Innovation summary

There is a limited number of public mental health workers and specialists in Rwanda, yet a high burden of mental health conditions. To meet this need, Inshuti Mu Buzima (IMB), a sister organization of Partners In Health (PIH), in collaboration with the Rwanda Ministry of Health, has developed a training and service delivery model in the Burera and Kayonza districts of Rwanda. The Mentorship and Enhanced Supervision at Health Centers for Mental Health (MESH MH) model integrates core packages of services for severe mental disorders into routine primary health care, and provides training to primary care nurses under supervision from public district mental health staff, together allowing for affordable community-based care and effective treatments to be provided by non-specialists.

While piloting this model, the Ministry of Health and PIH/IMB identified the need to expand the mental health system and incorporate additional clinical services into service delivery. They opted to strengthen the non-pharmacologic elements of existing services by integrating evidence-based psychotherapies for treating common mental health conditions, such as depression and anxiety. In 2017, the Rwanda team adapted and piloted the World Health Organization’s Problem Management Plus Protocol (PM+), to integrate evidence-based psychotherapy for common mental conditions into the primary care system

Impact summary

Between October 2014 and September 2016:  

  • 48 nurses at 19 health centers have been trained to provide mental health care, and 946 community health workers have been trained to identify mental health disorders, reduce stigma, and support patient care
  • MESH MH Health Centers have performed 15,744 patient visits, and 2,239 unique patients have received care at health centers
  • MESH MH is currently being implemented at all 19 health centers in Burera district, which has a population of 340,000

Between July 2021 and June 2022,

  • PIH-supported health facilities in Rwanda provided care to over 3,134 people living with mental health conditions across the three districts of Burera, Kayonza, and Kirehe.
  • From July 2021 to June 2022, over 35,400 community members attended community and health facility-based psychoeducation sessions.

 

“Working with the MESH program has changed my perception of patients with mental illness. I now know they are like other types of patients: they can be treated and they can get better."

- Vestine Niyonsaba, MESH Mental Health Nurse, Kinyababa Health Center

 

Innovation details

Mental health service delivery at IMB started through the Mentorship and Enhanced Supervision at Health Centers for Mental Health (MESH MH) model, implemented from 2014- 2016 via a seed grant from Grand Challenges Canada. MESH MH is a model adapted from the Mentoring and Enhanced Supervision at Health Centers Model (MESH), which was originally developed for HIV and other clinical areas2. MESH MH strengthens decentralized primary health care services at health centers through a combination of didactic training, ongoing clinical mentorship, and quality improvement activities3,6. 

  • Training: Health center nurses receive intensive training (40 hours) on identifying and managing four major neuropsychiatric disorders: schizophrenia, bipolar disorder, major depressive disorder, and epilepsy. Community health workers also receive sensitization and training on these disorders as well as on ways to support members of the community with common mental health conditions and psychosocial concerns.
  • Supervision: After the training, nurses receive regular supervision by trained Rwandan mental health nurse mentors. Mentors conduct regular supervision visits for clinical observation, case and documentation review, and brief didactic sessions, using a mental health supervision checklist. This checklist ensures standardization of activities and performance of key elements of psychiatric evaluation, diagnosis, and referral. Quality of care provided by health center nurses is defined by the successful completion of checklist items.  During supervision visits, the nurse mentor also discusses system-based performance issues and “quality gaps” with the health center nurses and director to formulate specific plans to improve patient care, referral pathways, and coordination between services. 

Over the course of MESH implementation, the MOH and PIH/IMB identified the need to strengthen the non-pharmacologic elements of existing services, specifically by integrating evidence-based psychotherapies for mental health disorders into the primary care system.

Rehabilitation: IMB engages in psychological rehabilitation and reintegration at various community levels and through extensive community outreach, and supports psychosocial rehabilitation, psychoeducation self-help groups, and income-generating activities. The social recovery and community reintegration programs include innovative activities such as agricultural activities, helping patients learn handicraft trade, and livestock programs.

