Innovation summary

Haiti suffers from the highest poverty levels and health morbidity indicators in the Western Hemisphere and, since the 2010 earthquake, continues to have very limited mental health services. Zanmi Lasante (ZL) is a local organization serving a catchment area of 1.5 million people through 12 government hospitals and clinics in the Central Plateau and Lower Artibonite valley in Haiti (also see: http://www.pih.org/country/haiti)

Following the 2010 Haiti earthquake, ZL, in partnership with its sister organization, Partners In Health (PIH), mounted a mental health response, developing a community-based mental health system integrated into primary care services across this catchment area. ZL created and trained on curricula, materials, and protocols tailored to different providers ((community health workers (CHW), psychologists and social workers, nurses, and physicians) across four care pathways: depression, epilepsy, psychotic disorders, and child and adolescent mental health (CAMH) conditions. Care is given through a task-sharing model across different provider levels and integrated into primary care services at ZL.

Impact summary

From July 2021 - June 2022 the ZL team:

  • Engaged the community in training and supervision on mental health care completing 774 community awareness, 661 community education, and 232 community leader activities
  • Trained 96 traditional birth attendants on mental health, building collaboration with the community to reduce post-partum depression. They also conducted 4 training sessions on child and adolescent mental health (CAMH) for 20 psychologists and 3 social workers
  • Provided crisis resource services and trained 68 physicians and nurses in the South of the country, in the wake of the devastating 2021 earthquake that killed more than 1,500 people

Between January- October 2016:

  • ZL enrolled 2,168 unique patients for mental health care across 11 facilities at 6,961 encounters
  • ZL trained 270 frontline providers, including psychologists, physicians, nurses, social workers, community health workers, and medicine trainees (residents)
  • A cost-effectiveness analysis has been completed and results are forthcoming 

 

Innovation should have as a main goal to improve people’s lives, and this is what we’re doing for people living in rural and poor areas in Haiti.4

 

- Eddy Eustache, or Père Eddy - Former Director of Mental Health for Zanmi Lasante

Innovation details

Zanmi Lasante has worked with the Haitian Ministry of Health (Ministère de la Santé Publique et de la Population--MSPP) in Haiti since 1987, creating and reinforcing a service delivery platform to deliver comprehensive HIV/TB care across 11 facilities serving a catchment area of over 1.3 million people in the Central Plateau and Lower Artibonite Valley. When Haiti was struck by a devastating earthquake in 2010, ZL became involved in developing a model community-based service for the nation in collaboration with the MSPP 1–3,5.   

While community-based mental health services and evidence-based treatments, including interpersonal therapy (IPT), have been piloted in other low resource settings, ZL has methodically built up a comprehensive system of integrated mental health services. Historically, the problem with acute disaster responses in low-resource settings, and as they relate to mental health, has been that they have often tended to be carried out with insufficient attention to the key components necessary for sustainable delivery of care. The systems approach piloted by ZL in Haiti provide a comprehensive and innovative approach to implementation that has not been explored elsewhere but could be replicated in other resource-limited settings, including other Partners In Health sites.

Mental Health Screening and Diagnosis
The ZL Mental Health team and several collaborators have developed a brief depression screening measure named the Zanmi Lasante Depression Symptom Inventory (ZLDSI) in Haitian Creole. They created the 13-item screening tool based on culturally-bound idioms with the input of Haitian psychologists, medical professionals, traditional healers, community elders, and religious leaders. ZL uses the ZLDSI in routine screening and care, and various stakeholders can apply the tool in multiple contexts in the country. The team provides training to providers; physicians, nurses, psychologists and social workers, across the continuum of care on curriculums, materials, and protocols iteratively developed across four priority disorder care pathways; depression, epilepsy, psychotic disorders and child and adolescent mental health problems, consistent with the World Health Organizations’ mhGAP model.

Community Engagement:
ZL offers community-based mental health services in Haiti's Artibonite and Centre regions by enhancing the capacities of CHWs to mental health screening, identification processes including referral cases to health facilities. Traditional birth attendants are trained through this initiative to prevent and identify signs and symptoms of post-partum depression and psychosis. The team is involved in the communities, with different strategies to provide community awareness and reduce stigma related to mental health conditions among providers, families and local communities. The team continues to adapt to difficulty by conducting mobile clinics within different communities and hard-to-reach areas, bringing outreach and continue access to mental health care.

