CAPACITY BUILDING FOR CHILD MENTAL HEALTH SERVICES PROGRAMMING Inge Petersen, PhD M MhINT
Overview Brief overview of primary mental heath integration scale up package in South Africa Implementation supports needed Workforce development challenges Lessons learned
COLLABORATIVE CARE PACKAGE BEING SCALED UP
Integrated package of care for common mental disorders comorbid with chronic conditions
Roles of key actors in the collaborative model for depression Primary care nurses identify depression, anxiety, AUD using PC101, provide supportive counselling, psycho-education and brief advice (AUD), refer appropriately for all conditions, and review response to treatments for depression at 9-10 weeks (case managers) Behavioural change counsellors provide psycho-education (morning talks), counselling for depression, and adherence counselling for all chronic conditions Doctors diagnose and review complex or severe cases, and if appropriate prescribe antidepressants and other psychotropic medication Psychologists (incl. interns/com servs) provide training, supervision and support to counsellors; debriefing for nurses; and a referral service for severe/treatment resistant cases
Scale up 10 clinics in Dr Kenneth Kaunda district in North West Province (NWP) in 2015 (PRIME/COBALT) 834 patients referred to counsellors over a 10 month period Roughly 2 patients per week per clinic Scaled-up to 10 clinics in Bojanala district in NWP in May 2016 (COBALT/PRIME) Scale-up to Amajuba district in KwaZulu-Natal and Gert Sibanda district in Mpumalanga in 2016-2017 (MhINT)
Bojanala Dr Kenneth Kaunda Gert Sibande Amajuba
SUPPORTS NEEDED
SUPPORT ONE High level ministerial and district support link to existing priorities and mental health care policies
Example: High level DoH support
Example: District mental health plan
SUPPORT TWO Sustainable integration platform
Example: Integrated chronic disease platform
Primary Care 101
SUPPORT THREE Training and resource tools
Nurses: Clinical Communication Skills and Primary Care 101
Counsellors: Depression counselling and adherence counselling
SUPPORT FOUR Specialists
Continuous Training: community outreach from tertiary facilities
Referral pathways: Severe/treatment resistant problems
Debriefing, mentoring and supervision: community outreach/mobile technology
SUPPORT FIVE Mental health indicators
Scale-up of integrated mental health services requires mental health metrics measure changes in treatment coverage monitor quality of care inform evidence-based planning of scaled-up integrated care Important to advocate for mental health indicators and performance targets Show how you can help to achieve indicators
SUPPORT SIX Quality Improvement
Embed intervention as standard practice; improve quality PDSA cycles
HUMAN RESOURCE CHALLENGES
HUMAN RESOURCE CHALLENGE ONE High staff turn-over and limited staff
Nurses Nurse turn over high Over 1500 resignations in 2015 in Dr KK Replaced only one third Frozen positions Poor working conditions Queue pressure Burn-out
Counsellors Counsellors (5 out of 10 PRIME resigned in a 12 month period) Lack of job security Poor/inconsistent remuneration Don t feel part of the system Lack of career pathways
Specialists Specialists limited and located in tertiary institutions District Gert Sibande, Mpumalanga Province Amajuba, KwaZulu-Natal Province Population 1,043,194 442, 266 Literacy Rate 55.6% 60% Administrative Structure 7 Sub-districts 3 Sub-districts Administrative Health Structure District Director; no Mental Health Co-ordinator in Ermelo; 7 Sub-district MH coordinators (1 for each sub-district) District Director; Clinical and Programmes Manager; Mental Health Coordinator; Sub-district MH coordinator at Madadeni Hospital; 2 Psychiatric nurses Health Care Services 9 Hospitals, 56 Clinics, 18 Community Health Centers 3 Hospitals, 1 Community Health Center, 19 Government Clinics, 3 Gateway Clinics, 2 Municipal Mobile Clinics. Mental Health Services Mental Health Professionals Mental Health Data Collected Essential medications available in district (PHC facilities obtain medications by placing an order every 6 months); no psychosocial therapies 0 Psychiatrists, 0 Psychologists (1 psychologist recently left) Mental health under 18; mental health 18 and older; mental health total; mental health screened; mental health treated; para-suicide admissions Psychologists hospital based and visit 3 PHC facilities, service Department of Basic Education, Rehabilitation Centre and Umzinyathi District hospital; all repeat prescriptions received from hospital; essential medicines available in district 0 Psychiatrists, 4 Psychologists Mental health under 18; mental health 18 and older; mental health total; mental health screened; mental health treated; screened for substance abuse and other drugs; para-suicide admissions
