Innovation summary

There is strong international consensus that narrowing the treatment gap in low- and middle-income countries requires integrating mental health into primary care.

PRIME is creating high quality research evidence on how best to implement and expand the coverage of mental health treatment programmes in low-resource settings1.

The research was conducted in the following stages:

INCEPTION PHASE

During the inception phase (Year 1-2), PRIME developed integrated mental health care plans (MHCPs) comprising packages of mental health care for delivery in primary health care and maternal healthcare suited to each study country’s unique setting.

IMPLEMENTATION PHASE

During the implementation phase (Years 2-5), PRIME implemented these MHCPs in 5 country district sites and evaluated the feasibility, acceptability and impact of the packages of care in primary health care and maternal health care with four separate studies, including a community survey, facility survey, a cohort study and a case study.

SCALE-UP PHASE

In the scale-up phase (Years 5-7), PRIME scaled up to 94 facilities across the five study countries. The scale-up phase was also evaluated using a case study.

EXTENSION PHASE

During the extension phase (Years 7-8), PRIME is writing up and disseminating its findings, and partnering with other countries beyond the PRIME network. A main goal of PRIME during this final phase is to help make a significant ongoing contribution to a broader investment in mental health and mental healthcare.

We are working hard to refine the intervention packages for each country and this will include strengthening maternal mental health intervention delivery where required. A key challenge has been ensuring adequate quality of care, and PRIME teams are implementing robust Quality Improvement (QI) measures in all countries.

PRIME teams are also actively working with partners in additional LMICs to assist in implementing PRIME’s approach in other countries. This assistance takes on various forms, including presenting workshops, taking part in meetings to share the tools and manuals PRIME has developed.

Impact summary

The PRIME mental healthcare plan has been implemented in 8 facilities and their surrounding communities. By December 2014, 381 service providers working in the district had been trained in the provision of mental healthcare.

In Ethiopia contact coverage for people with severe mental disorders was estimated at 81.7% (300/361) and being restrained in the past 12 months reduced from 25.3% to 10.6%. We found no improvement in treatment coverage, no increase in facility detection, but significant improvements in clinical and functioning outcomes for individuals with depression, psychosis and epilepsy who received care.

A project like PRIME can provide Ethiopia with valid, reliable, timely and useful information in the process of developing implementation guidelines and evidence-based practices, which will strengthen the implementation phase of our national mental health strategy. I am looking forward to supporting PRIME, and am very hopeful that is will make a positive contribution in supporting the national mental health strategy.

 

– Dr Tedla Wolde-Giorgis, Ministry of Health, Ethiopia    

Innovation details

Integration of mental health service delivery and care, with a focus on mhGAP priority disorders, (depression, psychosis, alcohol use disorders and epilepsy) into the existing Health system through a Health system strengthening approach in partnership with researchers, Ministries of Health and non-governmental organisations. The program implements and evaluates district level mental health care plans (MHCPs) at health organization, facility and community levels, initially in one district in each country, and then scaled up to more.

The MHCP is presented for the three levels of the health system in the Sodo district: the community, health facility and the healthcare organisation levels. Key to the implementation of this plan is both the provision of awareness raising and training for staff at all levels, and the establishment of ongoing support and supervision structures to enable sustainability of the plan over time. An important feature of the work in Ethiopia is continued interaction with the wider national Ministry of Health strategic plan for mental health, which envisages major scale up of mental health services in the coming years.2

Key drivers

  • Political will: High levels of support at the national and district levels
  • Mental health coordinator – helpful human resource in the District

Challenges

  • Logistical (transport to communities)
  • Administrative support (more staff required for a longer period)
  • Cost and task (task is much bigger than initially anticipated, number of staff needed with closer support and supervision, and medication was required to be available)
  • Human resources – activities of facility or community staff not predictable, needs to fit with their schedule, time pressures and high staff turnover
  • Adherence of patients to treatment and follow-up is unclear
  • Detection of depression
  • Ensuring sustainability

Partners

Funder

Evaluation methods

A Theory of Change approach is used to design locally acceptable and feasible MHCPs with the involvement of key stakeholders, and to provide a framework for the comprehensive evaluation of the plans.3

A range of quantitative and qualitative methods are being used to evaluate changes in treatment coverage, the impact on mental health, social and economic outcomes for people who receive the MHCPs, as well as to evaluate the acceptability and feasibility of these packages to health care providers and service users. A repeat cross-sectional community survey is being used to measure contact coverage for adults with depression or alcohol use disorders; a repeat cross-sectional facility-based survey is being used to measure detection of depression or alcohol use disorders and initiation of correct treatment; patients diagnosed with depression, alcohol use disorders, psychosis or epilepsy are being followed-up to assess the change in a range of individual patient outcomes, with additional follow-up of caregivers of people with psychosis or epilepsy; and a case study is being conducted using a range of a range of qualitative and quantitative methods to evaluate the process of implementing the MHCPs in each district.4

Cost of implementation

DfiD is funding the PRIME consortium $9,330,700 USD (£6 million) over 6 years.  In addition, national Ministries of Health are providing the human resources required to deliver the MHCPs. The budget for PRIME Ethiopia is US$696,308 (£451,038).

Impact details

The PRIME mental healthcare plan has been implemented in 8 facilities and their surrounding communities. By December 2014, 381 service providers working in the district had been trained in the provision of mental healthcare.

Coverage for people with severe mental disorders was estimated at 81.7% (300/361) and being restrained in the past 12 months reduced from 25.3% to 10.6%. We found no improvement in treatment coverage, no increase in facility detection, but significant improvements in clinical and functioning outcomes for individuals with depression, psychosis and epilepsy who received care. 5

References

1. Lund C, Tomlinson M, De Silva M, Fekadu A, Shidhaye R, Jordans M, et al. PRIME: a programme to reduce the treatment gap for mental disorders in five low-and middle-income countries. Plos Med. 2012;9(12):e1001359(3–5).

2. Fekadu A, Hanlon C, Medhin G, Alem A, Selamu M, Giorgis T, Shibre T, Teferra S, Tegegn T, Breuer E, Patel V, Tomlinson M, Graham Thornicroft, Martin Prince, and Crick Lund (2015). Development of a scalable mental healthcare plan for a rural district in Ethiopia. The British Journal of Psychiatry. DOI: 10.1192/bjp.bp.114.153676.

3. Breuer E, De Silva MJ, Shidaye R, et al. Planning and evaluating mental health services in low and middle income countries using Theory of Change. British Journal of Psychiatry. Oct 2015.

4. De Silva M, Rathod S, Hanlon C, Breuer E, Chisholm D, Fekadu A, Jordans M, Kigozi F, Petersen I, Shidhaye R, Medhin G, Ssebunnya J, Prince M, Thornicroft G, Tomlinson M, Lund C, Patel V (2015). Evaluation of district mental healthcare plans: the PRIME consortium methodology. British Journal of Psychiatry. Oct 2015 doi: 10.1192/bjp.bp.114.153858.

5. PRIME (2019). PRIME Impact Report: Improving access to mental healthcare in low- and middle-income countries

Research

Tools

Multimedia

Reports
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