Innovation summary

Partners In Health, Sierra Leone (PIH-SL) formalized its mental health program in 2018 to address critical human resource and mental health infrastructure gaps in the country. Through progressive decentralization, Sierra Leone’s community-based mental health program in Kono District integrates mental health into general health care services at the district, primary care, and community level. Combining strong mentorship and a growing mental health workforce, PIH-SL is focusing on creating a robust referral system between the facilities and community-based care through their pilot of the Common Elements Treatment Approach (CETA) and expansion of innovative homeless outreach program, and community awareness teams. In collaboration with the Ministry of Health, they are working to completely renovate infrastructure and strengthen quality of clinical care at Sierra Leone Psychiatric Teaching Hospital (SLPTH)- the oldest psychiatric hospital in sub-Saharan Africa.

Key words: Progressive Decentralization; Community Outreach; Psychiatric Hospital/Asylum; Homeless Reintegration; Psychotherapy; Social Support; Education

Impact summary

  • From 2019-2022, PIH-SL health supported facilities in Kono District, Sierra Leone team conducted more 17,627 mental health visits at the Koidu Government Hospital in Kono District.
  • In partnership with the Ministry of Health, PIH-SL supported the development of the first psychiatry residency program in Sierra Leone at the renovated SLPTH.
  • Established a Psychological First Aid (PFA) hotline to provide remote psychosocial support born out of COVID-19, and as a result, over 25 stakeholders have been trained in PFA, resulting in the delivery of over 700 remote consultations

“Welbodi nor dae, wae dae mind nor wel.” Or “There is no health without mental health” popular quote in Sierra Leonean Krio.

Innovation details

Following decades-long Civil War and the Ebola outbreak, an estimated 10% of Sierra Leone’s population experiences mental health conditions; yet the country has only one specialized mental health facility and less than a handful of trained psychiatrists. PIH Sierra Leone’s community-based mental health program expands access to mental health services by integrating care at the community and primary care levels.

Community Mental Health and Primary Care Program in Kono District: Through community outreach and extensive training, community health workers (CHWs) and counsellors work to reduce stigma and link people living with mental health conditions to appropriate care at Wellbody primary health care unit and Koidu Government Hospital (KGH). Supportive visits and mentorship further enhance the identification and management of common mental health conditions. The team’s acute needs and homeless outreach program (started with a training from PIH Liberia) continues to offer treatment and psychosocial support to people living with mental health conditions and to facilitate reintegration with the community.

Facility Development for Psychiatric Treatment: In strong partnership with the Ministry of Health, PIH is working to restore SLPTH by strengthening referral networks and ensuring access to essential medications and services for severe mental health conditions. The highest levels of government have recognized the infrastructural and psychiatric developments that have taken place as SLPTH continues to expand clinical operations, build a greater workforce, and strengthen the overall health system.

Key drivers

Strong linkage between the community and health facility. Strong referral systems at the community and health facility levels are essential for the progressive decentralization of mental health services. PIH Sierra Leone’s mental health program is integrating electronic medical records (EMR) and digital data collection methods to enhance efficiency and ensure that people living with mental health conditions have access to the appropriate services and support within the community and at health facilities.

Social Support. Recognizing the social and financial burdens compounded by mental health conditions, PIH Sierra Leone works to ensure that patients receive social support (such as food, housing, transportation support, etc.) along with clinical support. The homeless care program is just one example of how the team complements treatment of mental health conditions with social support, with the goal of reintegrating with the community.

Task sharing. Due to limited mental health professionals, the PIH Sierra Leone mental health team has expanded its own capacity as well as integrated mental health trainings for other health professionals, community members, and community health workers.

Challenges

Limited infrastructure and human resources for mental health service delivery. Sierra Leone faces major gaps in mental health service delivery with only one psychiatric hospital and an extremely limited number of trained mental health professionals to care for a population of over 8 million people. As a growing number of people seek mental health care at SLPTH and Kono District, the team lacks the workforce and space to properly address the growing magnitude of patients.

Defining non-specialist roles within mental health. To mitigate human resource challenges, PIH Sierra Leone utilizes a task sharing approach where community health workers (CHWs) play a key role in the delivery of mental health services. Compared to general CHWs, distinguishing the scope of work of mental health CHWs and implementing a mentorship structure can prove challenging.

Continuation

PIH Sierra Leone continues to improve care of common mental health conditions by strengthening its psychotherapy and medication management services within the community and at the health facility level. The team will continue to provide Psychological First Aid and support via their outreach approach throughout the duration of the COVID-19 pandemic and thereafter. Moving forward, the team plans to roll out remote psychotherapy and mental health support services.

Team Expansion

During and following the COVID-19 pandemic, PIH focused on expanding clinical operations and strengthening the health system at SLPTH via occupational therapy, supply chain procurement, and data management. Infrastructural improvements include priority projects such as the construction of a new visitor and patient meeting hut, renovating clinical wards and the laboratory, and overhaul of electrical and water systems.

In continued partnership with the Ministry of Health and Sanitation, PIH Sierra Leone is contributing to the development of Sierra Leone’s National Mental Health Strategy.

