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 3 facilities and their surrounding communities. By December 2014, 172 service providers working in the district had been trained in the provision of mental healthcare.

In India we found no improvement in treatment coverage, a small improvement in facility detection and modest improvement in clinical outcomes for individuals with depression and AUD who received care.

“I am excited at the launch of PRIME, as it is very important since mental health has been given low priority until now all over the world, especially in developing countries. PRIME will develop very good models for the diagnosis and provision of mental health care for patients.”

 

– Dr KK Thassu, Ministry of Health, India 

Innovation details

Integration of mental health service delivery and care, with a focus on mhGAP priority disorders, (depression, psychosis and alcohol use disorders) 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, with a view to scaling up in other districts.

The MHCP in India can broadly be divided into enabling and service delivery packages. The enabling packages such as Programme Management, Capacity-building and Community mobilization essentially focus on establishing the foundation for facilitating the service delivery packages, which in turn focus on awareness for mental disorders, identification, treatment and recovery. 2

PRIME in India is being piloted in the Sehore District of the Madhya Pradesh (MP) State. Local partners involved in the implementation include the Public Health Foundation of India (PHFI), Sangath and the Ministry of Health & Family Welfare in the government of MP State. The implementation of the MHCP was initially piloted in one district site (Bilkisganj Community Health Centre) from July 2013 – March 2014, expanding into two further sites (Shyampur and Doraha Community Health Centres) since March 2014.2

Key drivers

Human resources

  • Mental Health Service delivery can be strengthened with strong facilitation by an external resource team such as PRIME team
  • An additional human resource in the form of a case manager is essential to establish true collaborative models of care and to enhance the psychosocial aspect of mental health care

Tools

  • Enabling packages (programme management, capacity building and community mobilisation) need to be installed as a foundation prior to the implementation of service delivery packages (awareness for mental disorders, identification, treatment and recovery)
  • The focus of the MHCP from three priority disorders needs to be broadened to include patients with medically unexplained somatic presentations.2

Challenges

  • No identification of patients with priority disorders at the community level by Front Line Workers (FLWs) and non-provision of Mental Health First Aid
  • Low identification and treatment initiation for priority mental disorders by facility Medical Officers (MOs)
  • Non-establishment of linkage/ collaboration between Facility MOs and Specialist at the district level
  • Non-availability of psycho-tropic drugs in the facility
  • Non-reporting of mental health indicators  

Strategies have been put in place to overcome each of these challenges:

Facilitation by PRIME team members of community based activities by establishing contacts with FLWs (ASHA workers) and their supervisors.

Specialist clinics by District Mental Health Programme (DMHP) team (including a Psychiatrist and Psychologist) organised regularly at the facility to provide immediate clinical services and follow up on old cases at the nearest facility. In addition to the clinics they also train and supervise the work of Medical Officer’s and para-medical workers on mental health concerns of the people visiting the facility.

Clear directives from State and District Level administration have been obtained for supply of essential psycho-tropic drugs at the facilities to aid the first line treatment of mental illnesses by Medical professional trained in mental health care. PRIME team members interact and work consistently with Medical Officers to strengthen the process of identification and treatment related issues of people with mental illness. This serves as a way to strengthen the bottom-up feedback loop in the implementation mental health care packages.

Clear directives from State and District Level administration have also been obtained for reporting on key performance indicators related to mental health service delivery such as number of patients with priority mental disorders identified and treated. A report from each of the facilities is being sent to the administrative officers on the indicators. 2

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 are funding the PRIME consortium $9,330,700 USD (£6 million) over 6 years.  In addition, national Ministries of Health are providing the human resources required to deliver the MHCPs. The budget for PRIME India is US$ 868,400 (£ 562,716).

Impact details

The PRIME mental healthcare plan has been implemented in 3 facilities and their surrounding communities. By December 2014, 172 service providers working in the district had been trained in the provision of mental healthcare.

In India we found no improvement in treatment coverage, a small improvement in facility detection and modest improvement in clinical outcomes for individuals with depression and AUD who received care 5.

References

1. Lund C et al. (2102) PRIME: a programme to reduce the treatment gap for mental disorders in five low-and middle-income countries. Plos Med, 9(12):e1001359(3–5). 

2. Shidhaye R et al. (2015) Development and piloting of a plan for integrating Mental Health in primary care in Sehore District, Madhya Pradesh, India. The British Journal of Psychiatry, DOI: 10.1192/bjp.bp.114.153700.

3. Breuer E et al. (2015) Planning and evaluating mental health services in low and middle income countries using Theory of Change. British Journal of Psychiatry.

4. De Silva M et al. (2015) Evaluation of district mental healthcare plans: the PRIME consortium methodology. British Journal of Psychiatry. 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

Associates

PI - PRIME India
Vikram Patel PRIME Research Director
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