Strengthening mental health systems in low- and middle-income countries: the Emerald programme

Emerald entails a large programme of work that is being implemented through a range
of innovative methodologies (see, for example, the OneHealth tool mentioned below).
In addition, emphasis is placed on service user and carer involvement, reduction of
stigma and discrimination, and dissemination of research findings. To ensure the comparability
and generalizability of findings, broadly the same activities and methods are employed
across all six participating countries of the programme, though some country-specific
adaptations may be made for data collection methods or research instruments to ensure
that these are in line with the different in-country contexts and to account for the
relative strengths and weaknesses of the health systems of individual countries. For
instance, in investigating how to strengthen governance processes to facilitate integrated
services through key informant interviews, a generic interview schedule that covered
the key governance issues to be explored was initially developed; countries then adapted
the schedule to ensure that it was contextually relevant. South Africa’s adaptations
included, for example, ensuring that the challenges associated with implementation
of the recent Mental Health Policy and Action Plan at provincial and district level
were explored. India adopted the schedule to incorporate questions related to the
draft Mental Health Care Bill and new National Mental Health Policy. In South Africa
also, a range of local service and epidemiological data were used to adapt the OneHealth
tool (see below) to the South African context. Furthermore, in Nepal, where the provision
of psychotropic drugs in primary health care is largely absent, a qualitative study
was conducted to better understand the barriers around procurement and distribution.
In Ethiopia, the non-availability of electricity for most homes and the lack of diversity
of possessions had to be taken into account when adapting the household economic survey
(see below for details).

All data from the different sub-studies of the programme are analysed both on a country-specific
level as well as on a cross-country level. The current status of work varies between
the different sub-studies of the programme in line with the aims and objectives of
the programme; whilst some are close to completion, others are ongoing or yet to commence.
A case study of some of the work that is being conducted in one of the Emerald countries,
Ethiopia, is provided in Box 1.

Health system inputs

One of Emerald’s key objectives involves the identification of health system resources,
finance mechanisms, and information needed to scale-up mental health services and
move towards universal coverage. This is laid out across three tasks:

i).
Adequacy of resourcing for mental health: For this, work is in progress to develop and integrate a module on MNS disorders
within the United Nation’s OneHealth systems planning tool 26]. OneHealth is a tool to strengthen health system analysis, costing and financing
scenarios at the country level. It does so by bringing together disease-specific planning
and health systems planning, as well as incorporating modules to estimate the predicted
health impact of scaling up interventions over time and for assessing fiscal space/financial
sustainability. Through application of this tool, Emerald provides new estimates of
the cost and impact of scaling up interventions for MNS disorders, as well as assessing
the health system implications of planned scale-up. This facilitates an integration
of mental health programme-specific strategies into broader national health plans.
By drawing on data from the real world settings of six diverse LMICs, key requirements
for and constraints to local mental health service provision and scale-up are being
built into the tool regarding local mental health service provision and needs, in
a manner that has not previously been possible. These include, for example, human
resource availability and capacity at the primary care level, capacity to deliver
psychosocial interventions, and medication availability at different levels in the
system. Three capacity-building workshops in use of the OneHealth tool have already
been conducted (in Ethiopia, India, and Nigeria), and currently the estimates of costs
and impacts of scaling up in the six participating Emerald countries are being finalized
within the OneHealth tool.

ii).
Fair financing and improved economic outcomes for mental health: Work is underway for a large survey in each of the six participating countries with
household members of people with MNS disorders who attend health care facilities in
the study district (Table 1), to assess the economic impact of people living with an MNS disorder and the economic
impact of improved care. The household survey is based on the previously validated
WHO survey on health and ageing (SAGE) developed specifically for use in LMICs 27], but has been adapted to fit the aims and objectives of the Emerald programme. The
survey includes questions around household composition, income, and spending (on health
care, including sources and sectors beyond the professional such as use of traditional/religious
healers, as well as other services and goods).

iii).
Sustainable financing for mental health: This will involve data analysis as well as in-depth consultations with policymakers,
planners, economists, and other stakeholders regarding potential financing mechanisms
for mental health care in each country, building on findings derived from the OneHealth
tool (resource needs) and the household survey (financial burden and equity).

