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1.
Lancet ; 396(10251): 612-622, 2020 08 29.
Artigo em Inglês | MEDLINE | ID: mdl-32861306

RESUMO

BACKGROUND: Traditional and faith healers (TFH) provide care to a large number of people with psychosis in many sub-Saharan African countries but they practise outside the formal mental health system. We aimed to assess the effectiveness and cost-effectiveness of a collaborative shared care model for psychosis delivered by TFH and primary health-care providers (PHCW). METHODS: In this cluster-randomised trial in Kumasi, Ghana and Ibadan, Nigeria, we randomly allocated clusters (a primary care clinic and neighbouring TFH facilities) 1:1, stratified by size and country, to an intervention group or enhanced care as usual. The intervention included a manualised collaborative shared care delivered by trained TFH and PHCW. Eligible participants were adults (aged ≥18 years) newly admitted to TFH facilities with active psychotic symptoms (positive and negative syndrome scale [PANSS] score ≥60). The primary outcome, by masked assessments at 6 months, was the difference in psychotic symptom improvement as measured with the PANSS in patients in follow-up at 3 and 6 months. Patients exposure to harmful treatment practices, such as shackling, were also assessed at 3 and 6 months. Care costs were assessed at baseline, 3-month and 6-month follow-up, and for the entire 6 months of follow-up. This trial was registered with the National Institutes of Health Clinical Trial registry, NCT02895269. FINDINGS: Between Sept 1, 2016, and May 3, 2017, 51 clusters were randomly allocated (26 intervention, 25 control) with 307 patients enrolled (166 [54%] in the intervention group and 141 [46%] in the control group). 190 (62%) of participants were men. Baseline mean PANSS score was 107·3 (SD 17·5) for the intervention group and 108·9 (18·3) for the control group. 286 (93%) completed the 6-month follow-up at which the mean total PANSS score for intervention group was 53·4 (19·9) compared with 67·6 (23·3) for the control group (adjusted mean difference -15·01 (95% CI -21·17 to -8·84; 0·0001). Harmful practices decreased from 94 (57%) of 166 patients at baseline to 13 (9%) of 152 at 6 months in the intervention group (-0·48 [-0·60 to -0·37] p<0·001) and from 59 (42%) of 141 patients to 13 (10%) of 134 in the control group (-0·33 [-0·45 to -0·21] p<0·001), with no significant difference between the two groups. Greater reductions in overall care costs were seen in the intervention group than in the control group. At the 6 month assessment, greater reductions in total health service and time costs were seen in the intervention group; however, cumulative costs over this period were higher (US $627 per patient vs $526 in the control group). Five patients in the intervention group had mild extrapyramidal side effects. INTERPRETATION: A collaborative shared care delivered by TFH and conventional health-care providers for people with psychosis was effective and cost-effective. The model of care offers the prospect of scaling up improved care to this vulnerable population in settings with low resources. FUNDING: US National Institute of Mental Health.


Assuntos
Cura pela Fé/organização & administração , Medicina Tradicional Africana , Atenção Primária à Saúde/organização & administração , Transtornos Psicóticos/terapia , Adulto , Análise por Conglomerados , Análise Custo-Benefício , Feminino , Gana , Humanos , Colaboração Intersetorial , Masculino , Pessoa de Meia-Idade , Nigéria , Resultado do Tratamento , Adulto Jovem
2.
Br J Psychiatry ; 217(5): 623-629, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32720628

RESUMO

BACKGROUND: With the development of evidence-based interventions for treatment of priority mental health conditions in humanitarian settings, it is important to establish the cost-effectiveness of such interventions to enable their scale-up. AIMS: To evaluate the cost-effectiveness of the Problem Management Plus (PM+) intervention compared with enhanced usual care (EUC) for common mental disorders in primary healthcare in Peshawar, Pakistan. Trial registration ACTRN12614001235695 (anzctr.org.au). METHOD: We randomly allocated 346 participants to either PM+ (n = 172) or EUC (n = 174). Effectiveness was measured using the Hospital Anxiety and Depression Scale (HADS) at 3 months post-intervention. Cost-effectiveness analysis was performed as incremental costs (measured in Pakistani rupees, PKR) per unit change in anxiety, depression and functioning scores. RESULTS: The total cost of delivering PM+ per participant was estimated at PKR 16 967 (US$163.14) using an international trainer and supervisor, and PKR 3645 (US$35.04) employing a local trainer. The mean cost per unit score improvement in anxiety and depression symptoms on the HADS was PKR 2957 (95% CI 2262-4029) (US$28) with an international trainer/supervisor and PKR 588 (95% CI 434-820) (US$6) with a local trainer/supervisor. The mean incremental cost-effectiveness ratio (ICER) to successfully treat a case of depression (PHQ-9 ≥ 10) using an international supervisor was PKR 53 770 (95% CI 39 394-77 399) (US$517), compared with PKR 10 705 (95% CI 7731-15 627) (US$102.93) using a local supervisor. CONCLUSIONS: The PM+ intervention was more effective but also more costly than EUC in reducing symptoms of anxiety, depression and improving functioning in adults impaired by psychological distress in a post-conflict setting of Pakistan.

