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STRENGTHENING HEALTH SYSTEMS FOR MENTAL
HEALTH POLICY DIALOGUE REPORT
Date: 8th April 2011
Time: 8:00 – 16:30
Venue: Blue Nile Inn
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CONTENTS
Acknowledgements…………………………………………………………………….……3
Abbreviations………………………………………………………………………………..4
Participants……………………………………………………………………………………6
Programme……………………………………………………………………………………7
Concept Note…………………………………………………………………………………9
Introductory Speech by ZAMFOHR Executive Director…………………………………...10
Ministry of Health Permanent Secretary’s Speech…………………………………………11
Mental Health System Overview……………………………………………………………14
Experiences of Mental Health System Users………………………………..……………...19
Policy Brief Power Presentation…………………………………………………………….21
Plenary Discussion Findings………………………………………………………………...23
Appendix A…………………………………………………………………………………..29
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Acknowledgements
The Zambia Forum for Health Research would like to express sincere thanks to the Alliance for
Health Policy and Systems Research (AHPSR) and Supporting the use of research evidence (SURE)
for policy in African health systems project. Health Policy and Systems Research was funded by the
Alliance (Project ID number ID‐ EIP ‐12). SURE is funded by the European Commission’s Seventh
Framework Programme (Grant agreement number 222881). The funders did not have a role in
drafting, revising or approving the content of the policy brief. Andy Oxman, principal investigator
of the SURE project, guided the preparation of the policy brief.
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ABBREVIATIONS
AIDS Acquired Immune Deficiency Syndrome
ART Anti-retroviral Therapy
CDSR Cochrane Database of Systematic Reviews
CHCH Chainama Hills College Hospital
CHW Community health workers
COP Clinical officer psychiatry
CSO Central Statistical Office
DARE Database of Abstracts of Reviews of Effectiveness
EMBASE
EU European Community
EVIPNet Evidence Informed Policy Network
HIV Human immuno-deficiency virus
HMIS Health Management Information Systems
KT knowledge translation
MCH Maternal and Child Health
MHaPP Mental Health and Poverty Project
MHAZ Mental Health Association of Zambia
MHUNZA Mental Health Users Network
NGO Non-governmental organisation
PMO Provincial Medical Officer
RAG Research to Action Group
REACH Regional East African Community Health
RMN Registered Mental health Nurse
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SMAG Safe-motherhood Activities Group
STI Sexually transmitted infections
SURE Supporting the Use of Research Evidence
TB Tuberculosis
UNZA University of Zambia
USD United States Dollar
WHO World Health Organisation
ZAMFOHR Zambia Forum for Health Research
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PARTICIPANTS
Name Organisation Phone No. Email Address
1 Dr Peter Mwaba Permanent Secretary
2 Mr Silishebo Silishebo CCZ Director 0977646620 hasisi81@yahoo.co.uk
3 Mr John Mayeya
(Chairperson)
Chief Mental Health
Officer
0977843918
4 Mr Joseph Kasonde Care Ministries for
the Mentally Ill
0977782543 care.ministries@gmail.com
5 Dr R. Chavuma District Director of
Health, Lusaka
0966763698 rchavuma@gmail.com
6 Ms Zaliwe Mwale District Mental
Health Coordinator
097828111 zaliweali@yahoo.co.uk
7 Mwape Mulubwa For Dr Caroline
Kaunda
0965781058 mwapemulubwa@yahoo.co.uk
8 Dr John Mudenda
(Moderator)
Apex Medical
University
9 Dr Margaret Maimbolwa Assistant Dean,
School of Medicine,
UNZA
0977800067
10 Dr Maria Akani (Rapporteur) Psychiatry Dept,
UNZA
0977616426 mariahakani@gmail.com
11 Ms Didduh Mubanga Psychiatry Dept,
CHCH
didduhbm@yahoo.com
12 Kanyata Kanyata Mental Health kkanyatattc@yahoo.co.uk
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Nursing, CHCH
13 Mr Paul Chungu Mental Health
Association of
Zambia
paulchungu@yahoo.com
14 Mr Eddie Mbewe 0977846648 ronchola@yahoo.com
15 Dr Chandwa Ng’ambi PMO, Copperbelt
Province
0977806754 chandwang@yahoo.com
16 PMO, Eastern
Province
0978320636 malamakennedy@gmail.com
17 Dr Felix Silwimba PMO, Northern
Province
0977412840 silwimbaf@yahoo.co.uk
18 Dr George Liabwa PMO, North-western
Province
0977867553 gliabwa@yahoo.com
19 Dr Mubita Mubita PMO, Western
Province
0977414183 mubitamubita34@yahoo.com
20 Mr Noah Kabwita Yellow Ribbon
Coordinator
0977499936 kcnox@yahoo.com
21 Ms Elizabeth Jere STEPS OVC/CRS –
Technical Advisor
0977400703 Elizabeth.Jere@crs.org
22 Mercy Zulu Lifeline Zambia 0977809381 lifeline@zamnet.zm
23 Gabriel Karuma Social Work Dept,
CHCH
0955433887 himgabby@yahoo.com
24 Dr Lutangu Alisheke 0977854854 lalisheke@yahoo.co.uk
25 Dr Lonia Mwape UTH, School of
Nursing
0979093045
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26 Dr Joseph Kasonde ZAMFOHR –
Executive Director
27 Mr Derick Hamavwa ZAMFOHR
28 Ms Nkunda Vundamina ZAMFOHR
29 Ms Alicia Cundall ZAMFOHR Intern
*Media personnel not included in list of participants (ZNBC, MUVI TV, etc)
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PROGRAMME
Chairperson: Mr John Mayeya
Moderator: Dr John Mudenda
Rapporteur: Dr Maria Akani
Time Activity
08:00 Registration of Participants (Alicia/Nkunda)
08:30 Policy Brief Questionnaire Administration (Ms. Mwape)
09:15 Welcome Remarks (Dr Kasonde, Executive Director ZAMFOHR)
09:30 Official Opening (P.S. MoH)
09:45 Mental Health System Overview (Mr Mayeya)
10:05 Experiences of Mental Health System Users (Mr Sylvester Katontoka, MHUNZ)
10:25 Policy Brief PowerPoint Presentation (Ms Mwape)
10:45 Tea/Coffee Break
11:15 Policy Dialogue Group Discussions (Dr Mudenda, Moderator)
12:30 Plenary (Dr Mudenda, Moderator)
13:00 Lunch Break
14:00 Policy Dialogue Cont’d (Dr Mudenda, Moderator)
15:30 Policy Dialogue Questionnaire Administration (Ms Mwape)
16:00 Tea/Coffee Break
16:30 Closing Remarks (Dr Kasonde)
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CONCEPT NOTE
STRENGTHENING THE HEALTH SYSTEMS FOR MENTAL HEALTH IN ZAMBIA
DIALOGUE BETWEEN POLICY MAKERS, RESEARCHERS AND STAKEHOLDERS
BACKGROUND and RATIONALE
Mental health problems continue to pose serious threats to individuals and the community at large. A good
number of studies have shown that mental health problems are common among people seeking health care,
but often with extremely limited access to mental health services especially at primary health care level.
Whilst Government, civil society and family initiatives are having some impact, it is now widely
acknowledged that this impact is enormously inadequate and is failing to address the crisis at the scale or
pace needed. There is broad consensus that responsive initiatives are only possible if the national health
systems at the primary health care level are significantly capacitated and knowledge and skills delivered to
the health workers operating at this level of care.
To this end ZAMFOHR has embarked on an innovative way to create conducive environments for key
stakeholders in the health service to come together and deliberate on matters that threaten survival and
development in Zambia. Our goal is to strengthen the capacity to undertake and utilise research and evidence
in health policy development and implementation. To date ZAMFOHR together with key stakeholders has
written and successfully produced the second policy brief which has been internally and externally reviewed.
OBJECTIVES
ZAMFOHR remains committed to providing an environment in which health research evidence forms the
basis for policy and practice, leading to improved health. This vision will see ZAMFOHR and its
stakeholders developing several policy briefs and conducting several policy dialogues over the next few
years, with the third round delivery of policy briefs and dialogues currently underway. As part of the series
of this process, ZAMFOHR held a policy dialogue in Lusaka Zambia on the 8th of April to engage with
policy makers, researchers, and stakeholders around strengthening the mental health system. The meeting
brought together key stakeholders from Government, Academic Institutions, Civil Society, mental health
users’ representatives.
The primary objective of the meeting was to present research evidence in support of the policy makers
involved in strengthening the health systems for mental health services. The second, but equally important
objective was to develop relationships among policy makers, researchers, and stakeholders.
This report includes presentations and results of discussions. A questionnaire (Appendix B) was
administered at the start of the day’s programme.
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INTRODUCTORY SPEECH BY ZAMFOHR EXECUTIVE DIRECTOR
The meeting was officially opened at 9.20am by the Executive Director, Dr Joseph Kasonde, who introduced
himself and welcomed all guests. All participants were asked to introduce themselves, which they did. A
special welcome was given to the PS and a brief overview of the program also given.
Dr Kasonde stated that around the world there is a movement toward evidence based medicine which also
implies evidence based public health. Many years ago, this was not seen as important as it is today. Across
the world, there is now the understanding that evidence is required. It is on the background of this
understanding that Zambia Forum for Health Research (ZAMFOHR) was created.
ZAMFOHR works through research to action groups (RAGs) that address specific issues in different areas of
research such as reproductive health, human resources for health and mental health. These groups then
identify an issue of importance and find evidence that pertains to it. Knowledge translation (KT) involves
gathering existing research on the issue in order to create policy briefs. If existing research is inadequate and
there is a need for research, the RAG conducts it.
Dr Kasonde also stated that the Policy brief in question was prepared through the intensive work of Dr Lonia
Mwape who looked at existing research both internationally and locally. Thus this Policy dialogue is about
considering what this policy brief suggests for mental health in Zambia today. It is not about pushing a
particular option forward and translating it into action. That is the role the policy makers such as the Ministry
of Health will assume after a thorough dialogue on the options presented.
All were thanked for attending the meeting and encouraged to fully participate.
MoH PERMANENT SECRETARY’S SPEECH
Invited guests, colleagues and partners, members of the press, ladies and Gentlemen
It gives me profound pleasure to find myself addressing this inaugural and first ever meeting on the mental
health services in Zambia. I am proud and pleased to notice that this room is composed of people with whose
work directly and indirectly links up with our agenda today of finding ways and best options for
improvement of mental health services in Zambia, especially for the integration of mental health at primary
care level.
Distinguished colleagues, partners, ladies and gentlemen, this meeting gives us an opportunity to seriously
consider and analyse how people think and perceive mental health illness and mental health, how individuals
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are treated, what treatments are available to them and what remains to be done to achieve our objective of
arriving at the best option and approach we can adopt to improve service delivery for mental health at
primary care level.
Over and above, we need a Zambia where recovery from mental illness should be the expected outcome and
where mental illness should be prevented or cured. We need a Zambia where everyone suffering from mental
illness will have access to early detection, effective treatment, care and support essential to live, work, learn
and participate fully in their expected community responsibilities.
Ladies and gentlemen, you may wish to know that there was no formal mental health care in Zambia, then
Northern Rhodesia, until the establishment of the main mental hospital, Chainama Hospital, in 1962.
Chainama Hills hospital provided guidance on mental health policy issues until 1974 when the ministry of
health took over. By 1978, all the provincial general hospital had mental health facilities. With the
introduction of the primary health care programme in 1981, the structure of mental health services was
established from the village, health centre, district, provincial and specialised levels.
However, there were gaps in the service provision. For instance, during the implementation of community
mental health services, some members of staff were not willing to participate in the programmes because
they believed that their role was to work at the hospital level. Allow me, also, to state that although
community mental health services were introduced as it were, they could not be sustained due to logistical
challenges. By the time we introduced health reforms in Zambia in 1991, there was, among many other
needs, a crisis of psychotropic drugs and a crisis of infrastructure for mental health services.