Government Collaboration:

ZL has worked closely with the MSPP to build on this work and ensure quality is equitable across the systems. They integrate mental health and primary care services through training and supervision in continued collaboration with MSPP. The team has been essential in involvement in advocacy and implementation of mental health integration.

Monitoring, Evaluation and Quality Improvement (MEQ)
ZL has strengthened data collection systems to allow for the collection of patient-level data and tracking of symptoms and clinical outcomes over time. With the use of an Electronic Medical Record (EMR) that began in 2016 and CommCare (mobile health app), they now collect health information at point of care.
They provide regular refresher trainings across all 12 sites, deepening the system for sustained supervision, with a focus on patient safety and quality improvement. The ZL Mental Health teams regularly design and implement quality improvement (QI) projects involving multiple stakeholders working towards a shared goal of care delivery improvement.

Training:

Developing a curriculum and timeline to roll out a Psychiatry Residency program at HUM, in recognition of the importance of formal education and accreditation in attracting young providers to mental health work

 

Key drivers

Task sharing
Use of Local Personnel in a Task-shared approach and focus on adaptation of materials to local context. A commitment to transfer of training roles to existing institutions and local managers, reliance on and continuous use of qualitative user feedback, use of cultural psychological, ethnographic, and participatory methods in pathway and tools design, reliance on Haitian personnel to assume clinical and management roles, inclusion of CHWs and other staff across continuum of care.
Partnership
ZL and PIH are collaborative partners across all aspects of program implementation. They have been sister organizations for over 25 years, and have a deep and sustainable model of working together. Accompaniment is at the forefront of all of our work. ZL/PIH also have a longstanding partnership with the MSPP and have developed trust and goodwill over almost thirty years in Haiti.

 

Challenges

Current challenges for Mental Health Care in Haiti:

  • Need for resources across entire health system and lack of understanding of burden of disease related to mental health
  • Stigma, leading to limited resources for mental health services and discrimination against people suffering from mental illness in the community.
  • There is a very small number of mental health specialists in the country and a recently developing system for formal education in mental health/psychiatry.
  • Potential overburdening of providers with new tasks
  • Degree of successful uptake by care providers can be affected by socio-economic and other barriers
  • Risk to patients and need for patient safety
  • Need for good data and time-consuming nature of data collection
  • Sustained supervision, monitoring evaluation and quality improvement requires attention to detail and a robust team, however human resource shortages can be a barrier to this.
  • Need for political will - our work across partnerships requires careful consideration of stakeholder involvement, limitations, interests and capabilities every step of the way.

Continuation

Modelling

This model serves as a strong model for the nation and there is hope that it can be shared outside of ZL’s catchment area. ZL and MSPP are working together to assess mental health service availability in other catchment areas, to outline an implementation plan for Haiti’s national mental health policy, and advocate for funding. In addition, this work may serve as a model for mental health service integration across other low resource countries, through adaptation of the curriculum, materials and implementation steps to other contexts, both at PIH sister sites and in other health systems.

Collaboration:

Partnership with the medical education sector in Haiti, particularly the residency at Mars and Klein hospital, will ensure the integration of the curriculum and practical training for generalist practitioners – the future of the larger Haitian health system. In addition, there are hopes to formalize a psychiatry residency program at ZL, drawing from partner hospitals and institutions in Boston through the Global Health Delivery Partnership.

Partners

Funders

Historic funders:

Current funders:

Evaluation methods

This intervention has been evaluated on number of providers trained and the volume of patients accessing services, as well as the number and success of community stigma reduction events. In deepening the data collection system, the team will also be able to evaluate clinical and functional improvement for patients over time, as well as volume of patients accessing the system and the impact of community based events. A cost analysis is also being carried out, tying outcomes to expenses.

The intervention was evaluated using quantitative, qualitative, systems, and cost data.

The primary clinical outcome was the Zanmi Lasante Depression Symptom Inventory (ZLDSI) score (depression-specific) and the primary functioning outcome was the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 Brief.