3.
Health Policy Plan ; 35(5): 567-576, 2020 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-32150273

RESUMO

This study examines the level and distribution of service costs-and their association with functional impairment at baseline and over time-for persons with mental disorder receiving integrated primary mental health care. The study was conducted over a 12-month follow-up period in five low- and middle-income countries participating in the Programme for Improving Mental health carE study (Ethiopia, India, Nepal, South Africa and Uganda). Data were drawn from a multi-country intervention cohort study, made up of adults identified by primary care providers as having alcohol use disorders, depression, psychosis and, in the three low-income countries, epilepsy. Health service, travel and time costs, including any out-of-pocket (OOP) expenditures by households, were calculated (in US dollars for the year 2015) and assessed at baseline as well as prospectively using linear regression for their association with functional impairment. Cohort samples were characterized by low levels of educational attainment (Ethiopia and Uganda) and/or high levels of unemployment (Nepal, South Africa and Uganda). Total health service costs per case for the 3 months preceding baseline assessment averaged more than US$20 in South Africa, $10 in Nepal and US$3-7 in Ethiopia, India and Uganda; OOP expenditures ranged from $2 per case in India to $16 in Ethiopia. Higher service costs and OOP expenditure were found to be associated with greater functional impairment in all five sites, but differences only reached statistical significance in Ethiopia and India for service costs and India and Uganda for OOP expenditure. At the 12-month assessment, following initiation of treatment, service costs and OOP expenditure were found to be lower in Ethiopia, South Africa and Uganda, but higher in India and Nepal. There was a pattern of greater reduction in service costs and OOP spending for those whose functional status had improved in all five sites, but this was only statistically significant in Nepal.

4.
PLoS One ; 14(11): e0224799, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31689332

RESUMO

AIM: The aim of this study was to assess the association between depression symptom severity and household income, consumption, asset-based wealth, debt and use of distress financing strategies, to understand how depression symptom severity and household economic welfare are related. METHODS: A household survey was administered to the households of primary health clinic-attenders who were screened for depression symptoms using the 9-item Patient Health Questionnaire in the chronic care units of four primary health clinics in the North West province of South Africa. Univariate and multivariable regression models were used to assess whether a range of household economic measures were significant predictors of depression symptom severity; and whether depression symptom severity significantly predicted changes to household economic welfare, across a number of different economic measures using both multiple linear regression and logistic regression analyses. RESULTS: On univariate analysis, certain characteristics were associated with significantly worse (higher) PHQ-9 scores, namely: households in which the household head was younger, female, and unmarried; households in which the indexed patient was younger, and did not receive an education beyond primary school; increasing household size, receipt of a social grant, households living in housing constructed of metal sheet walls and households making use of a public tap as their primary water source. In addition, univariate analysis demonstrated that higher log-transformed food expenditure, lower log-transformed capacity to pay, the presence of household debt and both reducing the size or frequency of meals and drawing up retail shop accounts in response to financial distress over the past three years were associated with significantly worse (higher) PHQ-9 scores. Multivariable analysis demonstrated that larger household sizes (p<0.05), receipt of social grants (p<0.05), higher food expenditure (p<0.01), and drawing up retail shop accounts in response to financial distress (p<0.05) were independently predictive of worse (higher) PHQ-9 scores. Inversely, increasing age of the household head (p<0.05), having piped water directly into the household (as opposed to making use of a public water sources) (p<0.01), and increasing capacity to pay (p<0.01) were independently predictive of better (lower) PHQ-9 scores. Similarly, multivariable analysis demonstrated that worse (higher) PHQ-9 scores were independently predictive of lower household capacity to pay (p<0.10) and higher food expenditure (p<0.01). CONCLUSIONS: This study is the first of its kind in South Africa, identifying household economic factors associated with increased depression symptom severity on a continuum; and demonstrating that financial risk protection efforts are needed across this continuum. The study demonstrates that the relationship between poverty and mental health extends beyond the individual to affect household economic functioning. These findings must be included in policy considerations to achieve effective protection for vulnerable households facing the interaction of depression and adverse economic circumstances.


