Innovation summary

Inadequate provisions and poor utilization are well known global characteristics of mental health services. The situation is however worse in low resourced countries with higher mental health service gaps. The goal of this program was to improve access to mental health service in Ogun State with a population of approximately four million people.

Launched in October 2011, the program trained health professionals from primary healthcare center (PHC) in all 20 local government areas of Ogun State, provided materials (including medications), with ongoing support and supervision by specialists for mental health service provision.

Impact summary

  • Approximately 1200 people with mental disorders have been seen, correctly diagnosed, and effectively treated/referred, and followed up at the health centers across the state since inception of program
  • Availability of affordable essential medications by clients at the PHCs

'We are all here today at the threshold of history’.

-​​“Dr Ogunlesi, Chief Medical Director of the Neuropsychiatric Hospital Aro in his opening remarks at the inauguration ceremony of the Aro Primary Care Mental Health Programme 

Innovation details

Development of the Training Package

The Aro Primary Care Mental Health Programme for Ogun State (APCMHP) was conceived during the commemoration of World Mental Health Day 2009, a day that was marked by the theme: ‘Mental Health In Primary Care: Enhancing Treatment and Promoting Mental Health.1 Following this, the team began to develop the mhGAP-IG based training package and piloted it with a group of PHC workers in October 2010. The program aimed to equip the PHC workers to assess, diagnose and treat/refer five priority mental health conditions (psychosis, depression, epilepsy, other significant emotional complaints and substance use disorders) using the locally adapted mhGAP intervention guide.

Contents of the Training Package

The training course consists of a one-day plenary introductory lecture on ‘Mental health, and the classification, causes and treatment approaches of mental disorders’, delivered at the Neuropsychiatric hospital Aro Abeokuta, followed by four 2-day zonal training sessions of didactic lectures, video demonstrations, role plays, group exercises and discussions covering the 5 modules of priority mental health conditions.

The zonal trainings were delivered by a group of 3 psychiatrists, 4 psychiatric nurses and a clinical psychologists between September and October 2011, with 20 participants in each zonal training group.

Case record sheets were also designed for each of the five priority conditions, for simplified but detailed documentation of the clinical activities of the trained health workers. The trained health workers receive regular support and supervision from visiting psychiatric nurses, while referred cases are attended to by visiting consultants. Patients requiring immediate attention and hospitalization are referred to the base hospital directly.

Top-up training was provided for the trained health workers in 2013, while additional health workers were trained early 2014 to make up for the attrition in manpower due to high turnover of the PHC health professionals.

Key drivers

Support and Commitment from Stakeholders

Strong institutional commitment by the Neuropsychiatric Hospital Aro, support from the Ogun State Local government service commission, and inputs of the UK partners resulted in a successful training program

Enthusiastic and Dedicated Team Members

Enthusiasm of the project team members aided to successful program implementation

Challenges

Institutional Barriers

There were the initial challenges of institutional barriers between the federal government agencies (Aro hospital) and the local government health department, which were surmounted through careful negotiations and repeated stakeholders meetings

Attitude Towards Mental Health at PHC

Selling a mental health program to the primary care workers was another Herculean task due to the poor knowledge and negative attitude of health workers about mental illness, in addition to complaints about their heavy workload and manpower shortage

Continuous Engagement and Supervision

An ongoing challenge is the continuous engagement and supervision of the primary care workers over whom the field psychiatric nurse supervisors do not have statutory managerial control.

High Turnover at PHC

Trained manpower attrition due to high job turnover at the PHC

Traditional Beliefs and Attitudes

Prevalent traditional beliefs and negative attitude toward mental health conditions and services by community members remains a formidable and dynamic barrier to service utilization

Sustainability Challenges

Sustainability challenges related to ongoing financial need for continuing support and supervision of trained care workers, as well as supplementary trainings  

Continuation

As the only systematic and functional state-wide mhGAP intervention project in the country presently, the APCMHP for Ogun State is perfectly placed to be scaled up to a national level.  The hospital is currently collaborating and sharing its experience with other agencies and institutions across the country who are planning to embark on similar integration project.

Partners

Delivery Partners

  • Neuropsychiatric Hospital Aro Abeokuta (Nigeria)
  • Lancashire Care NHS Trust Preston (UK)
  • Ogun State Local Government Service Commission (Nigeria)
  • Ogun State Ministry of Health (Nigeria)

Funders

Training Course Development and Delivery

  • UK International Health Links Funding Scheme (UK)

Program Planning and Ongoing Service Delivery

  • Neuropsychiatric Hospital Aro Abeokuta (Nigeria)

Evaluation methods

Monitoring and support for the primary care workers is provided by zonal field supervisors every two weeks, to each PCMHS center. There are monthly zonal visits by field consultants to four selected zonal PHC centers for referrals conveyed through the field supervisors, while referrals requiring urgent interventions and hospitalization are made to the base hospital at Aro.

