HEALTH POLICY DIALOGUE REPORT - WHO | … Dr Maria Akani (Rapporteur) Psychiatry Dept, UNZA...

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STRENGTHENING HEALTH SYSTEMS FOR MENTAL

HEALTH POLICY DIALOGUE REPORT

Date: 8th April 2011

Time: 8:00 – 16:30

Venue: Blue Nile Inn

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CONTENTS

Acknowledgements…………………………………………………………………….……3

Abbreviations………………………………………………………………………………..4

Participants……………………………………………………………………………………6

Programme……………………………………………………………………………………7

Concept Note…………………………………………………………………………………9

Introductory Speech by ZAMFOHR Executive Director…………………………………...10

Ministry of Health Permanent Secretary’s Speech…………………………………………11

Mental Health System Overview……………………………………………………………14

Experiences of Mental Health System Users………………………………..……………...19

Policy Brief Power Presentation…………………………………………………………….21

Plenary Discussion Findings………………………………………………………………...23

Appendix A…………………………………………………………………………………..29

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Acknowledgements

The Zambia Forum for Health Research would like to express sincere thanks to the Alliance for

Health Policy and Systems Research (AHPSR) and Supporting the use of research evidence (SURE)

for policy in African health systems project. Health Policy and Systems Research was funded by the

Alliance (Project ID number ID‐ EIP ‐12). SURE is funded by the European Commission’s Seventh

Framework Programme (Grant agreement number 222881). The funders did not have a role in

drafting, revising or approving the content of the policy brief. Andy Oxman, principal investigator

of the SURE project, guided the preparation of the policy brief.

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ABBREVIATIONS

AIDS Acquired Immune Deficiency Syndrome

ART Anti-retroviral Therapy

CDSR Cochrane Database of Systematic Reviews

CHCH Chainama Hills College Hospital

CHW Community health workers

COP Clinical officer psychiatry

CSO Central Statistical Office

DARE Database of Abstracts of Reviews of Effectiveness

EMBASE

EU European Community

EVIPNet Evidence Informed Policy Network

HIV Human immuno-deficiency virus

HMIS Health Management Information Systems

KT knowledge translation

MCH Maternal and Child Health

MHaPP Mental Health and Poverty Project

MHAZ Mental Health Association of Zambia

MHUNZA Mental Health Users Network

NGO Non-governmental organisation

PMO Provincial Medical Officer

RAG Research to Action Group

REACH Regional East African Community Health

RMN Registered Mental health Nurse

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SMAG Safe-motherhood Activities Group

STI Sexually transmitted infections

SURE Supporting the Use of Research Evidence

TB Tuberculosis

UNZA University of Zambia

USD United States Dollar

WHO World Health Organisation

ZAMFOHR Zambia Forum for Health Research

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PARTICIPANTS

Name Organisation Phone No. Email Address

1 Dr Peter Mwaba Permanent Secretary

2 Mr Silishebo Silishebo CCZ Director 0977646620 [email protected]

3 Mr John Mayeya

(Chairperson)

Chief Mental Health

Officer

0977843918

4 Mr Joseph Kasonde Care Ministries for

the Mentally Ill

0977782543 [email protected]

5 Dr R. Chavuma District Director of

Health, Lusaka


6 Ms Zaliwe Mwale District Mental

Health Coordinator


7 Mwape Mulubwa For Dr Caroline

Kaunda


8 Dr John Mudenda

(Moderator)

Apex Medical

University

9 Dr Margaret Maimbolwa Assistant Dean,

School of Medicine,

UNZA

0977800067

10 Dr Maria Akani (Rapporteur) Psychiatry Dept,

UNZA


11 Ms Didduh Mubanga Psychiatry Dept,

CHCH

[email protected]

12 Kanyata Kanyata Mental Health [email protected]

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Nursing, CHCH

13 Mr Paul Chungu Mental Health

Association of

Zambia

[email protected]

