A Cost-Effective Model for Increasing Access to Mental Health Care at the Primary Care Level in Nigeria

BACKGROUND: Although effective treatment modalities for mental health problems currently exist in Nigeria, they remain irrelevant to the 70% of Nigeria's 120 million people who have no access to modern mental health care services. The nation's Health Ministry has adopted mental health as the 9th component of Primary Health Care (PHC) but ten years later, very little has been done to put this policy into practice. Mental Health is part of the training curriculum of PHC workers, but this appears to be money down the drain. AIMS OF THE STUDY: To review the weaknesses and problems with existing mode of mental health training for PHC workers with a view to developing a cost-effective model for integration. METHODS: A review and analysis of current training methods and their impact on the provision of mental health services in PHC in a rural and an urban local government area in Nigeria were done. An analysis of tested approaches for integrating mental health into PHC was carried out and a cost-effective model for the Nigerian situation based on these approaches and the local circumstances was derived. RESULTS: Virtually no mental health services are being provided at the PHC levels in the two local government areas studied. Current training is not effective and virtually none of what was learnt appears to be used by PHC workers in the field. Two models for integrating mental health into PHC emerged from the literature. Enhancement, which refers to the training of PHC personnel to carry out mental health care independently is not effective on its own and needs to be accompanied by supervision of PHC staff. Linkage, which occurs when mental health professionals leave their hospital bases to provide mental health care in PHC settings, requires a large number of skilled staff who are unavailable in Nigeria. In view of past experiences in Nigeria and other countries, a mixed enhancement-linkage model for mental health in PHC appears to be the most cost-effective approach for these Nigerian communities. DISCUSSION: Nigeria is currently experiencing a 'double epidemic', and with high infant and maternal mortality rates, the burden of mental health problems is still invisible to policy makers. Meagre resources allocated to mental health need to be utilised maximally with cost-effective interventions. This mixed enhancement-linkage model draws on the strengths of both models, while taking into account their limitations. Concrete conclusions cannot be drawn until the model developed is fully tested. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This model has the potential of making mental health services available, accessible and acceptable in these communities. This should reduce the burden of suffering for the mentally ill by providing treatment and restorative care, promoting mental health and preventing mental illness in the populace. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The current mental health policy for Nigeria focuses on enhancement as the mode in which mental health can be successfully integrated into PHC and so far this has not been successful. Results emerging from this model can be presented to policy makers thereby supporting replication in other parts of the country. This could ultimately lead to a change in the mental health policy on training for mental health at the PHC level. IMPLICATIONS FOR FURTHER RESEARCH: Mental health services and mental health economics research are still at the stage of infancy in Nigeria. This study provides baseline information and should stimulate further research in these two vital areas.     

Evolution of primary health care in Thailand: what policies worked?

Thailand has a long history of primary health care (PHC) developmentwhich started before the Declaration of Alma Ata in 1978. TheNational PHC programme was implemented nation-wide as part ofthe Fourth National Health Development Plan (1977–1981)focusing on the training of ‘grass-root’ PHC workersconsisting of village health communicators and village healthvolunteers. Since then PHC has evolved through many innovativehealth activities: community organization, community self-financingand management, the restructuring of the health system and multisectoralco-ordination. Many of the essential elements of PHC have beenachieved. Improvements in the nutritional status of childrenunder five households accessiblity to clean water, immunizationcoverage, and the availablity of essential drugs have been observed.PHC has been successful in Thailand because of community involvementin health, collaboration between govermment and non-govermmentorganizations, the integration of the PHC programme, the decentralizationof planning and management, intersectors collaboration at operationallevels, resource allocation in favour of PHC, the managementand continuous supervision of the PHC programme from the nationaldown to the district level, and the horizontal teaining of villagersto villagers.     

