Emerging Mental Health Systems in Low and Middle Income Countries (Emerald)

Introduction

Emerging mental health systems in lower and middle-income countries (Emerald) program, was a multi-country study which was implemented in six LMICs; Ethiopia, India, Nepal, Nigeria, South Africa, and Uganda. The project duration was from November, 2012 to October, 2017.

Funding

The Emerald program was funded by the European Community’s Seventh Framework Program (FP7/2007-2013) under grant agreement no 305968.

Objectives

The major objectives of Emerald were to:

• Improve mental health outcomes by enhancing health system performance.
• Identify key health system barriers and seek for it’s solution for the scaled up mental health services in LMICs.

Details of Emerald Project can be viewed at Emerald’s website:

https://www.emerald-project.eu/

Activities

The Nepal specific emerald activities are presented below:

The Emerald project had been carrying out capacity-building activities for mental health system strengthening in which capacity building training was provided to service users and their caregivers and to researchers in Kathmandu and Chitwan districts. One-day mental health orientation and interaction program was conducted among policy makers and planners in Kathmandu and Chitwan districts. Furthermore, a qualitative study had been conducted among the service users and their caregivers, and researchers to assess the impact of the capacity building training efforts.

One of the components of the project was adequate, fair and sustainable resourcing for mental health. As a part of this, a study was conducted to assess the impact of inadequate mental health service access on household economy in which resource need assessment was conducted initially using WHO’s one health tool. It was then followed by household survey which was conducted to identify the economic consequences of mental illness on households in Nepal. Moreover, a study was conducted with key stakeholders from different governmental and non-governmental agencies to identify the funding mechanisms and for the development of strategies for sustainable financing of mental health services in low and middle income countries.

In regards to the integrated provision of mental health services, a study was conducted to identify the facilitating factors and barriers for the integration of mental health in primary health care centers. In a qualitative study conducted within this work package, a total of 110 in-depth interviews were conducted in 12 health facilities where the mental health integration program was already in place. In addition, for the development of mental health information system, indicators for mental health information system were developed through Delphi study from which 15 mental health indicators were developed and then contextualized in Nepal. These were then implemented in 33 health facilities of Chitwan district of Nepal. In addition, training was provided to the health workers from these 33 health facilities on the routine use of mental health service indicators.

Outputs:

• Two days capacity building training on ‘Mental health awareness and advocacy’ was provided to service users and their caregivers in Kathmandu and Chitwan districts during November, 2015.
• Three days capacity building training on ‘Mental Health System Research, Implementation Science and Service User Involvement in Research’ was provided to researchers from Chitwan on December, 2015 and four days training on ‘Mental health research’ was provided to researchers from Kathmandu on November, 2016.
• One-day mental health orientation and interaction program among policy makers and planners was conducted in Kathmandu and Chitwan districts.
• Short courses for researchers, service users and their caregivers and policy makers had been developed.
• Based on the short-course, a manual on “Public Engagement in Mental Health Awareness and Advocacy” was developed.
• Training presentation slides on topics like mental health research, mental health systems, health financing, implementation science, service user involvement in research, stigma and discrimination, were developed.
• Research capacity of two Emerald staffs from Nepal was built through MSc and PhD degrees with support of Emerald project.
• Number of peer-reviewed papers (listed below) published or planned for future publication

Published Papers

Cross-country publications

1. Information systems for mental health in six low and middle income countries: Cross country situation analysis (September, 2016)
2. Indicators for routine monitoring of effective mental healthcare coverage in low- and middle-income settings: a Delphi study (April, 2016)
3. Strengthening mental health systems in low- and middle-income countries: the EMERALD programme (April, 2015)
4. Service user and care-giver involvement in mental health system strengthening in low- and middle-income countries: A cross-country qualitative study (November, 2017)
5. Evaluation of performance and perceived utility of mental healthcare indicators in routine health information systems in five low- and middle-income countries (August, 2019)

Nepal specific publications:

1. Current situations and future directions for mental health system governance in Nepal: findings from a qualitative study. (June, 2017)
2. Mental health and psychosocial support services in primary health care in Nepal: Perceived facilitating factors, barriers and strategies for improvement (February, 2020)
3. Psychotropic drugs in Nepal: Perception on use and supply chain management

Major findings and recommendations from the approaches taken by Emerald:

• From the capacity building activities conducted by emerald, it demonstrates the high need on building human resource capacity for mental health system strengthening. No such capacity building efforts have been reported for these three target groups, specifically; service users and their care givers, researchers, and service planners and policy makers. Thus, capacity building for these three groups is considered vital to support system strengthening for scale-up of mental health.
• Scale-up of national health insurance scheme and integrating mental health into general health programs and insurance program may be the most feasible and sustainable strategies in Nepal for efficient use of resources and for scaled up mental health service delivery to achieve universal mental health coverage. Furthermore, as Nepal is moving towards federal structure of government, restructuring of health systems to suit states, changes in macro-economic policies and situation might be necessary.
• Priority indicators that came through record reviews, health workers surveys and qualitative interviews are ‘mental health diagnosis’, ‘intervention’, ‘treatment follow up’, ‘suicide rate’ and ‘medicine stock count’s that could be integrated in national HMIS based on utility, feasibility and acceptability and the process of integration would speed up only if the government takes ownership in integrating mental health in primary health care.

Policy briefs (English):

1. Development and use of mental health indicators
2. Facilitating factors and barriers of integration and scale-up of mental health services in primary health care
3. Health financing management and resources in Nepal for mental health: Identification and assessment of needs and strategies
4. Evaluation of impact of capacity building training among Researchers, Service Users and their caregivers

Policy briefs (Nepali):

1. मानसिक स्वास्थ्य सुचांकको विकास तथा प्रयोग
2. एकिकृत मानसिक स्वास्थय सेवाका सहयोगी पक्ष तथा बाधा अवरोधहरु
3. नेपालमा मानसिक स्वास्थ्यका लागि वित्तिय व्यवस्था तथा श्रोतहरुको आवश्यकता र रणनीतिहरुको पहिचान तथा लेखाजोखा
4. मानसिक स्वाथ्यको क्षेत्रमा अनुसन्धानकर्ता, सेवाग्राही तथा स्याहारकर्ताहरुको क्षमता अभिवृद्धिको लेखाजोखा

Conference presentation:

1. Barriers and Facilitators for service user and care giver involvement in mental health system strengthening

Press and media:

1. मानसिक स्वास्थ्य समस्यालाई नीतिगत रुपमै समेट्नुपर्ने
2. तनावले उत्पन्न हुन्छ मानसिक समस्या