Education: The team is partnering with the University of Global Health Equity (UGHE) in Rwanda to provide psychiatric training rotations for the next generation of medical professionals. Alongside UGHE, IMB is developing a Center for Mental Health Excellence and continues its close collaboration with the Ministry of Health’s Rwanda Biomedical Center (RBC) to support MESH MH expansion beyond districts supported directly by PIH, providing a model to be scaled up nationally.

 

A pilot delivery of a psychotherapy intervention is being rolled out using the World Health Organization’s Problem Management + Protocol (PM+)1. PM+ has been shown to be effective in Kenya and Pakistan4,5, and IMB will be the first to adapt PM+ for Rwanda and to deliver the intervention in a ministry/NGO setting. Implementation and pilot testing begins in 2017.

Goals of the intervention include:

  • Adapt PM+ Curriculum to the Rwandan context and train providers
  • Pilot delivery at the health center level by nurses
  • Train 1 nurse at each health center in Burera to deliver evidence-based psychotherapies to mental health patients
  • Train other health care professionals in Burera district, including at Butaro District hospital, on the integration of psychotherapies
  • Develop and implement a system for mentorship and supervision of nurses providing psychotherapy

Key drivers

Government Involvement

  • The Government of Rwanda has made a significant commitment to addressing mental health concerns, and the Ministry of Health is a key partner in the development and implementation of the MESH MH program
  • MESH MH is integrated into the pre-existing public health care system infrastructure, and the key providers in the model (MESH mentors, health center nurses, and community health workers) are all affiliated with the public sector
  • IMB is helping to build capacity within the MOH in the areas of design, implementation and measurement and evaluation of mental health services in Rwanda as well as through educational and professional development support to existing staff
  • This public sector integration, coupled with the Ministry of Health’s ongoing support, bolsters MESH MH sustainability

NGO Involvement

  • Partners in Health (PIH) is an international non-governmental organization that has 27 years of global health experience delivering community-based services in resource-poor settings across the world
  • PIH provides technical support to its sister organization in Rwanda, Inshuti Mu Buzima (IMB)
  • Since 2005, IMB has been supporting public health delivery systems in three rural districts in Rwanda, 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 IMB’s broad based and sustained presence in Rwanda, are additional key drivers for successful MESH MH implementation

Community Engagement:

  • IMB also engages in psychological rehabilitation and reintegration at community levels and through extensive community outreach and supports psychosocial rehabilitation. As of June 2022, 72 self-help groups with 3,073 members, including people living with mental health conditions and their families, have helped promote economic empowerment and social reintegration.

Partnerships & Collaborations

  • Since 2005, IMB has been supporting public health delivery systems in three rural districts in Rwanda, 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 IMB’s broad based and sustained presence in Rwanda, are additional key drivers for successful MESH MH implementation
  • The University of Global Health Equity (UGHE) will have a 6- week Psychiatry clerkship at three public-sector clinical sites. PIH has supported the integration of mental health care at these sites since 2009, and all locations are equipped with strong mental health teams that include a psychologist and mental health nurses. A key emphasis will be on thorough psychiatric evaluation as a foundation for sound medical practice. Given that the three district hospitals are linked to task-shared, public sector, community-based mental health systems, students will also gain an understanding of how mental health care can be integrated at the community level.

 

Challenges

Existing Health Systems: Gaps and Complexities

  • There is a gap of pre-existing health system capacity for the delivery of mental health services beyond the district-hospital level, thus MESH MH success depends on substantial capacity building at the health center and community level

  • Mentorship and supervision coverage is critical to maintaining and improving quality of care at health centers and providing support to nurses as they care for patients with mental illnesses. However, mentorship and supervision are time intensive and require ongoing relationship-building and patience. Mentors spend significant time with the nurses observing clinical interactions in the field and providing hands-on training. This real-world model strengthens the skills of the nurses and builds capacity for service delivery.