14 Mr Eddie Mbewe 0977846648 [email protected]

15 Dr Chandwa Ng’ambi PMO, Copperbelt

Province


16 PMO, Eastern

Province


17 Dr Felix Silwimba PMO, Northern

Province


18 Dr George Liabwa PMO, North-western

Province


19 Dr Mubita Mubita PMO, Western

Province


20 Mr Noah Kabwita Yellow Ribbon

Coordinator


21 Ms Elizabeth Jere STEPS OVC/CRS –

Technical Advisor


22 Mercy Zulu Lifeline Zambia 0977809381 [email protected]

23 Gabriel Karuma Social Work Dept,

CHCH


24 Dr Lutangu Alisheke 0977854854 [email protected]

25 Dr Lonia Mwape UTH, School of

Nursing

0979093045

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26 Dr Joseph Kasonde ZAMFOHR –

Executive Director

27 Mr Derick Hamavwa ZAMFOHR

28 Ms Nkunda Vundamina ZAMFOHR

29 Ms Alicia Cundall ZAMFOHR Intern

*Media personnel not included in list of participants (ZNBC, MUVI TV, etc)

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PROGRAMME

Chairperson: Mr John Mayeya

Moderator: Dr John Mudenda

Rapporteur: Dr Maria Akani

Time Activity

08:00 Registration of Participants (Alicia/Nkunda)

08:30 Policy Brief Questionnaire Administration (Ms. Mwape)

09:15 Welcome Remarks (Dr Kasonde, Executive Director ZAMFOHR)

09:30 Official Opening (P.S. MoH)

09:45 Mental Health System Overview (Mr Mayeya)

10:05 Experiences of Mental Health System Users (Mr Sylvester Katontoka, MHUNZ)

10:25 Policy Brief PowerPoint Presentation (Ms Mwape)

10:45 Tea/Coffee Break

11:15 Policy Dialogue Group Discussions (Dr Mudenda, Moderator)

12:30 Plenary (Dr Mudenda, Moderator)

13:00 Lunch Break

14:00 Policy Dialogue Cont’d (Dr Mudenda, Moderator)

15:30 Policy Dialogue Questionnaire Administration (Ms Mwape)

16:00 Tea/Coffee Break

16:30 Closing Remarks (Dr Kasonde)

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CONCEPT NOTE

STRENGTHENING THE HEALTH SYSTEMS FOR MENTAL HEALTH IN ZAMBIA

DIALOGUE BETWEEN POLICY MAKERS, RESEARCHERS AND STAKEHOLDERS

BACKGROUND and RATIONALE

Mental health problems continue to pose serious threats to individuals and the community at large. A good

number of studies have shown that mental health problems are common among people seeking health care,

but often with extremely limited access to mental health services especially at primary health care level.

Whilst Government, civil society and family initiatives are having some impact, it is now widely

acknowledged that this impact is enormously inadequate and is failing to address the crisis at the scale or

pace needed. There is broad consensus that responsive initiatives are only possible if the national health

systems at the primary health care level are significantly capacitated and knowledge and skills delivered to

the health workers operating at this level of care.

To this end ZAMFOHR has embarked on an innovative way to create conducive environments for key

stakeholders in the health service to come together and deliberate on matters that threaten survival and

development in Zambia. Our goal is to strengthen the capacity to undertake and utilise research and evidence

in health policy development and implementation. To date ZAMFOHR together with key stakeholders has

written and successfully produced the second policy brief which has been internally and externally reviewed.

OBJECTIVES

ZAMFOHR remains committed to providing an environment in which health research evidence forms the

basis for policy and practice, leading to improved health. This vision will see ZAMFOHR and its

stakeholders developing several policy briefs and conducting several policy dialogues over the next few

years, with the third round delivery of policy briefs and dialogues currently underway. As part of the series

of this process, ZAMFOHR held a policy dialogue in Lusaka Zambia on the 8th of April to engage with

policy makers, researchers, and stakeholders around strengthening the mental health system. The meeting

brought together key stakeholders from Government, Academic Institutions, Civil Society, mental health

users’ representatives.

The primary objective of the meeting was to present research evidence in support of the policy makers

involved in strengthening the health systems for mental health services. The second, but equally important

objective was to develop relationships among policy makers, researchers, and stakeholders.

This report includes presentations and results of discussions. A questionnaire (Appendix B) was

administered at the start of the day’s programme.

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INTRODUCTORY SPEECH BY ZAMFOHR EXECUTIVE DIRECTOR

The meeting was officially opened at 9.20am by the Executive Director, Dr Joseph Kasonde, who introduced

himself and welcomed all guests. All participants were asked to introduce themselves, which they did. A

special welcome was given to the PS and a brief overview of the program also given.