A pilot demonstration of comprehensive mental health services in inner-city public schools

BACKGROUND: National policy statements increasingly espouse the delivery of comprehensive mental health services in schools. In response to the limited evidence supporting this recommendation, the purpose of this study was to assess the need for, and feasibility, desirability, and outcomes of a full model of comprehensive mental health services in 2 public elementary schools in inner‐city neighborhoods. METHODS: The program, based upon a national model for comprehensive school mental health services, comprised universal and indicated preventive as well as clinical interventions designed to target needs identified in a baseline screening survey. The program was implemented over 1 school year by mental health professionals in collaboration with school teachers. Mental health outcomes comparing baseline to follow‐up data were assessed in multiple domains among students and teachers. RESULTS: After 1 year of intervention, students had significantly fewer mental health difficulties, less functional impairment, and improved behavior, and reported improved mental health knowledge, attitudes, beliefs, and behavioral intentions. Teachers reported significantly greater proficiency in managing mental health problems in their classrooms. School staff overwhelmingly endorsed satisfaction with the program. CONCLUSION: If the observed favorable findings from this pilot demonstration can be replicated in methodologically rigorous studies, additional support would be garnered for national policy recommendations about comprehensive school mental health services.     

Service providers' views of community participation at six Australian primary healthcare services: scope for empowerment and challenges to implementation

Community participation is a key principle of comprehensive primary health care (PHC). There is little literature on how community participation is implemented at Australian PHC services. As part of a wider study conducted in partnership with five South Australian PHC services, and one Aboriginal community controlled health service in the Northern Territory, 68 staff, manager, regional health executives, and departmental funders were interviewed about community participation, perceived benefits, and factors that influenced implementation. Additional data were collected through analysis of policy documents, service reports on activity, and a web‐based survey completed by 130 staff. A variety of community participation strategies was reported, ranging from consultation and participation as a means to improve service quality and acceptability, to substantive and structural participation strategies with an emphasis on empowerment. The Aboriginal community controlled health service in our study reported the most comprehensive community participation. Respondents from all services were positive about the benefits of participation but reported that efforts to involve service users had to compete with a centrally directed model of care emphasising individual treatment services, particularly at state‐managed services. More empowering substantive and structural participation strategies were less common than consultation or participation used to achieve prescribed goals. The most commonly reported barriers to community participation were budget and lack of flexibility in service delivery. The current central control of the state‐managed services needs to be replaced with more local management decision making if empowering community participation is to be strengthened and embedded more effectively in the culture of services. Copyright © 2014 John Wiley & Sons, Ltd.     

The impact of integrating the elimination programme for lymphatic filariasis into primary health care in the Dominican Republic

Integration of disease-specific programmes into existing health care delivery systems is a challenge for many countries, made more salient as the scope and scale of disease-specific programmes increases. This paper reports on the programmatic outcomes of 2 years of integrating the lymphatic filariasis (LF) elimination programme into primary health care (PHC) in the Dominican Republic during a period of national health care reform and decentralization. Data were collected retrospectively from community volunteers, PHC staff and LF programme staff using a mix of quantitative and qualitative methods. Benefits of integration for LF elimination included increasing the extent of the geographic coverage of mass drug administration (MDA) and a 21% increase in municipalities achieving the MDA target coverage rate of 80%. Benefits which accrued to PHC included improved information systems and strengthened relationships between the health services and the community. This study also identified challenges to implementing integration and the solutions found. These include the importance of focusing on the professional development of disease-specific program staff as their roles change, strengthening specific weakness in the general health system and finding alternative solutions where these are not easily solved, actively engaging senior management at an early stage, continually evaluating the impact of integration and not pushing integration for the sake of integration.     

Commentary: caring for the indigent mentally ill--new strategies and old problems.

Christianson and his colleagues examine how Medicaid beneficiaries receive mental health services in HMOs by analyzing two important aspects of service delivery: the use of community-based treatment programs by Medicaid beneficiaries enrolled in health maintenance organizations (HMOs) and the reimbursement levels paid to these programs by HMOs. The hypotheses studied are complex issues that concern mental-health advocates and providers. Traditional community-based mental health services have always struggled to maintain their presence in the health care field, having to contend with changing funding priorities and more serious and multiple problems presented by their patients. For prepaid plans to work effectively for the indigent mentally ill, the complex issues have to be made clear and acknowledged as meaningful variables.     