With the introduction of the mental health office at the then central board of health in 1998, we saw mental
health services being integrated in the 2001 to 2005 national health series strategic plan. The positive trend
and good will has continued, resulting in the following:
1. Development of a cabinet approved mental health policy of 2005
2. Development of the National Mental Health Services Strategic Plan of 2007-2011
3. Integration of Mental Health into the 5th National Development Plan of 2006-2010
4. Integration of Mental Health into the technical guidelines for the front-line health workers
5. Integration of Mental Health into the Standard treatment guidelines
6. Introduction of the direct entry training for clinical officers and registered mental health nurses
7. Supporting of the Bachelor of Science Mental Health training of clinical officers and registered
mental health nursing in Malawi
8. Introduction of the Masters of Medicine programme in Psychiatry
9. Upgrading of infrastructure at CHCH
In addition to what I have just said, we are now training Neuropsychologists at the University of Zambia
(UNZA), Department of Psychiatry. With this critical mass of human resource we have and are developing,
we strongly believe and feel that the technical backstopping required in terms of human resources, to
strengthen and sustain support for integration of mental health services in primary care is available.
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Our greatest challenge is in the area of logistical and financial support to do this. Against other competing
needs, the ministry of health, through the ministry of finance has been providing funding to mental health
services. But these are not enough and we require your support for counterpart funding. The Mode and ideal
of financial support we would like to see is to link mental health services to the already existing programmes.
We need to see the following linkages for the mental health services at primary health care level:
1. Mental health and HIV/AIDS
2. Alcohol, substance abuse and HIV/AIDS
3. Mental health and gender
4. Maternal, neonatal and child mental health
5. Integration of mental health in youth friendly services
6. Mental health and Malaria
7. Mental health and TB
Distinguished colleagues, ladies and gentlemen, the product of research we are discussing today provides the
passage, evidence and link to policy and practice improvement of mental health services in Zambia. We now
know that people with mental illness and indeed mental health problems need not be locked up, incarcerated
and warehoused in psychiatric facilities considering that there is now available an array of effective
treatments, both psychosocial and pharmaceutical, for even the most debilitating mental disorders. And as
such, we need to ensure that more Zambians receive and get access to mental health services outside
institutional settings.
Mental illness and mental health problems rank high among illness that causes disability, with huge costs not
only to individual families who live with it but also to all of us. In Zambia today, estimates show that over
2660 patients per 100,000 in the population are admitted to the only psychiatric hospital in the country, that
is, Chainama Hills College Hospital. The other issue is that although we have not done studies on direct and
indirect costs of mental health treatment, my assumption is that the figures may be high when you consider
Zambia’s demographic and epidemiological transitions, as well as the social challenges involving changing
family systems, poverty, rising rates of urbanisation, unemployment, alcohol and drug abuse, HIV/AIDS,
violence against women, divorce and single parenthood.
Individuals with mental health problems and mental disorders are particularly vulnerable to infringement of
their civil and human rights. They are marginalised, stigmatised and discriminated against. And for this
reason, we are in earnest working at repealing of the Mental Disorders Act Cap 305 of 1951 and we replace
it with the mental health act. Once in place, the mental health act will set a clear direction and focus for
mental health services country-wide, in the context of government’s vision of providing equity of access to
quality health care as close to the family as possible. This mental health act once in place will also see the
establishment of a framework for the protection of the rights and civil liberties of the afflicted individuals by
ensuring their full participation in the process of their care. This is the reason why the work and option you
are going to choose in integrating mental health services in primary health care is critical and important. It is
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in primary care that individuals with mental health problems can be availed the opportunity to participate in
the process of their care.
Therefore, what we are going to do in mental health today, to discuss the mental health policy brief, is highly
commendable and must be the route to follow if we have to effectively and practically link evidence to
policy and practice. For this reason, the Ministry of Health congratulates you for the work done. In
particular, we support the Zambia Forum for Health Research and its partners for the zeal and tireless effort
that went into the production and crafting of this piece of work and evidence. I urge all the Research to
Action groups on other thematic areas to conclude their work as well. Special congratulations to the Mental
Health Unit for providing leadership and an enabling environment for the conclusion of this work.
Ladies and gentlemen, I have taken longer in addressing you deliberately for the reason that we need to move
quickly in up-scaling the integration of mental health in primary health care. Remember, ‘there is no health
without mental health.’ And for this reason, I am appealing and directing the provincial medical officers to
ensure that mental health services are considered in all the action plans at provincial and district levels. We
have already posted many clinical officers –psychiatry and registered mental health nurses country wide. Use
them, especially in terms of coordination of mental health services and integration of services at primary care
level.
Thank you very much for taking your time to come and participate in this important meeting. I look forward
to receiving the final product and outcome of your deliberations. Enjoy your weekend, safe passage home
and May God bless you.
Dr Peter Mwaba,
Permanent Secretary,
Ministry of Health.
OVERVIEW OF MENTAL HEALTH SYSTEMS & SERVICES IN ZAMBIA
By Mr. John Mayeya, Chief Mental Health Officer, MoH
INTRODUCTION
• WHAT IS MENTAL HEALTH?
– According to WHO, mental health is “ a state of well being in which the individual realizes
his or her own abilities, can cope with the normal stresses of life, can work productively and
fruitfully, and is able to make a contribution to his or her community”
– It is all about how we think, feel and behave.
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• WHAT ARE- MENTAL ILLNESSES, MENTAL DISORDERS, AND MENTAL HEALTH
PROBLEMS?
– Mental illness is a non-communicable disease and term used to refer to a wide range of
mental disorders that can be diagnosed by a health care professional
– In this presentation, mental illness, mental disorders and mental health problems have the
same meaning
MENTAL HEALTH SYSTEMS AND SERVICES
• WHAT ARE MENTAL HEALTH SYSTEMS?
– These are activities whose primary purpose is to promote, restore or maintain mental health.
– The mental health system also includes all organizations and resources focused on
improving mental health.
– Mental Health Services in Zambia must be viewed and perceived from an industrial
perspective.
– And the concept of industry denotes manufacture of goods.
– In this case, the industry of mental health produces goods, which are, mental health services.
KEY DOMAINS OF A MENTAL HEALTH SYSTEM AND SERVICES
– Policy, plans, and legislation
– Financing of mental health services
– Organization of Mental health services
– Mental Health in Primary Health Care
– Human Resources
– Infrastructure
– Public Education
– Links with other Sectors
– Research, Monitoring and Evaluation
• POLICY, PLANS AND LEGISLATION
– Mental Health Policy developed in 2005
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– National Mental Health Services Strategic Plan-2007-2011
– Mental Health integrated into the National Health Services Strategic Plan since 2001
– Annual Activity Based Action Plans for Mental Health Services
FINANCING OF MENTAL HEALTH SERVICES
Government Grants through Ministry of Finance
1. Mental Health Unit-ZMK 385,000,000
2. Chainama Hills College Hospital- ZMK 3,960,000, 000
3. Provincial Mental Health Units-Unknown
4. District Mental Health Services-Unknown
5. Rehabilitation Centres:
Nsadzu-unknown
Kawimbe-unknown
Litambya-unknown
Projects
1. United Nations Office For Drugs And Crime (UNODC)-USD 150,000
2. World Health Organization-USD 10,000
3. USAID SHARE II-Undisclosed
4. STEPS –OVC-USD -Undisclosed
5. ZAMFOHR – about USD 5,000
ORGANIZATION OF MENTAL HEALTH SERVICES
• Zambia's mental health services remain highly centralized, with mental health services
remaining largely inaccessible at district level.
• Chainama Hills College Hospital – is the specialist mental health hospital for Zambia.
• Mental Health units present in 7 provincial hospitals, except for Northwestern province.
• District Mental Health Offices with District Mental Health Coordinators present in some
Districts
• No Mental Health Coordinators at provincial level except for Lusaka province
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• There is a Mental Health Unit at the Ministry of Health HQ
• Department of Psychiatry, University of Zambia, School of Medicine
• Department of Mental Health and Clinical Psychiatry, Chainama College of Health Sciences
Mental Health in Primary Health Care includes the following:
• identification and treatment of mental disorders
• Referral to other levels where required
• Attention to the mental health needs of people with physical health problems
• Mental health promotion and prevention.
• Where mental health is integrated into primary care, the following is the result:
• Access to mental health care is improved
• Mental disorders are more likely to be identified and treated, and
• Co-morbid physical and mental health problems managed in a seamless way.
To be fully effective and efficient, primary mental health care must be complemented by
additional levels of care such as:
• Secondary care components to which primary health workers can turn for referrals, support,
and supervision.
• Linkages to informal and community-based services
The following is the situation in Zambia regarding Mental Health in primary care:
1. Mental Health is part of the integrated technical guidelines for front-line health workers.
2. 98% of Primary Health Care Workers interviewed in 2009 agree that mental health must be
integrated in primary health care.
3. Close to 200 clinical officers and registered mental health nurses graduated and posted in
health facilities since 2009.
4. However, mental health services at primary health care level are still a challenge to
implement due to various system development reasons, which the policy brief may highlight
HUMAN RESOURCE
Numbers:
• Psychiatrists -4
• General Medical Officers -8
• Clinical officers in psychiatry-150 + or -
• Psychiatric nurses -150 + or -
• Psychologists x 2
• Social workers x 3
Capacity Building:
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1. MMed Psychiatry-UNZA-SOM-6 students
2. Clinical Officer Psychiatry-57
3. Registered Mental Nurse-74
4. Neuropsychologists-19
INFRASTRUCTURE
• The Buildings in most psychiatric facilities are in a deplorable state
• Chainama Hills Hospital-Two Blocks
• Kabwe Mental Health Unit
• Nsadzu rehabilitation centre
• Refurbished all 19 blocks
• Capacity for 125 patients
• Farming activities –piggery, gardening, piece work outside rehabilitation centres
PUBLIC EDUCATION
• Ad-hoc and usually done when there is availability of funds
• World Mental Health day features prominently on public mental health education
LINKS WITH OTHER SECTORS
1. Strong collaboration with Ministry of Community Development and Social Welfare
2. Task Force on mental Health Rehabilitation
3. NGOs:
a) Mental Health Users Network of Zambia
b) Mental Health Association of Zambia
c) Care Ministries for the Mentally Ill
d) Christian Organization for the Mentally Ill (COMP)
e) Zambia Forum For Health Research (ZAMFOHR)
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RESEARCH, MONITORING AND EVALUATION
1. Mental Health Research to Action Group under ZAMFOHR
2. Annual Audit of mental Health Services
3. Support Supervision
4. Draft Mental Health Information System forms
2011- MOH MENTAL HEALTH ACTION PLAN
• Up scaling the integration of mental health into primary care
• Annual Review and Feedback on Integration of MH into Primary Care
• Mental Health Services Support Supervision programme
• Commemoration of World No Tobacco Day 2011
• Commemoration of World Mental Health Day 2011
• Logistical Support to Development of Comprehensive Tobacco Control Legislation
• Strengthen Coordination of Mental Health Services
• Procure Laptop, Desktop Computers and Printer
• Support to development of Bsc Mental Health (Clinical and Nursing) Programme
• Develop protocols and guidelines on management of alcohol and drug abuse
• Provide support for psychotherapy and detoxification
• Training in management of co morbidity of mental disorders and HIV/AIDS
• Study of Mental Disorders in the General Population
• Logistical Support to MMed Psychiatry Programme
• Development of Print and Electronic Advocacy Materials
• Provide grants to occupational therapy sections in psychiatry units
• Strengthen Mental Health Information system
• Document Zambia's Mental Health Services Development from Past, Present and Future
CHALLENGES
• Infrastructure Development and Repair
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• Human Resources
a) Structure of Mental Health Services
b) Need for sub-directorate for mental health services
c) Mainstream lower level structures
• Non existence of a representative and responsive Mental health information system
• Financial Resources
• Monitoring of Psychotropic Medication
EXPERIENCES OF MENTAL HEALTH SYSTEM USERS
By Mr. Sylvester Katontoka (Mental Health Users Network of Zambia – MHUNZA)
• MHUNZA is a non-governmental Organization formed in 2000 and legally registered with the
Registrar of Societies on the 02nd January, 2003 (Registration number: ORS/102/35/2672.
• Its vision is to create a society free from stigma and discrimination against persons with mental
disability and HIV/AIDS and encourage them to fulfill their full potential.
• Its mandate is to promote, protect and ensure the full and equal enjoyment of all human rights and
fundamental freedoms by all persons with mental disability, and to promote respect for their inherent
dignity.
• The strategic directions of the organization involve lobbying and advocacy for the rights of persons
with mental disability.
Strategic Objectives
To contribute to the process of revising the Mental Disorders Act of 1951 and ensure a new
bill takes into consideration the protection of the rights of persons with mental disability.
