Innovation summary

Mental health services in low- and middle-income countries (LMIC) are often highly centralized. A limited number of specialist staff provide mostly medical services out of health facilities that are inaccessible to much of the population. This innovation aims to provide equitable access to a range of community-based medical and social interventions for people with mental disorders in low-resource settings.

In order to address the lack of specialist resources in Barwani, Madhya Pradesh, Ashagram adapted methods of community-based rehabilitation (CBR) for delivery by trained lay community health workers (CHWs) and community groups. Ashagram’s CBR model comprises of three levels of service delivery:

Ashagram clinic

  • Pharmacological treatment (as prescribed by specialist)
  • Psychoeducation
  • Family counselling

Community health workers

  • Psychoeducation
  • Family counselling
  • Adherence management
  • Linkage to general health and employment opportunities
  • Self-help group facilitation
  • Promotion of social and political participation

Families, local village health groups, self-help groups

  • Social network strengthening
  • Support for livelihoods through micro-credit
  • Promotion of social and economic participation

Impact summary

  • A comprehensive CBR programme for mental disorders was provided for a population of 125,260 persons in a geographically and economically challenging area
  • Two studies have shown the CBR programme to significantly reduce disability of people living with schizophrenia1,2​

Since a lack of professional resources is the reality in rural settings in India and other developing countries, the CBR method offers a model which involves active local community participation and low levels of technical expertise to deliver services. - Chatterjee et al. (2003)1

Innovation details

Ashagram (“village of hope”) is a non-governmental organization operating out of Barwani, originally established to provide rehabilitation services for leprosy in Madhya Pradesh. In 1998 Ashagram expanded its services to include community-based rehabilitation (CBR) for mental disorders. Ashagram’s CBR model features:

Outpatient care
A center for the outpatient and inpatient treatment of people with mental disorders, epilepsy and intellectual disabilities is staffed by a minimal number of specialists.

Home-based service delivery
A team of specialist staff and CHWs provide medications, psychoeducation, adherence management, rehabilitation and active support to improve social inclusion and access to work for people with severe mental disorders.

Training and continued supervision of CHWs
Lay, non-specialist CHWs learn to identify, engage with and provide psychosocial services to persons with severe and common mental disorders as well as epilepsy in the community.

Transactional self-help groups
Groups are established at villages in the catchment area to address the problems of lack of access to credit and to facilitate social inclusion.

Anti-stigma and discrimination efforts
Information is shared with the local government and community to address social problems like stigma and discrimination and lack of access to work faced by people with severe mental disorders and epilepsy.

Key drivers

  • Leadership and commitment of the organization and persons involved in the program despite difficult circumstances
  • Close involvement of families in all aspects of the programme
  • Collective strength of the village self-help groups in promoting social inclusion of persons with severe mental disorders
  • Advocacy with the local government to provide services in the public health system in the area by having a specialist at the District Hospital and access to psychotropic medications

Challenges

  • Severe lack of financial and human resources
  • Poor accessibility to many sections of the catchment area
  • Poor state of the public health system and absence of any mental health services locally prior to development of Ashagram outpatient clinic
  • Challenging social demographics of the region:
    • High rates of poverty (more than 80% of the catchment area population households were below the designated poverty line)
    • Large proportion of people from very disadvantaged social groups (like indigenous persons)

Continuation

The Ashagram program and the evaluation studies have been influential in the scaling up of community based services in many LMIC settings over the last decade.

The Ashagram experience has  contributed to recent efforts in India (through the INCENSE program) to incorporate community-based programs using CHWs into the services offered by two large psychiatric hospitals.

Partners

  • The Ashagram Trust

Funders:

Evaluation methods

Monitoring and evaluation of the program was conducted through nested action research. The innovation was evaluated in two phases:

  • A longitudinal study with a comparison arm evaluating CBR against outpatient services for people with chronic schizophrenia. This evaluation demonstrated that the CBR intervention was feasible to deliver and was more effective for this highly vulnerable group of service users.1
  • A longitudinal observational study of clinical and social outcomes of CBR service users with a range of severe mental disorders over a 4-year period. This study demonstrated that the CBR method was feasible, acceptable and effective in significantly reducing disabilities in most persons and improved overall social inclusion and employment for people with severe mental disorders.2

Both studies were designed to evaluate the effects of CBR in practice. In the future, Ashagram plans to test the effectiveness of the interventions through more rigorous means like randomized-control trials.

Cost of implementation

No formal cost-effectiveness or cost-benefit analysis has been conducted.

Impact details

  • A comprehensive CBR programme for mental disorders was provided for a highly vulnerable population of 125,260 persons in one of the most geographically and economically challenging areas of the country
    • More than 7,000 persons with mental disorders have been assessed and provided with outpatient treatment at the Ashagram clinic or at Ashagram-supported medical camps conducted in the sub-divisional headquarters of the district
    • More than 600 persons with severe mental disorders (like schizophrenia and bipolar disorder) have been provided with CBR services by Ashagram
    • More than 70 self-help groups comprising of people with severe mental disorders, their family members and others were formed to improve social inclusion and access to micro-credit in villages
  • Strong linkages were formed with the local government for providing access to work in ongoing government welfare plans like the Mahatma Gandhi National Rural Employment Guarantee Act (MGNREGA)
  • Improved social inclusion of persons with severe mental disorders by facilitating wide social contact, citizenship rights like access to existing  community development participation forums (like village developmental groups) and voting in elections and membership of self-help groups

References

1. Chatterjee et al. (2003) Evaluation of a community-based rehabilitation model for chronic schizophrenia in rural India. British Journal of Psychiatry, 182: 57- 62.

2. Chatterjee et al. (2009) Outcomes of people with psychotic disorders in a community-based rehabilitation programme in rural India. British Journal of Psychiatry, 195, 433–439

Research

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Country

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