Iowa Agricultural Health and Safety Service Project

A model community-based comprehensive agricultural occupational health and safety service program has been implemented in Iowa. The functional center of coordination is based in the College of Medicine at the University of Iowa. The community-based hub of the service is the community hospital, where the majority of the direct client services originate. The University provides training of hospital staff, programming, direction, consultation, and referral. The services offered include primary care, health surveillance, industrial hygiene and safety, and education. Through a detailed evaluation of the project's objectives we will be able to evaluate, modify, and disseminate a model agricultural health and safety services delivery program. This model should be effective in changing the farming population's health and safety attitudes and behaviors through a community-based program.     

Eliciting preferences for resource allocation in mental health care in Ireland

The proportion of total health care expenditure devoted to mental health care in Ireland, at just below 7%, is low relative to other countries. There have been few studies that have examined the relationship between public preferences for different kinds of health care expenditure and priority setting as undertaken by policy-makers and governments. This paper examines citizen's rankings and willingness to pay for a community-based mental health care programme in Ireland relative to two other programmes: cancer and elderly care. Respondents rank cancer as the most important programme, followed by elderly care and then mental health care. The contingent valuation survey demonstrated that people are willing to make significant tax contributions to new community-based services for people with mental health problems, counteracting the view sometimes expressed that people do not care at all about mental health care provision. However, the survey also found that people tend to value additional spending on mental health care lower than cancer and elderly care programmes.     

Eliciting preferences for resource allocation in mental health care in Ireland

The proportion of total health care expenditure devoted to mental health care in Ireland, at just below 7%, is low relative to other countries. There have been few studies that have examined the relationship between public preferences for different kinds of health care expenditure and priority setting as undertaken by policy-makers and governments. This paper examines citizen's rankings and willingness to pay for a community-based mental health care programme in Ireland relative to two other programmes: cancer and elderly care. Respondents rank cancer as the most important programme, followed by elderly care and then mental health care. The contingent valuation survey demonstrated that people are willing to make significant tax contributions to new community-based services for people with mental health problems, counteracting the view sometimes expressed that people do not care at all about mental health care provision. However, the survey also found that people tend to value additional spending on mental health care lower than cancer and elderly care programmes.     

Primary Health Care Service Use Among Women Who Have Recently Left an Abusive Partner: Income and Racialization,Unmet Need,Fits of Services,and Health

Primary health care (PHC) can improve the health of women who have experienced intimate partner violence; yet, access to and fit of PHC services may be shaped by income and racialization. We examined whether income and racialization were associated with differences in PHC service use, unmet needs, fit with needs, and mental and physical health in a sample of 286 women who had separated from an abusive partner. Mothers, unemployed women, and those with lower incomes used more PHC services and reported a poorer fit of services. Poorer fit of services was related to poorer mental and physical health.     

Challenges faced by general practitioners and allied mental health services in providing mental health services in rural Queensland

OBJECTIVE: To examine the views of rural practitioners concerning issues and challenges in mental health service delivery and possible solutions. DESIGN: A qualitative study using individual semi-structured interviews. SETTING: Eight general practices from eight rural Queensland towns, three rural mental health services and two non-government organisations, with interviews being conducted before recent changes in government-subsidised access to allied health practitioners. PARTICIPANTS: A sample of 37 GPs, 19 Queensland Health mental health staff and 18 participants from community organisations. MAIN OUTCOME MEASURES: Analysis of qualitative themes from questions about the key mental health issues facing the town, how they might be addressed and what challenges would be faced in addressing them. RESULTS: There was substantial consensus that there are significant problems with inter-service communication and liaison, and that improved collaboration and shared care will form a critical part of any effective solution. Differences between groups reflected differing organisational contexts and priorities, and limitations to the understanding each had of the challenges that other groups were facing. CONCLUSIONS: Improvements to mental health staffing and to access to allied health might increase the ability of GPs to meet the needs of less complex patients, but specific strategies to promote better integrated services are required to address the needs of rural and regional patients with complex mental health problems. The current study provides a baseline against which effects of recent initiatives to improve mental health care can be assessed.     

