Innovation summary

There is a huge gap in access to treatment for mental conditions in Nigeria, as in many sub-Saharan countries.1 Despite a recognition of the need to provide accessible services at a local level using a task-sharing approach, this has not been realized at scale in Nigeria. In part this is due to lack of knowledge about how to integrate mental health into existing health systems, and part due to lack of political will, prioritization and investment.2

There are two goals of this innovation:

  1. To show evidence of efficacy of a model designed to suit Nigeria’s specific health infrastructure
  2. To advocate for such a proven model to be scaled up across the country

To achieve these goals, a model has been developed in a participatory process (using Theory of Change methodology). This model focuses on creating a system where appropriate mental health care skills (using the evidence-base of mhGAP3) can be used by nurses and Community Health Extension Workers at PHC level services; whilst being supported by experts from Federal Neuropsychiatric Hospitals in Calabar and Kaduna. This process is being evaluated and monitored by the University of Ibadan, the London School of Hygiene & Tropical Medicine and CBM, and the results are being used in engagement with the Federal Ministry of Health from the start of the programme.

Impact summary

Impact will be evaluated by: 

  • A change in population contact coverage in 2 target States between 2014 and 2016, disaggregated by age and gender
  • The effect of mental health services on patient outcomes, including symptom and functional outcomes (patient cohort)
  • The cost-effectiveness of services delivered in 2 pilot sites (service costs and client/family costs)
  • Client satisfaction

"Nigeria has made declarations of commitments in the comity of nations, among peers at the Commonwealth Forum, and among partners at the World Health Assembly, to meet global targets with the scaling up of services delivery for the treatment and prevention of mental, neurological and substance-use disorders particularly in community settings nationwide."

 

- Professor C.O Onyebuchi Chukwu, Honorable Minister of Health, Nigeria8

Innovation details

Nigerian mental health policy has for many years recommended integration of mental health care into the general health system so that people can access affordable services through primary health care and general hospitals. This has been realized in only a few isolated examples to date (see examples below), with the result that only around 10-15% of people in this huge and important country access the care they need.1

Nigeria was identified as a priority country for the development of the WHO’s mhGAP programme, and the last ten years have seen a gradual development in Nigeria of ideas around how mental health can be incorporated successfully into the health system. The WHO and Federal Ministry of Health collaborated to form a Mental Health Action committee which helped to foster a greater interest in mental health at the highest levels. A new policy has been adopted4, and a strategy for the roll-out of mhGAP is under way. Several trial programmes, for example in Osun State (University of Ibadan)5, Lagos State, and Benue State (Methodist Church Nigeria), as well as advocacy initiatives6, have provided invaluable lessons that will help to bring the best evidence-base to design a model of mental health care delivery in Nigeria. The Aro Primary Care Mental Health Programme has been running since 2011.

The mhSUN programme is designed to test a model based on this experience, in two pilot sites – Kaduna and Cross River States. The main hub in each state will be the Federal Neuropsychiatric Hospitals, which will support the local (state) structures to integrate and maintain high standards of mental health in existing health services. This use of existing expertise to support decentralized services in a task-sharing model is innovative, and aims to address the problem of not having experts in decentralized locations, and not having sufficient support for people trained in basic skills (like mhGAP) to work in mental health in the field. 

One important reason for having a very strong, research-led evaluation is that this pilot aims to provide Federal Government with the information that they need to effectively plan mental health services according to the progressive new Mental Health Policy. This has also been identified as a global research priority.7 mhSUN is closely linked to the Federal Ministry of Health (FMOH) Mental Health Action Committee, and will report results to the Federal Government, as well as develop effective advocacy tools, such as policy briefs, to promote investment in mental health.

Key drivers

Local stakeholders

  • Leadership of local stakeholders in Cross River and Kaduna States is a key driver for successful implementation
  • As in many low income countries, the great majority of health care professionals are based in tertiary institutions - the model being used in this programme makes use of these professionals, while facilitating use of their skills and expertise in more accessible decentralised settings

Early engagement 

  • Early engagement with Federal Ministry of Health and oversight of National Mental Health Action Committee is another key driver
  • The ultimate aim of this programme is to ensure that the findings of the project are used as a resource for advocacy to scale up services in other states in Nigeria
  • By engaging with decision-makers early on, we will ensure not only using the experience and knowledge that they have, but gain buy-in and establish interest for when we present the results

Challenges

Political uncertainty

Political uncertainty is a risk in a programme aiming to advocate for change. For example, while we have established a strong working relationship with key civil servants in key ministries, such personnel tend to be moved, particularly political appointees. This is likely to be even more the case around the time of the election due in April 2015.

