Health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo: a multimethod study.

BACKGROUND: The integration of mental health into primary care-i.e., the process by which a range of essential mental health care and services are made available in existing multipurpose health care settings that did not previously provide them-can be facilitated or hindered by several health system factors that are still poorly understood. This study aimed to identify health system facilitators and barriers to the integration of mental health services into primary care in the Democratic Republic of the Congo (DRC) to improve the success rate of integration programs. METHODS: We conducted a multimethod, cross-sectional exploratory study. Stakeholders (managers, health service providers, service users, etc.) from sixteen of the twenty-six provinces of the DRC participated. We collected qualitative data through 31 individual, semistructured, face-to-face key informant interviews. We then collected quantitative data through a population-based survey of 413 respondents. We analyzed the interviews via thematic analysis, assigning verbatims to predefined themes and subthemes. For the survey responses, we performed descriptive analysis followed by binomial logistic regression to explore the associations between the variables of interest. RESULTS: Strong leadership commitment, positive attitudes toward mental health care, the availability of care protocols, mental health task sharing (p < 0.001), and sufficient numbers of primary care providers (PCPs) (p < 0.001) were identified as key health system facilitators of successful integration. However, barriers to integration are mainly related to a poor understanding of what integration is and what it is not, as well as to the poor functionality and performance of health facilities. In addition, stigma, low prioritization of mental health, lack of mental health referents, low retention rate of trained health professionals, lack of reporting tools, lack of standardized national guidelines for integration (p < 0.001), lack of funding (p < 0.001), shortage of mental health specialists to coach PCPs (p < 0.001), and lack of psychotropic medications (p < 0.001) were identified as health system barriers to integration. CONCLUSION: Improving the functionality of primary care settings before integrating mental health care would be beneficial for greater success. In addition, addressing identified barriers, such as lack of funding and mental health-related stigma, requires multistakeholder action across all building blocks of the health system.

Understanding the mix of services for mental health care in urban DR Congo: a qualitative descriptive study.

BACKGROUND: Mental health workers (MHWs) are exposed to conflicts of competence daily when performing tasks related to the provision of mental health services. This may be linked to a lack of understanding of their tasks as caregivers and providers. Furthermore, in most low-income settings, it is unclear how the available services are organized and coordinated to provide mental health care. To understand the above, this study aimed to identify the current mix of services for mental health care in the urban Democratic Republic of the Congo (DRC). METHODS: A qualitative descriptive study was carried out in Lubumbashi from February to April 2021. We conducted 7 focus group discussions (FGDs) with 74 key informants (family members, primary care physicians, etc.) and 13 in-depth interviews (IDIs) with key informants (traditional healers, psychiatrists, etc.). We performed a qualitative content analysis, guided by an analytical framework, that led to the development of a comprehensive inventory of MHWs from the household level to specialized facilities, exploring their tasks in care delivery, identifying existing services, and defining their current organization. RESULTS: Analysis of transcripts from the FGDs and IDIs showed that traditional healers and family caregivers are the leading providers in Lubumbashi. The exploration of the tasks performed by MHWs revealed that lifestyle, traditional therapies, psychotherapy, and medication are the main types of care offered/advised to patients. Active informal caregivers do not currently provide care corresponding to their competencies. The rare mental health specialists available do not presently recognize the tasks of primary care providers and informal caregivers in care delivery, and their contribution is considered marginal. We identified five types of services: informal services, traditional therapy services, social services, primary care services, and psychiatric services. Analyses pointed out an inversion of the ideal mix of these services. CONCLUSIONS: Our findings show a suboptimal mix of services for mental health and point to a clear lack of collaboration between MHWs. There is an urgent need to clearly define the tasks of MHWs, build the capacity of nonspecialists, shift mental health-related tasks to them, and raise awareness about collaborative care approaches.

Mental health care in the city of Lubumbashi, Democratic Republic of the Congo: Analysis of demand, supply and operational response capacity of the health district of Tshamilemba.

BACKGROUND: Integrating mental health care into the primary care system is an important policy option in the Democratic Republic of the Congo (DRC). From the perspective of the integration of mental health care in district health services, this study analyzed the existing demand and supply of mental health care in the health district of Tshamilemba, which is located in Lubumbashi, the second largest city of the DRC. We critically examined the district's operational response capacity to address mental health. METHODS: A multimethod cross-sectional exploratory study was carried out. We conducted a documentary review (including an analysis of the routine health information system) from the health district of Tshamilemba. We further organized a household survey to which 591 residents responded and conducted 5 focus group discussions (FGDs) with 50 key stakeholders (doctors, nurses, managers, community health workers and leaders, health care users). The demand for mental health care was analyzed through the assessment of the burden of mental health problems and care-seeking behaviors. The burden of mental disorders was assessed by calculating a morbidity indicator (proportion of mental health cases) and through a qualitative analysis of the psychosocial consequences as perceived by the participants. Care-seeking behavior was analyzed by calculating health service utilization indicators and more specifically the relative frequency of mental health complaints in primary health care centers, and by analyzing FGDs participants' reports. The mental health care supply available was described by using the qualitative analysis of the declarations of the participants (providers and users of care) to the FGDs and by analyzing the package of care available in the primary health care centers. Finally, the district's operational response capacity was assessed by making an inventory of all available resources and by analyzing qualitative data provided by health providers and managers regarding the district' capacity to address mental health conditions. RESULTS: Analysis of technical documents indicated that the burden of mental health problems is a major public problem in Lubumbashi. However, the proportion of mental health cases among the general patient population seen in the outpatient curative consultations in the Tshamilemba district remains very low, at an estimated 5.3%. The interviews not only pointed to a clear demand for mental health care but also indicated that there is currently hardly any offer of care available in the district. There are no dedicated psychiatric beds, nor is there a psychiatrist or psychologist available. Participants in the FGDs stated that in this context, the main source of care for people remains traditional medicine. CONCLUSION: Our findings show a clear demand for mental health care and a lack of formal mental health care supply in the Tshamilemba district. Moreover, this district lacks adequate operational capacity to meet the mental health needs of the population. Traditional African medicine is currently the main source of mental health care in this health district. Identifying concrete priority mental health actions to address this gap, by making evidence-based mental care available, is therefore of great relevance.

Intégration de la santé mentale dans les services de soins de santé primaires en République démocratique du Congo.

OBJECTIVE: The study aims to document the experience of integrating a mental health care package into the general health care system of Lubero district in the Democratic Republic of Congo (DRC) between 2011 and 2015, and more specifically, the effects of this integration on the access to and use of health services offering mental health care. METHOD: This is a retrospective study using a case study design. Data collected from different project documents and an analytic review of the official reports of the Ministry of Public Health were used for an analysis of the results of the integration. RESULTS: The results indicate that 3,941 patients with mental health problems used the care offered at the health centers and the district hospital between 2012 and 2015. In 2015, the average utilization rate of curative care in health centers for mental health problems was 7 new cases/1,000 inhabitants/year. The majority of these patients were treated on an outpatient basis, at primary health care level. DISCUSSION: Our study shows that it is possible to integrate mental health into existing general health services in the DRC. Nevertheless, the major problems in terms of access and use of basic care in the Lubero district indicate that the success of such an integration depends on the quality of the health system in place and the involvement of a wide range of both health and non-health actors, including key people within communities.