Dr Kasonde stated that around the world there is a movement toward evidence based medicine which also

implies evidence based public health. Many years ago, this was not seen as important as it is today. Across

the world, there is now the understanding that evidence is required. It is on the background of this

understanding that Zambia Forum for Health Research (ZAMFOHR) was created.

ZAMFOHR works through research to action groups (RAGs) that address specific issues in different areas of

research such as reproductive health, human resources for health and mental health. These groups then

identify an issue of importance and find evidence that pertains to it. Knowledge translation (KT) involves

gathering existing research on the issue in order to create policy briefs. If existing research is inadequate and

there is a need for research, the RAG conducts it.

Dr Kasonde also stated that the Policy brief in question was prepared through the intensive work of Dr Lonia

Mwape who looked at existing research both internationally and locally. Thus this Policy dialogue is about

considering what this policy brief suggests for mental health in Zambia today. It is not about pushing a

particular option forward and translating it into action. That is the role the policy makers such as the Ministry

of Health will assume after a thorough dialogue on the options presented.

All were thanked for attending the meeting and encouraged to fully participate.

MoH PERMANENT SECRETARY’S SPEECH

Invited guests, colleagues and partners, members of the press, ladies and Gentlemen

It gives me profound pleasure to find myself addressing this inaugural and first ever meeting on the mental

health services in Zambia. I am proud and pleased to notice that this room is composed of people with whose

work directly and indirectly links up with our agenda today of finding ways and best options for

improvement of mental health services in Zambia, especially for the integration of mental health at primary

care level.

Distinguished colleagues, partners, ladies and gentlemen, this meeting gives us an opportunity to seriously

consider and analyse how people think and perceive mental health illness and mental health, how individuals

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are treated, what treatments are available to them and what remains to be done to achieve our objective of

arriving at the best option and approach we can adopt to improve service delivery for mental health at

primary care level.

Over and above, we need a Zambia where recovery from mental illness should be the expected outcome and

where mental illness should be prevented or cured. We need a Zambia where everyone suffering from mental

illness will have access to early detection, effective treatment, care and support essential to live, work, learn

and participate fully in their expected community responsibilities.

Ladies and gentlemen, you may wish to know that there was no formal mental health care in Zambia, then

Northern Rhodesia, until the establishment of the main mental hospital, Chainama Hospital, in 1962.

Chainama Hills hospital provided guidance on mental health policy issues until 1974 when the ministry of

health took over. By 1978, all the provincial general hospital had mental health facilities. With the

introduction of the primary health care programme in 1981, the structure of mental health services was

established from the village, health centre, district, provincial and specialised levels.

However, there were gaps in the service provision. For instance, during the implementation of community

mental health services, some members of staff were not willing to participate in the programmes because

they believed that their role was to work at the hospital level. Allow me, also, to state that although

community mental health services were introduced as it were, they could not be sustained due to logistical

challenges. By the time we introduced health reforms in Zambia in 1991, there was, among many other

needs, a crisis of psychotropic drugs and a crisis of infrastructure for mental health services.

With the introduction of the mental health office at the then central board of health in 1998, we saw mental

health services being integrated in the 2001 to 2005 national health series strategic plan. The positive trend

and good will has continued, resulting in the following:

1. Development of a cabinet approved mental health policy of 2005

2. Development of the National Mental Health Services Strategic Plan of 2007-2011

3. Integration of Mental Health into the 5th National Development Plan of 2006-2010

4. Integration of Mental Health into the technical guidelines for the front-line health workers

5. Integration of Mental Health into the Standard treatment guidelines

6. Introduction of the direct entry training for clinical officers and registered mental health nurses

7. Supporting of the Bachelor of Science Mental Health training of clinical officers and registered

mental health nursing in Malawi

8. Introduction of the Masters of Medicine programme in Psychiatry

9. Upgrading of infrastructure at CHCH

In addition to what I have just said, we are now training Neuropsychologists at the University of Zambia

(UNZA), Department of Psychiatry. With this critical mass of human resource we have and are developing,

we strongly believe and feel that the technical backstopping required in terms of human resources, to

strengthen and sustain support for integration of mental health services in primary care is available.

