Partners in Health Lesotho Mental Health Integration Program
PIH Lesotho

Partners in Health Lesotho Mental Health Integration Program

Project type:
Program
Objectives:

To integrate community-based mental health services into the primary care system as a national model.

Brief description:

Mental health integration into primary care, focusing on people with MDRTB and mothers & children through advanced training, mentorship and supervision.

Social:

Summary

Innovation summary

The mental health program at Partners In Health Lesotho (PIHL), locally known as Bo-Mphato Litšebeletsong Tsa Bophelo, started in 2017 by conducting screenings for common mental health conditions among patients with multi-drug resistant tuberculosis (MDR-TB). Working closely with the Ministry of Health (MOH), PIHL first piloted the intervention at Nkau health facility in Mohale district and later established it at Botšabelo Hospital in Maseru, and in rural and community clinics across the country. The team engages in mental health case finding, depression treatment to promote adherence to MDR-TB treatment, and psychosocial support. PIHL provides these programs within the existing PIHL supported continuum of facility- and community-based primary care services in the poor, mountainous area of Mohale's Hoek, Lesotho. Following the success of their early childhood development program, PIH Lesotho is scaling up screening and mental health services for common mental health conditions across their health facilities.

Impact summary

From June 2019- July 2022:

  • The Lesotho Mental Health Team screened more than 7000 people for common mental health conditions
  • The Lesotho mental health team provided training to 827 health care providers expanding the capacity for provision of mental health services
  • PIH Lesotho provides psychoeducation during community outreach, and community health coordinators ensure that mental health medications are included for patients who receive care at health posts in rural areas around the country

As of June 2018:

  • 228 MDR TB patients screened out of which 94 patients were found to have mental health conditions and were offered treatment
  • 130 women enrolled on an early childhood development project were screened out of which 27 were found to have depression and were offered treatment

“Given that patients suffering of MDRTB and HIVAIDS are desperate, often depressed and already taking more than a 9 medications daily. It is essential that we raise the capacity of health care providers at all levels to screen for co-morbid psychiatric disorders, especially depression.”

Dr. Melino Ndayizigiye, Clinical Director PIHL

Innovation

Innovation details

Lesotho is a small, landlocked kingdom in South Africa with a population of 2 million people. There is a 25% prevalence of HIV in Lesotho2 and high prevalence of tuberculosis (TB) at 724/100,0001, 3. A study on the burden of mental illness conducted at PIH sites, using local data as well as from the Global Burden of Disease Study, showed that 32% of all Years Lived with Disability (YLDs) in Lesotho are attributable to mental illness6. This percentage is as great as all other YLDs due to non-communicable diseases in Lesotho combined6.

The aim of the Lesotho mental health program is to promote the integration of mental health care awareness and delivery among treatment supporters, counsellors, nurses and doctors, focusing on patients with high comorbidities of MDRTB and HIV/AIDS. Furthermore, people with infectious diseases such as HIV or TB are also likely to be affected by mental illness, often having depression as a comorbid condition2, 3.  Given the high prevalence of infectious diseases in Lesotho, which require chronic care, integrating mental health care within infectious disease service delivery will allow mental health care to reach a significant percent of the population. Furthermore, given the strong MDR-TB program within Lesotho, depression screening will be integrated into the existing program and be done by village health workers and clinicians. The program will be aligned with the Ministry of Health’s goals and objectives for mental health care.

Services are being rolled out in 2018 for delivery in the PIH - Ministry of Health Hospital, Botsabelo in Maseru, at district hospital in Mohales’ hoek and seven PIH supported sites in the rural high mountains of Lesotho. Plans to develop a task-sharing model using district psychiatric nurses and general nurses and physicians, through support and supervision from specialists, are underway. The program will include medication management and targeted psychosocial interventions by village health workers, social workers, psychologists, nurses and general physicians. Village health workers were selected by local communities based on trust and a competency criteria given by the Ministry of Health. Case finding, engagement, follow up and psychoeducation will also be conducted as part of the implementation. Furthermore, the program is developing training curricula for village health workers and clinicians, building off existing materials developed by the PIH Haiti and Rwanda team. A monitoring and evaluation plan is also being developed that integrates mental health indicators, encounter tools and outcomes into the existing TB, HIV and CAMH data collection systems.

Lesotho is a small, landlocked kingdom in South Africa with a population of 2 million people. There is a 25% prevalence of HIV in Lesotho2 and high prevalence of tuberculosis (TB) at 724/100,0001, 3. A study on the burden of mental illness conducted at PIH sites, using local data as well as from the Global Burden of Disease Study, showed that 32% of all Years Lived with Disability (YLDs) in Lesotho are attributable to mental illness6. This percentage is as great as all other YLDs due to non-communicable diseases in Lesotho combined6.