The government has also asked PIH to support the development of a psychiatry residency training program as their flagship initiative to support both specialist and non-specialist mental health training the country. Formally accredited in 2022 by the West African College of Physicians, the Residency Program comprises clinical exposure and practice, supported by a system of formal and informal instruction. Currently 8 Residents are enrolled in the Psychiatric Residency Program – all of whom are from Sierra Leone. currently has 8 Residents enrolled – all of whom are from Sierra Leone.

Partners

  • The Wellbody Alliance
  • Koidu Government Hospital
  • Sierra Leone, Ministry of Health and Sanitation (MOHS)
  • Sierra Leone Psychiatric Teaching Hospital (SLPTH)
  • The University of Sierra Leone Teaching Hospital Complex
  • Mass General Hospital Chester M. Pierce MD Division of Global Psychiatry at the Massachusetts General Hospital
  • Brigham and Women’s Hospital Program in Global Mental Health Equity at BWH
  • Mass General Brigham Collaborative in Global Mental Health Delivery

Funders

Partners in Health (PIH)
 

Evaluation methods

Strengthened Data Management Systems for Mental Health. PIH Sierra Leone is transitioning from paper forms to digital health systems for more reliable data management to deliver timely care. They have developed electronic medical records (EMRs) at Wellbody Clinic and Koidu Government Hospital. In addition, the team uses the mHealth tool CommCare for patient follow up at the community level. Patient and program level data is reviewed on a regular basis for continuous improvement of care delivery.

Training, Mentorship, and Supervision for Quality Improvement. PIH Sierra Leone continues to enhance the capacity of mental health providers through regular training, mentorship, and supervision. Team members meet on a regular basis to review cases and discuss implementation strategies. As mental health is integrated into the broader system, the team also provides trainings and support on mental health topics to general clinicians as well.

Cost of implementation

Not available at this time.

Impact details

Team expansion

Since community-based services for mental health began in early 2019, Partners In Health in Sierra Leone has seen a three-fold increase in the number of patients treated for mental health conditions in Kono District. From 2019- 2022, the Sierra Leone team conducted over 17,627 mental health visits at Koidu Government Hospital in Kono. The team credits the growth to increased outreach from CHWs, increased engagement of psychosocial counsellors, and the hiring of additional mental health clinicians including Kono District's first psychiatrist.

Collaboration

In 2019, PIH's mental health team in Liberia travelled to Sierra Leone to train their mental health team on how to begin providing care to the homeless population in rural Kono District. Since 2016, across both Sierra Leone and Liberia, Partners In Health has provided treatment and support to over 110 homeless patients with severe mental health conditions such as bipolar, epilepsy, and psychosis. Together, the teams have successfully reunited 74% of people with their families and communities and have made strides in reducing the stigma that is frequently a barrier to care for people living with severe mental health conditions.

Facility Renovation

In partnership with the Ministry of Health in Sierra Leone, Partners In Health renovated the SLPTH to create a strong referral system between the hospital and community-based care for mental health. Through PIH Sierra Leone's efforts, the team progressed from an average of 40 to 75 monthly admissions and from 75 to 300 monthly outpatient visits since the start of the program. The government asked PIH to support the development of a psychiatry residency training program as their flagship initiative to support both specialist and non-specialist mental health training in the country. The psychiatry fellowship was established and received accreditation in 2022. This is a unique opportunity to move toward decentralized and democratized learning platforms by strengthening academic institutions in the Global South, fostering mutual learning without dependence, and promoting bi-directional experience sharing. The training and education of psychiatrists and clinicians is critical to ensure sustained delivery of quality mental health care, innovate, support, and supervise effective strengthening of household, community, health system, and intersectoral mental health services across the country.

The clinicians at Sierra Leone Psychiatric Teaching Hospital opened the facility’s, and the country’s, first child and adolescent mental health unit in 2021.

Innovations

PIH Sierra Leone established a PFA hotline in 2022 to provide remote psychosocial support, including people directly affected by COVID-19. Since the start of the pandemic, the team has trained over 25 stakeholders in PFA and delivered over 700 remote consultations.

References

 

Alemu, W., Funk, M., Gakurah, T., Bash-Taqi, D., Bruni, A., Sinclair, J., … Eaton, J. (2012). WHO MIND: Profiles on Mental Health in Development Sierra Leone. Sierra Leone. I. World Health Organization. Retrieved from http://www.who.int/about/licensing/copyright_form/en/index.html

 

2. Harris, D., Endale, T., Lind, U. H., Sevalie, S., Bah, A. J., Jalloh, A., & Baingana, F. (2020). Mental health in Sierra Leone. BJPsych International, 17(1), 14–16. https://doi.org/10.1192/bji.2019.17

 

3. Improving access to mental health services in Sierra Leone | WHO | Regional Office for Africa. (n.d.). Retrieved April 6, 2020, from https://www.afro.who.int/news/improving-access-mental-health-services-sierra-leone

 

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Peresian Letayian
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Country

Sierra Leone

Affiliated organizations

Partners In Health

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