Innovation summary

In Nigeria it is estimated that less than 10% of people with mental disorders access medical treatment in a year.1 The treatment gap is likely higher for common mental disorders like depression. This implementation research project aims to address the treatment gap by informing the implementation and scale-up of the World Health Organization’s mental health gap intervention guidelines (mhGAP-IG) for depression.2

The implementation components of this project include:

  • Adapting mhGAP-IG for depression to be delivered in primary care in Nigeria
  • Incorporating proactive adherence management using mobile phone support
  • Training non-specialist health professionals in one district of Lagos (Ikeja) to deliver the intervention
  • Implementing the intervention (screening, treatment, adherence management) in Ikeja​

Research components of the project include:

  • Studying influences on the progress and effectiveness of implementation
  • Evaluating the intervention, including its clinical and cost-effectiveness
  • Disseminating evaluation results to promote full scale-up

This study is funded by Grand Challenges Canada

Innovation details

There is a growing evidence base for the use of stepped-care models to deliver care for depression in low- and middle-income countries (LMIC).3-4 Evidence from Nigeria suggests that interventions combining antidepressants with psychotherapy and proactive management in primary care settings are cost-effective and can provide 30% better coverage than other models of care.5 mhGAP-IG also recommends antidepressants, brief psychological therapy and psycho-education to be delivered in a stepped-care model.2

This project aims to implement a cost-effective and scalable intervention for depression in Nigeria by integrating mhGAP-IG into the local primary care deliver structure using a stepped-care model. The intervention is adapted and enhanced to improve its effectiveness in a Nigerian context. A Theory of Change exercise was used to plan the delivery of the intervention in partnership with local communities. In order to provide proactive management in this setting, m-health systems were adopted to assess and support retention in care and adherence to medication.

The project was formerly launched in 2012. Presently the following stages have been completed:

  • Identifying potential and actual influences on the progress and effectiveness of the implementation project
  • Developing and refining the integrated intervention package, adding m-health for proactive adherence management
  • Training of primary health care workers in a select geographical district of Lagos state to deliver the intervention

The next stage of the project will include:

  • Implementing the intervention in the district
  • Evaluating the intervention implementation and its clinical and cost-effectiveness

Reviewing the results of the evaluation and presenting the results to the scientific community and to policymakers with the aim of adoption for full scale-up

Key drivers

This intervention is designed to be sustainable within the existing primary health care system:

  • Intervention uses existing human resources
  • Addressing both physical and mental health issues in primary care avoids inefficiencies of a vertical model


The major challenges faced in implementing the innovation include:

  • Difficulties working with policy-makers and government employees
  • Difficulties reducing stigma and getting primary care workers to focus on mental health issues
  • Issues with trade unions and associations especially with the acceptance of task-shifting


After evaluation, this intervention will be further adapted as needed for scale up to a larger population. While the intervention is currently targeted at clients using the government-operated primary care system, scale-up would extend to all private health facilities and secondary care in the state. This will require the adoption of the project recommendations by the state Ministry of Health. 

Evaluation methods

A quasi-experimental design will be used to evaluate the impact of the intervention on client outcomes and its cost-effectiveness.

Cost of implementation

$909,087 USD funding has been secured for implementation research. The cost-effectiveness of the intervention itself will be evaluated as part of this project.

Impact details

This project expects to improve outcomes for people with depression and their families/carers in Lagos State, Nigeria.

Short term outcomes that will be evaluated as part of this project include:

  • Client access to evidence-based interventions for depression in the Ikeja division
  • Health worker capacity to identify and treat depression in the Ikeja division
  • Health outcomes in clients with depression receiving the intervention in the Ikeja division
  • Health worker and organizational capacity to practice task-shifting and collaborative stepped care
  • Mental health stigma among health workers and clients receiving the intervention
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