Small Steps, Big Impact: Expanding Mental Health Services in Ghana
Training of CHVs to support community case identification and referrals Bongo and Anloga District, November 2022.
Access to mental health services is a pressing issue globally. Scaling up accessible mental health services requires a multifaceted approach that improves case detection, management, and complete integration in primary healthcare. From my observation and experience as a team leading the implementation of a district mental healthcare plan in three pilot districts across Ghana, here is how we can adopt simple steps that will expand access and improve mental healthcare in resource-limited settings like Ghana.
Establish district mental health operations teams and develop mental healthcare plans:
Creating district-level supervision teams ensures oversight and support for mental health services. These teams can provide continuous training, monitor service quality, and support frontline healthcare workers. This structure ensures that mental health services are delivered efficiently and effectively across different regions.
After the formation of the district mental health operations team, a Theory of Change (ToC) needs to be developed for the district, through one or more participatory ToC workshops. ToC is an approach that explains how a given intervention is expected to lead to specific development change and can be used to develop district mental healthcare plans. The mental healthcare plans are basically innovative strategies that are intentionally planned to integrate mental health in primary healthcare, to reduce the mental healthcare gap.
I noticed increased case detection anytime there was supportive supervision, indicating the need for sustained supervision to achieve maximum impact. Once people understand they will be accounting for their stewardship through supervision from their team leaders, they are more likely going to work harder to earn the trust of their supervisors. Setting up this system is not new but only needs revival and strengthening, not an expensive adventure.
Build the capacity of primary healthcare workers to improve case detection, management, and referral
Detection of cases is important for effective mental health intervention. Training of primary healthcare workers on the Mental Health Gap Action Programme (mhGAP) for the identification of common mental health conditions proved to be an important strategy to ensure wider access to mental health services. The mhGAP intervention guide is easy to use, especially for primary healthcare workers. I noticed a lot more cases were being identified by primary healthcare workers that would have been missed by the routine health facilities.
I have visited the pilot districts three times for supportive supervision and observed that once the cases were identified, there was detailed case history taking, including effective management and referral systems which are essential for accurate diagnosis and personalised treatment plans. I am convinced beyond doubt that training healthcare workers to take detailed and precise case histories ensures that people with mental health conditions receive the most appropriate care. Additionally, establishing clear referral pathways guarantees that people with mental health conditions who need specialised care are directed to the right facilities promptly.
mhGAP supportive supervision of health workers, Asunafo North District, June 2022.
Build the capacity of primary healthcare workers to improve case detection, management, and referral
Detection of cases is important for effective mental health intervention. Training of primary healthcare workers on the Mental Health Gap Action Programme (mhGAP) for the identification of common mental health conditions proved to be an important strategy to ensure wider access to mental health services. The mhGAP intervention guide is easy to use, especially for primary healthcare workers. I noticed a lot more cases were being identified by primary healthcare workers that would have been missed by the routine health facilities.
I have visited the pilot districts three times for supportive supervision and observed that once the cases were identified, there was detailed case history taking, including effective management and referral systems which are essential for accurate diagnosis and personalised treatment plans. I am convinced beyond doubt that training healthcare workers to take detailed and precise case histories ensures that people with mental health conditions receive the most appropriate care. Additionally, establishing clear referral pathways guarantees that people with mental health conditions who need specialised care are directed to the right facilities promptly.
Improve psychotropic medicine supply
An adequate supply of psychotropic medications is fundamental to managing mental health conditions. By improving the supply chain and ensuring that essential medicines are available at all healthcare facilities, we can provide consistent and reliable treatment for patients. This not only improves patient outcomes but also builds trust in the healthcare system. I noticed that before the implementation of the district mental healthcare plan, psychotropic medicines were not always included in the district's request list submitted to the region. However, ensuring that psychotropic medicine is included in the general medicines needs of the district can go a long way to ensure timely supply and thereby bridging and complete integration of mental health services. Mental health will no longer be seen and treated as an isolated condition.
Capacity building for Community Health Volunteers in Anloga District in December 2022.
Reach out and collaborate with community ‘healers’
Community outreach is vital for raising awareness and reducing the stigma associated with mental health conditions. These healers are often the trusted figures in the community and can play a significant role in supporting mental health initiatives. Collaborating with traditional and faith-based healers can create a more inclusive approach to mental healthcare. By improving relationships with these community gatekeepers, we can integrate traditional practices with modern healthcare, providing holistic care that addresses both psychosocial and physical needs of people with mental health conditions.
