Integration of Mental Health Care into the Primary Health Care System

in Cross River State

2

Presentation Outline

• Introduction to Setting• Current Health System• Mission and Objectives• Priority Areas for Action• Program Design• Overcoming Barriers to Scaling Up• Strategies for Inclusion (Human rights & users)• Key Leadership Skills

Cross River State of Nigeria

• 18 Local Government Areas (LGA)• Located in South-South Region

Demographics: Cross River State

• Population of Nigeria (2006): 140,003,542

• Cross River State Population (2006): 2,888,966– Men- 51.7%– Women - 48.3%

• Number <18 Years of Age: 1,438,575

•

49%51%<18 Years of Age

>18 Years of Age

Demographics: Cross River State

• Literacy: South -South – Women: 78%– Men: 89%

• 15% of total population has no education• School Attendance (10-14): 95%• 3 Ethnic groups– Efik– Bekwara– Ejagam

Priority Areas of Intervention

• Mental Disorders: – DEPRESSION– PSYCHOTIC DISORDERS– ALCOHOL/SUBSTANCE ABUSE – CHILD/ADOLESCENTS MENTAL DISORDERS

• Addressing MH Care Seeking Behaviour:– 71% of people access traditional healers for MH

Care (Adewuya, 2009)

Limited literature from South Nigeria showing unmet needs for care

• Amoran, O., T. Lawoyin, et al. , 2007; n=1105; Overall prevalence of depression using GHQ was found to be 5.2%, Depression more common in rural areas than urban areas (Community setting)

• Gureje, O. and V. O. Lasebikan (2006). n=4,984 Only 9.0% of those with any 12-month DSM-IV disorder had received treatment. (Community setting)

• Amoran, O., O. Ogunsemi, et al.(nd); n=758, 18.9% PHC workers using GHQ questionnaire found 35.5% for depression and 4.8% ever treated; Partially reflects unmet need but also possibility of false positives, does not tell us where the data collection took place (Clinic/ community setting)

• Mba, N., O. O. Famuyiwa, et al. (2008) Two communities with different socio-economic standards (N1 = 189, N2 = 148). Rates of psychiatric morbidity on the GHQ-12 were 26.5 and 14.2 respectively (Clinic/ community setting)– Caveat – We are not sure about the actual way the populations were sampled

because though some studies state community setting, it is more likely to be a convenience sampling

Summary of Current MH SystemLevel of Care Distribution MH Human

ResourcesMH Services

3° Federal Psychiatric Hospital

Calabar +++ +++

Teaching Hospital

Calabar ++ ++2° District Hospitals 1/LGA + +1° PHCs 4/LGA

Community Village Health Workers

15/LGA

Current Mental Health Care System

Federal Psychiatric Hospital

GeneralHospital Hospital

3°

2°

1°

Community

Teaching Hospital

Traditional Healers

CRS Situation Analysis:3° Level Mental Health Services

Federal Psychiatric Hospital• Distribution:– 1: Calabar

• Services:– 70 Inpatient Beds & Outpatient services.

• Human Resources– 7 Psychiatrists – 15 Resident Doctors – 60 Psychiatric Nurses– 2 Clinical Psychologists– 2 Occupational Therapists– School of Psychiatric nursing

Gap: Centralized

Service!

CRS Situation Analysis: 3° Level Mental Health Services

University Calabar Teaching Hospital: Department of Psychiatry• Distribution:– 1: Calabar

• Services:– Outpatient

• Human Resources:– 1 Psychiatrist to train general doctors

Gap: Centralized

Service!