To work with the communities to ensure that they are aware and sensitized on mental health
issues and challenges and that they will take proactive action to address them
To carry out sensitization campaigns to prevent HIV/AIDS among people with mental
disability.
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Persons with Mental Health Problems and Human Rights Violations in the Community
• The purpose of this report (which is based on findings of a focus group discussion) is to provide
information on the human rights violation that persons with mental health problems face in the
community: The case of Lusaka Community.
• This report highlights the need for policy-makers and other key stakeholders to make pay serious
attention to the unmet needs of persons with mental health problems.
Background
• Persons with mental health problems are marginalized and vulnerable group. The challenges they
face among others include:
Stigmatization and discrimination
Violence and abuse
Denied opportunities to participate in society
Lack of access to education
Lack of access to income generating opportunities.
Findings
• The majority persons with mental health problems are not guaranteed equal and effective legal
protection against discrimination in all spheres of life.
• They are subjected to torture, cruelty, inhuman and degrading treatment which is the order of the
day.
• They face all forms of exploitation, violence and abuse, including their gender-based forms of
violence.
• Majority do not have adequate standard of living for themselves, including adequate food, clothing
and housing.
• They can also not make personal choices equal to others to choose their place of residence and with
whom they live with.
• Despite being of marriageable age and can have a family on the basis of free and full consent, they
do face discrimination in matters of marriage , family and parenthood.
• Persons with mental health problems are also denied the opportunity to gain a living by doing
meaningful work due to discrimination on the basis of having a mental health condition.
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Recommendations
• Mental health should be a priority because of the huge burden of disease that results.
• Mental health is also about MDGs especially MDG 1 and 6.
• The vulnerability of persons with mental health problems should see the enactment of a new law.
• Empower users to have a full recovery process.
• Promote and support Users networks country wide by government.
• Increase financial support to mental health programmes.
POLICY BRIEF PRESENTATION
By Dr Lonia Mwape
What is a policy brief?
• A document that puts together both local and global research evidence.
• The purpose is to inform deliberations about health policies and programmes.
• Through summarising available evidence about the problem and possible solutions.
• The evidence is then made available to policy makers, their support staff and other stakeholders,
mostly through a policy dialogue.
• Policy brief is discussed as a background document in today’s policy dialogue meeting.
Summary of the policy brief: The problem
• Mental health was not among the 12 priority areas in the NHSP.
• Therefore, it was also absent in the Basic Health Care Package.
• Only 0.38% of funding was earmarked for mental health in 2008.
• Mental Health services at primary health care are inadequate.
Factors underlying the problem
• Legislative challenges
• Inadequate finances;
• Inadequate Mental Health Information Systems (MHIS).
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• Immense burden of mental health problems.
• Interconnection between mental and physical problems.
• Treatment gap for mental health is enormous and respect for human rights is inadequate.
Policy Options
Policy options of integration of mental health into primary care.
1. An incremental option
• Suggests starting with a pilot to integrate mental into PHC.
• A well designed evaluation before scaling up.
• It is possible to make improvements in the plan before scaling up.
• The pilot will ensure full implementation achieves its intended objectives.
• It may be more feasible than rapidly scaling up.
2. A comprehensive option
• Involves introducing services at PHC in all provinces at once.
• It is less likely to stall than an incremental approach.
• Monitoring and evaluation could be used implementation is working as planned.
• Evidence for each option is presented in the main body of the policy brief.
Implementation Strategies
• Insufficient funding for mental health services
• A lack of collaborative efforts between mental health workers in tertiary care hospitals,
provincial units, primary care workers and community health workers and organizations.
• Primary care workers already overburdened due to low numbers of staff, limited types of
personnel trained in mental health.
• Poor awareness in the community about causes of mental illness.
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What is a policy Dialogue?
• A structured discussion of the policy brief on strengthening the health system for mental health
in Zambia.
• Deliberations among policy makers, researchers, the media, civil society and other stakeholders
have the potential to contribute to evidence-informed health policies.
• Adds value to the policy brief through clarification of the problem.
• Provides a forum to share an understanding of the problems and their possible solutions.
PLENARY SESSIONS
Moderated by Dr John Mudenda
Three working groups were formed from participants. The following were the group discussion items
presented in plenary session:
1. Problem Definition
Group 1
The group agreed that there is a problem. Mental health is not adequately addressed. There is also
lack of capacity in mental health care in terms of human resource, inadequate finances, poor
legislature, lack of drugs, poor or lack of mental health infrastructure at all centres and no integration
of mental health into general health services. Also, there is little involvement of community in
mental health care.
Group 2
This group stated that second level hospitals and in-patient facilities are available but in a deplorable
state and often isolated. Integration of mental health services in the main stream clinical and
preventive practices is lacking. In some cases, the establishments for mental health providers do not
adequately provide for mental health personnel. Data capturing has also been poor.
Group 3
There was a general consensus on that fact that there is a problem in mental health as is evident from
lack of adequate services, lack of adequate funding and stigma. Issues that should be added to the
problem are those such as:
a) Services are not specific to demographic groups
b) Relatives and caregivers of mental health patients are not adequately cared for and
educated on how they can help. It is important to define more accurately who is the
treatment team
25
c) Identify which organisations/groups (traditional healers, spiritual leaders, etc) that
are currently providing care and included them in the plan
d) Mental health is not adequately included in the national and demographic surveys
e) Research on mental is not coordinated and fed into policy using the KT approach
f) Inadequate training and importance of scaling-up training of mental health officers
(also need to train mental health social workers)
g) Natural and man-made disasters (e.g. drought) should be articulated. It is important
to strengthen MoH and MCD partnerships
h) The issue of stigma should be addressed as well
2. Options – Incremental Vs Comprehensive
As regards the debate on which of the two options Zambia should take up, the group reports were as
follows:
Group 1
This group opted for the adoption of both incremental and comprehensive approaches at different
levels in the plan. Comprehensive approach should be done to perfect what care and services are
already being offered and the incremental approach should be taken to establish a standard of an idea
care centre to be an example to all.
Group 2
Group 2 chose the incremental approach as a way of having a model to create an intervention
approach. They favoured the incremental approach for the following reasons:
a) Easy to monitor
b) Should be used as a pilot lessons will be learnt
c) Limited resource and finances can be put to good use.
Group 3
The group did not choose one particular option or approach but instead discussed the advantages and
disadvantages of both options.
Incremental Approach
Advantages – helps ensure quality of care, to have all components in place
‐ Once we have mental health in primary health care in one area, the users of
new approaches can sensitise and promote at other centres
Disadvantages – equity would be a challenge. How would one area be selected over another?
‐ The approach has potential of stalling work without completion by rolling
out to all centres.
26
Comprehensive Approach
Advantages – Current budgetary allocations already include districts
‐ The need for funding within short time frame maybe beneficial
‐ It will enable large amount of data to be available at onset of work all at
once
Disadvantages – Concern for quality because it may be compromised when a big project is
being set off.
‐ Lack of human resource
‐ Bureaucracy and time (advisory board component of it)
‐ Needs for increased funds to begin with
Other general issues
‐ Some services require incremental and some comprehensive
‐ Need to include/consider lessons learnt from countries similar to Zambia
‐ The advisory board could be incremental or comprehensive
‐ Use term ‘program’ not ‘project’ because ‘project’ implies that it will come
to an end at some point
‐ Need more emphasis on human resource issues
Main Points from Discussion in Plenary Session
‐ Consider orientation of mental health staff. A few key staff should be
identified and give an orientation.
‐ Consider training of caregivers in community, even the family members
since they are the first point of contact.
‐ Address curriculum in the training of medical staff to improve diagnostics.
Put diagnostic criteria in curricular. It will help diagnose clients easily and it
will be easier to manage clients before it is too late or ‘full blown’ and
difficult to manage.
‐ Even when medical personnel learn something about mental health, when
they get to their stations they do not practice. Therefore, there is need to
identify a strategy that will ensure they apply what they have learnt. The
element of continuity from what they were trained in to what they finally do
in clinical practice.
‐ Mental health is not prioritised and this is evident because it is not present in
major documents which do not encourage the health worker in the field.
27
‐ Competence by health staff may also be a problem. Findings from the
MHaPP study revealed that staff in the field needs capacity building to help
them improve skills.
‐ Consider including mental health services users in the strategy to dealing
with mental health because they are also stakeholders
‐ It would also help to have community groups initiated like the way
reproductive health has safe motherhood activities groups (SMAGs).
‐ The already existing persons in the SMAGs can be targeted to be link
persons for integration of mental health because this is a more primary level
than the CHWs
‐ Focus must not just be on those that are of low socio-economic only because
the services are lacking from both urban and rural settings
‐ There is need to also target the community health care package and improve
on it
‐ The Health Management Information System (HMIS) needs to be revised
because it only captures mental illness as either ‘psychosis’ or ‘neurosis’
‐ Diagnosis is a challenge. In dealing with other illness, there is a laboratory
to confirm diagnosis and monitor illness. What equivalent can we find in
rural areas that can be taught to community health workers?
‐ There is also need to identify a treatment team with all the components
(medical, social, psychological, etc)
‐ Pyramid approach. The pyramid has 6 levels from bottom to top with the
community at the base, followed by 1st level medical centre on top of it, then
2nd level medical centre, followed by 3rd level hospital and then provinces
with the headquarters finally at the apex. Both vertical and horizontal
approaches are necessary in order to have success. The pyramid can be
turned upside down with the community lead and putting pressure on top.
Incremental Vs Comprehensive Approach
‐ Learning from primary health care, the initial plan was incremental but then
other centres were pro-active about it so the governmental then changed into
comprehensive approach
‐ Better start one and do it well so that it serves as an example and an
inspirational to all. This has also been observed with other medical services
provided in Zambia such ART. Centres were targeted where this was started
in a particular area and then rolled out to other places later.
‐ It is important for us to define exactly what services we are talking about.
For example, stigma and awareness can be done comprehensively right
28
away and others, such as primary health care may use strategic incremental
approach with defined time frames.
‐ Incremental approach can be taken but for a centre in each province
‐ It is important that there is coordination with the community because there
is pressure from the community organisations to get things started and
advanced.
Concluding remarks:
The concept of integration is a must and should not just be at service delivery level but also on training level.
The review of various curricular would have to be done. It seems to be state that there is lack of quality
control mechanisms on what kind of mental health is taught when teaching medical staff. Attitudes of trained
mental health staff that are in general centres but do not practice mental health but instead keep referring
cases to ‘specialists’ need to change. They need to actively call upon their skills and practice.
There is need to include consumers of mental health services in these plans and making headway.
Communities need to be motivated to support mental health programmes.
A focal group to put all these ideas together and make a way forward will be needed this group should also
set up a model. Both incremental and comprehensive approach on different levels and in different issues can
still work.
* A questionnaire was administered (Appendix C) before the official closing of the day’s activities.
CLOSING
Dr Joseph Kasonde:
Acknowledged the efforts of donors such as the Alliance for Health Policy and Systems Research (AHSPR)
and the EU (through SURE project). Also, the Zambian government (through MoH) and stated how glad he
was that the permanent secretary could come and officiate the deliberations of the day. He thanked the
chairman, Mr John Mayeya, who was also in the place of a policy maker. Mr Mayeya has had many break-
throughs, has worked with Dr Mwape and others for a long time. He came forward and wanted to know the
research evidence before proceeding with options. Dr Kasonde also thanked Dr Lonia Mwape, presenter of
the policy brief, who worked on this brief for one and half years. He thanked Moderator who facilitated well.
The ZAMFOHR team of organisers – Derrick Hamavhwa, Nkunda Vundamina and Alicia Cundall were also
acknowledged including all others in attendance for a very productive day.
Mr John Mayeya:
29
Introduced the Provincial Medical Officer (PMO) for North-western province to do the official closing. Their
province is the first to have a provincial mental health facility and it is hoped that others will emulate this.
Dr George Liabwa:
Thanked ZAMFOHR for co-sponsoring the policy dialogue meeting and for also bringing an element of
research based policies and activities. He noted that the Issue of input of mental health into the HMIS needs
to be revised. He also advised all PMOs to take advantage of planning cycle which starts in 2 months time to
include mental health activities. He advised that a comprehensive plan be made that even other stakeholders
can buy into.
Finally, he thanked all in attendance and officially closed the meeting at 17:03hrs.