Give radio and school mental health talks
Using media platforms such as radio and conducting mental health talks in schools are effective ways to disseminate information and educate the public about mental health. These platforms can reach a wide audience, providing valuable information on recognising symptoms, understanding mental health conditions, and seeking help for people with mental health conditions.
Empower people with mental health conditions economically
Economic empowerment initiatives can significantly impact mental health by reducing the financial stress and costs that often exacerbate mental health conditions. Programmes that support economic stability, such as vocational training and microfinance opportunities, can improve mental well-being and enhance the overall quality of life for individuals and their families. Although a lot is yet to be done to achieve this objective, my experience with implementing the care plan reveals a giant step in deliberately pushing for service users to get the needed skills to be economically productive to support their needs. An example of a service user who is now a basket weaver is a testimony that people with mental health conditions can be economically productive when given the necessary support.
Enrol service users on NHIS, DACF and LEAP
Ensuring that service users are enrolled in National Health Insurance Schemes (NHIS), District Assembly Common Fund (DACF) and the Livelihood Empowerment Against Poverty (LEAP) provides financial support and access to essential services. These programmes can reduce the economic burden on individuals seeking mental health care, making treatment more accessible and affordable. These schemes are already in place but need commitment from duty-bearers to ensure that people with mental health conditions are enrolled.
Benefits of district mental healthcare plans
Over the past 4 years of implementing district mental healthcare plans in the pilot districts, I have noted very important successes including serving as a roadmap for improved mental healthcare, increasing access to mental healthcare, improved stakeholder commitment and key to addressing stigma and discrimination against people with mental health conditions. As a facilitator, my personal experience of the implementation of the mental healthcare plans indicates the following benefits:
The integration of mental health services into primary healthcare has been successful, with all implementing district facilities offering some form of mental health services.
This initiative has improved access to mental healthcare and reduced the mental healthcare gap in the pilot districts.
Case detection and management have significantly improved, with non-mental healthcare workers now trained to provide basic mental health care such us case identification and referral.
Although the supply of psychotropic medication has improved due to advocacy and support from philanthropists, further efforts are needed to meet demand.
Mental health service users have been enrolled in government poverty reduction strategies such as NHIS, LEAP, and DACF.
The initiative has involved all relevant stakeholders, providing clear direction for service implementation and creating a platform for resource mobilisation from various agencies to support the mental healthcare plan.
On the flip side, I also observed that implementing district mental healthcare plans in Ghana resourced-constraint settings face teething challenges including but not limited to staff attrition, erratic supply of psychotropic medicines, stigma and family neglect, difficulty in reaching out to people in hard-to-reach communities and lack of dedicated funding source for implementation. Nonetheless, the successful implementation of a mental healthcare plan hinges on several critical factors:
Committed leadership is paramount, driving initiatives and maintaining focus, as evidenced by the varying success across districts based on their leaders' dedication to mental health.
Once leadership is secured, allocating financial and physical resources is crucial for effective plan execution.
Engaging key stakeholders is also vital, fostering collaboration, resource mobilization, and comprehensive support.
Monitoring and evaluating progress through the District Health Information Management System (DHIMS) data helps identify areas for improvement.
Existing national mental health policies provide a structured framework, ensuring alignment with broader healthcare objectives.
Additionally, leveraging community support systems, such as utilizing community health volunteers (CHVs) for case identification and referral, promotes community involvement, reduces stigma, and enhances the program's reach and success.
Facilitating and supporting the implementation of district mental healthcare plans, I realised it is one key and sure strategy to improve and sustain access to mental health services in resource-constraint settings. This seems complex in theory due to the mirage of many moving parts that need to work together. It is, however, achievable when the needed commitment is in place. Focusing on early case detection, effective case management, community involvement, and economic empowerment, we can create a robust mental healthcare system that serves everyone's needs. I have concluded that collaborative efforts and innovative strategies will pave the way for a future where mental healthcare is a fundamental right for all. The effort needed to make this happen is not much, a function of leadership commitment, but the impact is big.
For more information on the evidence supporting the district mental healthcare plans implementation, visit (https://www.ghanasomubi.com/publications)
Also, read more about the work by Ghana Somubi Dwumadie here (https://www.ghanasomubi.com)