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Our greatest challenge is in the area of logistical and financial support to do this. Against other competing

needs, the ministry of health, through the ministry of finance has been providing funding to mental health

services. But these are not enough and we require your support for counterpart funding. The Mode and ideal

of financial support we would like to see is to link mental health services to the already existing programmes.

We need to see the following linkages for the mental health services at primary health care level:

1. Mental health and HIV/AIDS

2. Alcohol, substance abuse and HIV/AIDS

3. Mental health and gender

4. Maternal, neonatal and child mental health

5. Integration of mental health in youth friendly services

6. Mental health and Malaria

7. Mental health and TB

Distinguished colleagues, ladies and gentlemen, the product of research we are discussing today provides the

passage, evidence and link to policy and practice improvement of mental health services in Zambia. We now

know that people with mental illness and indeed mental health problems need not be locked up, incarcerated

and warehoused in psychiatric facilities considering that there is now available an array of effective

treatments, both psychosocial and pharmaceutical, for even the most debilitating mental disorders. And as

such, we need to ensure that more Zambians receive and get access to mental health services outside

institutional settings.

Mental illness and mental health problems rank high among illness that causes disability, with huge costs not

only to individual families who live with it but also to all of us. In Zambia today, estimates show that over

2660 patients per 100,000 in the population are admitted to the only psychiatric hospital in the country, that

is, Chainama Hills College Hospital. The other issue is that although we have not done studies on direct and

indirect costs of mental health treatment, my assumption is that the figures may be high when you consider

Zambia’s demographic and epidemiological transitions, as well as the social challenges involving changing

family systems, poverty, rising rates of urbanisation, unemployment, alcohol and drug abuse, HIV/AIDS,

violence against women, divorce and single parenthood.

Individuals with mental health problems and mental disorders are particularly vulnerable to infringement of

their civil and human rights. They are marginalised, stigmatised and discriminated against. And for this

reason, we are in earnest working at repealing of the Mental Disorders Act Cap 305 of 1951 and we replace

it with the mental health act. Once in place, the mental health act will set a clear direction and focus for

mental health services country-wide, in the context of government’s vision of providing equity of access to

quality health care as close to the family as possible. This mental health act once in place will also see the

establishment of a framework for the protection of the rights and civil liberties of the afflicted individuals by

ensuring their full participation in the process of their care. This is the reason why the work and option you

are going to choose in integrating mental health services in primary health care is critical and important. It is

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in primary care that individuals with mental health problems can be availed the opportunity to participate in

the process of their care.

Therefore, what we are going to do in mental health today, to discuss the mental health policy brief, is highly

commendable and must be the route to follow if we have to effectively and practically link evidence to

policy and practice. For this reason, the Ministry of Health congratulates you for the work done. In

particular, we support the Zambia Forum for Health Research and its partners for the zeal and tireless effort

that went into the production and crafting of this piece of work and evidence. I urge all the Research to

Action groups on other thematic areas to conclude their work as well. Special congratulations to the Mental

Health Unit for providing leadership and an enabling environment for the conclusion of this work.

Ladies and gentlemen, I have taken longer in addressing you deliberately for the reason that we need to move

quickly in up-scaling the integration of mental health in primary health care. Remember, ‘there is no health

without mental health.’ And for this reason, I am appealing and directing the provincial medical officers to

ensure that mental health services are considered in all the action plans at provincial and district levels. We

have already posted many clinical officers –psychiatry and registered mental health nurses country wide. Use

them, especially in terms of coordination of mental health services and integration of services at primary care

level.

Thank you very much for taking your time to come and participate in this important meeting. I look forward

to receiving the final product and outcome of your deliberations. Enjoy your weekend, safe passage home

and May God bless you.

Dr Peter Mwaba,

Permanent Secretary,

Ministry of Health.

OVERVIEW OF MENTAL HEALTH SYSTEMS & SERVICES IN ZAMBIA

By Mr. John Mayeya, Chief Mental Health Officer, MoH

INTRODUCTION

• WHAT IS MENTAL HEALTH?

– According to WHO, mental health is “ a state of well being in which the individual realizes

his or her own abilities, can cope with the normal stresses of life, can work productively and

fruitfully, and is able to make a contribution to his or her community”

– It is all about how we think, feel and behave.

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• WHAT ARE- MENTAL ILLNESSES, MENTAL DISORDERS, AND MENTAL HEALTH

PROBLEMS?