  • The complexity of the health care systems, with multiple key stakeholders at community, district, and national levels, can be challenging and necessitates a sustained high degree of communication and coordination among cross-sectoral partnerships.

     

Presence of Fear and Stigma

  • The presence of fear and stigma towards mental illness in local communities and in providers who have not had training is a challenge to implementation

 

Continuation

In 2005 the Rwanda Ministry of Health invited IMB to develop and test health system strengthening initiatives that had the potential to be scaled nationally; MESH MH is one of the results of IMB’s subsequent efforts. The general MESH model from which MESH MH was adapted has been used in other clinical domains within IMB’s catchment area.  

The goal over the next few years is to expand MESH MH to all IMB supported districts. In the future, the MOH also plans to expand MESH MH to districts outside of IMB’s catchment area and scale up the model nationally.

Lessons learned from implementing this intervention in a real world setting and from evaluation results will be shared to the broader global mental health community, to inform best practices in the field and share knowledge with organizations doing similar work.

IMB programs and lessons continue to serve as models for implementation and scaling mental health interventions in countries around the globe. For example, the psychosocial rehabilitation efforts originally piloted in Rwanda have informed efforts in PIH sister organizations in both Liberia and Peru.

Partners

Funders:

Evaluation methods

MESH Evaluation

Research: A mixed-methods outcomes evaluation with a pre- and post-test design was done at a subset of health facilities participating in the MESH MH program. Qualitative and quantitative outcome evaluations were conducted to determine whether patients receiving mental health care at supported health centers experienced clinical and functional improvement, and to explore the perspectives and experiences of health workers and patients who receive care through this program. The primary outcome measures were clinical symptoms and daily functioning at baseline, two months and six months.

Outcome measures included:

  • The General Health Questionnaire (GHQ-12)
  • World Health Organization Disability Assessment Schedule (WHO-DAS 2.0 Brief)
  • An adapted economic status instrument 

Outcome indicators were:

  • The number of patients with a 25% reduction in their score on both a symptom burden and a functioning scale
  • The number of nurse mentees whose supervision checklist scores reveal a within person improvement, after 6 months
  • The percentage of all mentored visits where both the kind of medication and its dosage are administered correctly by the nurse

As an adjunct to these evaluations, a process evaluation was conducted using service utilization data to assess changes in uptake of mental health services at participating health facilities within the district. MESH supervision checklists were used to determine whether participating health center nurses adequately provide basic quality mental health care.

Coverage indicators were:

  • The number of unique beneficiaries who have accessed care at one of the mentored health centers after two years of program implementation
  • The percentage of all active patients who came for at least one appointment during each quarter of program implementation

Detailed paper on this evaluation is linked in the research section: Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol

Psychotherapy PM+ Evaluation

An evaluation plan is currently being developed using screening tools from the PM+ assessment trialed by the World Health Organization4,5 and indicators for this component are currently being developed. The aim is to rigorously measure and evaluate the impact of psychotherapies delivered at the health center at both an individual and population level.

Supervision: After the MESH MH training, nurses receive regular supervision by trained Rwandan mental health nurse mentors. Mentors conduct regular supervision visits for clinical observation, case and documentation review, and brief didactic sessions, using a mental health supervision checklist. This checklist ensures standardization of activities and performance of key elements of psychiatric evaluation, diagnosis, and referral. Quality of care provided by health center nurses is defined by the successful completion of checklist items.

A process evaluation was conducted using service utilization data to assess changes in the uptake of mental health services at participating health facilities within the district. MESH supervision checklists were used to determine whether participating health center nurses adequately provide basic quality mental health care.

Coverage indicators were:

Cost of implementation

IMB’s mental health program is being implemented in partnership with the Rwanda Biomedical Center (RBC), with a goal to integrate mental health into primary care using existing Rwanda Ministry of Health care systems. The RBC is also planning to scale up the program nationally. Project costs are limited to ensure that the program will be financially adoptable by the RBC. Most of the project costs involve capacity building of human resources, strengthening medical supply channels, and advocating for policy change.