The aim of the Lesotho mental health program is to promote the integration of mental health care awareness and delivery among treatment supporters, counsellors, nurses and doctors, focusing on patients with high comorbidities of MDRTB and HIV/AIDS. Furthermore, people with infectious diseases such as HIV or TB are also likely to be affected by mental illness, often having depression as a comorbid condition2, 3.  Given the high prevalence of infectious diseases in Lesotho, which require chronic care, integrating mental health care within infectious disease service delivery will allow mental health care to reach a significant percent of the population. Furthermore, given the strong MDR-TB program within Lesotho, depression screening will be integrated into the existing program and be done by village health workers and clinicians. The program will be aligned with the Ministry of Health’s goals and objectives for mental health care.

Services are being rolled out in 2018 for delivery in the PIH - Ministry of Health Hospital, Botsabelo in Maseru, at district hospital in Mohales’ hoek and seven PIH supported sites in the rural high mountains of Lesotho. Plans to develop a task-sharing model using district psychiatric nurses and general nurses and physicians, through support and supervision from specialists, are underway. The program will include medication management and targeted psychosocial interventions by village health workers, social workers, psychologists, nurses and general physicians. Village health workers were selected by local communities based on trust and a competency criteria given by the Ministry of Health. Case finding, engagement, follow up and psychoeducation will also be conducted as part of the implementation. Furthermore, the program is developing training curricula for village health workers and clinicians, building off existing materials developed by the PIH Haiti and Rwanda team. A monitoring and evaluation plan is also being developed that integrates mental health indicators, encounter tools and outcomes into the existing TB, HIV and CAMH data collection systems.

Mental Health Integration to Tuberculosis Care: In 2017, PIH started integrating mental health services into existing multi-drug resistant tuberculosis (MDR TB) services and primary health care. MDR TB patients are from all over the country and when they are diagnosed, they are referred to the PIH-run MDR TB program. While getting MDR TB health services, individuals are screened for mental health conditions in the community, clinics and hospital, primarily for depression and anxiety. Those with confirmed mental health conditions receive counseling, psychotherapy, and medications depending on the severity of the condition. Patients with severe mental health conditions are admitted and receive bi-weekly evaluation, while those with mild to moderate mental health conditions are evaluated monthly during their follow up check-ups.
 

Mental Health Intergration to Maternal and Child Care: PIH piloted integration of an early childhood development (ECD) intervention into primary health care in one of the seven rural PIH-supported sites. One piloted intervention was screening mothers for depression. Since then, those with depression were enrolled into care and received counseling, medication, and psychoeducation, based on the severity of their condition. The team developed an ECD intervention integrated with a Lesotho-based adaptation of Socios En Salud’s (PIH Peru’s) CASITA program, which is centered around caring for the needs of children between 6 and 24 months old at risk of development delays, as well as their principal caregivers.
 

Government Accompaniment: In 2020, at the Ministry of Health's (MOH) invitation, the PIH Lesotho team served as the lead author and partner for the country's first National Mental Health Policy and Strategic Plan as part of the MOH's Technical Working Group. The Policy and Strategic Plan received support from PIH's Global Policy and Partnership, Global Mental Health, and Clinical Planning and Financing teams. The development of the policy and the expansion of innovative mental health care delivery models provides opportunities to bring together various stakeholders to discuss the vision of Lesotho's mental health care system. In 2022, the team worked closely with the MOH to reform the mental health program in Berea district. PIH Lesotho is integrating mental health services within different hospital departments by screening admitted patients for common mental health conditions and referring those who require support to the Berea Mental Observation and Treatment Unit.

Capacity Building: The team developed a task-sharing model leveraging village health workers, district psychiatric nurses and general nurses, to provide medication management and targeted psychosocial intervention while receiving support and supervision from specialists. Village health workers were selected by local communities based on trust and a competency criterion given by the MOH. Case finding, engagement, follow up, and psychoeducation are conducted. The team continues to develop curriculum and training programs for mental health care and provides technical advisement to the existing primary care systems.

Mental Health Services
Two psychiatric nurses from the team took part in a two-week training in the Common Elements Treatment Approach (CETA) in November 2019 in Freetown, Sierra Leone, where they actively participated in clinical supervision with global CETA experts. CETA continues to significantly increase the team’s capacity to provide evidence-based mental health care for common mental conditions. The program has grown and now supports integration of mental health services in primary health care services in the seven rural areas with focus on anxiety and depression among mothers, and persons living with TB and HIV with medication adherence challenges. To support this initiative, PIH Lesotho has trained two groups of nurses from Berea hospital, as well as village health workers, site directors, and nurses from PIH Lesotho's primary health care facilities. The team shares tools, protocols, materials and conducts trainings, continuing to capacitate primary care nurses to screen for anxiety and depression as well as equip them with psychosocial intervention approaches to respond a appropriately to patient needs.