The evaluation of the program activities and impact of program is carried out through reports of service delivery at the PCMHS centers by field supervisors at the monthly implementation committee meetings.

Pre and post evaluations of the impact of the training program on the PHC workers were carried out with questionnaires one year after the training.2 Some of the measures that the evaluation included were:

  • Number of active trained PHC workers
  • Number of people with mental disorders seen, correctly diagnosed, and effectively treated at the health centres

Percentage of PHC workers who received support/supervision sessions per month by the visiting psychiatric nurse supervisors

Cost of implementation

The program received a UK - IHLFS Grant of 15,000 GBP to develop and deliver the initial training program for 80 PHC workers.

Other costs borne by the Neuropsychiatric Hospital Aro, include:

  • Procurement of 2 Toyota Hilux project vehicles for daily trips to cover 40 programme health centres across the state
  • Supply of seed essential medications
  • Supply of stationeries – files, record sheets, posters, handbills
  • Salaries of 8 full time trained psychiatric nurses for support and supervision - on fortnightly visits to the centres. They also carry out community mobilisation activities with trained PHC workers
  • Top up training at 24-months to sustain knowledge of trained health worker at 24 months
  • Supplementary training of additional 37 PHC workers at 30 months to make up for manpower attrition
  • Cost of ongoing support and monitoring activities of the field supervisor

Impact details

On average, about 400 new clients with priority mental health conditions were seen yearly during the three years of program implementation.

The first 12 months evaluation revealed:

  • 473 patients assessed and managed (excluding the pilot patients) at the 40 PHC centers in the state (Diagnosis: 45.9% psychosis, 38.3% epilepsy and 10% depression)
  • 54 % had attended 3 or more follow ups
  • 60% had experienced ≥ 30% symptom reduction since first presentation
  • 42% had experienced at least 2-point increase in their global rating of subjective wellbeing since first presentation
  • 63% of the total caseload were still attending at the 12-months evaluation
  • 4.2% referred to consultant psychiatrists

References

  1. Garrison P. (2009) World Federation for Mental Health: 2009 World Mental Health Day campaign highlights need for more attention to mental health services in primary health care. Mental Health in Family Medicine, 5(3):189-190.
  2. Adebowale T et al. (2014) Evaluation of a mental health training course for primary care workers in Ogun State, South West Nigeria. Journal of Psychiatry, 17(5):14-25.

Research

Multimedia

Associates

Timothy Adebowale

Comments

Submitted by Timothy Adebowale on Saturday, 1st August 2015
The Aro Primary Care Mental Health Programme (APCMHP) of the Neuropsychiatric Hospital Aro Ogun State Nigeria, received the Nigerian Healthcare Excellence Award, as the Primary Healthcare Provider of the year in June, The hospital was also ranked the best hospital in Nigeria, and 6th among the 100 best hospitals in Africa in July 2015. The 'Ranking Web of World Hospital' is an initiative of the CybermetricsLab, a research group belonging to the Consejo Superior de Investigacioness Cientificas (CSIC), the largest public research body in Spain. The APCMHP is currently adopting the Quality Improvement approach of the Institute for Healthcare Improvement, as a member of the A Billion Minds and Lives (ABML), to enhance its service delivery in the participating Primary Healthcare centres across the 20 LGAs of the state..

Submitted by Timothy Adebowale on Friday, 4th December 2015
The Neuropsychiatric Hospital Aro, Nigeria has just trained 20 Secondary School Guidance Counsellors for their newly developed state School-based Mental Health Service, which is an offshoot of the Aro Primary Care Mental Health Programme for Ogun State. The 2-day mhGAP-IG based intensive training workshop held on 2nd & 3rd December 2015 was co-sponsored by the hospital and the State Teaching Service Commission, as part of the ongoing collaboration between the hospital and stakeholder agencies of the state government to provide school-based mental health service in schools spread across all local government areas of the state. Like the existing primary care mental health programme, service would be provided by trained school counsellors and school health workers, with ongoing well-structured support and supervision by mental health professionals from the hospital. The service is essentially an integration of mental health into the existing state school health programme, with the counsellors being the first tranche of trained personnel. Their training covered developmental, behavioral as well as substance (alcohol and drug) use problems among children and adolescents. .
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