30
APPENDIX A
17 février 2012
An Evidence-Based Policy Brief
Strengthening the health system
for mental health in
Zambia
Included:
- Description of a health system problem
- Viable options for addressing this problem
- Strategies for implementing these options
Not included: recommendations
This policy brief does not make recommendations
regarding which policy option to choose
Who is this policy brief for? Policymakers, their support staff, and other stakeholders with an interest in the problem addressed by this policy brief
Why was this policy brief prepared? To inform deliberations about health policies and programmes by summarizing the best available evidence about the problem and viable solutions
What is an evidence-based policy brief? Evidence-based policy briefs bring together global research evidence (from systematic reviews*) and local evidence to inform deliberations about health policies and programmes *Systematic Review: A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from this research
This policy brief was prepared by the Zambia Forum for Health Research
2
Authors
Lonia Mwape, BSc(N), PhD, Lecturer, University of Zambia
Prudencia Mweemba, BSc(N), PhD, Lecturer, University of Zambia
Joseph M. Kasonde, MD, Zambia Forum for Health Research
Address for correspondence
Joseph M Kasonde, MD, Executive Director, Zambia Forum for Health Research
23 Chindo Road, Woodlands
PostNet 261, Crossroads
Lusaka 10101
Zambia
Contributions of authors
All of the authors contributed to drafting and revising the policy brief.
Competing interests
None known.
Acknowledgements
This policy brief was prepared with support from the “Alliance for Health Policy and Systems Research (AHPSR) and
Supporting the use of research evidence (SURE) for policy in African health systems project. Health Policy and Systems
Research is funded by the Alliance (Project ID number ID‐ EIP ‐12). SURE is funded by the European Commission’s Seventh
Framework Programme (Grant agreement number 222881). The funders did not have a role in drafting, revising or
approving the content of the policy brief. Andy Oxman, principal investigator of the SURE project, guided the preparation of
the policy brief.
We would like to thank the following people for providing us with input and feedback: John Mayeya, Eddie Mbewe, Paul
Chungu , and The Mental Health Research‐to‐Action Group
The following people provided helpful comments on an earlier version of the policy brief: Margaret Maimbolwa, Dr.
Mukonka and Dr. Chipoya
Suggested citation
Mwape L, Mweemba P.. Strengthening the health system for mental health in Zambia (policy brief). Lusaka, Zambia: The
Zambia Forum for Health Research, 2010.
3
The Zambia Forum for Health Research (Zamfohr) is a Knowledge Translation institution that aims to promote evidence-informed decision-making among researchers and research users. It is not a funder of research but rather an institution designed to bring together the key producers and users of knowledge, serving researchers, institutes, the Ministry of Health, Cooperating Partners, practitioners and civil society. www.zamfohr.org
Since its inception in 1999, the Alliance’s overall goal has remained unchanged – promoting the generation and use of health policy and systems research (HPSR) as a means to improve health and health systems in developing countries. The Alliance pursues this goal by developing and harnessing existing methods and approaches to improve both the quality of research and its
ultimate uptake. www.who.int/alliance-hpsr/en/
SURE – Supporting the Use of Research Evidence (SURE) for Policy in African Health Systems – is a collaborative project that builds on and supports the Evidence-Informed Policy Network (EVIPNet) in Africa and the Regional East African Community Health (REACH) Policy Initiative. SURE is funded by the European Commission’s 7th Framework Programme. www.evipnet.org/sure
The Evidence-Informed Policy Network (EVIPNet) promotes the use of health research in policymaking. Focusing on low and middle-income countries, EVIPNet promotes partnerships at the country level between policymakers, researchers and civil society in order to facilitate policy development and implementation through the use of the best scientific evidence available. www.evipnet.org
4
Key messages
The problem:
Although mental illness constitutes a large
proportion of the burden of disease in Zambia, it
receives inadequate attention.
• Mental health was not among the twelve priority areas in the National
Health development plan and was not provided for in the basic
package of services defined by the Ministry of Health.
• Only 0.38% of health care funding was directed towards mental illness
in 2008.
• Mental health services are lacking in general in general health care,
including secondary and primary care levels.
Policy options:
An incremental versus a comprehensive option for
integrating mental health into primary care
An incremental option
This option would start with a pilot project introducing mental
health services into primary care with a well-designed evaluation
prior to scaling up. Key advantages of this option are:
It is possible to make improvements in the plan, if needed, prior to
scaling up.
The pilot would help ensure that full implementation of the plan
achieves its intended objectives and could provide better data
for estimating the costs of scaling up.
It may be more feasible than rapidly scaling up throughout the
country.
A comprehensive option
This option would entail implementation of a comprehensive plan
to introduce mental health services into primary care in all nine
provinces of Zambia. Key advantages of this option are:
Scaling up could occur more rapidly.
5
Monitoring and evaluation could be used to ensure that the
implementation of the plan is working as intended.
It may be less likely to stall and than an incremental approach.
Implementation strategies:
Strategies to implement either option must address a
number of barriers, including:
Insufficient funding for mental health services due to inadequate
advocacy, inadequate mental health indicators, inadequate
public awareness of mental illnesses, social stigma attached to
mental illnesses, mental health care not being perceived as cost-
effective or affordable, and resources that are allocated to
mental health at the district level not being earmarked
Lack of collaborative efforts between mental health workers in the
tertiary care hospital and provincial units, primary care
workers and community health workers and organizations
Primary care workers already being overburdened due to low
numbers and limited types of health workers trained and
supervised in mental health care, poor working conditions in the
public health service, lack of incentives to work in rural areas,
and inadequate training of the general health workforce in
mental health
Insufficient funding for mental health services due to inadequate
advocacy, inadequate mental health indicators, inadequate
public awareness of mental illnesses, social stigma attached to
mental illnesses, mental health care not being perceived as a
serious problem.
6
Executive summary
The problem Mental illness constitutes a large proportion of the burden of disease in Zambia. Although
data regarding the burden of mental disorders in the country are lacking, there are some
indicators of the magnitude of the problem. For example, Mayeya et al (2004) found a
prevalence of 36 and 18 per 100 000 for acute psychotic states and schizophrenia
respectively, based on hospital figures. Acute psychotic states refer to mental illnesses which
present in an acute state and do not normally exceed a period two weeks for resolution while
schizophrenia refers to a chronic state of psychotic illness. Further, according to the Mental
Health and Poverty Project (MHaPP) Country Report of 2008, about 2667 patients per
100,000 population are admitted annually to the only tertiary referral psychiatric hospital
and units around the country. It is expected that mental health problems in general will
increase, taking into account the extent of predisposing factors like HIV/AIDS, poverty and
unemployment. It is recognised that this is a very high incidence when compared to expected
prevalence of about 3 percent for severe mental disorders and 19 percent for mild to
moderate disorders. This observation would support the proposition that there is lack of
provision for mental health at the primary and secondary level and that mental health
services mostly accessed at tertiary level.
By contrast, mental health care services have continued to receive inadequate attention:
mental health was not among the twelve priority areas in the National Health development
plan; mental health was not provided for in the basic package of services defined by the
ministry of Health; and only 0.38% of health care funding was directed towards mental
illness in 2008. Moreover, legislation related to mental health care, not updated since 1951,
fails to mention basic human rights related to the mentally ill.
The current system of mental health care is based largely on secondary and tertiary health
institutions. Mental health services at the primary health care level are either inadequate or
lacking due to several factors, the main one being the low level and misplacement of mental
health professionals.
7
Policy options
In considering the way forward the government was confronted with two options for improving
mental health services. The first is strengthening of the status quo by making the “vertical” system
work more efficiently. This would imply investment in secondary and tertiary institutions to increase
the number and competencies of human resources as well as the physical structures and logistics.
Secondly, there was the option of investing in integrating mental health in primary health care
services. The government decided on the latter.
Integrating mental health into primary health care: strategic options
The two strategic options that are considered here focus on integration of mental health into primary
health care using (1) an incremental approach or (2) a comprehensive approach. In the incremental
system, it is envisaged that a few centres will be selected for implementation with a view to scaling
up at a later stage. In the comprehensive system an effort is made to initiate a process widely across
the country without a need for extending to other centres at a later date. The important distinction
between these two options is the implication for resource allocation in specific context of Zambia. It
is important to take into account the country’s ability to fulfil the resource allocation implications of
these options before adopting one or the other or both. The two options, how they would differ and
their advantages and disadvantages are summarized in Table 1 in relation to the ten WHO/WONCA
principles for integrating mental health into primary care.
Table 1. Key characteristics of two options for integrating mental health into primary care
Principles The status quo Option 1
Incremental implementation starting with a pilot project
Option 2
A comprehensive plan for scaling up
1. Policy and plans need to incorporate primary care for mental health
The Ministry of Health is committed to integrating mental health in primary care. Implementation of this policy has been slow, nonsystematic and uncoordinated
A systematic and coordinated plan for integrating mental health in primary care
The plan will initially be implemented in a small number of districts
A comprehensive plan for scaling up the integration of mental health in primary care will be implemented throughout the country
2. Advocacy is required to Several independent A voluntary coalition of A mental health advisory
8
Principles The status quo Option 1 Option 2
shift attitudes and behaviour organizations (e.g. MUHNZA, MHAZ) are working largely independently
organizations will collaborate in advocating for change
board will be established to ensure input into the plan and its implementation and to help monitor and coordinate implementation of the plan, as well as to advocate for change
3. Adequate training of primary care workers is required
Limited training for specialised skills at the only tertiary care mental health hospital, limited mental health training in the curricula for general health workers, and limited efforts and resources for in service training
A pilot project in a small number of districts including systematically planned and coordinated training and supportive supervision for primary care workers
A cascade approach for training relevant cadre of primary care workers throughout the country
4. Primary care tasks must be limited and doable
Treatable mental health problems commonly go unrecognised, minimal mental health services provided in primary care, lack of follow-up for discharged psychiatric patients
Improved recognition of high priority mental illnesses, diagnosing and treating high priority conditions that are optimally managed in primary care, improving referrals and communication with specialized mental health workers, and follow-up of discharged psychiatric patients
Implemented initially in a small number of districts focusing on a minimal number of high priority conditions and tasks
Implemented throughout the country and the prioritised conditions and tasks may be expanded to include all priorities that are best provided in primary care
5. Specialist mental health professionals and facilities must be available to support primary care
Inadequate specialist mental health professionals, they do not have responsibility or time to provide adequate support, and the referral process is ineffective and inefficient
Increased supply of mental health professionals, posts providing support as a key component of the job description, and an effective and efficient referral process
Implemented initially in a small number of districts with a minimal sufficient increase in capacity
Implemented throughout the country and may include additional expansion of the specialist mental health service to increase its capacity to handle referrals as well as to provide outreach, supervision and
9
Principles The status quo Option 1 Option 2
support for primary care workers
6. Patients must have access to essential psychotropic and other mental health medications in primary care
No psychotropic drugs included in the primary health care kit or available in private pharmacies, and inappropriate drugs are being used
Include appropriate psychotropic and other drugs for mental health problems (e.g. depression) in the primary health care drug kit
Implemented initially in a small number of districts for a minimal number of high priority conditions
Implemented throughout the country and the prioritised conditions may be expanded to include all priorities for which drugs are needed in primary care
7. Integration is a process, not an event
The process of integrating mental health into primary care does not have a timeline and is uncoordinated
Stage by stage changes building on experience, beginning with a pilot project, including rigorous evaluation of both impacts and processes
A plan for achieving comprehensive mental health care over a defined period of time with ongoing monitoring, evaluation and adaptation
8. A mental health service coordinator is crucial
Currently there is a National Mental Health Services Unit with a small number of staff
Strengthen the National Mental Health Services Unit and ensure that it has a clear mandate and capacity for coordinating the integration of mental health into primary care
Initially focusing on ensuring a clear mandate and capacity for coordinating the pilot project
In addition establishing establish coordinators at the provincial level and focal point persons at the district level
9. Collaboration with key stakeholders is required
Not currently coordinated The National Mental Health Services Unit will be responsible for indentifying key stakeholders and working with them
An advisory board with key stakeholders will be established (see 2 above)
10. Financial resources are needed
No earmarked funds allocated to integrating mental health in primary care
Earmarked funds for the pilot project and other elements of this option outlined above, including for training, drugs, mental health professionals to support primary care
Earmarked funds for mental health professionals to support an advisory board, training, additional tasks undertaken by primary care workers, drugs, mental health professionals to
10
Principles The status quo Option 1 Option 2
workers, evaluation, and strengthening coordination
support primary care workers and to manage increases in referrals, and coordination
Implementation considerations There will be several barriers to the implementation of either option. Inconsistent and unclear
advocacy may result in unclear messages. It will be necessary to establish mechanisms for common
approaches among stakeholders for either approach. It will also be necessary to devise
comprehensive indicators that do not give a skewed view of the burden of mental illness.
