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