CRS Situation Analysis: 2° Level Health Services

General Hospitals• Distribution:– 1/LGA

• Services:– General Medical Care

• Human Resources: Vary between Hospitals– General Duty Doctors– Nurses– Midwives– Psychiatric Nurses

Gap: Limited Number

of Trained MH Workers and MH

Services

CRS Situation Analysis: 1° Level Health Services

Primary Health Clinic (PHC)• Distribution:– 3-4 PHCs/District

• Services:– Primary Health Care

• Human Resources– CHOs: 50% clinic/50% community– CHEW 25% clinic/75% community – JCHEW 100% in Community

Gap: Limited

Number of Trained MH Workers and MH Services

CRS Situation Analysis:Community Level Health Services

Village Health Workers• Distribution:– 15/LGA

• Services:– Basic Detection of health issues– Health Promotion– Referral to PHC

• Human Resources:– Volunteers

Gap: No Training

in MH!

Other Resources

• Ministries: Education, Social Welfare• NGOs: Health, Education, Protection• University & Teaching Hospital• mhLAP (Ibadan)

Mission

To integrate Mental Health Care for Common Mental Disorders, Severe

Mental Disorders and Child/Adolescent Mental Disorders into the primary health

care system of Cross River State.

Objectives

• Increase the number of persons receiving treatment for mental disorders

• Establish collaborations with relevant stakeholders at the state and community level

• Increase community awareness of mental disorders and available Mental Health Care

• Promote positive public attitude towards persons living with mental disorders

Areas selected for the Pilot Intervention

• Calabar Municipality: State Capital

• Akpabuyo: Efik (South)• Ikom: Ejagam (Central)• Bekwarra:

Bekwarra(North)

Phase 1: Preparation

Phase 3: Service Delivery

Phase 4: Holistic Community MH Care

Ong

oing

Eva

luati

on &

Pla

nnin

g

Phase 1: Preparation

•Appoint:• Technical Advisory Group• Community Mental Health Team (CMHT)

•Focus Groups with Stakeholders

•Establish MH in PHC Guidelines:• Referral Processes• Supervision & Advisory Structure

Community Mental Health Team (CMHT)

• Multidisciplinary Team of 5: • 1 Team Leader + 4 Team Members• Comprised of Psychiatrist, Psych. Nurse, Clinical

Psychologist, Social Worker

• Each Team Member assigned to an LGA

• Provide collaborative support, supervision, training, M&E at 1°&2° levels

Phase 1: Establishing Referral Pathway

Federal Psychiatric Hospital

General Hospital

Primary Health Clinics

Village Health Workers

Teaching Hospital

•Detect & Refer to 1°•Home Visits: Monitor drug compliance, basic counselling, psychoeducation

•Detection•Treatment: Pharm., counselling, psychosocial •Follow up•Refer to 2°

•Treatment: Pharm., counselling, psychosocial•Refer to 1 ° or 3 °

•Specialized Treatment•Refer to 1 °

Phase 1: Establish Supervision & Advisory Structure

Federal Psychiatric Hospital: Hospital- Medical Director

General Hospital: Psychiatric Nurse

Primary Health Clinics: Chief Health Officer

Village Health Workers

Teaching Hospital: HoD,

Psychiatry

Com

mun

ity

Men

tal

Hea

lth T

eam

Technical Advisory

Group

Community Action Groups-

Leader

School Wellness Program-

Primary Health Care

Coordinator

Phase 2: Capacity Building

•3° Level• CMHT: Specialist Collaborative Workshops•2° & 1° Level• CMHT: • Training & supervision in detection, treatment,

management & referrals of CMD/SMD and advocacy• TOT: Identify & support MH Focal Points @ PHCs to

link with VHWs•Community Level• PHC MH Focal Point: Train & supervise VHWs in

detection, basic management & referral of CMD/SMD and advocacy

Phase 3: Service Delivery

•2° & 1° Level• General Hospitals & PHCs: Detect, treat, manage &

refer • CMHT: • Monitor referral flow• Continue with Training & Supervision

•Community Level• PHC MH Focal Point: • Continue to support & training VHWs • Identify 1 VHW demonstrating leadership to

support CAG•Drug Revolving Fund

Phase 3: Proposed Mental Health Care System

Federal Psychiatric Hospital

General Hospital

Primary Health Clinics

Village Health Workers

Teaching Hospital

Com

mun

ity

Men

tal

Hea

lth T

eam

Traditional Healers

Technical Advisory

Group

Drug revolving fund

• Drugs on essential drug list are stored in the drug cupboard

• Drugs Replenished monthly from the central drug store.