Lack of general public awareness of mental illnesses and the social stigma that is attached to mental
illnesses are bound to undermine efforts to provide mental health services in primary care.
Moreover, mental health care and provision of psychotropic drugs may not be perceived as cost‐
effective or affordable. Finally, and most importantly, allocation of resources earmarked for mental
health may continue to be scarce despite the adoption of either policy option for integrating mental
health care in primary care.
11
MAIN REPORT
Table of contents
Preface 8 The problem 9 Policy options 16 Implementation considerations 27 Next steps 28 Appendix 29 Abbreviations 30
References 31
12
Preface
“The problem of under‐diagnosis and under‐treatment of mental health problems cannot be
remedied by simple provision of guidelines and protocols, no matter how elegant; it will require a
reordering of the actual structure and process of primary care” (deGruy, 1997).
The purpose of this report
The purpose of this report is to inform deliberations among policymakers and stakeholders. It
summarises the best available evidence regarding integration of mental health into primary healh
care. It was prepared as a background document to be discussed at meetings of those engaged in
developing mental health and primary health care policies and stakeholders. In addition, it is
intended to inform other stakeholders and to engage them in deliberations about those policies. It is
not intended to prescribe specific options or implementation strategies. Rather, its purpose is to
introduce systematic and transparent consideration of the available evidence of the likely impacts of
different options into deliberations about mental health care.
How this report is structured
This policy brief has a list of key messages, an executive summary, and a full report to present policy‐
relevant research evidence about the impacts of integrating mental health into primary health care.
Although this entails some replication of information, the key messages and summary address the
concern that not everyone for whom the report is intended will have time to read the full report.
How this report was prepared
We searched for relevant evidence describing the problem, the impacts of options for addressing the
problem, barriers to implementing those options, and implementation strategies to address those
barriers. We searched particularly for systematic reviews describing the effects of policy options and
implementation strategies. Reviews that we assessed as being most relevant were used to extract
key findings and information that facilitates interpretation of those findings in the Zambian context.
We supplemented information extracted from the included systematic reviews with information
13
from other relevant studies and documents. The report was revised iteratively based on feedback
from the Mental Health Research to Action Group, key informants and external reviewers.
Limitations of this report
Because this policy brief is based largely on previously completed systematic reviews and research,
there may be important gaps in addressing options for which we did not find relevant evidence. We
have attempted to address this limitation in three ways: by relying on other documents to fill in the
gaps, through personal contact with experts, and through external review of the report.
14
The problem Background
A large proportion of the burden of disease in Zambia and around the world is due to mental illness
(WHO 2005). The common mental disorders are depression (42%) and schizophrenia (21%) while the
diagnosis of acute transient psychoses is rare. The majority of people with mental illness do not have
access to mental health services in Zambia [Mental Health Atlas, 2005]. The World Health
Organization (WHO) and the Ministry of Health, along with non‐governmental organizations dealing
with mental health advocate integrating mental health into primary care to address this problem. In
a survey conducted to explore attitude of health workers towards integrating mental health into
primary health care in Zambia revealed that over 98.2 percent of the health workers were of the
view that such integration was either extremely important (71.2%) or just important (27.0%) and this
ranged from a high of 88.5 percent among Zambian Registered Nurses to 25.1 percent among
Environmental Health Technologist who indicated that it was extremely important (Mwape, et. Al.,
2010). Although the Ministry of Health has made some strides towards integrating mental health into
primary health care, the process of integration to address the inadequacy of mental health service
provision has been slow and has not been systematically planned or implemented.
The decision to focus this policy brief on mental health care was influenced by the Mental Health and
Poverty Project conducted in four African countries (Ghana, South Africa, Uganda and Zambia) to
investigate policy level interventions required to break the vicious cycle of human poverty and
mental illness. This project was undertaken in order to generate lessons for a range of low and
middle‐income countries. Subsequently, discussions with key policymakers in the Ministry of Health,
mental health professionals and mental health organizations’ staff revealed that integration of
mental health into primary health care is a priority of current policy interest. Further, it was evident
that there was need for research evidence to inform decisions about how to effectively integrate
mental health into primary health care.
Over the past two decades the focus of care in mental health has been through the provision of
curative care, situated in big third level provincial hospitals (Petersen 1999). However, in the Mental
Health Policy document (2005), the Ministry of Health has committed to integrating mental health
into primary care. This integration is expected to address a full range of services so that continuity of
care and a balanced mix of community and inpatient services are ensured. The process was also
planned to be sensitive to prevailing cultural beliefs and practices. Further, the Ministry of Health has
included mental health in the current National Health Services Strategic Plan which is as part of the
Fifth National Development Plan (2006 – 2010) and has integrated it in Clinical Technical Guidelines,
15
as they pave the way to integrating mental health at primary health care level (Mental Health Unit,
MoH, 2008).
Reasons for integrating mental health into primary health care, as outlined by the World Health
Organization (WHO 2008), include:
• The burden of mental disorders is great.
• Mental and physical health problems are interwoven.
• The treatment gap for mental disorders is enormous.
• Primary care for mental health enhances access.
• Primary care for mental health promotes respect of human rights.
• Primary care for mental health is affordable and cost effective.
• Primary care for mental health generates good health outcomes.
Size of the problem
Treatment for mental illness is either lacking or provided in a fragmented manner at the primary
health care level for an estimated 200 000 people with mental disorders (of an adult population of 5
million) in Zambia [WHO, 2004; MHaPP, 2008; Mental Health Atlas, 2005]. It is cause for concern that
mental health at the primary care level has been largely overlooked in Zambia [Mayeya et al., 2004].
It is not one of the top ten priorities and has not been included within the Zambian Basic Health Care
Package. Consequently, psychotropic medications are not included in the primary care health kit and
are generally unavailable in primary care.
Because mental health is omitted from the health package, mental health care services are
unavailable throughout most of Zambia. There is currently only one mental care specialist in each of
the nine provinces. There are only three psychiatrists in the country, for a population of 12 million,
and none working in public health care (MHaPP, 2008; Mental Health Atlas. 2005). Mental health
services are mainly hospital based with Chainama Hills Hospital, located in the capital city of Lusaka,
as the only third level inpatient, long‐term care facility in Zambia. It is supported by a network of
psychiatric units in seven provincial general hospitals and three general psychiatric rehabilitation
units (Mental Health Policy Document, 2005). However, the Mental Health Policy Document (2005)
reports that the rehabilitation centres are not funded by the Ministry of Health, are inadequate, and
are located far away from patients. The document further notes that there are scant mental health
services for vulnerable groups such as children, young people, women, single parents, terminally ill,
unemployed, prisoners, retrenchees, widows, divorcees and the homeless.
16
Although data regarding the burden of mental disorders in Zambia are lacking, some indicators are
available. Mayeya et al (2004), for example, found a prevalence rate based on hospital figures of 36
and 18 per 100 000 population for acute psychotic states and schizophrenia respectively, with
alcohol and drug misuse cases accounting for 10 percent of acute psychotic states. This prevalence is
slightly higher than global burden which when measured by years lived with disability and years lost
as a result of premature death in disability‐adjusted life years, accounted for 13% of the global
disease burden in 2002 (WHO, 2002). However both the global and the Zambian prevalence do not
capture other types of burden associated with mental disorders, including the burden of care giving
for family members, financial costs, stigma, and human rights violations (Saxena, 2007). In addition,
and mentioned earlier, it is recognised that this is a very high incidence when compared to expected
prevalence of about 3 percent for severe mental disorders and 19 percent for mild to moderate
disorders. This observation would support the proposition that there is lack of provision for mental
health at the primary and secondary level and that mental health services mostly accessed at tertiary
level.
Further, the burden of mental disorders is likely to have been underestimated because of inadequate
appreciation of the connectedness between mental illness and other health conditions (Prince, Patel,
Saxena, Maj, Maselko, Phillips, & Rahman, 2007). The WHO’s 2005 (Mental Health Atlas, 2005)
estimates of the global burden of disease provide evidence on the relative effect of health problems
worldwide. WHO’s 2005 report attributed 31∙7% of all years lived‐with‐disability to neuropsychiatric
conditions: the five major contributors to this total were unipolar depression (11∙8%), alcohol‐use
disorder (3∙3%), schizophrenia (2∙8%), bipolar depression (2∙4%), and dementia (1∙6%).
According to the Mental Health and Poverty Project (MHaPP) Country Report [2008], about 2667
patients per 100 000 population are admitted to Chainama and psychiatric units around the country.
The total number of beds at Chainama is 210, excluding 167 (floor beds) which are not officially
recognised by the Ministry of Health. Primary health care units (health centres) form the first level in
terms of the structure of health care provision. They are expected to refer complex cases to district
hospitals (second level) and the district hospitals are expected to refer to third level (tertiary)
hospitals. However, neither health centres nor district hospitals have mental health plans. Both are
fragmented and uncoordinated in their provision of mental health services [Mental Health Policy
Document, 2005; Gleisner, 2001; Gleisner, 2002].
Mental health care providers at the primary care level are generally clinical officers who have
undergone three years of training. They are able to diagnose mental illness and they illegally provide
prescriptions for psychotropic drugs, meanwhile medical officers are generally not available at the
primary care level, especially in rural areas, yet they are the ones that have the legal provision to
prescribe drugs for mental illness (MHaPP, 2008). Training of nurses and general practitioners about
17
mental illness is limited. This may be attributed to the lack of knowledgeable trainers for mental
illness and care (MHaPP, 2008). Generally, research in mental health in Zambia is scarce, with no
research, apart from the MHaPP project, having been conducted on issues around integration of
mental health within primary health care [MHaPP, 2008; Mayeya et al., 2004; Gleisner, 2001;
Gleisner, 2002].
Factors underlying the problem
Key factors underlying the failure to integrate mental health into primary care are a lack of
legislation, inadequate financing and an inadequate mental health information system.
Legislative challenges
Legislation related to mental health care in Zambia is an appendage of a colonial legacy. Created in
1951 the policy discusses how the general population needs to be protected from the mentally ill but
fails to mention basic human rights related to those living with mental illness (MHaPP, 2008). Zambia
is still under the guidance of this legislation, which does not recognize nor provide for the protection
of the human rights of mentally ill patients or involvement of communities in the provision of mental
health care. The National Mental Health Bill, which will repeal the Mental Health Ordinance of 1951,
has been in under review for about 10 years. This has delayed repealing the Mental Health Ordinance
of 1951 and enacting the new bill. The Mental Health Policy was ratified in 2005, still based on the
Mental Health Ordinance of 1951, and has not been fully implemented. This has perpetuated the
slow pace at which integration of mental health services into primary health care is progressing,
despite the good intentions of the Ministry of Health’s vision of ‘providing equity of access to quality
health care as close to the family as possible’.
Inadequate financing
Only 0.38% of health care funding is directed towards mental illness (MHaPP, 2008). The Zambia
Mental Health Policy (2005) makes it clear that this is insufficient. The Ministry of Health’s Annual
Action Plan (2010) with a total of K756 billion (app. $151 million) shows Mental Health as having
been allocated only K889 million (app. $178 000) under six activities: strengthening coordination of
mental heal services in the provinces; support to tobacco control activities; training and research in
mental health; creation of public awareness in mental health; the prevention of alcohol and drug
abuse and facilitation of the provision of community mental health services in provinces. In
comparison, STI/HIV was allocated K8.6 billion (app. $1.7 million) and K2.4 billion (app. $478 000)
was allocated for tuberculosis and leprosy activities. This situation is similar to other states in the
world despite the huge burden of mental illness and the availability of effective interventions; few
resources are directed toward mental health care. Mental health spending in many countries in the
world is less than 1% of health expenditures (which are already very low in most middle‐ and low‐
18
income countries), 31% percent of countries have no separate mental health budget, and the
number of mental health professionals is grossly deficient (Mental Health Atlas, 2005; Saxena,
Sharan, Saraceno, 2003).
