Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform

Inge Petersen; André van Rensburg; Fred Kigozi; Maya Semrau; Charlotte Hanlon; Jibril Abdulmalik; Lola Kola; Abebaw Fekadu; Oye Gureje; Dristy Gurung; Mark Jordans; Ntokozo Mntambo; James Mugisha; Shital Muke; Ruwayda Petrus; Rahul Shidhaye; Joshua Ssebunnya; Bethlehem Tekola; Nawaraj Upadhaya; Vikram Patel; Crick Lund; Graham Thornicroft

doi:10.1192/bjo.2019.7

Scaling up integrated primary mental health in six low- and middle-income countries: obstacles, synergies and implications for systems reform

BJPsych Open. 2019 Aug 6;5(5):e69. doi: 10.1192/bjo.2019.7.

Authors

Inge Petersen¹, André van Rensburg², Fred Kigozi³, Maya Semrau⁴, Charlotte Hanlon⁵, Jibril Abdulmalik⁶, Lola Kola⁷, Abebaw Fekadu⁸, Oye Gureje⁹, Dristy Gurung¹⁰, Mark Jordans¹¹, Ntokozo Mntambo¹², James Mugisha¹³, Shital Muke¹⁴, Ruwayda Petrus¹⁵, Rahul Shidhaye¹⁶, Joshua Ssebunnya¹⁷, Bethlehem Tekola¹⁸, Nawaraj Upadhaya¹⁹, Vikram Patel²⁰, Crick Lund²¹, Graham Thornicroft²²

Affiliations

¹ Research Professor and Director, Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa.
² Senior Researcher, Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa.
³ Senior Consultant Psychiatrist/Researcher, Butabika National Referral and Teaching Mental Hospital, Uganda.
⁴ Research Fellow, Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London; and Global Health and Infection Department, Brighton and Sussex Medical School, UK.
⁵ Adjunct Associate Professor, Department of Psychiatry, Addis Ababa University, Ethiopia; and Reader in Global Mental Health, Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
⁶ Senior Lecturer, Department of Psychiatry, University of Ibadan, Nigeria.
⁷ Researcher, Department of Psychiatry, University of Ibadan, Nigeria.
⁸ Professor in Global Mental Health, Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Ethiopia; and Global Health & Infection Department, Brighton and Sussex Medical School, UK.
⁹ Professor of Psychiatry and Director, WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Substance Abuse, Department of Psychiatry, University of Ibadan, Nigeria; and Professor Extraordinary, Department of Psychiatry, Stellenbosch University, South Africa.
¹⁰ Research Coordinator, Transcultural Psychosocial Organisation, Nepal.
¹¹ Reader, Center for Global Mental Health, King's College London, UK.
¹² Researcher, Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, South Africa.
¹³ Senior Lecturer, Department of Sociology, Kyambogo University and Butabika National Referral and Teaching Mental Hospital, Uganda.
¹⁴ Researcher, Sangath, India.
¹⁵ Senior Lecturer, Department of Psychology, School of Applied Human Sciences, University of KwaZulu-Natal, South Africa.
¹⁶ Clinical Psychiatrist, Public Health Foundation of India and CAPHRI School for Public Health and Primary Care, Maastricht University, the Netherlands.
¹⁷ Researcher, Butabika National Referral and Teaching Mental Hospital, Uganda.
¹⁸ Research Associate, Health Service & Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
¹⁹ Researcher, Transcultural Psychosocial Organisation, Nepal.
²⁰ Professor, Department of Global Health and Social Medicine, Harvard Medical School and Harvard TH Chan School of Public Health, Harvard University, USA; and Sangath and the Public Health Foundation of India, India.
²¹ Professor of Public Mental Health, Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, South Africa; and Professor of Global Mental Health and Development, Centre for Global Mental Health, Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.
²² Professor of Community Psychiatry, Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK.

Abstract

Background: There is a global drive to improve access to mental healthcare by scaling up integrated mental health into primary healthcare (PHC) systems in low- and middle-income countries (LMICs).

Aims: To investigate systems-level implications of efforts to scale-up integrated mental healthcare into PHC in districts in six LMICs.

Method: Semi-structured interviews were conducted with 121 managers and service providers. Transcribed interviews were analysed using framework analysis guided by the Consolidated Framework for Implementation Research and World Health Organization basic building blocks.

Results: Ensuring that interventions are synergistic with existing health system features and strengthening of the healthcare system building blocks to support integrated chronic care and task-sharing were identified as aiding integration efforts. The latter includes (a) strengthening governance to include technical support for integration efforts as well as multisectoral collaborations; (b) ring-fencing mental health budgets at district level; (c) a critical mass of mental health specialists to support task-sharing; (d) including key mental health indicators in the health information system; (e) psychotropic medication included on free essential drug lists and (f) enabling collaborative and community- oriented PHC-service delivery platforms and continuous quality improvement to aid service delivery challenges in implementation.

Conclusions: Scaling up integrated mental healthcare in PHC in LMICs is more complex than training general healthcare providers. Leveraging existing health system processes that are synergistic with chronic care services and strengthening healthcare system building blocks to provide a more enabling context for integration are important.

Declaration of interest: None.

Keywords: Mental health services; global mental health; integrated care; low -and middle-income countries; primary healthcare.

Abstract

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