencies
A WHO series on mental health services provision using mhGAP and its accompanying resources, manuals, and guides.
Access here.
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Guidelines for MHPSS Staff Providing Tele-MHPSS to Clients during the COVID-19 Pandemic
Category: Key Guidance, Service Strengthening
Audience: Implementing agencies
IMC guidelines to support the transition of mental health service delivery to remote support (tele-MHPSS) to ensure a safe continuity of clinical care during COVID-19 pandemic -
Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: experiences of UNHCR
Category: Field Examples and Applications
Audience: Implementing agencies
Use this publication to learn how mental health was integrated into PHCs using mhGAP in refugee settings for Rohingyas in Bangladesh, including key implications for practice.
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Guidance on Community Mental Health Services
Category: Key Guidance
Audience: Implementing agencies, Governments, Donors
Use this resource to promote efforts to align mental health systems and services delivery with international human rights standards, including the Convention on the Rights of Persons with Disabilities. The guidance calls for a focus on scaling up community-based mental health services that promote person-centred, recovery- oriented and rights-based health services. It provides real-world examples of good practices in mental health services in diverse contexts worldwide.
Toolkit for the Integration of Mental Health into General Healthcare
Step 3. Strengthen Mental Health Services & Systems
Strengthening of mental health services at facility and community levels provided by trained and supervised healthcare staff in addition to strengthening systems through improved coordination and referral between service providers, HMIS documentation, and psychotropic medication supply.
WHY is this step needed?
While staff capacity building is a critical component, it is not enough to establish a functioning system of community based mental health care. Various parts of the system need to work together to ensure that persons with mental health problems can be identified, appropriately managed and cared for, have access to psychotropic medications and can be referred to essential clinical or community services and followed up, as part of a functioning system. Strengthening these systems means that persons receive the care they need, and that integration can be sustained.
HOW is this step done?
Use your assessment/situational analysis to identify where your planned mental health program falls within the larger systems of health, mental health and community services as well as within humanitarian response efforts. Work with national, regional and local authorities as well as with health facility staff to strengthen MH services (e.g. identification, management, referral) and systems (e.g. space and time for services, mapping of service providers, HMIS, psychotropic medication). Ensure that trained staff and other service providers understand their role in the MH system.
MINIMUM elements of Strengthening Mental Health Services &...
Strengthening of mental health services provided by trained health staff (doctors, nurses and CHWs) consisting of:
- Identification, assessment and diagnosis (e.g. initial identification through CHWs, assessment by PHC providers).
- Management of mental disorders (e.g. psycho-education for patients and family members, psychosocial interventions, psychotropic medication- if needed).
- Follow-up (e.g. continued appointments, visits by CHWs, phone calls/text messages).
- Referral to other services including to more specialized mental health service providers.
Strengthening of mental health system through:
- Ensuring that trained staff understand their roles in MH service provision (e.g. outlining protocols, referral pathways, job descriptions).
- Ensuring there is designated and appropriate space (e.g. private space, locked files) and time (e.g. afternoons one day a week) for staff to see persons with MH problems.
- Adaptating Health Information Systems, in line with national systems, to collect data on persons with mental disorders identified in primary care.
- Supporting procurement of essential psychotropic medications in coordination with the government.
- Mapping of community services (e.g. protection, social services) and specialized MH service providers.
- Setting up processes for referral to and from MH PHC services.
- Establishing links and communication with local specialized MH services (e.g. psychiatrist) for referral of persons with severe mental health problems.
COMPREHENSIVE additional elements of Strengthening Mental...
Strengthening of mental health services through additional capacity building such as:
- Training of non-specialized staff (social workers, counselors, case managers, etc.) to provide evidence based psychological interventions with mechanisms for support, follow up and supervision by specialized mental health professionals.
- Peer to peer support activities with leadership from mental health service users.
- Setting up mechanisms for patient identification, basic support and follow up by mobilizing community health workers.
Strengthening of mental health system through:
- Supporting communication, care coordination and multi-disciplinary teamwork among various staff (e.g. health and social services, psychiatrists, psychologists and other MH professionals) to address multiple and complex needs of persons with mental illness and their families.
- Supporting Health Information Systems, in line with national systems, to collect and report data on persons with mental disorders treated at different levels of care (e.g. in primary care, mental health outpatient facilities, mental hospitals).
- Comprehensive Mapping of formal and informal service providers in the area (e.g. specialized MH services, protection services, community services, traditional healers).
- Supporting the availability and affordability of psychotropic medications including effective maintenance or establishment of sustainable supply chains (e.g. staff know when and how to order medication and feel empowered to advocate for availability of medication with government or other stakeholders).
- Setting up an effective monitoring and evaluation system for MH services and organizational level change.
- Setting up interagency referral workshops to establish clear referral pathways and guidelines among different service providers.
WHEN is this step done?
This is a continual process which requires ongoing monitoring, planning and active participation of all stakeholders from the beginning. The resources presented as Specific Tools and Materials should be used by those who have been trained as mental health care providers.
KEY CONSIDERATIONS
- Do ensure that investment in primary care is preceded by, or at least carried out in tandem with, development of community and secondary mental health services.
- Do invest in local human resources (displaced and host) to respond to MH needs.
- Do help ensure provision of a quiet and private space to meet with persons with mental health problems.
- Do address mental health needs at the appropriate level of care, while being aware of available up and down referral systems and pathways if needed.
- Do set up a system where trained health staff can connect with MH specialists for support and guidance, and for emergencies (e.g. responding to acute suicidal ideation).
- Do utilize CHWs and community leaders for outreach and connect with formal and informal service providers for referrals.
- Do respect the privacy and confidentiality of persons with MH problems.
- Do take into consideration that families/carers of people with mental disorders may also need support.
- Do discuss in training how to establish referral links with traditional healers and religious leaders who are often the first point of contact for persons with severe mental illness.
- Do not refer all persons to a specialized provider (e.g. psychiatrist or psychologist).
- Do not set up a parallel system of MH care.
- Do not forget that persons with mental health problems may have other complex needs that also need to be addressed (e.g. other general health conditions or injuries, protection concerns, housing issues).
- Do not assume people with mental illness will come to a health care facility on their own.
- Do not introduce expensive psychotropic medications that cannot be sustained in the long term and work in line with the ministry of health’s essential drug list.
- Do not allow medication supply to be interrupted.
- Do not contribute to an influx of referrals to already stretched services, without working to strengthen those existing services first.