Assuntos
Depressão/economia , Depressão/epidemiologia , Características da Família , Adulto , Estudos Transversais , Feminino , Humanos , Renda , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , África do Sul/epidemiologia
5.
BJPsych Open ; 5(3): e34, 2019 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-31530317

RESUMO

BACKGROUND: Little is known about the household economic costs associated with mental, neurological and substance use (MNS) disorders in low- and middle-income countries. AIMS: To assess the association between MNS disorders and household education, consumption, production, assets and financial coping strategies in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. METHOD: We conducted an exploratory cross-sectional household survey in one district in each country, comparing the economic circumstances of households with an MNS disorder (alcohol-use disorder, depression, epilepsy or psychosis) (n = 2339) and control households (n = 1982). RESULTS: Despite some heterogeneity between MNS disorder groups and countries, households with a member with an MNS disorder had generally lower levels of adult education; lower housing standards, total household income, effective income and non-health consumption; less asset-based wealth; higher healthcare expenditure; and greater use of deleterious financial coping strategies. CONCLUSIONS: Households living with a member who has an MNS disorder constitute an economically vulnerable group who are susceptible to chronic poverty and intergenerational poverty transmission. DECLARATION OF INTEREST: D.C. is a staff member of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

6.
BJPsych Open ; 5(5): e67, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31530318

RESUMO

BACKGROUND: Strengthening of mental health systems in low- and middle-income countries (LMICs) requires the involvement of appropriately skilled and committed individuals from a range of stakeholder groups. Currently, few evidence-based capacity-building activities and materials are available to enable and sustain comprehensive improvements. AIMS: Within the Emerald project, the goal of this study was to evaluate capacity-building activities for three target groups: (a) service users with mental health conditions and their caregivers; (b) policymakers and planners; and (c) mental health researchers. METHOD: We developed and tailored three short courses (between 1 and 5 days long). We then implemented and evaluated these short courses on 24 different occasions. We assessed satisfaction among 527 course participants as well as pre-post changes in knowledge in six LMICs (Ethiopia, India, Nepal, Nigeria, South Africa, Uganda). Changes in research capacity of partner Emerald institutions was also assessed through monitoring of academic outputs of participating researchers and students and via anonymous surveys. RESULTS: Short courses were associated with high levels of satisfaction and led to improvements in knowledge across target groups. In relation to institutional capacity building, all partner institutions reported improvements in research capacity for most aspects of mental health system strengthening and global mental health, and many of these positive changes were attributed to the Emerald programme. In terms of outputs, eight PhD students submitted a total of 10 papers relating to their PhD work (range 0-4) and were involved in 14 grant applications, of which 43% (n = 6) were successful. CONCLUSIONS: The Emerald project has shown that building capacity of key stakeholders in mental health system strengthening is possible. However, the starting point and appropriate strategies for this may vary across different countries, depending on the local context, needs and resources. DECLARATION OF INTEREST: S.E.L. received consulting fees from Lundbeck.

7.
BJPsych Open ; 5(5): e70, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31530320

RESUMO

BACKGROUND: In most low- and middle-income countries (LMIC), routine mental health information is unavailable or unreliable, making monitoring of mental healthcare coverage difficult. This study aims to evaluate a new set of mental health indicators introduced in primary healthcare settings in five LMIC. METHOD: A survey was conducted among primary healthcare workers (n = 272) to assess the acceptability and feasibility of eight new indicators monitoring mental healthcare needs, utilisation, quality and payments. Also, primary health facility case records (n = 583) were reviewed by trained research assistants to assess the level of completion (yes/no) for each of the indicators and subsequently the level of correctness of completion (correct/incorrect - with incorrect defined as illogical, missing or illegible information) of the indicators used by health workers. Assessments were conducted within 1 month of the introduction of the indicators, as well as 6-9 months afterwards. RESULTS: Across both time points and across all indicators, 78% of the measurements of indicators were complete. Among the best performing indicators (diagnosis, severity and treatment), this was significantly higher. With regards to correctness, 87% of all completed indicators were correctly completed. There was a trend towards improvement over time. Health workers' perceptions on feasibility and utility, across sites and over time, indicated a positive attitude in 81% of all measurements. CONCLUSION: This study demonstrates high levels of performance and perceived utility for a set of indicators that could ultimately be used to monitor coverage of mental healthcare in primary healthcare settings in LMIC. We recommend that these indicators are incorporated into existing health information systems and adopted within the World Health Organization Mental Health Gap Action Programme implementation strategy. DECLARATION OF INTEREST: None.