– Mental illness is a non-communicable disease and term used to refer to a wide range of

mental disorders that can be diagnosed by a health care professional

– In this presentation, mental illness, mental disorders and mental health problems have the

same meaning

MENTAL HEALTH SYSTEMS AND SERVICES

• WHAT ARE MENTAL HEALTH SYSTEMS?

– These are activities whose primary purpose is to promote, restore or maintain mental health.

– The mental health system also includes all organizations and resources focused on

improving mental health.

– Mental Health Services in Zambia must be viewed and perceived from an industrial

perspective.

– And the concept of industry denotes manufacture of goods.

– In this case, the industry of mental health produces goods, which are, mental health services.

KEY DOMAINS OF A MENTAL HEALTH SYSTEM AND SERVICES

– Policy, plans, and legislation

– Financing of mental health services

– Organization of Mental health services

– Mental Health in Primary Health Care

– Human Resources

– Infrastructure

– Public Education

– Links with other Sectors

– Research, Monitoring and Evaluation

• POLICY, PLANS AND LEGISLATION

– Mental Health Policy developed in 2005

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– National Mental Health Services Strategic Plan-2007-2011

– Mental Health integrated into the National Health Services Strategic Plan since 2001

– Annual Activity Based Action Plans for Mental Health Services

FINANCING OF MENTAL HEALTH SERVICES

Government Grants through Ministry of Finance

1. Mental Health Unit-ZMK 385,000,000

2. Chainama Hills College Hospital- ZMK 3,960,000, 000

3. Provincial Mental Health Units-Unknown

4. District Mental Health Services-Unknown

5. Rehabilitation Centres:

Nsadzu-unknown

Kawimbe-unknown

Litambya-unknown

Projects

1. United Nations Office For Drugs And Crime (UNODC)-USD 150,000

2. World Health Organization-USD 10,000

3. USAID SHARE II-Undisclosed

4. STEPS –OVC-USD -Undisclosed

5. ZAMFOHR – about USD 5,000

ORGANIZATION OF MENTAL HEALTH SERVICES

• Zambia's mental health services remain highly centralized, with mental health services

remaining largely inaccessible at district level.

• Chainama Hills College Hospital – is the specialist mental health hospital for Zambia.

• Mental Health units present in 7 provincial hospitals, except for Northwestern province.

• District Mental Health Offices with District Mental Health Coordinators present in some

Districts

• No Mental Health Coordinators at provincial level except for Lusaka province

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• There is a Mental Health Unit at the Ministry of Health HQ

• Department of Psychiatry, University of Zambia, School of Medicine

• Department of Mental Health and Clinical Psychiatry, Chainama College of Health Sciences

Mental Health in Primary Health Care includes the following:

• identification and treatment of mental disorders

• Referral to other levels where required

• Attention to the mental health needs of people with physical health problems

• Mental health promotion and prevention.

• Where mental health is integrated into primary care, the following is the result:

• Access to mental health care is improved

• Mental disorders are more likely to be identified and treated, and

• Co-morbid physical and mental health problems managed in a seamless way.

To be fully effective and efficient, primary mental health care must be complemented by

additional levels of care such as:

• Secondary care components to which primary health workers can turn for referrals, support,

and supervision.

• Linkages to informal and community-based services

The following is the situation in Zambia regarding Mental Health in primary care:

1. Mental Health is part of the integrated technical guidelines for front-line health workers.

2. 98% of Primary Health Care Workers interviewed in 2009 agree that mental health must be

integrated in primary health care.

3. Close to 200 clinical officers and registered mental health nurses graduated and posted in

health facilities since 2009.

