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This blog is part of our series celebrating World Health Day 2017. This year's theme is Depression: Let's Talk and we're showcasing inspiring innovations addressing depression across Africa - the Aro Primary Care Mental Health Programme.


Aro Primary Care Mental Health Programme focuses on the development and delivery of the mhGAP intervention package for five priority conditions at primary healthcare centres in Ogun State, Nigeria

 
Tell us about your country’s context and the circumstances that inspired your innovation.

The existing treatment gap in mental health services is a global phenomenon, which is amplified in low and medium income countries of the world. Studies in Nigeria suggest that only about 10% of those in need of mental health services get what can be considered as quality care. Attributable factors include availability, accessibility and acceptability issues related to sociocultural beliefs regarding mental Illness etiologies and treatments. The latter had created dynamic barriers against the utilisation of the existing services which are also mainly hospital-based with highly stigmatised and institutionalised public perception.

The drive for community service at the Neuropsychiatric hospital which was however constrained by the limited professional manpower birthed the innovation, which involved professional task shifting - integration of mental health service at the primary health care (PHC) level in a state of about 4 million population. The hospital initiated a community mental health programme, which required mobilisation of the insufficient hospital based professionals into the community. The solution to the challenge was the adoption of the task shifting approach of training non-mental health professionals to provide the service under ongoing supervision and support.

Of the five priority conditions addressed by the innovation, Psychosis, Depression and Epilepsy had constituted 96% of cases seen and successfully treated at the health centres. Cases of depression seen and treated had consistently remained at about 10% being less seen than psychosis (44%) and epilepsy (42%). This finding suggests the hidden and possibly camouflaged nature of depression at the community and Primary Health Care (CPH) level.

What aspect of your project are you most excited about? How is the project innovative or unique?

One of the most exciting aspect of the innovation is successful negotiation of the barriers between tertiary healthcare and the primary healthcare management structures for a mutually beneficial collaborative work at the PHC level. The programme supervisors have over the time acquired skill of supervising health workers over which they do not have formal control. This is a scenario of leading across boundaries. The programme has also opened the opportunities for community mobilisation and engagements for mental health service delivery in the very remote rural communities of the state. Special enlightenment programmes have been mounted for Depression awareness and recognition at community level, as well as the retraining of the programme PHC workers to address the low presentation/recognition of cases of depression at the PHC.


Have you noticed an impact ‘on the ground’? What is the best feedback you have received (from service users, team members, or otherwise)?

Since programme inception five years back, the rate of service use has not declined despite challenges of manpower attritions necessitating additional task for the programme supervisors who had to assume care-provider roles in certain centres until replacement of trained PHC workers lost to either retirement, resignations or transfers/promotion to other schedules. Participants in the programme remained proud and passionate about the service rendered. The programme is gaining more state, national and international recognition as an efficient model for appropriate mental health service delivery at grassroots level. It is very encouraging and exciting to find rural health centres proudly including mental health service among services they provide on their signages. This shows we are winning the war against stigma.
What’s next?

Service expansion is required in the area of increasing the number of trained health workers and number of participating treatment centres for mental health services delivery. Top-up training is also needed for the trained health workers especially for depression assessment and recognition. The barriers to these had been human resource shortage at the PHC, and funding limitations for additional training. We are encouraging the local government service commission to recruit additional health personnel to boost primary health care service in the state.

What is the one message about depression you want people to take away from your innovation?

People with depression are not readily recognised by family and community members, compared with individuals with psychosis or epilepsy, and hence do not often readily present for orthodox care. When they do, they are likely to present with other bodily complaints that makes their recognition rather difficult for the trained primary care health workers.
The proof of this is that we applied Quality Improvement methodology to enhance recognition of depression among all patients presenting at PHC, by testing the idea of routine screening for depression by all PHC workers apart from those trained to carry out mental health care. The 2-week test yielded significant improvement in the recognition and management of depression, but the routine screening for all patients by all PHC workers was unsustainable because of workload complaints resulting from manpower shortage.

 

First published at Mental Health innovation Network Africa.