8.
BJPsych Open ; 5(5): e71, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31530321

RESUMO

BACKGROUND: Successful scale-up of integrated primary mental healthcare requires routine monitoring of key programme performance indicators. A consensus set of mental health indicators has been proposed but evidence on their use in routine settings is lacking. AIMS: To assess the acceptability, feasibility, perceived costs and sustainability of implementing indicators relating to integrated mental health service coverage in six South Asian (India, Nepal) and sub-Saharan African countries (Ethiopia, Nigeria, South Africa, Uganda). METHOD: A qualitative study using semi-structured key informant interviews (n = 128) was conducted. The 'Performance of Routine Information Systems' framework served as the basis for a coding framework covering three main categories related to the performance of new tools introduced to collect data on mental health indicators: (1) technical; (2) organisation; and (3) behavioural determinants. RESULTS: Most mental health indicators were deemed relevant and potentially useful for improving care, and therefore acceptable to end users. Exceptions were indicators on functionality, cost and severity. The simplicity of the data-capturing formats contributed to the feasibility of using forms to generate data on mental health indicators. Health workers reported increasing confidence in their capacity to record the mental health data and minimal additional cost to initiate mental health reporting. However, overstretched primary care staff and the time-consuming reporting process affected perceived sustainability. CONCLUSIONS: Use of the newly developed, contextually appropriate mental health indicators in health facilities providing primary care services was seen largely to be feasible in the six Emerald countries, mainly because of the simplicity of the forms and continued support in the design and implementation stage. However, approaches to implementation of new forms generating data on mental health indicators need to be customised to the specific health system context of different countries. Further work is needed to identify ways to utilise mental health data to monitor and improve the quality of mental health services. DECLARATION OF INTEREST: None.

9.
BJPsych Open ; 5(5): e72, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31530323

RESUMO

BACKGROUND: The Emerald project's focus is on how to strengthen mental health systems in six low- and middle-income countries (LMICs) (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda). This was done by generating evidence and capacity to enhance health system performance in delivering mental healthcare.A common problem in scaling-up interventions and strengthening mental health programmes in LMICs is how to transfer research evidence, such as the data collected in the Emerald project, into practice. AIMS: To describe how core elements of Emerald were implemented and aligned with the ultimate goal of strengthening mental health systems, as well as their short-term impact on practices, policies and programmes in the six partner countries. METHOD: We focused on the involvement of policy planners, managers, patients and carers. RESULTS: Over 5 years of collaboration, the Emerald consortium has provided evidence and tools for the improvement of mental healthcare in the six LMICs involved in the project. We found that the knowledge transfer efforts had an impact on mental health service delivery and policy planning at the sites and countries involved in the project. CONCLUSIONS: This approach may be valid beyond the mental health context, and may be effective for any initiative that aims at implementing evidence-based health policies for health system strengthening.

10.
BJPsych Open ; 5(5): e73, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31530325

RESUMO

BACKGROUND: There is a large treatment gap for mental, neurological or substance use (MNS) disorders. The 'Emerging mental health systems in low- and middle-income countries (LMICs)' (Emerald) research programme attempted to identify strategies to work towards reducing this gap through the strengthening of mental health systems. AIMS: To provide a set of proposed recommendations for mental health system strengthening in LMICs. METHOD: The Emerald programme was implemented in six LMICs in Africa and Asia (Ethiopia, India, Nepal, Nigeria, South Africa and Uganda) over a 5-year period (2012-2017), and aimed to improve mental health outcomes in the six countries by building capacity and generating evidence to enhance health system strengthening. RESULTS: The proposed recommendations align closely with the World Health Organization's key health system strengthening 'building blocks' of governance, financing, human resource development, service provision and information systems; knowledge transfer is included as an additional cross-cutting component. Specific recommendations are made in the paper for each of these building blocks based on the body of data that were collected and analysed during Emerald. CONCLUSIONS: These recommendations are relevant not only to the six countries in which their evidential basis was generated, but to other LMICs as well; they may also be generalisable to other non-communicable diseases beyond MNS disorders. DECLARATION OF INTEREST: None.

11.
BJPsych Open ; 5(5): e68, 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31530327

RESUMO

BACKGROUND: Current coverage of mental healthcare in low- and middle-income countries is very limited, not only in terms of access to services but also in terms of financial protection of individuals in need of care and treatment. AIMS: To identify the challenges, opportunities and strategies for more equitable and sustainable mental health financing in six sub-Saharan African and South Asian countries, namely Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. METHOD: In the context of a mental health systems research project (Emerald), a multi-methods approach was implemented consisting of three steps: a quantitative and narrative assessment of each country's disease burden profile, health system and macro-fiscal situation; in-depth interviews with expert stakeholders; and a policy analysis of sustainable financing options. RESULTS: Key challenges identified for sustainable mental health financing include the low level of funding accorded to mental health services, widespread inequalities in access and poverty, although opportunities exist in the form of new political interest in mental health and ongoing reforms to national insurance schemes. Inclusion of mental health within planned or nascent national health insurance schemes was identified as a key strategy for moving towards more equitable and sustainable mental health financing in all six countries. CONCLUSIONS: Including mental health in ongoing national health insurance reforms represent the most important strategic opportunity in the six participating countries to secure enhanced service provision and financial protection for individuals and households affected by mental disorders and psychosocial disabilities. DECLARATION OF INTEREST: D.C. is a staff member of the World Health Organization.

