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.
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.
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.
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