4. However, mental health services at primary health care level are still a challenge to

implement due to various system development reasons, which the policy brief may highlight

HUMAN RESOURCE

Numbers:

• Psychiatrists -4

• General Medical Officers -8

• Clinical officers in psychiatry-150 + or -

• Psychiatric nurses -150 + or -

• Psychologists x 2

• Social workers x 3

Capacity Building:

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1. MMed Psychiatry-UNZA-SOM-6 students

2. Clinical Officer Psychiatry-57

3. Registered Mental Nurse-74

4. Neuropsychologists-19

INFRASTRUCTURE

• The Buildings in most psychiatric facilities are in a deplorable state

• Chainama Hills Hospital-Two Blocks

• Kabwe Mental Health Unit

• Nsadzu rehabilitation centre

• Refurbished all 19 blocks

• Capacity for 125 patients

• Farming activities –piggery, gardening, piece work outside rehabilitation centres

PUBLIC EDUCATION

• Ad-hoc and usually done when there is availability of funds

• World Mental Health day features prominently on public mental health education

LINKS WITH OTHER SECTORS

1. Strong collaboration with Ministry of Community Development and Social Welfare

2. Task Force on mental Health Rehabilitation

3. NGOs:

a) Mental Health Users Network of Zambia

b) Mental Health Association of Zambia

c) Care Ministries for the Mentally Ill

d) Christian Organization for the Mentally Ill (COMP)

e) Zambia Forum For Health Research (ZAMFOHR)

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RESEARCH, MONITORING AND EVALUATION

1. Mental Health Research to Action Group under ZAMFOHR

2. Annual Audit of mental Health Services

3. Support Supervision

4. Draft Mental Health Information System forms

2011- MOH MENTAL HEALTH ACTION PLAN

• Up scaling the integration of mental health into primary care

• Annual Review and Feedback on Integration of MH into Primary Care

• Mental Health Services Support Supervision programme

• Commemoration of World No Tobacco Day 2011

• Commemoration of World Mental Health Day 2011

• Logistical Support to Development of Comprehensive Tobacco Control Legislation

• Strengthen Coordination of Mental Health Services

• Procure Laptop, Desktop Computers and Printer

• Support to development of Bsc Mental Health (Clinical and Nursing) Programme

• Develop protocols and guidelines on management of alcohol and drug abuse

• Provide support for psychotherapy and detoxification

• Training in management of co morbidity of mental disorders and HIV/AIDS

• Study of Mental Disorders in the General Population

• Logistical Support to MMed Psychiatry Programme

• Development of Print and Electronic Advocacy Materials

• Provide grants to occupational therapy sections in psychiatry units

• Strengthen Mental Health Information system

• Document Zambia's Mental Health Services Development from Past, Present and Future

CHALLENGES

• Infrastructure Development and Repair

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• Human Resources

a) Structure of Mental Health Services

b) Need for sub-directorate for mental health services

c) Mainstream lower level structures

• Non existence of a representative and responsive Mental health information system

• Financial Resources

• Monitoring of Psychotropic Medication

EXPERIENCES OF MENTAL HEALTH SYSTEM USERS

By Mr. Sylvester Katontoka (Mental Health Users Network of Zambia – MHUNZA)

• MHUNZA is a non-governmental Organization formed in 2000 and legally registered with the

Registrar of Societies on the 02nd January, 2003 (Registration number: ORS/102/35/2672.

• Its vision is to create a society free from stigma and discrimination against persons with mental

disability and HIV/AIDS and encourage them to fulfill their full potential.

• Its mandate is to promote, protect and ensure the full and equal enjoyment of all human rights and

fundamental freedoms by all persons with mental disability, and to promote respect for their inherent

dignity.

• The strategic directions of the organization involve lobbying and advocacy for the rights of persons

with mental disability.

Strategic Objectives

To contribute to the process of revising the Mental Disorders Act of 1951 and ensure a new

bill takes into consideration the protection of the rights of persons with mental disability.

To work with the communities to ensure that they are aware and sensitized on mental health

issues and challenges and that they will take proactive action to address them

To carry out sensitization campaigns to prevent HIV/AIDS among people with mental

disability.

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Persons with Mental Health Problems and Human Rights Violations in the Community

• The purpose of this report (which is based on findings of a focus group discussion) is to provide

information on the human rights violation that persons with mental health problems face in the

community: The case of Lusaka Community.

• This report highlights the need for policy-makers and other key stakeholders to make pay serious

attention to the unmet needs of persons with mental health problems.

Background

• Persons with mental health problems are marginalized and vulnerable group. The challenges they

face among others include:

Stigmatization and discrimination

Violence and abuse

Denied opportunities to participate in society

Lack of access to education

Lack of access to income generating opportunities.

Findings

• The majority persons with mental health problems are not guaranteed equal and effective legal

protection against discrimination in all spheres of life.

• They are subjected to torture, cruelty, inhuman and degrading treatment which is the order of the

day.