12.
Int J Equity Health ; 18(1): 121, 2019 07 31.
Artigo em Inglês | MEDLINE | ID: mdl-31366362

RESUMO

BACKGROUND: There is a lack of high quality population-based studies from low- and middle-income countries examining the relative economic status of households with and without a member with a mental health problem. The aim of the study was to explore the socio-economic status of households with a person with severe mental disorder (SMD; psychosis or bipolar disorder) or depression compared to households without an affected person. METHODS: A population-based, comparative, cross-sectional household survey was conducted in Sodo district, south Ethiopia, between January and November 2015. Two samples were recruited, each with its own comparison group. Sample (1): households of 290 community-ascertained persons with a clinician-confirmed diagnosis of SMD and a comparison group of 289 households without a person with SMD. Sample (2): households of 128 people who attended the primary health care centre and who were identified by primary care staff as having a probable diagnosis of depressive disorder; and comparison households of 129 patients who attended for other reasons and who did not receive a diagnosis of depression. Household socioeconomic status (household income, consumption and asset-based wealth) was assessed using a contextualized version of theWorld Health Organization (WHO) Study on global Ageing and adult health (SAGE) questionnaire. Each disorder group (SMD and depression) was further divided into higher and lower disability groups on the basis of median score on the WHO Disability Assessment Schedule. RESULTS: Households of a person with SMD who had higher disability were more likely to have a poorer living standard (no toilet facility; p < 0.001). Having a reliable source of regular income was significantly lower in households of a person with SMD (p = 0.008) or depression (p = 0.046) with higher disability than the comparison group. Households of persons with SMD with higher disability earned less (p = 0.005) and owned significantly fewer assets (p < 0.001) than households without SMD. Households including persons with depression who had higher disability had lower income (p = 0.042) and reduced consumption (p = 0.048). CONCLUSIONS: Households with a member who had either SMD or depression were socioeconomically disadvantaged compared to the general population. Moreover, higher disability was associated with worse socio-economic disadvantage. Prospective studies are needed to determine the direction of association. This study indicates a need to consider households of people with SMD or depression as a vulnerable group requiring economic support alongside access to evidence-based mental healthcare.


Assuntos
Transtornos Mentais/epidemiologia , Saúde Mental , Pobreza/estatística & dados numéricos , População Rural/estatística & dados numéricos , Adulto , Estudos Transversais , Depressão/epidemiologia , Pessoas com Deficiência/estatística & dados numéricos , Etiópia/epidemiologia , Feminino , Humanos , Renda/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Projetos de Pesquisa , Inquéritos e Questionários
13.
BMC Public Health ; 19(1): 930, 2019 Jul 11.
Artigo em Inglês | MEDLINE | ID: mdl-31296207

RESUMO

BACKGROUND: The extent of catastrophic health expenditure and impoverishment associated with depression in low-and middle-income countries is not known. The aim of this study was to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) health expenditure, level of impoverishment and coping strategies used by households of persons with and without depression in a rural Ethiopian district. METHODS: A comparative cross-sectional survey was conducted, including 128 households of persons with depression and 129 households without. Depression screening was conducted using the Patient Health Questionnaire, nine item version (PHQ-9). People in the depression group were classified into high and low disability groups based on the median value on the World Health Organization Disability Assessment Schedule (WHODAS) polytomous summary score. Health expenditure greater than thresholds of 10 and 25% of total household consumption was used for the primary analyses. The poverty headcount, poverty gap and normalized poverty gap were estimated using retrospective recall of total household expenditure pre- and post-OOP payments for health care. Linear probability model using binreg command in STATA with rr option was used to estimate risk ratio for the occurrence of outcomes among households with and without depression based on level of disability. RESULTS: Catastrophic OOP payments at any threshold level for households with depression and high disability were higher than control households. At the 10% threshold level, 24.0% of households of persons with depression and high disability faced catastrophic payments compared with 15.3% for depression and low disability and 12.1% for control households (p = 0.041). Depression and high disability level was an independent predictor of catastrophic OOP payments: RR 2.1; 95% CI:1.1, 4.6. An estimated 5.8% of households of persons with depression and high disability were pushed into poverty because of paying for health care compared with 3.5% for households of persons with depression and low disability and 2.3% for control households (p = 0.039). CONCLUSIONS: Households of people with depression and high disability were more likely to face catastrophic expenditures and impoverishment from OOP payments. Financial protection interventions through prepayment schemes, exemptions and fee waiver strategies need to target households of persons with depression.


