mhGAP Implementation in Kashmir
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mhGAP Implementation in Kashmir

Project type:
Program
Objectives:

To reduce the treatment gap through the implementation of a mental health program in the Ganderbal District of Kashmir.

Brief description:

mhGAP training for health professionals including interactive sessions, role play and group discussions.

Project status:
Complete
Social:

Summary

Innovation summary

A recent situational analysis conducted in Kashmir indicated that there was a centralized mental health care system in place, marked by poor treatment standards, lack of mental health drugs and lack of knowledge in health professionals to appropriately diagnosis mental health problems. 

This innovation seeks to use the World Health Organization's mhGAP framework to train health professionals from diverse specialties to reduce the treatment gap found in Kashmir and eventually decentralize the current mental health system. The training program uses WHO validated tools to train as well as to monitor and evaluate the effectiveness of the program in reducing the treatment gap. Two preliminary short trainings have been conducted and a year-long pilot is currently taking place in the Ganderbal District.

Impact summary

  • 110 health professionals trained in two weeks of preliminary training 
  • Planned evaluation to take place after pilot program is completed

The main image is a submission by Masood Hussain, a renowned Kashmiri artist. It depicts a praying woman's face and hands peeping through a lattice window - a symbolic image intertwined with the success of the project.

Innovation

Innovation details

The World Health Organization's Mental Health Gap Action Programme (mhGAP) has been developed with the aims of training and capacity building in order to deliver services for people with mental, neurological and substance use disorders for countries especially with low and middle income. According to the WHO “Mental, neurological and substance use disorders are common in all regions of the world, affecting every community and age groups across all income countries. While 14% of the global burden of disease is attributed to these disorders, most of the people affected -75% in many low-income countries- do not have access to the treatment they need”.

Kashmir has been going through conflict since 1947 and in the last 25 years there has been armed conflict which has led to many fold increase in mental disorders. Conflict is ongoing and people continue to suffer, with limited access to mental health services. There is only one psychiatric hospital based in capital Srinagar with 25 to 30 psychiatrists for the whole population of Kashmir valley (approximately 800,000 people). Given the system is very centralized, there are not any psychiatric services at the primary care level and there is very limited access to psychiatrists at the district level.

District Mental Health Program

Objectives

The District Mental Health Program, part of the National Mental Health Program, is the flagship program for mental health intervention in India. It is the first initiative to move away from institutionalization to community care by collaborative arrangement with strong community participation, linkages with voluntary sector and civil society initiatives,with academic institutions from inter disciplinary backgrounds and use of private sector knowledge and skill base with adequate safeguards against commercial interests prevailing over public interests.

The overall objectives are:

  • To deliver a standardized mhGAP training to prescribers and non-prescribers working in primary care settings in Kashmir
  • To increase participants’ confidence and skills in the assessment, diagnosis and management  of the priority conditions prioritized by mhGAP
  • To increase participants’ skills in a range of training techniques, facilitators and supervision skills, identifying a pool of local mhGAP champions
  • To raise the profile of mental healthcare among primary care workers

The innovation works alongside the District Mental Health Program to use a decentralized community based approach to the problem by:

  1. Training the mental health team at the identified nodal institutes within the state
  2. Increasing awareness about mental health problems and effective health seeking patterns
  3. Providing adequate services to promote early detection and treatment of mental illness in the community itself with both outpatient and indoor treatment and appropriate follow up measures
  4. Collecting data and experience for future planning, research and improving service provision

Further it seeks to take the mhGAP training program one step further by evaluating the training. This element is an innovative feature, one that other mhGAP programs do not usually include.

3 Phases of Training in Kashmir

To date there have been 3 phases of training in Kashmir as part of this innovation, supported by the Director of Health Kashmir:

Preliminary Primary Care Training  (September 2013)

A two-week preliminary primary care training was conducted for 120 health professionals from all over Kashmir in September 2013. The training was delivered by a team of UK, Kashmiri and Dutch psychiatrists and psychologists who were recruited from the Royal College of Psychiatrists Volunteering and International Psychiatry Special Interest Group.