Inadequate mental health information system
The Zambian Ministry of Health collects health information from health facilities in the country
through a data capture form that clinicians complete by tallying conditions of patients seen each day.
The data capture form has a list of conditions from which clinicians select. However, there are only
two categories (psychosis and neurosis) through which mental health problems are captured leaving
all others unrecorded. This has significantly contributed to under reporting of mental health
disorders. It has further contributed to patients being referred to the only tertiary level hospital
without being treated at the primary care level. The Mental Health and Poverty Project survey (2008)
reports that patients with mental disorders are sent to a tertiary level hospital right away without
being screened and in most cases, without a provisional diagnosis. This is done regardless of the
distance the patient should cover to the hospital or the cost of transportation.
Other factors underlying the need for improving the integration of mental health into primary care
can be summarised in relationship to the reasons for integrating mental health into primary health
care listed above.
The burden of mental health problems is immense
Mental health problems are increasing in the Zambian population, mostly arising from the socio‐
economic difficulties that exist in the country. These include: HIV/AIDS, poverty, and joblessness.
With the population of 12 million people, an HIV prevalence of 17 percent and only about 400 000
formal jobs, over 68 percent of the population live on one US Dollar per day or less (CSO, 2007). Amid
all the mental health problems arising from socio‐economic difficulties, the health system in Zambia
considers a disease as a priority if it represents a large burden (in terms of mortality, morbidity or
disability), has high economic costs, or is associated with violations of human rights (Mental Health
and Poverty Project, 2008). Although WHO has identified depression, schizophrenia and other
psychotic disorders, suicide, epilepsy, dementia, disorders due to use of alcohol, disorders due to use
of illicit drugs, and mental disorders in children as priority conditions, these did not fit the criteria
that were used to prioritize conditions in Zambia. Disability and the economic burden imposed by
these disorders includes loss of gainful employment, with the attendant loss of family income; the
requirement for care giving, with further potential loss of wages; the cost of medicines; and the need
for other medical and social services. These costs are particularly devastating for poor populations
[Mweemba, et al, 2009; WHO/WONCA, 2008].
19
However there have been almost no epidemiological studies conducted in Zambia to determine the
exact burden of mental health problems. Few isolated studies have been undertaken and the
findings have indicated prevalence rates among various groups. A study that was undertaken to
determine mental distress among primary care attendees reported a prevalence rate of 12.4 percent
and 15.4 percent in men and women respectively (Chipimo & Fylkesnes, 2009). Another study which
was conducted to explore psychological distress among women in the perinatal period reported a
prevalence rate of 48 percent during the antenatal period and 37 percent during the postnatal period
(Mwape, 2010)
Mental and physical problems are interlinked
Consistent associations have been have reported between physical conditions and mental health
problems in both low and high‐income countries (Chipimo & Fylkesness, 2009). Further, an
association has been found between mental health problems and epilepsy (Lee & No, 2010; Gilliam,
2006); pregnancy (Mwape, 2010) and HIV/AIDS (Chipimo & Fylkesness, 2009). The WHO in the 2010
world report shows that between 11% and 63% of HIV‐positive people in low‐ and middle‐income
countries have depression. People with the condition also are prone to anxiety due to the
unpredictable nature of AIDS progression. Stress has been reported to impair immunity, and
depression is likely to affect adherence to antiretroviral therapy. A study conducted in Tanzania
revealed that 57 percent of HIV‐positive women experienced depression and that depression was
associated with disease progression and death. Further, in both the general population and in
general medical‐care settings, at least, a third of all somatic symptoms (commonly pain, fatigue, and
dizziness) remain medically unexplained. although, at least a third of those with somatisation have
no comorbid mental disorder medically unexplained somatic symptoms and syndromes are strongly
associated with common mental disorders (Prince, Patel, Saxena, Maj, Maselko, Phillips, & Rahman,
2007). In recognition of the relationship between mental health problems and physical conditions,
some international agencies have supported mental health through programmes that support
physical health problems. Mental health was integrated in round four and eight of the Global Fund
with a component on mental health and Anti Retroviral Treatment, and mental health and alcohol
and substance abuse in the context of HIV/AIDS included respectively. In addition, the United Nations
Office for Drugs and Crime has provided support capacity building for service delivery in relation to
substance abuse.
20
The treatment gap for mental health is enormous and respect of human rights is lacking
Mental Health did not qualify to be one of the six main health thrusts, and subsequently was left out
in the first (1995‐1998) and second (1998‐2000) National Health Strategic Plans (Ministry of Health,
2005). Table 2 shows the priority area ranking in Zambia in what forms the Basic Health Care
Package.
The Basic Health Care Package consists of interventions for the prevention and management for each
of the priority conditions, on the basis of evidence about the effectiveness and feasibility of scaling
up these interventions. An intervention has been defined as an agent or action (biological,
psychological, or social) that is intended to reduce morbidity or mortality (Mental Health and Poverty
Project, 2008), and could be directed at individuals or communities. The interventions were
identified on the basis of their effectiveness, cost effectiveness, equity, ethical considerations
including human rights, feasibility or deliverability, and acceptability.
As a consequence of not including mental health in the basic health care package, psychotropic drugs
are not included in the primary care drug kit. (Mental Health and Poverty Project, 2008; Ministry of
Health Strategic Plan 2005‐2011). This was confirmed by the Mental Health and Poverty Project
survey that was conducted in 2009, which found that out of the twenty three health centres in
Lusaka, only two had psychotropic drugs in stock. Further, although the process of integration is
slowly commencing, there has not yet been an attempt made to review the basic health care
package in order to incorporate mental health. Yet mental health services delivered in primary care
minimise stigma and discrimination. They also remove the risk of human rights violation
(WHO/WONCA, 2008).
If the gaps in mental health services, resources, and policies are not addressed, the basic human
rights of the mentally ill (including the right to treatment) will continue to be neglected, and the
mentally ill will continue to suffer.
Table 2: National Health Priorities (Basic Health Care Package)
No Priority Area/Condition Strategic Intervention
1 Child health and nutrition To reduce the mortality rate among children under five
2 Integrated reproductive Health To reduce the maternal mortality ratio
3 HIV/AIDS, TB, and STIs To halt and begin to reduce the spread of HIV, TB, STIs
4 Malaria To reduce incidence and mortality due to malaria
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5 Epidemics To improve public health surveillance and control of epidemics
6 Hygiene, sanitation and Safer water To promote and implement appropriate interventions aimed at improving hygiene and access to acceptable sanitation and safer water
7 Human resources To train, recruit, and retain appropriate and adequate staff at all levels
8 Essential drugs and medical supplies To ensure availability of essential drugs and medical supplies at all levels
9 Infrastructure and equipment To ensure availability of appropriate infrastructure and equipment at all levels
10 Systems strengthening. To strengthen existing operational systems, financing mechanisms, and governance arrangements for effective delivery of health services
Source: Mental Health Poverty Project Country Report (2008).
Primary health care for mental health enhances access
Mental health services at the primary health care level are either inadequate or lacking due to
several factors, including low levels and misplacement of mental health professionals. Human
resources for mental health in Zambia have been declining over the past years. This has been largely
attributed to low numbers of health care providers being trained in mental health, retirement, death
due to HIV/AIDS, and migration. As of 2001, Zambia had a total of about 132 mental health workers
for an estimated population of 12 million people. After the reintroduction of the Registered Mental
Health Nursing and the Clinical Medicine Psychiatry programmes in 2006, the numbers are slowly
increasing.
In addition to being scarce, mental health workers are often misplaced and end up being assigned
duties in the provision of general health care because of the low priority given to mental health
problems as well as the decrease in human resource for health. For example, none of the mental
health workers in the urban clinics within the capital city were providing mental health care because
they had been placed outside the mental health care system (Mental Health and Poverty Project,
2008).
22
Primary care for mental health is affordable, cost effective, and generates good health outcomes
Evidence shows that mental health services at the primary health care level are less expensive than
psychiatric hospitals for both patients and government [Mwape, et al, 2010; Mweemba, et al, 2009].
In Zambia, due lack of integration of mental health services at the primary health care level, patients
are neither screened nor treated for mental illness. Generally, patients with mental illness are
referred to the only tertiary hospital in the country without being screened (Mwape et al, 2010). This
imposes a financial burden on patients, most of who are living in poverty, which is perpetuated by
their mental disability (Flisher, 2007). Integrating mental health services that are affordable and cost
effective into primary care can lead to improvements in health seeking behaviour that ultimately
lead to better health outcomes (Chisholm et al, 2007).
Policy options Globally, mental health has been integrated into primary health care across a range of
circumstances, including difficult economic and political circumstances. The specific models of
integration vary due to differences in socioeconomic situations, health care systems and health care
resources. Generally, success is achieved through leadership, commitment, and clear policies
(WHO/WONCA, 2008). As has been highlighted earlier, in Zambia integration of mental health into
primary health care has been slow and there is therefore, a need to carefully select an option that
will be compatible and that will yield the intended results within a short period of time. The two
policy options that are discussed in this section focus on integration of mental health into primary
health care using WHO/WONCA’s (2008) ten principles for integrating mental health into primary
health care: (1) an incremental approach and (2) a comprehensive approach. We describe the
current situation of mental health in primary health care before describing two options for
addressing challenges to integrating mental health into primary care.
The Current Zambian Mental Health and Primary Health Care Situation
According to MHaPP (2008) access to basic health services was affirmed as a fundamental human
right by the Declaration of Alma‐Ata in 1978. The goal of the Alma Ata declaration was to enable
people to receive a basic health care package as close to their residence as possible. However, this
goal has not been realised, especially in low‐income countries (MHaPP, 2008). In the Zambian
context, as stated earlier the integration of mental health into primary health care has been slow.
There is a critical shortage of human resources at the primary care level. Frontline mental health care
workers are inadequate. According to Mental Health Policy (2005) there were less than 260 mental
health workers working in mental institutions. Gleisner (2001) revealed that apart from declining
23
numbers, there is misplacement of mental health workers into areas where they are unable to
provide mental health services.
There are a number of challenges that must be addressed in order to effectively integrate mental
health into primary care. These are described in relationship to WHO/WONCA’s (2008) ten principles
for integrating mental health into primary care.
l. Policy and plans need to incorporate primary care for mental health
The current mental health policy, which commits the Ministry of Health to integrating mental health
into primary care, came into effect in 2005. However, it has taken over ten years to review the
mental health bill needed to repeal the Mental Disorders Act, Cap 305 enacted in 1951. Further,
there is not yet a coordinated plan or efforts to implement the policy.
2. Advocacy is required to shift attitudes and behaviour
There are several non‐governmental organisations (NGOs) working in the area of mental health.
These organizations will play an important role in shifting the attitude and behaviour for scaling up of
mental health services in primary care.
3. Adequate training of primary care workers is required
The government recently re‐introduced the training of specialist mental health workers in primary
care ‐ the Clinical Officer Psychiatry (COP) and Registered Mental Health Nurse (RMN). It will take a
long time to produce required numbers of staff for all primary health care facilities. Currently, the
Ministry of Health has been undertaking capacity building workshops for general health workers
from primary health care facilities in identification and management of mental health problems.
However, there is no systematic plan to scale up training and it is not clear who or how many should
be trained over a specific period of time.
4. Primary care tasks must be limited and doable
Currently there is lack of integration of mental health into primary health care and as such tasks have
not been specified.
5. Availability of Specialist mental health professionals and facilities to support primary care
As described above, there is a critical shortage of mental health specialists in Zambia. Specialised
mental health care is concentrated at the one tertiary hospital (Chainama Hills College Hospital) and
there is a scarcity of specialist mental health workers in primary care facilities. Hence, those requiring
mental health services are referred to the tertiary hospital and there is no provision of mental health
care at primary care level.
24
6. Access to essential psychotropic medications in primary care
There is a central procurement unit that ensures regulation of dangerous drugs, including
psychotropic medications to allow for easy accountability and tracking of consumption patterns.
However, psychotropic medications are not included in the essential drug kit and are in limited
amounts at the tertiary hospital (Mwape, et al., 2010).
7. Integration is a process, not an event
Important steps that have been taken towards integrating mental health in primary care include the
development and launch of the mental health policy in Zambia. The mental health bill is currently
undergoing review.