A qualitative evaluation titled “Recovery from Psychotic Disorders in Rural Haiti: The Perspectives of Persons with Lived Experience of Psychosis, Family Caregivers, Health Care Providers, and Community Leaders to Improve the System of Care” was conducted as part of a Master’s degree in the Department of Global Health and Social Medicine at Harvard Medical School.

A return on investment analysis was completed in collaboration with and using a framework provided by Dan Chisholm from the World Health Organization’s Department of Mental Health and Substance Abuse.

Facility assessments at each health center were conducted at baseline and the end of the 2015-2016 grant, through interviews with Medical Directors and providers, using a tool developed by the ZL Monitoring and Evaluation and the mental health team that incorporated elements from prior facility assessments in other clinical areas at ZL and the mhGAP Situation Analysis Toolkit for the Facility and Clinic level.

Cost of implementation

A cost-effectiveness analysis was completed and results are forthcoming. From preliminary findings, salaries of supervisors and frontline service providers was identified as a key cost driver. 

Impact details

Number of people treated and impact of service:

  • 10,835 mental health patient visits, with 10,176 patients receiving some kind of treatment
  • 8,537 patients screened with ZLDSI
  • 1,935 patients diagnosed with depression
  • 1,360 patients diagnosed with epilepsy
  • 990 patients diagnosed with psychotic disorder
  • 1,004 patients with suicidal ideation

Completed trainings across 4 cadres of health care providers on mental health care pathways:

  • 428 attendees at trainings over grant period-
    • Training of 88 CHWs, 114 mid-level providers (psychologists and social workers), 86 nurses, 37 physicians
    • 72 nurses and 31 physicians were trained in pharmacology

Stigma reduction activities:

  • Stigma reduction programs are ongoing in each of the 11 Zanmi Lasante Sites. Activities include: radio shows, meetings with religious leaders, community leaders, and ongoing trainings.
  • Over 200 stigma Reduction activities recorded between 2012-2015

References

  1. Belkin GS, Unützer J, Kessler RC, Verdeli H, Raviola GJ, Sachs K, et al. Scaling Up for the “Bottom Billion”: “5×5” Implementation of Community Mental Health Care in Low-Income Regions. Psychiatr Serv. 2011 Dec 1;62(12):1494–502.
  2. Raviola G, Severe J, Therosme T, Oswald C, Belkin G, Eustache E. The 2010 Haiti earthquake response. Psychiatr Clin North Am. 2013 Sep;36(3):431–50.
  3. Raviola G, Eustache E, Oswald C, Belkin GS. Mental health response in Haiti in the aftermath of the 2010 earthquake: a case study for building long-term solutions. Harv Rev Psychiatry. 2012 Feb;20(1):68–77.
  4. Friday L. Père Eddy, Haiti’s Patron Saint of Mental Health [Internet]. 2015 [cited 2017 Feb 7].
  5. Grelotti DJ, Lee AC, Fils-Aimé JR, Jean JS, Therosmé T, Petit-Homme H, et al. A Pilot Initiative to Deliver Community-based Psychiatric Services in Rural Haiti After the 2010 Earthquake. Ann Glob Health. 2015 Sep 1;81(5):718–24.
  6. Verdeli H, Therosme T, Eustache E, Hilaire OS, Joseph B, Sönmez CC, et al. Community Norms and Human Rights: Supervising Haitian Colleagues on Interpersonal Psychotherapy (IPT) With a Depressed and Abused Pregnant Woman. J Clin Psychol. 2016 Aug;72(8):847–55.
  7. Rasmussen A, Eustache E, Raviola G, Kaiser B, Grelotti DJ, Belkin GS. Development and validation of a Haitian Creole screening instrument for depression. Transcult Psychiatry. 2015 Feb;52(1):33–57.
  8. Legha RK, Solages M. Child and Adolescent Mental Health in Haiti: Developing Long-Term Mental Health Services After the 2010 Earthquake. Child Adolesc Psychiatr Clin N Am. 2015 Oct;24(4):731–49.
  9. Legha R, Eustache E, Therosme T, Boyd K, Reginald F-A, Hilaire G, et al. Taskshifting: translating theory into practice to build a community based mental health care system in rural Haiti. Intervention. 2015 Nov;13(3):248–67.

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