Health service staff attitudes to community representatives on committees

PURPOSE: This paper sets out to report attitudes of staff on key health service committees towards community participation before and after appointment of community representatives. DESIGN/METHODOLOGY/APPROACH: The paper shows a self-completed questionnaire administered to staff on committees as a baseline measure and 12 months after community representatives had been appointed. FINDINGS: The paper finds that significantly more staff at the follow-up survey reported that they and other staff were clear about the role of community representatives and how to work with them on committees. Significantly more staff at follow-up felt that the health service was ready for this type of initiative. There was no significant increase in the percentage of staff who felt that financial and other supports for community representatives were sufficient and no significant changes in staff views about the potential for community representatives to influence decision making, although there were strong trends in a positive direction. RESEARCH LIMITATIONS/IMPLICATIONS: The study in this paper was conducted in one health service and did not follow changes in attitudes of particular staff over time. Larger samples would be necessary to assess generalisability of findings and future studies should examine in more depth staff beliefs about the role and influence of community members on committees. PRACTICAL IMPLICATIONS: The paper implies that the development of ongoing and constructive relationships between health services and communities clearly takes time and, at least in part, results from direct experience working alongside community members. ORIGINALITY/VALUE: The paper shows that this is the first study examining how the attitudes of health service staff to community participation change over time and as a direct result of interaction with community members on committees. A better understanding of health service staff attitudes to community participation is important for health care managers to effectively address structural and attitudinal barriers to community participation.     

Oral health problems and support as experienced by people with severe mental illness living in community‐based subsidised housing – a qualitative study

The purpose of this study was to explore how persons with severe mental illness (SMI) experience oral health problems (especially dry mouth), and weigh the support they received in this regard from professionals and staff at community‐based congregate housing through a controlled intervention programme. Oral health problems and dry mouth are found in association with apathy and indifference, cognitive deficits, and long‐term medication with psycho‐pharmacological drugs. The present study describes the results from one part of a longitudinal intervention programme, which sought effective ways of mitigating dry mouth through increased support with oral health problems. This part consists of 67 informal interviews with ten participants in two community‐based urban housing projects between November 2006 and June 2007, with a follow‐up session in December 2007. Content analysis of the results yielded five categories: The shame of having poor dental health, history of dental care, experiences of self‐care, handling of oral health problems, and experiences of staff support. Poor oral health caused shame and limited participation in social activities. Participants avoided oral health issues by such circumventions as denial of a tooth ache or dental infections, or postponing oral problems with the hope that they would die away. Offers of support were frequently resisted because of unsatisfactory prior encounters with dental professionals and staff. Our findings suggest that self‐care needs to be facilitated in an unobtrusive manner with minimal staff involvement, and clients should be referred to dental care providers experienced in treating people with SMI.     

Listening to those on the frontline: lessons for community-based tuberculosis programmes from a qualitative study in Swaziland

This study explored the experience of people involved in a new community-based tuberculosis (TB) programme in rural Swaziland. Patients have their treatment observed in the community after choosing a treatment supporter (either community health worker or family member) in dialogue with the TB nurse. Interviews were conducted with TB patients, treatment supporters, clinic nurses, nurses working in the hospital-based TB team and medical staff. The study generated two main themes: (1) issues relating to the TB programme and (2) wider societal issues. Both are important, however this paper reports only the issues directly related to the TB programme. The study found that community-based care is preferred to hospital care, which should be retained only for the very ill patients. The importance of selecting suitable patients and ensuring individualised and flexible arrangements was highlighted. Although treatment outcomes are known to have improved since introducing the new TB programme a number of issues require further attention. Communication between different levels of the health service needs to be improved and consultation communication skills, taught prior to introducing the programme, need to be refreshed. All relevant staff must be trained on the TB programme and patient education (on TB, HIV and treatment adherence) needs to be reinforced throughout TB treatment. Health education of the wider community is also needed. Ongoing support of treatment supporters must recognise that their role is not simply treatment observation. In this context, where the large majority of TB patients are HIV positive, better co-ordination with the HIV/AIDS services is required, including treatment of other HIV-related infections and home-based care for TB patients who deteriorate. Although the findings and recommendations of this study are context specific they are likely to be of relevance to other programmes.     

