Innovation summary

Known locally as Bo-Mphato Litšebeletsong tsa Bophelo, PIH started working in Lesotho in 2006 through an invitation from the Ministry of Health (MOH). Similar to other PIH sites, Partners In Health Lesotho (PIHL) works within the structure and health care centres of the MOH.  

There is a high prevalence of infectious diseases in Lesotho which requires chronic care at health facilities. Integrating mental health care within infectious disease service delivery provides a much needed opportunity for mental health care to reach a significant proportion of the population1-3. Furthermore, people with infectious diseases such as HIV or TB are also likely to be affected by mental illness, often presenting with depression as a comorbid condition4-5.

Given the robust MDR-TB program already functioning within Lesotho, depression screening will be integrated into the existing program. PIHL has since identified three priority clinical areas within Lesotho in which to implement mental health screening and treatment:

  1. Primary health care clinics, including those integrating HIV, TB and Maternal, Neonatal, Reproductive and Child Health (MNRCH) care
  2. Multi Drug Resistant Tuberculosis clinics
  3. National Health Reform - PIH Lesotho has been supporting the local Ministry of Health over the last 4 years in improving its health system to include capacity-building and mentorship for health care workers, a well-established care pathway for patients with mental health conditions and stronger M&E systems for other conditions to include mental health screening, indicators and treatment

As of 2016, the integration of mental health training and treatment into primary health care has become a high priority.

Impact summary

As of June 2018:

  • 228 MDR TB patients screened out of which 94 patients were found to have mental health conditions and were offered treatment
  • 130 women enrolled on an early childhood development project were screened out of which 27 were found to have depression and were offered treatment

“Given that patients suffering of MDRTB and HIVAIDS are desperate, often depressed and already taking more than a 9 medications daily. It is essential that we raise the capacity of health care providers at all levels to screen for co-morbid psychiatric disorders, especially depression.”

Dr. Melino Ndayizigiye, Clinical Director PIHL

Innovation details

Lesotho is a small, landlocked kingdom in South Africa with a population of 2 million people. There is a 25% prevalence of HIV in Lesotho2 and high prevalence of tuberculosis (TB) at 724/100,0001, 3. A study on the burden of mental illness conducted at PIH sites, using local data as well as from the Global Burden of Disease Study, showed that 32% of all Years Lived with Disability (YLDs) in Lesotho are attributable to mental illness6. This percentage is as great as all other YLDs due to non-communicable diseases in Lesotho combined6.

The aim of the Lesotho mental health program is to promote the integration of mental health care awareness and delivery among treatment supporters, counsellors, nurses and doctors, focusing on patients with high comorbidities of MDRTB and HIV/AIDS. Furthermore, people with infectious diseases such as HIV or TB are also likely to be affected by mental illness, often having depression as a comorbid condition2, 3.  Given the high prevalence of infectious diseases in Lesotho, which require chronic care, integrating mental health care within infectious disease service delivery will allow mental health care to reach a significant percent of the population. Furthermore, given the strong MDR-TB program within Lesotho, depression screening will be integrated into the existing program and be done by village health workers and clinicians. The program will be aligned with the Ministry of Health’s goals and objectives for mental health care.

Services are being rolled out in 2018 for delivery in the PIH - Ministry of Health Hospital, Botsabelo in Maseru, at district hospital in Mohales’ hoek and seven PIH supported sites in the rural high mountains of Lesotho. Plans to develop a task-sharing model using district psychiatric nurses and general nurses and physicians, through support and supervision from specialists, are underway. The program will include medication management and targeted psychosocial interventions by village health workers, social workers, psychologists, nurses and general physicians. Village health workers were selected by local communities based on trust and a competency criteria given by the Ministry of Health. Case finding, engagement, follow up and psychoeducation will also be conducted as part of the implementation. Furthermore, the program is developing training curricula for village health workers and clinicians, building off existing materials developed by the PIH Haiti and Rwanda team. A monitoring and evaluation plan is also being developed that integrates mental health indicators, encounter tools and outcomes into the existing TB, HIV and CAMH data collection systems.