• A Pharmacist visits to – access the stock,– replenish,– collect statistics and cheque for the drugs.

Phase 4: Holistic Community MH Care

•Community Level

•Community Action Groups

•Traditional Healers

•School Wellness Program

Community Action Groups (CAG)• CAG Purpose:

– Support the inclusion of persons living with mental disorders

– Reduce stigma & increase knowledge in the community

– Support the detection & referral of CMD/SMD

• Distribution:– 1 Community Action Group/LGA– Choose LGA with VHW showing leadership and enthusiasm

• Recruitment:– VHW recruits a variety of interested stakeholders from the community

CAG Membership

Community Action Group

Women’s Group: Church,

Markets

Age Grade Men’s Groups

Scout & Brownie

Leaders

People Living with Mental Disorders

& Families

University

Student

Groups

Traditional Healers & Religious Leaders

Sunday School Teachers

And More…

Strategies to Involve Traditional Healers• CAG Membership• Foster positive

relationships & build trust– Information Sharing

• E.g. Emergency Management , Case Detection

– Capitalize on TH strengths

• Establish informal referral pathways– MH System Orientation

• Traditional Healer

• Village health

Worker

Involvement

School Wellness Programme• Technical support to integrate mental health in to

the existing School Health Programme• School Counsellors to impart: – Sensitisation training for teachers and students

(psychoeducation)– Basic identification and referral– Workshops at PTA meetings

• Participatory school learning techniques – Student essay and quiz competitions in newsletter– Question/Suggestion Box– Explore peer education opportunities on a pilot basis

Phase 4: Proposed Mental Health Care System

Federal Psychiatric Hospital

General Hospital

Primary Health Clinics

Village Health Workers

Teaching Hospital

Community Action Groups

School Wellness Program

Com

mun

ity

Men

tal

Hea

lth T

eam

Traditional Healers

Technical Advisory

Group

Ongoing Evaluation & Planning

• Partner with University to implement M&E plan• RCT in similar LGA to determine effectiveness• M&E Specialist will analyze data and produce reports• Formative and Summative Evaluation• Quantitative and Qualitative Data• Sources of Data: Training Logs, Pre-/post-tests, Patient

register, case files, interviews, Quality of Care & Satisfaction Surveys

• M&E Specialist will share formative findings with CMHT on a quarterly basis.

35

Logic FrameworkInputs Process Outputs Outcomes Impact•Est. Tech. Advisory Group (mhLAP, ministry reps, PLWMD)•Est. program mgmt. team (PM, Admin, M&E)•NGO/WHO Trainers•mhGAP materials•CMHT (Manager, Psychiatrists, Psy. Nurses, OT, Social Worker, Clinical Psychologist)•GH Teams•PHC Teams•Village Health Workers•CAG members•School Counselors•Funding•Training Space•Meeting space•Referral Materials and Supplies•Displays•Transportation•Time•Audio-visual equipment/specialist• Community Announcements•University partners

•Recruit/orient PM team•Recruit/train CMHT•Do focus groups•Est. MH guidelines•Orient/involveGH Teams•Train GH/PHC Teams•Recruit VHW•Train VHW•Identify strong leaders at PHC and train ToT techniques•Form CAG•Hold CAG meetings•Implement CAH activities•Train school counselors•Implement School activities•Implement 1-day refresher trainings•Conduct supervisory/on-site training •Film trainings/activities•Meet with and train university partners•Develop M&E plan•Collect data

• # PM team hired/oriented• # CMHT hired/trained• # VHW recruited/VHW trained•#GH workers oriented/involved•#GH workers trained•# PHC workers trained•# PHC workers identified and trained for VHW•# members recruited for CAG•# CAG meetings/activities held•# school counselors trained•# school activities held• # refresher trainings held•# supervisory on-site visits•# AV products produced•# university partners trained• M&E plan created•M9 &E data collected

1. # people receiving treatment for MH disorders will increase.