8. A mental health service coordinator is crucial
The directorate of Public Health and Research at the Ministry of Health is responsible for the mental
health unit. The mental health unit has a coordinator and an officer responsible for policy
development, implementation and coordination of mental health services in Zambia. There is
inadequate coordination of mental health services at primary care level.
9. Collaboration with key stakeholders
Due to lack of integration of mental health into primary health care, collaborative activities have not
been implemented.
10. Financial resources
As earlier stated, financial resources for mental health services are inadequate.
Incremental and Comprehensive Options
1) An incremental option for integrating mental health into primary care
The first option for addressing the challenges to integrating mental health into primary care
(described above) is incremental implementation of a plan for integrating mental health into primary
care. It will start with a pilot project introducing mental health services into primary care with a well‐
designed evaluation prior to scaling up.
2) A comprehensive option for scaling up the integration of mental health into primary care
25
The second option is comprehensive implementation of a plan for scaling up the integration of
mental health into primary care. It will introduce mental health services into primary care in all nine
provinces of Zambia.
These two options are summarized in Table 1 in the Executive Summary and described here using the
same ten principles for integrating mental health into primary health that were used above to
describe the current situation.
l. Policy and plans need to incorporate primary care for mental health
Both options build on having a systematic and coordinated plan for implementing the current policy
of integrating mental health into primary care. The need for a plan is based largely on lessons from
other countries where mental health has been successfully integrated into primary care [WHO 2008;
WHO, 2007; Prince, Patel, Saxena, Maj, Maselko, Phillips, & Rahman, 2007)]. Other lessons learned
from case studies of experiences in other countries include:
• National directives can be fundamental in encouraging and to shaping local activities and
improvements
• It may be essential to ensure that all stakeholders are involved in local identification of needs
and possible solutions, planning and implementation of the identified solutions
• The policy and plan must be embraced by local‐level health managers, not only those
involved in mental health. This includes both health and local authority managers
The incremental option will initially implement the plan in a small number of districts; e.g. two rural
and two urban districts. The impacts of integrating mental health into primary care in these districts
will be evaluated in comparison to similar districts in which the plan is not implemented. Lessons
learned from the pilot project will guide any necessary revisions to the plan and inform strategies for
scaling up. In addition, success in a small number of districts may encourage other districts to
implement changes [WHO 2008].
The comprehensive option will begin with a comprehensive plan for scaling up the integration of
mental health in primary care that will be implemented throughout the country.
2. Advocacy is required to shift attitudes and behaviour
Both options would use information in deliberate and strategic ways. This is likely to be important to
change attitudes and behaviour [WHO 2008, Prince, Patel, Saxena, Maj, Maselko, Phillips, & Rahman,
2007]. Estimates of the prevalence of mental disorders, the burden they impose if left untreated, the
existence of effective primary care‐based treatments, and lack of access to those treatments are
26
important arguments to persuade health authorities and stakeholders. Time and effort is required to
sensitize government and health system leaders, mental health specialists, primary care workers and
the public about the importance of mental health integration. Lessons learned from case studies in
other countries include [WHO 2008]:
• Discussions with policy makers and others in advance of major changes are likely to be
important
• Advocacy may be required to overcome initial resistance and shift attitudes of mental health
specialists and general health workers
The incremental option will involve civil society and other stakeholders in mental health through
collaborative efforts together in their advocacy for integrating mental health into primary health
care. A voluntary coalition of these organisations will also serve to strengthen community
participation in the integration process.
The comprehensive option will establish an advisory board that will engage key stakeholders,
including community representatives and leaders from other sectors. In addition to providing a
formal forum for coordinating and helping to ensure effective advocacy for change, the advisory
board will
• Ensure input into the plan and its implementation and
• Help monitor and coordinate implementation of the plan
In addition, a team will be organising at the district level to work with the advisory board and help to
ensure that there is coordinated and effective advocacy locally as well as nationally.
3. Adequate training of primary health care workers is required
Both options need to address challenges due to limited
• Training for specialised skills at the only tertiary care mental health hospital ()
• Mental health training in the curricula for general health workers
• Efforts and resources for in service training in mental health for general health workers
Appropriate and adequate training of primary health care workers is essential to effectively integrate
mental health into primary care [WHO 2008, Mental Health Policy, 2005, Mwape, et al, 2010]. Other
lessons learned from case studies of experiences in other countries include:
• Improvements in pre‐service and in‐service training of primary care workers on mental
health issues is often needed
• Training should provide
27
• Basic education on the epidemiology, identification, and treatment of major mental
disorders
• Relationships between mental and physical health and illness
• Communication skills, including active listening, showing empathy, using open and closed
questioning techniques, and manage nonverbal communication
• Knowledge and skills to discuss information with patients and families in a patient‐
centred and positive manner, to negotiate treatment plans, and to motivate and prepare
patients to self‐manage and follow their treatment plans at home
• In‐service training is essential to
• Provide basic education to health workers that have not been exposed previously to
mental health care
• Consolidate existing knowledge
• Ensure that changes in practice based on new research are disseminated and
implemented
• Ongoing support and supervision from mental health specialists are essential
• Collaborative or shared care models, in which joint consultations and interventions take
place between primary care workers and mental health specialists are especially promising
[Patel, Flisher, Hetrick, & McGorry, 2007]
The incremental option will start with systematically planned and coordinated training in a pilot
project in a small number of districts. It will also include supportive supervision for primary care
workers. The training will be targeted at nurses and clinical officers who are already working in
primary care. Initially, they will be trained to identify and manage common mental health problems
at this level of care and to recognise other mental health problems that should be referred to mental
health specialists. Additional training will be targeted at
• Mental health specialists to provide supportive supervision
• Traditional healers and community health workers to recognize and refer people with
mental health problems
• District managers to recognise
• The burden of disease from mental illnesses
• The existence and importance of cost‐effective treatments
• Organisational changes that are needed to enable primary care workers to provide
mental health care and collaboration among general health care and specialist mental
health care workers
The comprehensive option will use a cascade approach for training the same cadre of primary care
workers throughout the country [Chisholm D, Lund C, Saxena S., 2007]. In addition, it will implement
28
a plan for expanding the capacity of specialist mental health workers throughout the country to
provide supportive supervision to primary care health workers. It will also include and implement a
plan for strengthening mental health in the pre‐service curricula of general health workers, and for
strengthening training for providing supportive supervision in the curricula of specialized mental
health workers.
4. Primary care tasks must be limited and doable
Both options will focus on
• Improved recognition of high priority mental illnesses
• Diagnosing and treating high priority conditions that are optimally managed in primary care
• recognition and referral of patients with other mental health problems
• Follow‐up of discharged psychiatric patients
It is essential that the focus is on a limited number of additional tasks that is doable by already
overburdened primary care workers. Caution is needed to ensure that primary care tasks for mental
health do not impede the delivery of other prioritized tasks. Primary care providers, mental health
specialists, policy makers and stakeholders need to agree on which conditions are best managed in
primary care and which specific tasks should be undertaken in primary care [WHO 2008; Patel,
Flisher, Hetrick, & McGorry, 2007]. Other lessons learned from case studies of experiences in other
countries include:
• Decisions about which mental health conditions and tasks to priortize in primary care must
be taken after careful consideration of local circumstances
• This requires consultation with policy‐makers and health care workers, as well as users of
mental health services and their families
• Functions may be expanded as practitioners gain confidence. In Chile, practitioners
progressed
• It may be cost‐effective to develop specialized primary care services for mental health that
target particular population subgroups such as children
The incremental option will be implemented initially in a small number of districts focusing on a
minimal number of high priority conditions and tasks.
The comprehensive option will Implemented throughout the country and the prioritised conditions
and tasks may be expanded to include all priorities that are best provided in primary care.
29
5. Specialist mental health professionals and facilities must be available to support primary care
Both options need to address
• The inadequate capacity of specialist mental health professionals
• Their lack of responsibility and time to provide adequate support
• Ineffective and inefficient referral arrangements
To address these challenges they will both
• Increase the supply of mental health professionals
• Create mental health posts that include the provision of support to general health workers as
a key component of the job description
• Develop and implement effective and efficient referral processes
Specialist mental health professionals and facilities must be available to support primary health care
[WHO 2008]. Making mental health services accessible at primary health care level will have a
multiplier effect on the demand for services. Therefore, supply of mental health professionals should
be accelerated to meet the demand. According to WHO [2008] other lessons learned from case
studies of experiences in other countries include:
• Providing support to mental health workers in form of resources and supervision is a vital
component of the job description of specialist mental health professionals
• An effective and efficient referral process is needed
• Specialized mental health professionals may interact in a variety of ways, including
• Referral and backreferral
• Telephone consultation
• Outreach visits that include supportive supervision
• Regular meetings
• Collaborative or shared care models
• Onsite mental health workers
Primary care providers, mental health specialists, policy makers and stakeholders need to agree on
how best to ensure adequate support from specialist mental health professionals and facilities, and
how to ensure effective and efficient referral arrangements. Decisions about how best to do this
must be taken after careful consideration of current arrangements and circumstances.
The incremental option will be implemented initially in a small number of districts with a minimal
sufficient increase in capacity.
30
The comprehensive option will be implemented throughout the country and may include additional
expansion of the specialist mental health service to increase its capacity to handle referrals as well as
to provide outreach, supervision and support for primary care workers.
6. Patients must have access to essential psychotropic medications in primary care
Both options need to address the following challenges:
• Psychotropic drugs are not included in the primary health care kit or available in private
pharmacies
• Inappropriate drugs are being used
To address these challenges both will include appropriate psychotropic and other drugs for mental
health problems (e.g. depression) in the primary health care drug kit. For both options, after
appropriate training, regulations will need to be modified to authorize primary care workers to
prescribe medications for the agreed upon range of conditions [WHO 2008]. Primary care providers,
mental health specialists, policy makers and stakeholders need to agree on which drugs should be
available and prescribed in primary care. Problems are likely to exist in procuring and distributing
these medications and these will need to be identified and addressed.
The incremental option will be implemented initially in a small number of districts for a minimal
number of high priority conditions.
The comprehensive option will be implemented throughout the country and the prioritised
conditions may be expanded to include all priorities for which drugs are needed in primary care.
7. Integration is a process, not an event
Both options need to address the lack of a timeline and coordination of developing and
implementing the current government policy, which supports integration of mental health into
primary care. Integration is not a single or one‐off event. It is a gradual process [WHO 2008]. Other
lessons learned from case studies of experiences in other countries include:
• Meetings with a range of concerned parties are likely to be essential
• There may be considerable scepticism or resistance that must be overcome
• Training manuals and clinical guidelines are likely to be needed and implemented [National
Health Policy, 2005]
• Health workers will need training and additional staff will likely need to be employed
• For any of this to occur, budgets typically will require agreement and allocation
• Problems inevitably arise that must be addressed
31
The incremental option will use a process that can be characterised as a stage by stage approach to
changes that builds on experience. It will begin with a pilot project and might include subsequent
pilot projects. To maximise the ability to learn from experience pilot projects should include rigorous
evaluations of both desirable and undesirable impacts of the changes that are being implemented
and costs. In addition, process evaluations should examine how and why the strategies that are used
worked or did not work as intended.
The comprehensive option will develop and implement a plan for achieving comprehensive mental
health care over a defined period of time (e.g. 5 to 10 years) with ongoing monitoring, evaluation
and adaptation.
8. A mental health service coordinator is crucial
Both options will strengthen the National Mental Health Services Unit and ensure that it has a clear
mandate and capacity for coordinating the integration of mental health into primary care. Case
studies have found that primary care for mental health is usually most effective where a coordinator
is responsible for overseeing integration [WHO 2008]. Other lessons learned from case studies of
experiences in other countries include:
• Both anticipated and unexpected problems can sometimes threaten the success of efforts to
integrate mental health into primary care
• Coordinators may be crucial in steering programmes around these challenges and driving
forward the integration process
• Coordinators are important at both national and local levels
The incremental option will initially strengthen the National Mental Health Services Unit and ensure
that it has a clear mandate and capacity for coordinating the pilot project.
The comprehensive option, in addition to strengthening the National Mental Health Services Unit,
will in establish coordinators at the provincial level and focal point persons at the district level. This
will help to ensure coordination at the provincial and local levels as well as at the national level.
9. Collaboration with key stakeholders is required
Both options will address the current lack of ongoing collaboration among the Ministry of Health,
other sectors of the government, NGOs, community health workers and volunteers. Government
sectors outside health can work effectively with primary care to help patients with mental disorders
access the educational, social and employment initiatives required for their recovery and full
integration into the community [WHO 2008]. NGOs, community health workers and volunteers also
often play an important role in supporting primary care for mental health.