Reliance of oil revenue

Reliance on Nigeria of oil revenue means that the Federal and State Government budgets are significantly reduced when the oil price is low. Nigeria is reliant on oil for 95% of its foreign currency income. A dramatic reduction in the price of the oil (as is the case in 2014/2015) means that budget projections (including in allocations for health) cannot be met. When this is at the level of halving of the oil price, the result is such a fall in revenue that even recurrent costs like salaries may not be paid, and new spending is almost impossible to achieve.

Security issues

Security threats can make it difficult to travel to all parts of the country. The Boko Haram insurgency is making it too risky to travel to the North of the country, and such situations of insecurity make scale up and strengthening of health services difficult.

Continuation

The programme is specifically designed to provide strong evidence to promote greater investment. While it is designed to last for 2 years, the services will be integrated into existing structures, and the expectation is that the models will be extended to other states.

 

Partners

 Funders

Evaluation methods

The results are being evaluated by a team based at University of Ibadan in collaboration with the London School of Hygiene & Tropical Medicine. Outcomes of interest and methods for evaluation of the impact of the intervention include:

  • Change of coverage of the service as a result of the model being implemented (calculated from patient numbers seen and baseline prevalence)
  • Cohort of patients followed for 18 months to measure impact on clinical, functional, and social outcomes
  • Case study of services in intervention and control sites (including facility case studies, fidelity to model and process indicators)  

Cost of implementation

The overall programme has a cost of $530,000 USD over three years, but this includes costs for evaluation as well as implementation of the programme.

Cost-effectiveness is being evaluated at both service level and client/family level. Comparative costs will be linked to health and functioning outcomes in intervention and control sites. The main reason for collecting such data is for use in advocacy for government funding for scaling up services.

 

Impact details

In each of the two pilot sites, the service model will be implemented in three Districts, and around 5 primary care centres in each district. A typical District (‘Local Government Area’) would have around 200,000 people in Nigeria. A typical implementation of such a package of care would aim to achieve 20% coverage of common mental disorders, and 50% of severe mental disorders.  

The cohort will measure client outcomes in schizophrenia, depression and epilepsy. This will allow us to ensure that the coverage is more than just contact with services, but that the services are of sufficient quality to provide client benefit. In addition to clinical outcomes, disability and functioning will also be measured (WHO-DAS).

CBM is a disability organization that seeks to put people with psychosocial disabilities in as strong a position as possible, and sees access to services as a right. It is therefore important to ensure that we assess the degree to which the services meet the expressed needs of the clients rather than just issues that are perceived by others (professionals) to be important. The process of assessing this itself will reinforce the participation of people with psychosocial disabilities in the service design and delivery (they are represented in the governance structures of the programme).

Exact impact will be measured in the evaluation and results published and disseminated.

References

  1. Gureje O. (2002) Psychological disorders and symptoms in primary care: association with disability and service use after 12 months. Social Psychiatry and Psychiatric Epidemiology, 37: 220-4.
  2. Daar A et al. (2014) Declaration on mental health in Africa: moving to implementation. Global Health Action, 7: 24589.
  3. World Health Organization (2008) Mental Health Gap Action Program (mhGAP): scaling up care for mental, neurological and substance abuse disorders. Available at: http://www.who.int/entity/mental_health/mhgap/evidence/en/index.html [Accessed 13.03.15].
  4. Nigeria Mental Health Policy (2013) Federal Ministry of Health. Available at: http://www.mindbank.info/collection/country/nigeria/mental_health_policies [Accessed 13.03.15].
  5. Abdulmalik J et al. (2013) Country Contextualization of the Mental Health Gap Action Programme Intervention Guide: A Case Study from Nigeria. PLoS Med, 10(8): e1001501.
  6. Abdulmalik J et al. (2014) The Mental Health Leadership and Advocacy Program (mhLAP): a pioneering response to the neglect of mental health in Anglophone West Africa. Int Journal of Mental Health Systems, 8:5. 
  7. Collins PY et al. (2011) Grand Challenges in Global Mental Health. Nature, 475(7354): 27–30.
  8. mhGAP Intervention Guide adapted for Nigeria (2013) Preface.
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