Assuntos
Doença Catastrófica/economia , Depressão/epidemiologia , Características da Família , Gastos em Saúde/estatística & dados numéricos , Pobreza/estatística & dados numéricos , Estudos Transversais , Pessoas com Deficiência/estatística & dados numéricos , Etiópia/epidemiologia , Feminino , Humanos , Masculino , População Rural/estatística & dados numéricos
14.
Int J Ment Health Syst ; 13: 38, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31164918

RESUMO

Background and aims: Current coverage of mental health care in low- and middle-income countries is limited, not only in terms of access to services but also in terms of financial protection of persons in need of care and treatment. This is especially pertinent considering the established relationship between mental illness and poverty and the need to ensure the financial risk protection of persons with mental disorders and their families as part of country's efforts to attain universal health coverage. This study set out to review the health and socio-economic contexts of Nigeria as well as to generate strategies for sustainable mental health financing that will be feasible, within the specific context of the country. Methods: A multi-methods approach was developed and applied, consisting of three steps: a situational analysis of Nigeria's health system, macro-fiscal economic profile, and socio-political status, including a strengths, weaknesses, opportunities and threats (SWOT) analysis of the Nigerian socio-economic, general and mental health context; key informant interviews with 12 expert stakeholders drawn from state and non-state actors in the health and financial sectors; and a policy analysis of sustainable financing options. Results: Key challenges identified were: poor funding; reduced access to care, resulting in a huge treatment gap; and out of pocket payment for services-leading to impoverishment. Comprehensive coverage of mental health conditions within the ongoing health insurance reforms was identified as a key strategy for moving towards sustainable mental health financing in Nigeria. Other identified strategies include enhanced integration of mental health into primary care; incorporation of mental health into other strategic and currently funded programmes; adoption of performance-based financing measures; and renewed engagement with stakeholders, including external donor institutions. Conclusions: A suite of feasible and actionable measures can be implemented to increase mental health service financing, reduce health-related financial burden on households, increase help-seeking and access to quality mental health care and, ultimately, reduce the large treatment and financing gap for mental disorders in Nigeria.

15.
Int J Ment Health Syst ; 13: 39, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31164919

RESUMO

Background: There are limited data on healthcare spending by households containing a person with severe mental disorder (SMD) in low- and middle-income countries (LMIC). This study aimed to estimate the incidence and intensity of catastrophic out-of-pocket (OOP) payments and coping strategies implemented by households with and without a person with SMD in a rural district of Ethiopia. Methods: A comparative cross-sectional community household survey was carried out from January to November 2015 as part of the Emerald programme (emerging mental health systems in low- and middle-income countries). A sample of 290 households including a person with SMD and 289 comparison households without a person with SMD participated in the study. An adapted and abbreviated version of the World Health Organization SAGE (Study on global Ageing and adult health) survey instrument was used. Households were considered to have incurred catastrophic health expenditure if their annual OOP health expenditures exceeded 40% of their annual non-food expenditure. Multiple logistic regression was used to explore factors associated with catastrophic expenditure and types of coping strategies employed. Results: The incidence of catastrophic OOP payments in the preceding 12 months was 32.2% for households of a person with SMD and 18.2% for comparison households (p = 0.006). In households containing a person with SMD, there was a significant increase in the odds of hardship financial coping strategies (p < 0.001): reducing medical visits, cutting down food consumption, and withdrawing children from school. Households of a person with SMD were also less satisfied with their financial status and perceived their household income to be insufficient to meet their livelihood needs (p < 0.001). Conclusions: Catastrophic OOP health expenditures in households of a person with SMD are high and associated with hardship financial coping strategies which may lead to poorer health outcomes, entrenchment of poverty and intergenerational disadvantage. Policy interventions aimed at financial risk pooling mechanisms are crucial to reduce the intensity and impact of OOP payments among vulnerable households living with SMD and support the goal of universal health coverage.

