Experiences in using a Theory of Change for developing and implementing mental healthcare plans in remote areas
Mental health is not a priority for many countries worldwide, and this is more pronounced in resource-limited countries. With a treatment gap of around 98%, stakeholders in mental health must identify and develop strategies to confront the huge treatment gap. Fortunately, a theory of change (ToC) as a strategy has the potential to identify and implement mental healthcare plans to bridge the care gap, with an overarching goal of integrating mental health into primary healthcare.
A ToC is a method that explains how a given intervention, or set of interventions, is expected to lead to specific development change. It draws on a causal analysis based on available evidence and resources.
The ToC approach involves the following key steps:
Surfacing challenges and agreeing on an impact or real change that the district wants to achieve in the long run
Identifying measurable outcomes
Identifying key assumptions that need to happen before outcomes are achieved
Thinking through the rationale or evidence of a relationship between outcomes
Identifying interventions or key activities that need to be in place to achieve the desired impact and
Deciding on indicators for measuring success.
Ghana Somubi Dwumadie facilitated three consecutive participatory ToC workshops for district-level key mental health stakeholders at Bongo, Asunafo North and Anloga. The ToC workshop trained participants to strategically develop district-level mental healthcare plans, harnessing locally available resources for implementation. The idea was to identify innovative strategies to integrate mental health into primary health care, to reduce the mental healthcare gap in Ghana.
The ToC workshops in each demonstration site lasted two days and involved participants from the District Health Management Teams, Regional Mental Health Coordination, District Assembly, Education, Legal and Justice, and Community members.
“The Ghana Somubi Dwumadie ToC training workshop would help us to scientifically tackle the numerous mental health challenges in Ghana and find solutions to them to scale up quality mental health services” – Participant 01.
Each District team agreed on what success looked like and proceeded to generate ToC maps on mental healthcare plans. The maps reflect the teams' understanding and commitment to the pathways of change to create opportunities for improved wellbeing and quality of life for persons with mental health conditions in these districts. The maps showed specific interventions, outcomes, and corresponding key indicators along their respective causal pathways, including important assumptions and potential barriers.
“Very participatory, the fact that participants did everything made them own the ToC plan and hence implementation is expected to be with minimal challenges” – Participant 02.
All three districts defined the success of district mental healthcare plans along the wellness model of health in terms of improved wellbeing and quality of life of persons with mental health conditions living in the districts. Whilst the Bongo team focused on improving clinical outcomes as the primary outcome for achieving the desired impact of improved quality of life of persons with mental health conditions in the district, Asunafo-North and Anloga teams committed to both improvements in clinical outcomes and economic empowerment or poverty as important intermediate outcomes for achieving the desired impact of improved wellbeing for persons with mental health conditions.
Planning session during the ToC workshop in Asunafo North District.
The ToC approach provides tools for planning, logically identifying challenges and desired outcomes and proposing interventions that will be implemented to address the identified challenges. Strikingly, all districts identified the role of integrated care as the critical causal pathway to improving access to quality and affordable mental health services. Regarding the broad interventions for achieving integrated care, all district teams settled on implementing the Mental Health Gap Action Programme (mhGAP).
Key areas identified to improve mental health care services include:
Measures to improve mental health staffing needs through mhGAP training
Measures to address stigma and discrimination against people with mental health conditions
Improving the financial support for people with mental health conditions
Measures to improve the supply of psychotropic medicines
Improving mental health literacy
Encouraging family support
Increasing the detection of cases in the community using community health volunteers
ToC participant presenting strategies to address inadequate mental health services in the Bongo District.
“The ToC workshop is very informative and broadened my scope of knowledge on mental health. Facilitators are well organised and mastered their area of facilitation” - Participant 03.
Key lessons from the workshops include:
“I like the participatory approach. Every participant was involved in the discussions of the various topics treated” - Participant 04.
The ToC workshops built the essential capacity of district operations teams to come up with a blueprint for the development and implementation of district mental health care plans in Ghana.
Districts can begin to address the many challenges facing mental health and disability without heavily relying on support from central government.
Districts can surmount these challenges with key stakeholder consultation and sustained engagement. The participants have become more confident in proposing local solutions or interventions to address challenges confronting mental health and disability care systems.
The need to provide continued support and technical assistance to the three demonstration districts to implement the mental health and disability care plans.
ToC is an essential tool for the development of local action plans for implementing mental health and disability care plans in remote areas bedevilled with limited resources, with an anticipated aim of increasing access to mental health services and overall impact of improving the quality of life and wellbeing of people with mental health conditions.
You can read more about our approach and the preliminary evidence in our policy brief here.