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 aims to generate evidence on implementing and scaling up integrated packages of care for mhGAP priority mental disorders in primary and maternal health care in five countries. PRIME focuses on health system strengthening in partnerships between 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.

PRIME is currently in its second phase of investigation:

Phase I: Formative research for the development of district MHCPs

Phase II: MHCPs are implemented in districts and evaluated

Phase III: MCHPs are adapted and improved based on evaluation findings, then scaled up to other districts

Impact summary

  • Developing and evaluating MHPCs in primary health care and maternal health care in 5 low-resource districts
  • $9,619,800 USD in funding over 6 years

"Scaling up of mental health services is a very important public health priority. Our message to countries is to take urgent actions to improve access to evidence-based care for these conditions."
-Dr Shekhar Saxena, World Health Organization

Innovation details

A key principle of PRIME is a partnership between researchers and the Ministries of Health in each of the PRIME countries. As part of this partnership, the human resources for the implementation of PRIME are largely provided by the Ministries of Health while the researchers provide training, technical support and evaluation.

PRIME includes a strong emphasis on capacity building and the translation of research findings into policy and practice, thus contributing to the global scale up of mental health care, particularly for poor and vulnerable populations.

PRIME has 3 overlapping phases over 6 years:

  • Phase 1: Inception (May 2011 – March 2012)

PRIME has developed draft MHCPs including packages of care for depression, alcohol use disorders, psychosis (and additionally epilepsy in Ethiopia and Uganda). The MHCPs are broadly based on mhGAP with extensive local contextualization and additional interventions. These will be implemented within three levels of the health system: healthcare organization, health facility and community.

  • Phase 2: Implementation (April 2012 – March 2015)

PRIME is evaluating the feasibility, acceptability and impact of the MHPCs in primary health care and maternal health care in one low-resource district in each country. While the goal of each package of the intervention is similar across settings (e.g., to improve mental health outcomes), the content of the package (e.g., which human resource cadre delivers the component) is informed by local needs in each setting.

  • Phase 3: Scaling Up (April 2015 – April 2017)

PRIME will evaluate the scaling up of these MHCPs to other districts.

Key drivers

Key factors that have ensured the successful development of MHCPs for each district include initial engagement and continuing partnership with the MoH in each country to ensure that the MHCPs address the political priorities of the government and are designed in a sustainable way by integrating them into the existing health system using MoH resources. This has also enabled us to build a realistic program to which MoH are willing to commit resources.

Challenges

Key challenges faced in the development of MHCPs for each district include:

  • Changes in key MoH and district level personnel which meant that new relationships have to be formed.
  • Changes in MoH priorities which led to the focus of the MHCPs changing in one country.
  • Limited ability of the MoH to provide any additional resources for the MHCPs, meaning we must work within existing budgets.
  • The risk of high staff turnover, which may undermine training and supervision interventions. To address this we aim to build capacity among local clinical staff that is appropriate to their needs, and in a manner that enables them to use their new skills in their local setting.

Continuation

PRIME partners have been centrally involved in developing mental health policy or action plans at national level in Ethiopia, India, Uganda and South Africa. For example in South Africa, the new national Mental Health Policy and Action Plan was recently approved by the Minister of Health (July 2013) and this includes several components which are informed by PRIME research, such as the establishment of District Mental Health Teams.

Evaluation methods

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 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.

Phase I:

  • In depth situation analysis in each district to understand the local context, constraints and drivers
  • In depth qualitative research with service users, service providers and health care organisational staff to explore the acceptability and feasibility of the MHCPs in each district
  • Theory of Change workshops in each district to develop the MHCP in a participatory approach involving key local stakeholders
  • Development of a costing tool to estimate the resources required to implement the MHCP in each district informed by local data and consultations
  • Once the MHCPs are finalized, training materials will be developed or adapted from the WHO mhGAP Intervention Guide

Phase II: A range of quantitative and qualitative methods are being used including:

  • A repeat cross-sectional community survey to measure changes in the treatment gap after the implementation of the MHCP in each district
  • A repeat cross-sectional survey carried out in health facilities to assess changes in the ability of primary care workers to correctly identify and initiate evidence based treatment for people with mental health problems before and after services are implemented
  • Cohort studies to track changes in individual clinical, social and economic outcomes for people receiving care through the MHCP
  • A range of methods to gather process indicators on the implementation of the MHCPs, for e.g. routine monitoring and evaluation, studies to assess the quality and fidelity of training and supervision, and gathering contextual information about factors which affect the implementation and effectiveness of the MHCP

Phase III:  The coverage and impact of scaled up MHCPs in other districts will be evaluated. The evaluation will ensure that the MHCPs are comprehensively evaluated at district level, but also that data from across all countries can be combined to generate evidence about the integration of mental health into primary care in low resource settings more generally.

Cost of implementation

DfiD are funding the PRIME consortium £6 million over 6 years.  In addition, national Ministries of Health are providing the human resources required to deliver the MHCPs.

Impact details

Impact results are not yet available as the MHCPs have not yet been evaluated.

Within the time frame of the program, PRIME hopes to reduce the treatment gap and bring about improved mental health, social and economic outcomes for persons with mental disorders in the districts in which the PRIME research program will be carried out.

In addition, PRIME hopes to build sustainable research capacity in participating country institutions to develop, undertake, and disseminate the research to implement and scale up mental health services. A key outcome will be sustainable partnerships for future collaborations between the international partners and, in each country, between academic partners, Ministries of Health and NGOs, including other areas of the health care sector.

In the longer-term, PRIME hopes to achieve increased uptake of its research findings for mental health policy and practice in other regions of the study countries, other low- and middle-income countries and by international development agencies and donors, to support scaling up of mental health care and reduce the treatment gap for mental disorders globally.

Comments

It is such a pleasure to work on the PRIME project with all our incredible collaborators in the 5 countries. Lets hope the findings can be used to scale up services in these countries and beyond.
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Ethiopia, India, Nepal, South Africa, Uganda

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