16.
Lancet Glob Health ; 7(7): e951-e960, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31097414

RESUMO

BACKGROUND: Little is known about how to scale up care for depression in settings where non-physician lay workers constitute the bulk of frontline providers. We aimed to compare a stepped-care intervention package for depression with usual care enhanced by use of the WHO Mental Health Gap Action Programme intervention guide (mhGAP-IG). METHODS: We did a cluster-randomised trial in primary care clinics in Ibadan, Nigeria. Eligible clinics were those with adequate staffing to provide various 24-h clinical services and with regular physician supervision. Clinics (clusters), anonymised and stratified by local government area, were randomly allocated (1:1) with a computer-generated random number sequence to one of two groups: an intervention group in which patients received a stepped-care intervention (eight sessions of individual problem-solving therapy, with an extra two to four sessions if needed) plus enhanced usual care, and a control group in which patients received enhanced usual care only. Patients from enrolled clinics could participate if they were aged 18 years or older, not pregnant, and had moderate to severe depression (scoring ≥11 on the nine-item patient health questionnaire [PHQ-9]). The primary outcome was the proportion of patients with remission of depression at 12 months (a score of ≤6 on the PHQ-9, with assessors masked to group allocation) in the intention-to-treat population. This trial is registered with the International Standard Randomised Controlled Trials Number registry (ISRCTN46754188) and is completed. FINDINGS: 35 of 97 clinics approached were eligible and agreed to participate, of which 18 were allocated to the intervention group and 17 to the control group. 1178 patients (631 [54%] in the intervention group and 547 [46%] in the control group) were recruited between Dec 2, 2013, and June 29, 2015, among whom 976 (83%) were female and baseline mean PHQ-9 score was 13·7 (SD 2·6). Of the 562 (89%) patients in the intervention group and 473 (86%) in the control group who completed 12-month follow-up, similar proportions in each group had remission of depression (425 [76%] in the intervention group vs 366 [77%] in the control group; adjusted odds ratio 1·0 [95% CI 0·70-1·40]). At 12 months, 17 (3%) deaths, one (<1%) psychotic illness, and one (<1%) case of bipolar disorder in the intervention group, and 16 deaths (3%) and one (<1%) case of bipolar disorder in the control group were recorded. No adverse events were judged to be related to the study procedures. INTERPRETATION: For patients with moderate to severe depression receiving care from non-physician primary health-care workers in Nigeria, a stepped-care, problem-solving intervention combined with enhanced usual care is similarly effective to enhanced usual care alone. Enhancing usual care with mhGAP-IG might provide simple and affordable approach to scaling up depression care in sub-Saharan Africa. FUNDING: UK Medical Research Council.


Assuntos
Pessoal Técnico de Saúde , Assistência à Saúde/métodos , Transtorno Depressivo Maior/terapia , Atenção Primária à Saúde , Adulto , Idoso , Análise por Conglomerados , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Nigéria , Resultado do Tratamento
17.
Int J Ment Health Syst ; 13: 11, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30891082

RESUMO

Background: People with mental disorders in low-income countries are at risk of being left behind during efforts to expand universal health coverage. Aims: To propose context-relevant strategies for moving towards universal health coverage for people with mental disorders in Ethiopia. Methods: We conducted a situational analysis to inform a SWOT analysis of coverage of mental health services and financial risk protection, health system characteristics and the macroeconomic and fiscal environment. In-depth interviews were conducted with five national experts on health financing and equity and analysed using a thematic approach. Findings from the situation analysis and qualitative study were used to develop recommended strategies for adequate, fair and sustainable financing of mental health care in Ethiopia. Results: Opportunities for improved financing of mental health care identified from the situation analysis included: a significant mental health burden with evidence from strong local epidemiological data; political commitment to address that burden; a health system with mechanisms for integrating mental health into primary care; and a favourable macro-fiscal environment for investment in human capabilities. Balanced against this were constraints of low current general government health expenditure, low numbers of mental health specialists, weak capacity to plan and implement mental health programmes and low population demand for mental health care. All key informants referred to the under-investment in mental health care in Ethiopia. Respondents emphasised opportunities afforded by positive rates of economic growth in the country and the expansion of community-based health insurance, as well as the need to ensure full implementation of existing task-sharing programmes for mental health care, integrate mental health into other priority programmes and strengthen advocacy to ensure mental health is given due attention. Conclusion: Expansion of public health insurance, leveraging resources from high-priority SDG-related programmes and implementing existing plans to support task-shared mental health care are key steps towards universal health coverage for mental disorders in Ethiopia. However, external donors also need to deliver on commitments to include mental health within development funding. Future researchers and planners can apply this approach to other countries of sub-Saharan Africa and identify common strategies for sustainable and equitable financing of mental health care.