• They face all forms of exploitation, violence and abuse, including their gender-based forms of

violence.

• Majority do not have adequate standard of living for themselves, including adequate food, clothing

and housing.

• They can also not make personal choices equal to others to choose their place of residence and with

whom they live with.

• Despite being of marriageable age and can have a family on the basis of free and full consent, they

do face discrimination in matters of marriage , family and parenthood.

• Persons with mental health problems are also denied the opportunity to gain a living by doing

meaningful work due to discrimination on the basis of having a mental health condition.

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Recommendations

• Mental health should be a priority because of the huge burden of disease that results.

• Mental health is also about MDGs especially MDG 1 and 6.

• The vulnerability of persons with mental health problems should see the enactment of a new law.

• Empower users to have a full recovery process.

• Promote and support Users networks country wide by government.

• Increase financial support to mental health programmes.

POLICY BRIEF PRESENTATION

By Dr Lonia Mwape

What is a policy brief?

• A document that puts together both local and global research evidence.

• The purpose is to inform deliberations about health policies and programmes.

• Through summarising available evidence about the problem and possible solutions.

• The evidence is then made available to policy makers, their support staff and other stakeholders,

mostly through a policy dialogue.

• Policy brief is discussed as a background document in today’s policy dialogue meeting.

Summary of the policy brief: The problem

• Mental health was not among the 12 priority areas in the NHSP.

• Therefore, it was also absent in the Basic Health Care Package.

• Only 0.38% of funding was earmarked for mental health in 2008.

• Mental Health services at primary health care are inadequate.

Factors underlying the problem

• Legislative challenges

• Inadequate finances;

• Inadequate Mental Health Information Systems (MHIS).

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• Immense burden of mental health problems.

• Interconnection between mental and physical problems.

• Treatment gap for mental health is enormous and respect for human rights is inadequate.

Policy Options

Policy options of integration of mental health into primary care.

1. An incremental option

• Suggests starting with a pilot to integrate mental into PHC.

• A well designed evaluation before scaling up.

• It is possible to make improvements in the plan before scaling up.

• The pilot will ensure full implementation achieves its intended objectives.

• It may be more feasible than rapidly scaling up.

2. A comprehensive option

• Involves introducing services at PHC in all provinces at once.

• It is less likely to stall than an incremental approach.

• Monitoring and evaluation could be used implementation is working as planned.

• Evidence for each option is presented in the main body of the policy brief.

Implementation Strategies

• Insufficient funding for mental health services

• A lack of collaborative efforts between mental health workers in tertiary care hospitals,

provincial units, primary care workers and community health workers and organizations.

• Primary care workers already overburdened due to low numbers of staff, limited types of

personnel trained in mental health.

• Poor awareness in the community about causes of mental illness.

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What is a policy Dialogue?

• A structured discussion of the policy brief on strengthening the health system for mental health

in Zambia.

• Deliberations among policy makers, researchers, the media, civil society and other stakeholders

have the potential to contribute to evidence-informed health policies.

• Adds value to the policy brief through clarification of the problem.

• Provides a forum to share an understanding of the problems and their possible solutions.

PLENARY SESSIONS

Moderated by Dr John Mudenda

Three working groups were formed from participants. The following were the group discussion items

presented in plenary session:

1. Problem Definition

Group 1

The group agreed that there is a problem. Mental health is not adequately addressed. There is also

lack of capacity in mental health care in terms of human resource, inadequate finances, poor

legislature, lack of drugs, poor or lack of mental health infrastructure at all centres and no integration

of mental health into general health services. Also, there is little involvement of community in

mental health care.

Group 2

This group stated that second level hospitals and in-patient facilities are available but in a deplorable

state and often isolated. Integration of mental health services in the main stream clinical and

preventive practices is lacking. In some cases, the establishments for mental health providers do not

adequately provide for mental health personnel. Data capturing has also been poor.