Community-based health care in Kibwezi, Kenya: 10 years in retrospect

In response to the interest of the Kenya government in community-based health care, the Kibwezi Rural Health Scheme was developed by the African Medical and Research Foundation (AMREF) in a semi-arid district in eastern Kenya. Based on a community co-operative philosophy and focussing on health promotion and prevention, the scheme includes the following: a health centre with a 15-bed in-patient unit including four maternity beds, out-patient services, and a 15-bed nutrition rehabilitation unit; a cadre of volunteer community health workers, trained by AMREF, who form the backbone of the project; maternal child health/family planning and nutrition services including an applied nutrition programme, a water project; and a mobile health unit. Designed as a replicable model health programme, the intention was that services would be gradually taken over by the Ministry of Health of Kenya. Much has been learned in the development of the project which should be meaningful to others considering similar endeavours. One of the first lessons learned was that the time taken to sensitize the community to community-based health care is critical to the success of the project and may need to be as long as 1-2 years. Another was that gaining the support of the community for the community health workers (CHW) requires a considerable effort on the part of project staff, but seems to be the only viable solution to the remuneration and recognition of the CHW's work. It also became apparent that preventive and promotive health services should be integrated structurally and operationally with curative health services to provide the most benefits for the community served. Finally, although there are some differences of opinion, it is felt that with some refinements, the project could be replicated in other parts of Kenya.     

Practical skills and valued community outcomes: the next step in community-based education

OBJECTIVES: Community-based medical education (CBE) has clear value. However, there are aspects of CBE where improvement is possible. First, communities do not generally receive valued outcomes in exchange for participation in the CBE process. Secondly, students are usually not trained to influence health in the community using methods that are realistic in busy clinical practice. DESIGN: A CBE rotation was designed to address these problems. Rotation activities were structured to facilitate development of a health programme desired by the community while giving students practical skills for later use. Working with community residents and health staff, sequential groups of students carried out, in turn, problem analysis, resource identification, planning and implementation activities aimed at establishing a community tuberculosis (TB) control programme. SETTING: The University of Natal in Durban, South Africa. SUBJECTS: Final-year medical students. RESULTS: At the end of the academic year, the TB control programme was approximately 60% in place, and 90% of TB patients cared for by the students were completing treatment. Overall, students rated the experience good for learning about health care in community settings and about methods for community health programme development. Student ratings were significantly higher for those groups whose activities brought them into greater contact with community residents. The 'real-time' nature of planning the sequential student groups' work created logistical problems and, as an isolated activity, the rotation had little impact on student attitudes toward community-based careers. CONCLUSIONS: Expanding the goals for CBE is both feasible and important. Further work should focus on refining designs for this next step in CBE.     

Priority setting in mental health services

This paper sets out an approach to priority setting in mental health services, built around programme budgeting and marginal analysis (PBMA). The paper also discusses the question of building in equity, especially the concept of vertical equity which, given the relative neglect of mental health services when resources have been allocated in the past, might serve as a mechanism for redressing the imbalance in resource allocation to the mentally ill. Beyond that the importance of eliciting community values to aid priority setting in mental health services is highlighted, particularly with respect to the principles underlying the mental health services or what one might call 'the nature of the good' that society wants from its mental health services. While it can be argued that trying to ascertain these principles or the nature of the good applies in all health services--and that is not disputed here--in mental health there is yet more need for clarification than in many other, indeed most other, health services. The need to exercise value judgments is emphasised. There is also a word of caution on the dangers of over-reliance on waiting for perfect evidence. Finally the paper considers how best to operationalise priority setting in mental health services, and perhaps make it less of a nightmare for mental health service planners than it currently seems to be.     

Responding to the needs of the homeless mentally ill

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.