32
The incremental option will ensure that the National Mental Health Services Unit has a clear
responsibility for indentifying key stakeholders and working with them.
The comprehensive option will establish an advisory board with representatives from key sectors of
the government and other stakeholders.
10. Financial resources are needed
Both options will require earmarked funds allocated to integrating mental health into primary care.
For the success of the integration process, financial resources need to be made available to support
training and other activities. The additional time required to address mental health issues means that
more primary care workers might be needed and incentives may be needed to motivate primary care
workers. Mental health specialists who provide support and supervision also must be employed or
paid for these activities. [WHO 2008; Ducharme, Knudsen, & Roman, 2006]. Other lessons learned
from case studies of experiences in other countries include:
The incremental option will require earmarked funds for the pilot project and other elements of this
option outlined above, including for training, drugs, mental health professionals to support primary
care workers, evaluation, and strengthening coordination.
The comprehensive option will require earmarked funds for mental health professionals to support
an advisory board, training, additional tasks undertaken by primary care workers, drugs, mental
health professionals to support primary care workers and to manage increases in referrals, and
coordination
Costs
The key costs for each option and rough estimates were based on Chisholm D, Lund C, Saxena S
[2007] who have estimated that the cost per capita of providing a core package at target coverage
levels ranged from $1.85 to $2.60 (USD) per year in low‐income countries. Although significant new
resources need to be invested, the absolute amount is not large when considered at the population
level and against other health investment strategies. These estimates included training costs, but
may not have included all of the costs of scaling up. Nonetheless, they provide a good indication of
the likely recurrent costs once target levels of coverage have been achieved. Since the cost of
coverage would be less while scaling up, the total cost while scaling up is likely to be less, or at least
no greater than the yearly costs once target levels of coverage have been reached. In Zambia, with a
population of 12 million, this corresponds to a total yearly cost of $22.2 to 31.2 million (USD) (K114
to 161 billion), or roughly 15 to 21% of the Ministry of Health’s Annual Action Plan for 2010. This is
budget to big for the Zambian economy, but it can either be adjusted to fit into available funds.
Therefore, the most ideal scenario is to adjust the current core package to make it affordable and
33
gradually increase the core package to include latest psychotropic medications. The ministry of
health will need to identify additional sources of funds during a transition phase.
Equity considerations
Epidemiologic research over the last 20 years indicates that the social and economic conditions of
poverty are linked with common mental disorders in low and middle‐income countries [Lund C,
Breen A, Flisher AJ, et al., 2010]. The mechanisms by which the cycle of poverty and common mental
disorders is maintained are complex and multi‐dimensional. An importand conclusion that can be
drawn for a systematic review of this is that efforts to address the burden of common mental
disorders will be limited if they only target individual‐level interventions. The relatively consistent
association between common mental disorders and poverty, in addition to the large burden of
disease caused by mental illness, strengthens the case for the inclusion of mental health as a priority.
Improving recognition and treatment of mental illness by integrating mental health in primary care is
likely to reduce inequalities.
Monitoring and evaluation
Although there is high quality evidence of the effectiveness of many clinical interventions for mental
disorders, evidence of the effects of strategies for integrating mental health into primary care is
limited and, to a large extent, comes from case studies. Consequently, the impacts and costs of both
options are uncertain.
The incremental option addresses this uncertainty primarily by piloting implementation of the plan
for integration and evaluating the impacts (both desired and undesired) and costs. It also
incorporates process evaluations to examine how and why the strategies used to integrate mental
health into primary care worked or did not work as intended. The key advantage of this approach ‐ in
terms of evaluation ‐ is that it makes it possible to make improvements in the plan, if needed, prior
to scaling up [Supporting the Use of Research Evidence (SURE) Guides, 2010]. The key disadvantage is
that, to the extent that the plan is effective and works as intended, it delays scaling up and the
anticipated benefits of integrating mental health into primary care.
The comprehensive option addresses uncertainty about the impacts and costs of integrating mental
health into primary care through monitoring and evaluation. Monitoring of financial, material and
human resources as inputs can address uncertainties about the magnitude of the resources that are
required and allow for adjustments to the budget, if needed [SURE) Guides, 2010]. Monitoring of
impacts is unlikely to provide strong evidence that any changes in outcomes such as changes in the
burden of disease from mental illness are attributable to integrating mental health into primary care.
It can, however, inform decisions about whether changes are needed in the services that are
provided or how they are provided. More rigorous evaluation of the impacts of integration could be
34
incorporated into the comprehensive option by, for example, randomising the order in which it is
scaled up in different districts (using the districts where integration occurs later for comparison), or
sequentially introducing integration in different districts.
Advantages and disadvantages of the two options
Possible advantages of both options for integrating mental health into primary health care are that
they will:
• Bring mental health services closer to the community in line with the Ministry of Health
vision (1991)
• Help reduced travel costs for the patients and relatives who travel to Chainama hospital in
their effort to access mental health services
• Reduce stigma and discrimination considering that people with mental health problems will
be seen within the same setting as other patients
• Reduce the number of patients accessing the service at tertiary level, thus decongesting
tertiary and provincial level hospitals
Possible disadvantages of both options for integrating mental health into primary care are that they
will:
• Increase the workload for already overburdened primary health workers
• Compromise quality of care being provided due increase in workload
• Require deployment of more health care providers
• Increase the need for supervision
• Increase the need for financial resources.
• Waste of resources if integration is found not to be feasible
• Reduce the time available for primary care workers to attend to their usual patients
Possible advantages and disadvantages of the two options where compared to each other are
summarised in Table 3.
Table 3. Advantages and disadvantages of the two options
Favours Option 1
Incremental implementation starting with a pilot project
Favours Option 2
A comprehensive plan for scaling up
It is possible to make improvements in the plan, if needed, prior to scaling up and the pilot would help ensure that full
To the extent that the plan is effective and works as intended, it delays scaling up and the anticipated benefits of
35
implementation of the plan achieves its intended objectives integrating mental health into primary care and monitoring and evaluation could be used to ensure that the implementation of the plan is working as intended
Lower costs initially and the pilot could provide better data for estimating the costs of scaling up
• May be more feasible, affordable (initially) and acceptable to the government and others concerned about expanding the governments budget for health care
• It may be difficult to rapidly meet needs for more mental health specialists. Inadequate support for general health workers and capacity for increased referrals could have undesirable effects on the quality of care
More coverage initially. The incremental option is likely to take longer to achieve target leves of coverage and may stall
A voluntary coalition would require less government resources, but may give less of a voice to organizations and their members
An advisory board may provide a mechanism for ensuring better input into policy decisions, implementation of policies, and monitoring and evaluation. It might also strengthen engagement of stakeholders – provided there is a clear understanding of the role of the board and appropriate processes for involving stakeholders. An advisory board could also include community representatives and representatives from other sectors
May provide better coordination in early phases and therefore more effective implementation, provided coordination is is effective
Implementation considerations
Key barriers to integrating mental health into primary care and implementation strategies for
addressing these are summarised in Table 4. The same strategies and barriers are relevant for both
options.
36
Table 4. Barriers to implementing the policy options and implementation strategies
Barriers to implementing policy options Implementation strategies
Insufficient funding for mental health services [MHaPP 2008] due to
• Inconsistent and unclear advocacy
• Inadequate mental health indicators in the HMIS which currently capture only neurosis and psychoses and leave out other mental illnesses (particularly depression and schizophrenia)
• Lack of general public awareness of mental illnesses
• Social stigma attached to mental illnesses
• Mental health care, including psychotropic drugs, may not be perceived as cost-effective or affordable
• Establishment of a coalition (option 1) or an advisory board (option 2) with a mandate to coordinate advocacy efforts amongst key stakeholders
• Include an appropriate spectrum of mental illnesses in HMIS so as to provide a better picture of the burden of disease due to mental illnesses
• Mass media campaigns to increase awareness and understanding of mental illnesses, their recognition and treatment options, and to reduce the stigma attached to mental illnesses [Grilli 2002]
• Include guidance on strategies for reducing the stigma attached to mental illness in training targeted at primary care workers [Clement 2010; Mak 2007]
• Summarise and disseminate evidence of the cost-effectiveness of mental health care compared to other drugs and types of care currently included in primary care [Ducharme, Knudsen, & Roman, 2006]
• Undertake a detailed cost analysis of including psychotropic and other appropriate medications and other key costs of each option (see ’Costs’ in the description of the two options above)
• Based on the detailed cost analysis develop a plan for increasing funds for mental health over the next five to ten years, including transitional costs of a pilot project and scaling up
37
Barriers to implementing policy options Implementation strategies
• Resources that are allocated to mental health at the district level are not earmarked for mental health
• Training for district managers to sensitize them to the need to priortise mental health and use funds allocated for mental health for that purpose rather than other purposes
• Regulations that make district managers accountable for using national funds that are earmarked for mental health for that purpose
• There is a lack collaborative efforts between mental health workers in the tertiary care hospital and provincial units, primary care workers and community health workers and organizations
• Setting up or refurbishing mental health units at health centres and at the district level
• Involve the community in the provision of mental health services [SURE 2010]
Primary care workers are already overburdened
• Low numbers and limited types of health workers trained and supervised in mental health care
• Poor working conditions in the public health service
• Lack of incentives to work in rural areas
• Inadequate training of the general health workforce in mental health
• Strategies for recruiting, redeployment and retaining health workers in underseverd areas
• Redeployment (some mental health specialists are curently misplaced and not providing mental health services
• Use of community health workers [Lewin 2010]
• Training, as a component of both options
• Strengthen mental health as a component of core curriculum for general health workers
• Lack of infrastructure to enable community-based supervision • Incorporate strategies for implementing community-based supervision in plans, as described for both options [Bosch-Capblanch 2008]
• Lack of continuous supply of psychotropic and other appropriate drugs in primary care
• Systematically review and improve the procurement and distribution of psychotropic drugs and include appropriate drugs in the primary care drug
38
Barriers to implementing policy options Implementation strategies
kit
• Mental health leaders have limited public health skills and experience and public health leaders have limited mental health skills and experience
• Both options include coordinators to lead integration of mental health into primary care
• Leadership recruitment and training [refs], training for district managers in mental health, and public health training for mental health specialists who will be providing supervision [Ducharme, Knudsen, & Roman, 2006]
• Stengthen mental health in public health curriculum and public health in mental health curriculum
Next steps
The aim of this policy brief is to foster dialogue and judgements that are informed by the best
available evidence. The intention is not to advocate specific options or close off discussion. Further
actions will flow from the deliberations that the policy brief is intended to inform. These might
include:
• Deliberation amongst policymakers and stakeholders regarding the two options described in
this policy brief
• Refining the preferred option, for example by incorporating components of both options,
removing or modifying components
• Establish a coordinator with authority and accountability to lead the development and
implement of a plan and a team of people to work with that person in developing and
implementing the plan within an acceptable time frame
39
Appendix
How this policy brief was prepared
The methods used to prepare this policy brief are briefly described in the preface. The problem that
the policy brief addresses was clarified iteratively through discussion among the authors, review of
relevant documents and research, discussion within the Zambia Forum for Health Research
(Zamfohr) and external review of a preliminary description of the problem. Research describing the
size and causes of the problem was identified by reviewing government documents, routinely
collected data, searching Pub Med and Google Scholar, through contact with key informants, and by
reviewing the reference lists of relevant documents that were retrieved.
Strategies used to identify potential options to address the problem included considering
interventions described in systematic reviews and other relevant documents, considering ways in
which other jurisdictions have addressed the problem, consulting key informants and brainstorming.
We searched electronic databases of systematic reviews, including: the Health Systems Evidence
database of systematic reviews of delivery, financial and governance arrangements, and
implementation strategies (http://www.healthsystemsevidence.org/). This database includes
records of policy‐relevant systematic reviews that were identified through electronic searches of
MEDLINE, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of
Reviews of Effectiveness (DARE) and EMBASE.
40
Abbreviations
AIDS - acquired immune deficiency syndrome
ART - antiretroviral therapy
CHW - community health workers
HIV - human immunodeficiency virus
MCH - maternal and child health
MHaPP - Mental Health and Poverty Project
WHO - World Health Organization
41
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