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 4 facilities and their surrounding communities. By January 2015, 94 service providers working in the district had been trained in the provision of mental healthcare.

In South Africa we found a significant improvement in detection of depression and alcohol-use disorder and a significant improvement in clinical outcomes for individuals with depression who received care.

 “We very excited about everyone coming together to look at how we can move forward. The PRIME idea of trying to focus on one district, looking at what lessons have been learnt, and then scaling-up services is a good one.” 

 

– Prof Melvyn Freeman, Chief Director: Non-Communicable Diseases, Department of Health, South Africa

Innovation details

Health system strengthening in partnership with researchers, Ministries of Health and non-governmental organisations. The program is implementing and evaluating a district level mental health care plan (MHCP) at health organization and  facility levels in one district in each country, with a view to scaling up in other districts.

In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders foreground the need for integrating mental health into chronic care at district level. A mixed methods approach to the formative phase was used comprising a situational analysis; Theory of Change (ToC) workshops; qualitative interviews with service managers, service providers, service users and carers of service users; and piloting of the preliminary MHCP in one clinic. A district MHCP which included three collaborative stepped care models for depression, alcohol misuse and schizophrenia was developed as a result of this formative work and piloted. A toolkit was developed to pilot the MHCP.

The MHCP was piloted in one Primary Health Care (PHC) facility. Facility-based HIV counsellors and auxiliary social workers deployed by the sub-district mental health society were oriented to mental health care and trained to run psychosocial support groups for patients with depression and schizophrenia respectively. Process evaluations were conducted to assess the barriers and challenges to implementing the MHCP.  The MHCP was revised to address these challenges. The MHCP was then rolled out to three additional facilities in the area. A baseline facility detection survey with 12 month follow-up was conducted to assess improvement in detection of depression and alcohol misuse as a result of the intervention. A parallel study to validate the Patient Health Questionnaire 9 (PHQ9), a 9-item scale to screen for depression was also conducted. The results have been published in an article in BMC Psychiatry.

Implementation included training of facility managers and refresher training in PC101+ (4 additional mental health modules), training of counsellors for the 4 clinics, change management for nurse led chronic care managers and PHC facility-based professional nurses. A quasi-experimental study was also conducted to assess the clinical, social and economic outcomes of PHC patients diagnosed with depression or psychosis and who receive the PRIME-SA psychosocial intervention at baseline and 3 and 12 month follow-up. Outputs from the implementation included an additional module for lay counsellors to provide adherence counselling, and change management workshop guidelines for nurse led chronic care.

Key drivers

  • Regular meetings with PHC managers and facility managers to identify bottlenecks and implement strategies to overcome these
  •  Good relationship with Department of Health at the national and district levels

Challenges

  • High patient loads leads to limited consultation & limited indicators/targets for mental health
  • Low demand & poor mental health literacy/stigma
  • Unattended personal issues; task orientation; CMDs seen as social problems; lack of confidence in diagnosing CMDs

PSR groups

  • Negotiation with the Department of Social Development to utilize auxiliary social workers to facilitate the PSR intervention has stalled
  • Social mobilizers were trained in the PSR component by PRIME-SA, at the suggestion of the DOH, but found to be unfeasible in terms of availability
  • Low numbers in PSR groups due to decentralization of provision of follow-up medication at PHC facilities is not functioning optimally due to doctors at the district hospital not down referring stable patients consistently. Many patients with SMDs still visit the sub-district hospital to collect their medication.  Medication is also not always available at the PHC facilities resulting in defaulting/going back to the sub-district to collect their medication

PC 101+

  • The number of PC101 training sessions received by PC101 nurses through the cascade model of training was not uniform across the clinics/or within the clinics resulting in nurses having different levels of mental health orientation and education
  • There is a need for mentoring for diagnosis and management of mental disorders as nurses do not feel confident to make a diagnosis even after training
  • The lack of targets for mental health diagnosis and referrals has resulted in fewer cases of depression being diagnosed
  • While the clinic services have been re-organized for the provision of ICDM, staff are not orientated or capacitated with the necessary skills for collaborative chronic care
  • Many nurses suffer stress, burn-out and have poor socio-emotional well-being themselves. EAP services are not utilized as they are not easily accessed

Depression counselling intervention

  • HIV counsellors were trained to use the PRIME-SA counselling guidelines for people with depression during the pilot as per the original MHCP but were unwilling to engage in the programme citing other work burdens and requesting additional remuneration
  • PRIME-SA had to employ their own counsellors to perform this function. This compromises the scalability of the MHCP
  • Two PHC psychologists are available in the district but are not easily accessible for PHC patients as they only speak English and Afrikaans,( the predominant language in the district is Setswana) and have very long waiting lists

The above challenges are being addressed in the following ways:

  • Revised DoH mental health indicators, Strengthening recording of MH information on chronic care form, Introduction of CCMDD for stable chronic patients, Strengthening tracing of defaulters
  • Information leaflets & morning talks
  • Change management (PHC nurses) including patient-centred care, changing roles, stress & burnout, Strengthening EAP & providing mentoring in PC101
  • Implementation tools have been developed (e.g. training manuals and group facilitator guides)

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.4

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.5

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. The budget for PRIME South Africa is US$1,241,396 (£ 803,350).

Impact details

The PRIME mental healthcare plan has been implemented in 3 facilities and their surrounding communities. By January 2015, 94 service providers working in the district had been trained in the provision of mental healthcare.

In South Africa we found a significant improvement in detection of depression and AUD and a significant improvement in clinical outcomes for individuals with depression who received care 6.

References

1. Lund C, Tomlinson M, Da Silva M, et al. (2012) PRIME: A programme to reduce the treatment gap for mental disorders in five low and middle-income countries. PLoS Med; 9(12): e1001359. doi:10.1371/journal.pmed.1001359

2. Petersen I, Fairall L, Bhana A, et al. (2015) Integrating mental health into chronic care in South Africa: the development of district mental health plan. British Journal of Psychiatry

3. Asmall S, Mahomed OH. (2013) The Integrated Chronic Disease Management Manual. Pretoria: Department of Health.

4. Breuer E, De Silva MJ, Shidaye R, et al. (2015) Planning and evaluating mental health services in low- and middle-income countries using Theory of Change. BJP Supplement

5. De Silva M, Rathod S, Hanlon C, et al. (2015) Evaluation of district mental healthcare plans: the PRIME consortium methodology. British Journal of Psychiatry. doi: 10.1192/bjp.bp.114.153858.

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

Research

Tools

Multimedia

Reports
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Country

South Africa

Affiliated organizations

Alan J Flisher Centre for Public Mental Health

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