HUMAN RESOURCE CHALLENGE TWO Paucity of pre-service training for task sharing for mental health
Nurses & PHC doctors PHC providers biomedical focus - not orientated to patient-centred care Psychiatric stigma Insufficient mental health pre-service training PHC doctor prescribing of anti-depressants: < 5% Nurse identification of depression: 6% Nurse identification of AUD: 0% In-service training requires constant re-training Cascade model of training
Counsellors Pre-service training of lay counsellors/chws inconsistent and doesn t include counselling Need identified cadre of CHW/mid-level workers whose role can include mental health counselling Structured evidence-based counselling training should be included in the pre-service curriculum
LESSONS
LESSON ONE Leverage existing priorities
Why, if scientific evidence shows an intervention to be obvious, might a government not scale up? (Prof Melvyn Freeman) Leverage existing priorities such as HIV/AIDS National Burden of Disease Study 2000 Neuropsychiatric 8% Cardiovascular and diabetes 7% Respiratory disease 5% Unintentional injuries 7% Neoplasms 3% Other noncommunicable 10% Intentional injuries 7% HIV & AIDS 31% Perinatal.matern al and nutritional 10% Infectious and parasitic (excluding HIV/AIDS) 9% Respiratory infections 3% Source: Revised South African National Burden of Disease Estimates for 2000 Norman et al, 2006 Total DALYs=16 297 203
Co-morbidity of chronic conditions with depressiono-morbidity of chronic conditions with depression Link to 90-90-90 targets Between 9 3% and 23 0% of people with NCDs had comorbid depression 1. Twofold greater risk of major depressive disorder in people living with HIV/AIDS 2 Chronic patients with comorbid depression 2-3 times less likely to be adherent 1,3 1.Moussavi, S., S. Chatterji, et al. (2007). "Depression, chronic diseases, and decrements in health: results from the World Health Surveys." Lancet 370(9590): 851-858 2.Ciesla JA, Roberts JE. Meta-analysis of the relationship between HIV infection and risk for depressive disorders. Am J Psychiatry. 2001 May;158(5):725-30. 3.Makimuli-Mpungu E, et al : 2011. Depression, Alcohol Use and Adherence to Antiretroviral Therapy in Sub-Saharan Africa: A Systematic Review. AIDS Behav
LESSON TWO Obtain high level Ministerial support and MOU
PRIME/COBALT Policy Advisory Committee Agreed upon purpose of the committee Provide oversight of both PRIME and COBALT projects to ensure that they are in line with current policy imperatives Represent the interests of stakeholders as end-users of the research and intervention (policy makers, primary care providers and service users) Guide the dissemination of the project and trial results to facilitate their impact on policy and practice Optimize the application of lessons learned within routine health systems
LESSON THREE Include all key stakeholders in developing the implementation plan
Development of a collaborative care package Theory of Change workshops and extensive formative and piloting work as part of PRIME project in one large PHC facility (2012-2013) Ensure intervention is part of district/local plan
LESSON FOUR Identify and leverage a sustainable integration platform - an existing cadre of generalists and with a minimum number of specialists
Specialist posts are necessary for training, supervision and referral pathways within a collaborative stepped care Absence of a critical number of specialist posts Task sharing can become task dumping Harness a stable workforce for task sharing Utilize cascade method of training where there is a shortage of specialists
LESSON FIVE Engage in advocacy for greater investment
Advocacy Cost-benefit studies Policy briefs Combine evidence with testimonials from users
Response of Nurses: Results of FDS for depression and alcohol use disorder (selfreport) Response of patients with depression: results of the cohort study at 3 months 18 16 14 14 12 10 12 10 8 6 Baseline PHQ9+ Followup PHQ9+ Baseline AUD+ Follow-up AUD+ 8 6 4 2 Intervention Control 4 2 0 Baseline PHQ9 3mth follow-up PHQ9 0 Baseline PHQ9+ Followup PHQ9+ Baseline AUD+ Follow-up AUD+
Funding PRIME is funded by the UK Department for International Development (DFID) COBALT is funded by the National Institute of Mental Health (NIMH) Mental Health Integration (MhINT) is funded by Centers for Disease Priorities and Prevention (CDC)
VIDEO OF MA AGNES