Secondary Care Training (August 2014)

The second phase was coordinated by the secondary care level to link primary and secondary levels of care effectively. This phase included new participants from secondary care and from the private sector. The training specifically focused on the child development modules of the mhGAP. 

Pilot Program in Ganderbal District (August 2014)

Following a series of meetings over 2013-2014, a steering group was formed for development and implementation of the pilot project in the Ganderbal district. This steering group was essential in preparing an extensive background sketch for the implementation of the pilot. 

Training was repeated in August 2014 and focused on primary care physicians in Ganderbal district. The meeting was held with the Chief Medical Officer, the Block Medical Officer and medical officers of the Ganderbal district to establish a robust supervision, monitoring and evaluation system over the following year as per supervision and monitoring framework. The BMO and MO were identified as supervisors.

The objectives of the pilot training program were:

  • To train all GPs in the Ganderbal district of Kashmir (India) in mhGAP implementation guide tool 
  • To implement the mhGAP based integrated mental health primary care service in Ganderbal
  • To implement a supervision framework for 1 year for GPs in Ganderbal

Key drivers

Support from Key Partners

Support from the health department has been essential for the innovation for implementation and incorporation into the District Mental Health program

Challenges

Lack of Human Resources

The structure of the innovation depends on one lead employee, who works with volunteers, to support the trainings and implementation of program. For further successful implementation, it will be key to increase the number of people working on this initiative. 

Gathering Data for Monitoring and Evaluation

Gathering data required for M&E will be a challenge as patient records are not well kept and patients often see different GPs. Patients also may visit traditional healers or other doctors, again contributing to gaping holes in their medical records.

Continuation

If the evaluation proves that the innovation is effective, the program will be rolled out to other districts in Kashmir.

Partners

Implementing Partners

Funders

Logistical support

In-Kind Support

 

             

Impact

Evaluation methods

The study will monitor all GP practices in Ganderbal with a specific intervention of mhGAP program. 

Study Design

The study design is a quasi-experimental design. Given that the innovation takes place in a real world situation, there are many confounders that cannot be controlled for. The baseline data will serve as the comparison, as the logistics of a sample from another area are too complex for this study. The baseline data will be compared to the data collected from 3, 6, 9 and 12 month checkups in the district.  

The study is a prospective study beginning at the end of 2014 and continuing on for 1 year.   

Monitoring and Audit Systems

A monitoring system will be implemented through the WHO toolkit. Data that will be collected will include the number of cases seen, drug prescriptions prescribed and the number of cases seen for follow up. A health information systems program that is used at the Primary Healthcare level will record the diagnostic category, which will also be monitored through the WHO toolkit.

The audit system will measure practice against the standard of mhGAP protocols. This will be done through supervision using the monitoring and evaluation component of the WHO toolkit. Interventions at PHC level will be recorded according to module standard and can be quantified and audited as appropriate. In addition, the supervisor will directly observe the practitioners and evaluate whether they able to assess, diagnose and manage cases according to an appropriate standard. If issues are detected, an intervention will be developed to ensure good quality of care. 

Evaluation Indicators

A sample of the indicators the innovation will be measuring:

Number of prescriptions – GPs will record the number of prescriptions they prescribe. Indirect indicator might be the prescribing of vitamin tablets and injections which is very common in Kashmir. With mhGAP model one would expect a decrease of such prescribing.

Quality indicator –  Patients will be asked their satisfaction with the innovation. The Verona Service Satisfaction scale from the EPSILON study will be used.2 This scale has not been used in Kashmir and would need an adaptation. 

A complete list of indicators for mhGAP can be found in the resource section. 

Cost of implementation

Total project costs: $88,636 (USD).  A cost analysis has not been conducted.

Research

Tools

Multimedia

Reports