Key drivers

Mental health training for healthcare providers: Trainees and healthcare providers enthusiastically participate and emphasize the relevance of the issues discussed at the trainings to the quality of care delivered to patients.

Partnerships: PIH Lesotho’s Mental Health team serves as a partner for the country's first National Mental Health Policy and Strategic Plan as part of the MOH's Technical Working Group. The Policy and Strategic Plan has and continues to receive support from PIH's Global Policy and Partnership, Global Mental Health, and Clinical Planning and Financing teams. The development of the policy and the expansion of innovative mental health care delivery models provides opportunities to bring together various stakeholders to discuss the vision of Lesotho's mental health care system.
Community-centered care: The Lesotho team has enhanced their equity-focused mental health care by establishing an advisory committee and involving all community leadership structures in their mental health efforts in 2022. This intervention helps ensure that the rights of people with mental health conditions are protected and that the services offered address the needs of communities around the country- PIH Lesotho supported primary health care catchment areas.

Challenges

  • The work requires continuous high-quality mentorship and supervision coverage. Such aspects are critical to maintaining and improving quality of care at health centers and providing support to nurses as they care for patients with mental illnesses. However, mentorship and supervision are time intensive and require ongoing relationship-building and patience. Mentors spend significant time with the nurses observing clinical interactions in the field and providing hands-on training. This real-world model strengthens the skills of the nurses and builds capacity for service delivery.
  • The complexity of the health care systems, with multiple key stakeholders at community, district, and national levels, can be challenging and necessitates a sustained high degree of communication and coordination among cross-sectoral partnerships.

Continuation

The program is in the process of being developed and rolled out, adapting best practices and lessons learned from PIH programs in Haiti, Rwanda, Liberia, and Malawi.

Partners

Funders

Impact

Evaluation methods

MEQ efforts have been strengthened through the development of a mental health register, refinement of mental health indicators to align with the Lesotho context, and verification and entry of data into the mental health dashboard. The team uses the CommCare platform, utilizing the mental health dashboard to systemically collect patient-level data.

Cost of implementation

The full program costs are in the process of being determined. Preliminary cost estimations for training and implementation are mentioned below:

  • Cost for a 4-day training including associated travel and logistics: $5,720.00
  • Mental health office and administrative supplies, annual cost: Approximately $3,580

Impact details

As of 2018:

  • We have screened 228 MDR TB patients and have found 94 patients with mental health conditions
    • 94 out of 228 MDR TB patients were found to have mental health conditions. These conditions included Depression (33%), Psychosis (40%), Epilepsy (10%), Substance Abuse (13%) and Dementia (4%).  
  • 130 women enrolled in an early childhood development project were also screened through the program, as a result of which 27 have been found to have depressive symptomology.
    • Only one of these women had a severe depression score and was prescribed medication while the rest of the patients received talk therapy.

Total number of people trained:

  • 2018 trainings- 5 doctors and 5 nurses have been trained
  • 2017 trainings- 2 doctors and 12 nurses have been trained

References

  1. Partners In Health Lesotho [Internet]. Partners In Health (2016). Available from: http://www.pih.org/country/lesotho
  2. Ministry of Health Lesotho (2012) Lesotho Global AIDS Response Progress Report. Ministry of Health and Social Welfare, Lesotho; 2012 Mar.
  3. USAID (2015) Enhancing care for orphans and vulnerable children in Lesotho [Internet]. Available from: https://www.usaid.gov/results-data/success-stories/enhancing-care-orpha…
  4. Ige OM & Lasebikan VO (2011) Prevalence of depression in tuberculosis patients in comparison with non-tuberculosis family contacts visiting the DOTS clinic in a Nigerian tertiary care hospital and its correlation with disease pattern. Ment Health Fam Med, 8(4):235–41.
  5. Issa BA, Yussuf AD, Kuranga SI (2009) Depression comorbidity among patients with tuberculosis in a university teaching hospital outpatient clinic in Nigeria. Ment Health Fam Med, 6(3):133–8.
  6. Vigo D (2016) Burden of Disease framework: Contribution to needs assessment for resource planning in PIH country-sites. Partners In Health Cross Site Mental Health Meeting; Beverly, MA.