2. Collaborations with stakeholders at community and state level will be established.

3. Community awareness of MH disorders and service availability will increase.

4. Public attitude toward persons living with mental disorders will be improved.

• Integration of Mental Health into the primary health care system in 4 LGAs of Cross River State.

Intervention Human Resources

Other Resources Barriers Strategies to address barriers

Community •Detection•Basic Management•Follow-up•Referral to PC•Community Awareness

•Village Health Workers•CAG comprising multiple stakeholders•Traditional Healers

•Training & materials•Incentives•Transportation

•Low motivation•Community knowledge•Health seeking behavior•TH Preference•Stigma

•Incentives•Public education campaign•Engage TH •Psychosocial Education

•School Wellness Program

•School wellness Counselors

•Transportation•Mobile top-up•CMHT

•Parent Resistance•Detection and referral•Workload of WC

•PTA•Training for teacher & parents•Pilot SWP on small scale

Primary Health Clinics •Detection•Diagnosis•Treatment - OP•Referral to DH•Follow-up

•CHO•CHEW•JCHEW

•Training /materials•Medication•Transportation•Mobile Top-Up•CMHT

•Evidence based intervention•Overburdening PHC system•Community Knowledge/Health seeking behavior•Absence of MD

•mhGAP •Psych Nurse Internships•Youth Corps•Public Education Campaign

General Hospitals •Detection•Diagnosis•Treatment-OP/IP•Referral to FH

•GP•Psych. Nurse•RNs•Midwives

•Training /materials•Medication•CMHT

•Referral follow through•Staff Turnover

•Communication with Community level•Advocacy to MoH

Psychiatric Hospital & University Teaching Hospital

•Detection•Diagnosis•Treatment-OP/IP•Referral back to PHC

•Psychiatrists•Psych. Nurses•RNs•SW•OT•Residents

•Training•Training of Trainers•CMHT

•Staff Turnover•Resistance to decentralization•Time for training

•Advocate to MoH•Build ownership with specialists

Including Perspectives of Persons Living with Mental Disorders

• Focus Group Discussions• CAG Membership• Technical Advisory Group Membership• Speakers at Collaborative Workshops &

Training• Quality of Care & Satisfaction Surveys

Equity

• Age– School Wellness Program– VHW for elderly & out of school children– University groups: data collection & CAGs

• Gender– Target equal representation from women & men’s groups in

CAGs– Collaborative Workshops: ObGyn

• Rural/Urban• Ethnicity

– Selection of Pilot LGAs

Protecting Human RightsArticle UNCRPD Right Strategy

General Principles

Autonomy, dignity, full/effective participation, inclusion in society, equality between men & women

Focus Groups, CAG, Collaborative Workshops, School Wellness Program

5 Equity & Non-Discrimination CAG, Selection of Pilot LGAs , Collaborative Workshops, Data Collection, School Wellness Program

6 Women CAG, Collaborative Workshops

7 Children School Wellness Program, CAG

8 Awareness Raising CAG designed action plans

10 Right to Life Access to quality health care

17 Physical & Mental Integrity Access to quality health care, CAG

21 Freedom of Expression & Opinion, Access of information

CAG, Collaborative Workshops, Advocacy Training

24- 1(c) Participation CAG, Collaborative Workshops, Advocacy Training, Focus Groups

25 Health Access to quality health care

Leadership Skills

• Proactive & Assertive• Visionary• Listening• Charismatic• Team Player• Cultural Sensitivity• Strives for synergy

COMMENTS?QUESTIONS?THANK YOU!

• Emeka Nefoh - Nigeria• Heather Weaver – Canada/Sierra Leone• Grace Adejuwon - Nigeria• Olayinka Egbokhare - Nigeria• Sunita Singh - India• Melita Vaz - India• Shivani Mathur - India• Vrishali Rohankar - India• Jennifer Marsh - USA