Rwanda has a nation-wide community-based health insurance system, Mutuelle de Santé, in which premiums go into a local risk pool administered by communities. Premiums are determined on a sliding scale, and indigent populations are subsidized by the government. MESH MH treatment costs are covered in large part by Mutuelle de Santé, which increases the financial sustainability of the program and reduces the share of the cost carried by patients.

Impact details

Between October 1st, 2014 and September 30th, 2016, significant improvements in nurses’ skills and knowledge in managing mental illness were measured. Following MESH services, integration of mental health in primary care was accelerated and service has improved. At the beginning mentors were taking the lead in mental health care, but now health nurses who have been trained and mentored for at least six months are taking the lead of care.

To date, 48 nurses at 19 health centers have been trained to provide mental health care and are continuing to receive ongoing mentorship through MESH MH. Mental health services at the community level have also improved through community talks and training. 946 community health workers have been trained to identify mental health disorders, reduce stigma, and support patient care in the community, as well as helping patients’ families to cope with the stress related to mental illness.

Access to mental health care has improved, as more mental health patients have been identified and have access to care: 2,239 unique patients have received mental health care, and 15,744 total mental health patient visits have occurred at MESH MH health centers.

The evaluation component of the program was started in October 2014 and is ongoing; data on service user outcomes and experiences of care is pending. 

IMB has continued to build capacity both with the growing teams and training opportunities as well as the establishment of additional structural interventions.

  • Since 2019, IMB has scaled up the MESH MH model from Burera District to two additional regions: Kayonza and Kirehe Districts, overall incorporating the model at 31 health facilities across the country.
  • From July 2021 to June 2022, IMB equipped Rwinkwavu District Hospital in Kayonza with an electroencephalogram (EEG) machine to optimize epilepsy care, and increased the number of mental health visits provided to 53,547.
  • Since the scale-up of mental health interventions in Burera District in 2011, referrals to the national level-psychiatric hospital have decreased from about 10% to 1%, indicating increased access to mental health care at community levels.
  • Between 2018- 2022, there were a total of 2897 patients receiving PM+ with growing expansion as service provision has expanded to the eastern provinces.

References

  1. World Health Organization. (2016). Problem Management Plus (PM+): Individual psychological help for adults impaired by distress in communities exposed to adversity. (Generic field-trial version 1.0). Geneva, WHO.
  2. Anatole, M., Magge, H., Redditt, V., Karamaga, A., Niyonzima, S., Drobac, P., … Hirschhorn, L. R. (2013). Nurse mentorship to improve the quality of health care delivery in rural Rwanda. Nursing Outlook, 61(3), 137–144. 
  3. Hansen, E. (2016, 22). Model Mental Health Care in Rwanda. Retrieved January 18, 2017.
  4. Sijbrandij, M., Bryant, R. A., Schafer, A., Dawson, K. S., Anjuri, D., Ndogoni, L., … van Ommeren, M. (2016). Problem Management Plus (PM+) in the treatment of common mental disorders in women affected by gender-based violence and urban adversity in Kenya; study protocol for a randomized controlled trial. International Journal of Mental Health Systems, 10(1).
  5. Sijbrandij, M., Farooq, S., Bryant, R. A., Dawson, K., Hamdani, S. U., Chiumento, A., … van Ommeren, M. (2015). Problem Management Plus (PM+) for common mental disorders in a humanitarian setting in Pakistan; study protocol for a randomised controlled trial (RCT). BMC Psychiatry, 15(1). 
  6. Smith, S. L., Misago, C. N., Osrow, R. A., Franke, M. F., Iyamuremye, J. D., Dusabeyezu, J. D., … Raviola, G. J. (2017). Evaluating process and clinical outcomes of a primary care mental health integration project in rural Rwanda: a prospective mixed-methods protocol. BMJ Open, 7(2), e014067. 

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