Integrating MHPSS services in primary health care facilities in post-earthquake Nepal

Innovation summary

The earthquake in Nepal occurred in a context where the health system as a whole has been fragile and there is a tremendous paucity of available mental health services. Services that do exist are concentrated in large urban areas and, on average, there are only 0.22 psychiatrists and 0.06 psychologists per 100,000 people. However, in rural areas the ratio is only one psychiatrist per 266,000 people and one psychosocial counsellor per 209,000 people.¹ The discrepancies in service between urban and rural areas is further exacerbated by the fact that 85% of the Nepali population lives in rural areas.² It is exactly in these remote and rural areas where the earthquakes caused the most damage.

The lack of trained professionals available to address mental health problems is not the only challenge that is found in Nepal. Challenges such as the lack of necessary psychotropic medications, few referral mechanisms for people requiring specialized mental health services, stigmatization of mental illness and a non-existent central coordinating body for mental health at the national level further worsen the country’s capability to respond to the mental health burden³that has been further exacerbated by the earthquakes.

The long term goal of this innovation is to make quality mental health and psychosocial support (MHPSS) services more widely available and accessible, especially in earthquake affected regions.

The program consists of:

Strengthening the capacity of medical officers, health workers in the health facilities and community members to integrate mental health and psychosocial services into the existing primary health care system and communities
Developing a sustainable and multidisciplinary referral network of community based mental health and psychosocial service providers
Providing mental health and psychosocial interventions in the form of psychotropic medication, basic emotional support, focused psychosocial counselling and detection and referral services to those affected by the earthquake and with pre-existing mental health problems
Improving the access to services and support seeking behaviour of mental health patients by increasing community awareness about mental health issues and decreasing stigma

Impact summary

In the health facilities, 126 prescribers were trained using WHO’s mhGAP and 130 non-prescribers were trained to provide basic emotional support and referral. In the communities, 56 Community Psychosocial Workers and 623 Female Community Health Volunteers will be trained to detect, refer and provide home based follow up
Primary healthcare workers will demonstrate at least 80% competency score on post knowledge test and on the job supervision checklist
1800 mental health patients in 3 districts will be treated with psychotropic medication in one year

“Disasters like these have the capacity to create acute short-term impacts on the affected individuals, families, and communities which, if not addressed, can develop into chronic psychosocial and mental health problems"

- TPO Nepal

Innovation details

The long term goal of this innovation is to develop a cadre of primary health care workers (medical officers, health workers, community based psychosocial counsellors, female community health volunteers) who are able to recognize priority mental health problems and then provide appropriate interventions (e.g. psychotropic medication, basic emotional support, focused psychosocial counselling) and referral. This program is being implemented in the Dhading, Sindhuli, and Gorkha districts to promote psychosocial well-being of the population as well as ensure integrated and coordinated provision of psychosocial and mental health services into primary health care. This is accomplished through collaboration with local partners, the Transcultural Psychosocial Organization Nepal (TPO Nepal) and the Integrated Community Development Campaign Nepal (ICDC Nepal).

The program has the following objectives:

Coordination

Regular coordination meetings with local stakeholders such as Ministry of Health and Population, District Health Office, District Development Committee, Village Development Committee, Women Development Office, local police, local political leaders and non-formal community leaders will be conducted to:

Facilitate interagency coordination related to the provision of psychosocial/mental health services, building psychosocial capacity and directly providing psychosocial services, as recommended by the Inter-agency Standing Committee (IASC) guidelines⁴ and contextualized specifically for this emergency setting
Help share common challenges, lessons learnt and best practices and making recommendations related to provision of mental health and psychosocial services

Capacity Building

Several categories of prescribers (medical officers and health assistants), non-prescribers (health assistants (HA), auxiliary health workers (AHW), auxiliary nursing midwifes (ANM), mother and children health workers (MCHW)), community psychosocial workers/home based care workers, female community health volunteers, and psychosocial counsellors will be trained in mental health and psychosocial issues. Regular supervision and refresher trainings will be provided accordingly.

Trainings

In total, 120 prescribers from 52 health facilities in 3 districts (3 district hospitals, 8 primary health care centres and 41 health posts) were trained for 9 days using a standard package of training on mhGAP HIG⁵ training on mental health (contextualized for Nepal), basic psychosocial support, screening, assessment and management of the six priority disorders identified for this program
In total, 130 non-prescribers from 76 health facilities in 3 districts (3 district hospitals, 8 PHCCs and 65 health facilities) will receive a 5-day training on psychosocial support topics, such as the general concept of mental health and priority disorders in the post emergency context of Dhading, Gorkha and Sindhuli, basic psychosocial support (knowledge and skills), screening and assessment of mental health and psychosocial issues, reducing stigma and referral.
Community Psychosocial Workers and Home Based Care Workers will receive a 20 days course on common mental health and psychosocial problems and the six identified priority disorders (Depression, Suicide, Alcohol Use Disorder, Epilepsy, Psychosis and PTSD). They will identify mental health problems using the Community Informant Detection Tool (CIDT)⁶, assess the needs of the patient and his/her family, provide basic psychosocial support and refer to prescribers, non-prescribers and psychosocial counsellors. The HBCWs will be following up with the patients that are seen by the prescribers. They visit them in their homes to assure medication compliance and to provide psycho-education to the family members.
Female community health volunteers (398 in Sindhuli and Gorkha, and a target of 225 in Dhading) will receive a 2 day basic training on mental health issues, the use of the CIDT and referral options.Some FCHVs will be hired as home-based care workers for the project and receive a one-day refresher training based on identified problems and challenges
Community based psychosocial counsellors (17 in total, of which 2 existing staff of Integrated Community Development Campaign) have received a 12 day refresher training on focused psychosocial support using training modules that are endorsed by National Health Training Center.

