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 13 facilities and their surrounding communities. By August 2014, 18 service providers working in the district had been trained in the provision of mental healthcare.

In Uganda we found a small non-significant improvement in treatment coverage, a significant improvement in facility detection of depression and AUD (which was not sustained over the longer term) and improvements in clinical symptoms and functioning in individuals with depression and epilepsy and improvements in functioning in individuals with psychosis who received care.

“ The launch of PRIME is a landmark in being able to look at what kind of models that can, indeed, integrate mental health into primary health care. We think this is the only philosophy which can ensure access to mental health care by most of our people.”

 

– Dr Sheila Ndyanabangi, Ministry of Health, Uganda

Innovation details

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

Packages of care focus on the adapted mhGAP Intervention guide, which is being used to train primary care workers in the detection, treatment and referral of these disorders. The MHCP is presented at three levels: the service organisation, facility and community levels. In Uganda’s case, epilepsy is added to the PRIME priority disorders of depression, alcohol use disorders and psychosis. Packages of care focus on the adapted WHO mhGAP Intervention Guide, which is being used to train primary care workers in the detection, treatment and referral of these disorders. In a similar manner to other countries, the piloting experience revealed reluctance to taking on new mental health tasks on the part of primary healthcare workers, and a request for more extensive mental health training and more frequent supervision for mental healthcare.2

Key drivers

  • Human Resources: Improvement in the staffing – 4 new psychiatric nurses recruited during the life of PRIME
  • Training: A noticeable increase in case detection and reporting and referrals at some of the health facilities, following the training of PHC workers 
  • Increased awareness of MH: Resulting in ↑ demand for services

Challenges

PRIME-Uganda has experienced many challenges:

  • Understaffing at  health facilities
  •  Low morale among the health workers
  •  Stock-out of the essential medicines at the health facilities greatly affecting attendance and service utilization
  •  Attitude of the general health workers. (E.g. failure/reluctance to diagnose or record diagnosis of some mental conditions like depression)
  •  Limited funds from government to support implementation in the district
  •  Inconsistencies in reporting between records at health facilities and the submitted HMIS data
  •  Adherence to treatment and follow up

These challenges are being addressed as follows:

  • Stronger involvement and interaction with the district administrators and health managers
  • Advocacy for increased resource allocation for recruitment, medicines and supervision
  • Plans for further training of HWs using mhGAP-IG as part of capacity building
  • Strengthening the support supervision component

Continuation

PRIME is also being implemented in Ethiopia, India, Nepal and South Africa. In the current implementation phase, we are evaluating the feasibility, acceptability, and impact of packages of care in primary health care and maternal health care. In the final scaling up phase, we will evaluate the scaling up of packages of care at the level of administrative health units.  

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 £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 Uganda is US$ 994,991 (£ 661,535) over 6 years 5.

Impact details

The PRIME mental healthcare plan has been implemented in 13 facilities and their surrounding communities. By August 2014, 18 service providers working in the district had been trained in the provision of mental healthcare.

In Uganda we found a small non-significant improvement in treatment coverage, a significant improvement in facility detection of depression and AUD (which was not sustained over the longer term) and improvements in clinical symptoms and functioning in individuals with depression and epilepsy and improvements in functioning in individuals with psychosis who received care.

References

1. Lund C 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(3–5).

2.  Kigozi F et al. (2015) Development of a district mental healthcare plan in Uganda. The British Journal of Psychiatry Oct 2015, DOI: 10.1192/bjp.bp.114.153742.

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, DOI: 10.1192/bjp.bp.114.153841

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
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Country

Uganda

Affiliated organizations

Alan J Flisher Centre for Public Mental Health

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