18.
Br J Psychiatry ; 215(3): 528-535, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30767826

RESUMO

BACKGROUND: Contextually appropriate interventions delivered by primary maternal care providers (PMCPs) might be effective in reducing the treatment gap for perinatal depression. AIM: To compare high-intensity treatment (HIT) with low-intensity treatment (LIT) for perinatal depression. METHOD: Cluster randomised clinical trial, conducted in Ibadan, Nigeria between 18 June 2013 and 11 December 2015 in 29 maternal care clinics allocated by computed-generated random sequence (15 HIT; 14 LIT). Interventions were delivered individually to antenatal women with DSM-IV (1994) major depression by trained PMCPs. LIT consisted of the basic psychosocial treatment specifications in the World Health Organization Mental Health Gap Action Programme - Intervention Guide. HIT comprised LIT plus eight weekly problem-solving therapy sessions with possible additional sessions determined by scores on the Edinburgh Postnatal Depression Scale (EPDS). The primary outcome was remission of depression at 6 months postpartum (EPDS < 6). RESULTS: There were 686 participants; 452 and 234 in HIT and LIT arms, respectively, with both groups similar at baseline. Follow-up assessments, completed on 85%, showed remission rates of 70% with HIT and 66% with LIT: risk difference 4% (95% CI -4.1%, 12.0%), adjusted odds ratio 1.12 (95% CI 0.73, 1.72). HIT was more effective for severe depression (odds ratio 2.29; 95% CI 1.01, 5.20; P = 0.047) and resulted in a higher rate of exclusive breastfeeding. Infant outcomes, cost-effectiveness and adverse events were similar. CONCLUSIONS: Except among severely depressed perinatal women, we found no strong evidence to recommend high-intensity in preference to low-intensity psychological intervention in routine primary maternal care. DECLARATION OF INTERESTS: None.


Assuntos
Depressão/terapia , Cuidado Pós-Natal , Complicações na Gravidez/psicologia , Complicações na Gravidez/terapia , Cuidado Pré-Natal , Atenção Primária à Saúde , Adulto , Análise por Conglomerados , Análise Custo-Benefício , Feminino , Humanos , Análise Multivariada , Nigéria , Gravidez , Escalas de Graduação Psiquiátrica , Análise de Regressão , Adulto Jovem
19.
Artigo em Inglês | MEDLINE | ID: mdl-30679945

RESUMO

Background: With the implicit neglect for the integration of mental health services into general health service development in South Africa, there is an urgent need for an understanding of the ways in which existing reforms may be leveraged to incorporate the objectives of the National Mental Health Policy Framework and Strategic Plan (MHPF) and the mechanisms by which these reforms can be structured and financed in the context of fiscal constraint. Methods: A situational analysis guided by a newly developed analytical framework for sustainable mental health financing was conducted. The review was followed by qualitative, indepth interviews with a range of expert national stakeholders. Results: Although the MHPF is said to be consistent with ongoing efforts toward the implementation of National Health Insurance (NHI), there is clear evidence of discordance between the MHPF and the NHI. The most promising strategies for sustainable mental health financing include: increased decentralization of resources to primary and community mental health services; active integration of mental health into ongoing NHI implementation including expanding the mandate of District hospitals and drawing on the private sector; submission of costed budget bids to support a mental health conditional grant and ensuring that explicit outcomes and deliverables are in place to monitor Provincial implementation. Conclusion: This paper has suggested several ways in which existing reforms may be leveraged to incorporate the objectives of the MHPF and achieve better mental health outcomes for South Africans, revealing critical opportunities for mental health service scale-up to be embedded in South Africa's future health delivery strategy. The realization of a conditional grant for mental health will require technical expertise to cost existing services towards the development of an investment case for mental health service scale-up nationally, projecting potential resource requirements and returns on investment of a strong service platform. In the longer-term, the NHI benefit package must be expanded to include comprehensive mental health services at all levels. Explicit results-based financing mechanisms within the NHI Fund must also be incorporated for mental health to incentivise quality of care. Private providers engaged by the NHI must commit to make use of evidence-based mental health interventions.

20.
Glob Soc Welf ; 6(3): 159-175, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31984205

RESUMO

Collaborative research partnerships are necessary to answer key questions in global mental health, to share expertise, access funding and influence policy. However, partnerships between low- and middle-income countries (LMIC) and high-income countries have often been inequitable with the provision of technical knowledge flowing unilaterally from high to lower income countries. We present the experience of the Programme for Improving Mental Health Care (PRIME), a LMIC-led partnership which provides research evidence for the development, implementation and scaling up of integrated district mental healthcare plans in Ethiopia, India, Nepal, South Africa and Uganda. We use Tuckman's first four stages of forming, storming, norming and performing to reflect on the history, formation and challenges of the PRIME Consortium. We show how this resulted in successful partnerships in relation to management, research, research uptake and capacity building and reflect on the key lessons for future partnerships.

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