Trainings for providers (doctors, nurses and psychiatric nurses) were initiated in 2017 in Mohale’s Hoek district and in 2018 at the PIH/MOH Botsabelo Hospital in Maseru. Over a 4 day period, trainees engaged in lively discussion and interaction as they learned about mental health integration into primary care of their patients. Lecture, discussion and shared patient stories focused on:

  • Detection and measures for depression (PHQ-9)
  • Treatment for depression (including medication and talking therapy)
  • Psychoeducation (including stigma and suicide)
  • Family support
  • Depression in vulnerable populations e.g. mothers, children and adolescents and geriatric patients
  • Detoxification protocol for patients with alcohol abuse
  • End of life and palliative care

Key drivers

Buy-in from health providers

Trainees showed enthusiastic participation, they appreciated the relevance of the issues to their patients and findings from the evaluation showed that they were grateful for the training on raising awareness and building confidence to manage patients with mental health conditions

Challenges

Burden and logistical difficulties: 

  • Difficulty procuring the necessary supplies and logistics to fully implement the program
  • Continuous need for high quality mentorship and supervision to assure quality screening and management of patients.

Continuation

The program is in the process of being developed and rolled out, adapting the best practices and lessons learned from PIH programs in Haiti, Rwanda, Liberia and Malawi.

Partners

Ministry of Health

Funders

Partners in Health

Evaluation methods

A monitoring and evaluation plan that integrates mental health indicators, encounter tools and outcomes into the existing TB, HIV and CAMH data collection systems is currently in the process of being developed.

Cost of implementation

The full program costs are in the process of being determined. Preliminary cost estimations for training and implementation are mentioned below:

  • Cost for a 4-day training including associated travel and logistics: $5,720.00
  • Mental health office and administrative supplies, annual cost: Approximately $3,580

Impact details

As of 2018:

  • We have screened 228 MDR TB patients and have found 94 patients with mental health conditions
    • 94 out of 228 MDR TB patients were found to have mental health conditions. These conditions included Depression (33%), Psychosis (40%), Epilepsy (10%), Substance Abuse (13%) and Dementia (4%).  
  • 130 women enrolled in an early childhood development project were also screened through the program, as a result of which 27 have been found to have depressive symptomology.
    • Only one of these women had a severe depression score and was prescribed medication while the rest of the patients received talk therapy.

Total number of people trained:

  • 2018 trainings- 5 doctors and 5 nurses have been trained
  • 2017 trainings- 2 doctors and 12 nurses have been trained

References

  1. Partners In Health Lesotho [Internet]. Partners In Health (2016). Available from: http://www.pih.org/country/lesotho
  2. Ministry of Health Lesotho (2012) Lesotho Global AIDS Response Progress Report. Ministry of Health and Social Welfare, Lesotho; 2012 Mar.
  3. USAID (2015) Enhancing care for orphans and vulnerable children in Lesotho [Internet]. Available from: https://www.usaid.gov/results-data/success-stories/enhancing-care-orphans-and-vulnerable-children-lesotho
  4. Ige OM & Lasebikan VO (2011) Prevalence of depression in tuberculosis patients in comparison with non-tuberculosis family contacts visiting the DOTS clinic in a Nigerian tertiary care hospital and its correlation with disease pattern. Ment Health Fam Med, 8(4):235–41.
  5. Issa BA, Yussuf AD, Kuranga SI (2009) Depression comorbidity among patients with tuberculosis in a university teaching hospital outpatient clinic in Nigeria. Ment Health Fam Med, 6(3):133–8.
  6. Vigo D (2016) Burden of Disease framework: Contribution to needs assessment for resource planning in PIH country-sites. Partners In Health Cross Site Mental Health Meeting; Beverly, MA.

Associates

Amruta Houde
Jesse Wilson
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Country

Lesotho

Affiliated organizations

Partners In Health

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