Supervision

The clinical supervision of prescribers will be conducted once a month by the psychiatrist of TPO Nepal where prescribers are encouraged to make case presentations and discuss issues related to assessment and management of the case such as: history taking, making diagnosis, prescription and side effects of the drugs. The psychiatrist will provide feedback and finalize the diagnoses and management plans. If there aren’t enough case presentations, role-plays will be conducted to practice assessment and management plans.
The non-prescribers will be clinically supervised by TPO Nepal's clinical supervisor to help them manage cases. The district based counsellors will also be supported and supervised by the district clinical supervisor by holding case conferences every month and running care for care givers workshops for the counsellors. The counsellors will conduct monthly supervision of FCHVs, Home Based Care Workers and Community Psychosocial Workers to ensure that screening tools are properly filled in and regular efforts are made to identify people needing mental health and psychosocial support.

Provision of mental health and psychosocial support services

Screening and assessment of affected community members by FCHVs
Provision of pharmacological treatment of mental health problems by prescribers.
Provisions of individual, group and family counselling by psychosocial counsellors who provide problem-focused psychosocial counselling support to vulnerable children, women and families in addressing a range of issues such as moderate anxiety, stress or depression, social isolation, poor parenting skills, family conflict, domestic violence, and so on.
In order to increase the access and coverage of mental health services, several community based anti-stigma campaigns, awareness programs and psychoeducation sessions will be organized using Information, Education and Communication (IEC) materials. In Dhading, there is a weekly radio program that is broadcasted with information about mental health and psychosocial issues and the services that are provided in the program.

To boost the morale of patients/family members and to sustain the recovery, a self-help group for stabilized mental health patients and their family members will be formed at the community level and they will be provided with seed money to undertake income generating activities.

Key drivers

Regular coordination and collaboration with MoHP and district level government agencies, line agencies, peripheral health facilities etc.
Regular involvement of International Medical Corps MHPSS team, including a psychiatrist in finalizing the training materials for prescribers based on the mhGAP module of WHO and training on supervision and training facility skills to ensure the quality of program. Daily contact, coordination and capacity building from International Medical Corps to TPO and ICDC to ensure technical quality and smooth program implementation.
Active participation of the majority of trainees in all trainings reflected their interest in providing mental health and psychosocial service in respective health facility.
Regular Skype meetings with International Medical Corps and TPO- Nepal's technical advisors to develop tools and related training materials for the program.
Involvement of TPO Nepal and IMC in policy level activities on a national level: revision of national health treatment protocol to include additional mental disorders and the revision of the free drug list of psychotropic medication of the Government of Nepal.

Challenges

In the earlier stages of program implementation, the ongoing threat of mild to severe aftershocks
Travel and transportation problems due to fuel shortage and inaccessible roads due to earthquake damage and monsoon
Continuing political instability
Postponement of various training and planned activity due to strike, fuel crisis & undeclared blockade
Difficulties in reporting and data collection due to geographical difficulties, language problems and lack of connectivity

Continuation

This program can serve as a model for future efforts to integrate mental health and psychosocial support into primary care and capacity building for settings with minimal mental health and/or psychosocial workers or services. It also is a strong example of working with local partners to ensure that capacity is strengthened and sustained at the country level.

Partners

Evaluation methods

The team will conduct baseline and endline training assessments to measure progress on:

Increased capacity of the primary health care workers in MHPSS service provision
Implementation of community-based mental health and psychosocial support case management services
Feedback from people with mental disorders receiving services and improvements in functioning
Improvement in processes and resources for mental health at facility and national level (e.g. psychotropic medication supply)

Plans for a program evaluation are underway with M&E and MHPSS Technical Advisors

Cost of implementation

Providing mental health services through general health care is generally more cost effective than relying only on a few specialists and designated mental health care institutions. However a cost effectiveness analysis has not yet been conducted.

Impact details

The first planned capacity building activities (training/orientation) in Sindhuli, Gorkha and Dhading of different target groups (health workers-prescriber/non prescribers, frontline workers, FCHVs, HBCWs & psychosocial counsellors) have been completed: