Abwenzi Pa Za Umoyo: Integrating the MESH MH model in Malawi

Innovation summary

There are a limited number of public mental health workers and specialists in Malawi, as well as a high burden of mental illness. A recent study conducted 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 limited^1-2.

To meet this need, Abwenzi Pa Za Umoyo (APZU), a sister organization of Partners In Health (PIH), in collaboration with the Ministry of Health in Malawi3, developed a training and service delivery model in the Neno district. The Mentorship and Enhanced Supervision at Health Centers for Mental Health (MESH MH) model is:

Adapted from best practices in Malawi and Rwanda^4-5
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.

Impact summary

Currently, IC³ is providing treatment to 177 clients with severe mental illness and 680 registered clients with epilepsy
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

“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

Innovation details

Background

The Neno mental health program delivers services through an integrated mental health clinic and mentorship of providers using an adapted Mentorship and Enhanced Supervision at Health Centers (MESH) Checklist. The mental health clinic is incorporated into Neno District’s broader Integrated Chronic Care Clinic (IC3) program, which utilizes two hospital-based teams supporting all health centers in the district. The district hospital team, which started providing mental health services in 2012, is supported by a psychiatric nurse and Mental Health Clinical Officer Mark Chalamanda. The community hospital team is supported by a mental health clinical officer, Thokozani Kholomana and started enrolling mental health patients in May 2017.

The model operates through the existing Integrated Chronic Care Clinic (IC3) platform in Neno 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.

Service Delivery

The clinic primarily treats patients with psychosis, schizophrenia, epilepsy and mood disorders induced by HIV or epilepsy medications. The clinic also takes care of patients who have relapsed from lack of treatment or medication adherence issues5,9. Advanced mental health clinics are also held once a week at the hospital for more complex patients who need a higher level of care. Additionally, a visitation program started to reach patients who are reluctant to come to the health facility for medications or for patients with epilepsy that have compromised movement.

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 MESH checklist at least twice per month per mentee and initial results show progress in the clinical teams’ skills. Moving forward, the Malawi program hopes to integrate depression screening into the IC3 clinic for patients with chronic conditions including HIV/AIDs.

To supplement the mentorship approach, APZU has conducted 3 mental health trainings to Neno health providers between April 2017 and February 2018. The training aimed to enhance the knowledge capacity of health providers on the management of common mental disorders and how to handle psychiatric emergencies. Content for the training sessions was created by the Malawi team with help from Psychiatrists at Boston. Certain materials were also adapted from PIH/Zanmi Lasante’s Mental Health program in Haiti. The participants who were trained are followed up monthly for mentorship by Mental Health Clinical Officers.

Key drivers

Government Integration:

The model is integrated into the pre-existing public health care system infrastructure in Malawi. The 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 Ministry of Health’s ongoing support, bolsters the program’s sustainability

Strong relationships with partner NGOs:

Partners in Health (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 in Neno, Malawi- Abwenzi Pa Za Umoyo (APZU)
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 Rwanda, are additional key drivers for successful MESH-MH implementation

Challenges

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 the HIV 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 significant limitations in heath personnel, it can be challenging to ensure that those trained are always those in clinic. This can interfere with mentorship as one lesson learned was that the basic training significantly improved capacity for mental health delivery through the mentorship approach.

Continuation

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, we 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.

Partners

Partners In Health

Evaluation methods

Service delivery:

Mentees use the mental status examination tool to measure recovery among their clients e.g. asking questions about daily life activities. Mentors (psychiatric clinical officers) use the World Health Organization Disability Assessment Schedule (WHO-DAS) 2.0. During acute phases of treatment, clients are followed up every two weeks and others every month. Once stable, they are followed up every two months

Supervision:

Mental health clinical officers currently conduct mentorship sessions every month, the results of which are filled out on a checklist programmed into a tablet for monitoring and evaluation purposes
Weekly meetings between mentors are held for mentors to discuss complex clinical cases and develop strategies for mentees with low checklist scores

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

Impact details

Coverage:

Currently IC3 is providing treatment for 181 clients with mental illness and 680 registered clients with epilepsy

Treatment Outcome:

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

Retention

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

Capacity Building:

41 clinical staff members (chronic care clinic providers, health centre providers and inpatient providers) participated in three mental health training sessions held in March 2017, August 2017, and February 2018
12 outpatient and inpatient staff at Upper Neno showed an average of a 33% increase from pre-post test scores
Training among health centre providers showed an average of a 35% increase from pre-post-test
Training among IC³ providers showed an average of a 29% increase of from pre-post-test scores
Training topics included etiology of mental illness, mental health assessments, psychotic and mood disorders, psychiatric emergencies, alcohol and drug use disorders

References

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.