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The PRogramme for Improving Mental Health carE (PRIME) evaluated the process and outcomes of the implementation of a mental healthcare plan (MHCP) in Chitwan, Nepal.
To describe the process of implementation, the barriers and facilitating factors, and to evaluate the process indicators of the MHCP.
A case study design that combined qualitative and quantitative methods based on a programme theory of change (ToC) was used and included: (a) district-, community- and health-facility profiles; (b) monthly implementation logs; (c) pre- and post-training evaluation; (d) out-patient clinical data and (e) qualitative interviews with patients and caregivers.
The MHCP was able to achieve most of the indicators outlined by the ToC. Of the total 32 indicators, 21 (66%) were fully achieved, 10 (31%) partially achieved and 1 (3%) were not achieved at all. The proportion of primary care patients that received mental health services increased by 1200% over the 3-year implementation period. Major barriers included frequent transfer of trained health workers, lack of confidential space for consultation, no mental health supervision in the existing system, and stigma. Involvement of Ministry of Health, procurement of new psychotropic medicines through PRIME, motivation of health workers and the development of a new supervision system were key facilitating factors.
Effective implementation of mental health services in primary care settings require interventions to increase demand for services and to ensure there is clinical supervision for health workers, private rooms for consultations, a separate cadre of psychosocial workers and a regular supply of psychotropic medicines.
The PRogramme for Improving Mental health care (PRIME) designed, implemented and evaluated a comprehensive mental healthcare plan (MHCP) for Sehore district, Madhya Pradesh, India.
To provide quantitative measures of outputs related to implementation processes, describe the role of contextual factors that facilitated and impeded implementation processes, and discuss what has been learned from the MHCP implementation.
A convergent parallel mixed-methods design was used. The quantitative strand consisted of process data on mental health indicators whereas the qualitative strand consisted of in-depth interviews and focus group discussions with key stakeholders involved in PRIME implementation.
The implementation of the MHCP in Sehore district in Madhya Pradesh, India, demonstrated that it is feasible to establish structures (for example Mann-Kaksha) and operationalise processes to integrate mental health services in a ‘real-world’ low-resource primary care setting. The key lessons can be summarised as: (a) clear ‘process maps’ of clinical interventions and implementation steps are helpful in monitoring/tracking the progress; (b) implementation support from an external team, in addition to training of service providers, is essential to provide clinical supervision and address the implementation barriers; (c) the enabling packages of the MHCP play a crucial role in strengthening the health system and improving the context/settings for implementation; and (d) engagement with key community stakeholders and incentives for community health workers are necessary to deliver services at the community-platform level.
The PRIME implementation model could be used to scale-up mental health services across India and similar low-resource settings.
There is little practical guidance on how contextually relevant mental healthcare plans (MHCPs) can be developed in low-resource settings.
To describe how theory of change (ToC) was used to plan the development and evaluation of MHCPs as part of the PRogramme for Improving Mental health carE (PRIME).
ToC development occurred in three stages: (a) development of a cross-country ToC by 15 PRIME consortium members; (b) development of country-specific ToCs in 13 workshops with a median of 15 (interquartile range 13–22) stakeholders per workshop; and (c) review and refinement of the cross-country ToC by 18 PRIME consortium members.
One cross-country and five district ToCs were developed that outlined the steps required to improve outcomes for people with mental disorders in PRIME districts.
ToC is a valuable participatory method that can be used to develop MHCPs and plan their evaluation.
Few studies have evaluated the implementation and impact of real-world mental health programmes delivered at scale in low-resource settings.
To describe the cross-country research methods used to evaluate district-level mental healthcare plans (MHCPs) in Ethiopia, India, Nepal, South Africa and Uganda.
Multidisciplinary methods conducted at community, health facility and district levels, embedded within a theory of change.
The following designs are employed to evaluate the MHCPs: (a) repeat community-based cross-sectional surveys to measure change in population-level contact coverage; (b) repeat facility-based surveys to assess change in detection of disorders; (c) disorder-specific cohorts to assess the effect on patient outcomes; and (d) multilevel case studies to evaluate the process of implementation.
To evaluate whether and how a health-system-level intervention is effective, multidisciplinary research methods are required at different population levels. Although challenging, such methods may be replicated across diverse settings.
Developing evidence for the implementation and scaling up of mental healthcare in low- and middle-income countries (LMIC) like Ethiopia is an urgent priority.
To outline a mental healthcare plan (MHCP), as a scalable template for the implementation of mental healthcare in rural Ethiopia.
A mixed methods approach was used to develop the MHCP for the three levels of the district health system (community, health facility and healthcare organisation).
The community packages were community case detection, community reintegration and community inclusion. The facility packages included capacity building, decision support and staff well-being. Organisational packages were programme management, supervision and sustainability.
The MHCP focused on improving demand and access at the community level, inclusive care at the facility level and sustainability at the organisation level. The MHCP represented an essential framework for the provision of integrated care and may be a useful template for similar LMIC.
In South Africa, the escalating prevalence of chronic illness and its high comorbidity with mental disorders bring to the fore the need for integrating mental health into chronic care at district level.
To develop a district mental healthcare plan (MHCP) in South Africa that integrates mental healthcare for depression, alcohol use disorders and schizophrenia into chronic care.
Mixed methods using a situation analysis, qualitative key informant interviews, theory of change workshops and piloting of the plan in one health facility informed the development of the MHCP.
Collaborative care packages for the three conditions were developed to enable integration at the organisational, facility and community levels, supported by a human resource mix and implementation tools. Potential barriers to the feasibility of implementation at scale were identified.
The plan leverages resources and systems availed by the emerging chronic care service delivery platform for the integration of mental health. This strengthens the potential for future scale up.
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