Health system processes

Another key objective for Emerald is the evaluation of the context, process, experience,
and health system implications of mental health service implementation. All six participating
countries are using local adaptations of the WHO mhGAP Intervention Guide (mhGAP-IG)
14],15] to facilitate the scaling-up of integrated mental health services. The mhGAP-IG includes
diagnostic and treatment guidelines for nine MNS disorders common in LMICs, or which
have a major public health impact or are associated with human rights abuses. Key
strategies to support the development and implementation of mental health plans in
LMICs from the district through to national levels are identified within Emerald.
This is achieved, inter alia, through:

i). Documentary analyses of key legislation and policy documents at national, provincial,
and/or district level at the beginning of the programme, to facilitate the implementation
of legislative and policy imperatives (completed).

ii). Using a governance framework proposed by Siddiqi et al. 28], qualitative key informant interviews with relevant groups (such as policymakers,
managers, district service providers, community service officers, service users, and
carers) are being conducted at the start and end of the programme to better understand
governance processes that enable or inhibit the development and implementation of
mental health policies, plans, and legislature for integrated mental health care (including
factors outside of the professional health care system (such as traditional/religious
healers) due to the plurality of services), and to identify strategies to strengthen
these processes.

iii). A mixed-method baseline and endline assessment of the impact of integrated care
on the health system in the six participating countries, using questionnaires, observations
within health care facilities, and semi-structured interviews with key informants.

Health system outputs

Emerald’s third key objective focuses on the development, use, and monitoring of indicators
for mental health service coverage and system performance. This is achieved by: i)
review of existing information systems (completed); ii) a Delphi study, with an expert
panel consisting of 93 mental health researchers, clinicians, and policymakers almost
all working and residing in LMICs, who have generated and ranked a set of 52 indicators
for routine measurement of mental health service coverage and system performance (ongoing);
iii) in-depth interviews and focus group discussions with selected health information
personnel and health care providers, to assess barriers related to the introduction
and the use of selected indicators (ongoing); and iv) monitoring and evaluation of
the performance and utility of the selected indicators (ongoing).

Capacity-building in mental health systems research

In addition to the above three key objectives, Emerald has a strong focus to build
up the capacity of i) local researchers, ii) policymakers and planners to implement
system improvements for mental health care services, and iii) service users and caregivers
in each participating country. This is realised through tailored capacity-building
interventions for each of the three stakeholder groups (researchers, policymakers
and planners, and service users and caregivers) that can be delivered independently
within each of the Emerald countries. Approaches include ‘Training of Trainers’ courses;
funding for PhD (five so far; four are still planned) and Masters students (one so
far; another is planned); supervision and monitoring of PhD students; mentoring mid-level
researchers; workshops and policy dialogues; advocacy and empowerment workshops for
service users and caregivers; and capacity-building amongst health care providers
to work towards greater service user involvement.

In addition, three Masters-level teaching modules with 28 sub-modules (Table 2) have been developed to build capacity in mental health systems research within Emerald
countries and beyond, through integration of the modules into ongoing Masters courses
within countries. Each of the 28 sub-modules encompasses at least one full day of
face-to-face teaching, which were identified and agreed within the Emerald consortium
based on the group’s expertise. The sub-modules were developed through a collaborative
effort by all members of the Emerald team in the first half of 2014, both by adapting
materials that had been previously developed by them or their colleagues, and by newly
developing materials. A peer-review system is being employed to improve training materials,
which will be freely and publicly available to use by the end of the programme.

Table 2. Masters-level modules in mental health system strengthening developed within Emerald

Service user involvement and reduction of stigma and discrimination

Partnerships with service users are essential for the development of evidence-based
care in government guidance across the globe 29]-31]. They may protect those who receive involuntary treatment abuses, or those who are
marginalized due to their low socio-economic status or social stigma attached to MNS
disorders, through their greater involvement in the implementation of mental health
system processes. Close collaborations between service users/caregivers and healthcare
professionals have been pioneered in mental health and HIV/AIDS worldwide, and the
evidence of its usefulness is slowly emerging through a number of recent publications
32]. Service users and their families and caregivers are thus involved in all components
of the Emerald programme, for example, through consultations, including qualitative
work, to better understand contextual factors, capacity-building, and advocacy activities,
and to pilot collaboration to embrace involvement of all stakeholders.

Since the quantity and level of involvement of service user organizations varies widely
between Emerald countries (for example, in Uganda, 16,900 service users are members
of service user organizations, whereas in Ethiopia there are no such organizations),
country-specific strategies are being employed. As part of this, stigma and discrimination
are addressed as one of the key barriers for access to and successful delivery of
mental health services in LMICs 33]-35]. This involves a two-way process, in which increased service user and caregiver involvement
is established within the programme, and lessons are garnered on how best to reduce
stigma through interviews with service users and caregivers.

Dissemination

The Emerald programme is working to disseminate its research findings widely to engage
with different stakeholder groups (such as Ministries of Health and Finance in study
countries, policymakers and planners, national and international development agencies,
non-governmental organizations working in mental health, mental health researchers,
service users and providers, and caregivers). This includes the establishment of mental
health research networks within the programme and beyond. Channels that are employed
for this are joint publications in scientific journals, policy briefing papers, conference
presentations and posters, a project website, project flyer, social media sites, and
press conferences.