Group 3

There was a general consensus on that fact that there is a problem in mental health as is evident from

lack of adequate services, lack of adequate funding and stigma. Issues that should be added to the

problem are those such as:

a) Services are not specific to demographic groups

b) Relatives and caregivers of mental health patients are not adequately cared for and

educated on how they can help. It is important to define more accurately who is the

treatment team

25

c) Identify which organisations/groups (traditional healers, spiritual leaders, etc) that

are currently providing care and included them in the plan

d) Mental health is not adequately included in the national and demographic surveys

e) Research on mental is not coordinated and fed into policy using the KT approach

f) Inadequate training and importance of scaling-up training of mental health officers

(also need to train mental health social workers)

g) Natural and man-made disasters (e.g. drought) should be articulated. It is important

to strengthen MoH and MCD partnerships

h) The issue of stigma should be addressed as well

2. Options – Incremental Vs Comprehensive

As regards the debate on which of the two options Zambia should take up, the group reports were as

follows:

Group 1

This group opted for the adoption of both incremental and comprehensive approaches at different

levels in the plan. Comprehensive approach should be done to perfect what care and services are

already being offered and the incremental approach should be taken to establish a standard of an idea

care centre to be an example to all.

Group 2

Group 2 chose the incremental approach as a way of having a model to create an intervention

approach. They favoured the incremental approach for the following reasons:

a) Easy to monitor

b) Should be used as a pilot lessons will be learnt

c) Limited resource and finances can be put to good use.

Group 3

The group did not choose one particular option or approach but instead discussed the advantages and

disadvantages of both options.

Incremental Approach

Advantages – helps ensure quality of care, to have all components in place

‐ Once we have mental health in primary health care in one area, the users of

new approaches can sensitise and promote at other centres

Disadvantages – equity would be a challenge. How would one area be selected over another?

‐ The approach has potential of stalling work without completion by rolling

out to all centres.

26

Comprehensive Approach

Advantages – Current budgetary allocations already include districts

‐ The need for funding within short time frame maybe beneficial

‐ It will enable large amount of data to be available at onset of work all at

once

Disadvantages – Concern for quality because it may be compromised when a big project is

being set off.

‐ Lack of human resource

‐ Bureaucracy and time (advisory board component of it)

‐ Needs for increased funds to begin with

Other general issues

‐ Some services require incremental and some comprehensive

‐ Need to include/consider lessons learnt from countries similar to Zambia

‐ The advisory board could be incremental or comprehensive

‐ Use term ‘program’ not ‘project’ because ‘project’ implies that it will come

to an end at some point

‐ Need more emphasis on human resource issues

Main Points from Discussion in Plenary Session

‐ Consider orientation of mental health staff. A few key staff should be

identified and give an orientation.

‐ Consider training of caregivers in community, even the family members

since they are the first point of contact.

‐ Address curriculum in the training of medical staff to improve diagnostics.

Put diagnostic criteria in curricular. It will help diagnose clients easily and it

will be easier to manage clients before it is too late or ‘full blown’ and

difficult to manage.

‐ Even when medical personnel learn something about mental health, when

they get to their stations they do not practice. Therefore, there is need to

identify a strategy that will ensure they apply what they have learnt. The

element of continuity from what they were trained in to what they finally do

in clinical practice.

‐ Mental health is not prioritised and this is evident because it is not present in

major documents which do not encourage the health worker in the field.

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‐ Competence by health staff may also be a problem. Findings from the

MHaPP study revealed that staff in the field needs capacity building to help

them improve skills.

‐ Consider including mental health services users in the strategy to dealing

with mental health because they are also stakeholders

‐ It would also help to have community groups initiated like the way

reproductive health has safe motherhood activities groups (SMAGs).

‐ The already existing persons in the SMAGs can be targeted to be link

persons for integration of mental health because this is a more primary level

than the CHWs

‐ Focus must not just be on those that are of low socio-economic only because

the services are lacking from both urban and rural settings

‐ There is need to also target the community health care package and improve

on it

‐ The Health Management Information System (HMIS) needs to be revised

because it only captures mental illness as either ‘psychosis’ or ‘neurosis’

‐ Diagnosis is a challenge. In dealing with other illness, there is a laboratory

to confirm diagnosis and monitor illness. What equivalent can we find in

rural areas that can be taught to community health workers?

‐ There is also need to identify a treatment team with all the components

(medical, social, psychological, etc)

‐ Pyramid approach. The pyramid has 6 levels from bottom to top with the

community at the base, followed by 1st level medical centre on top of it, then

2nd level medical centre, followed by 3rd level hospital and then provinces

with the headquarters finally at the apex. Both vertical and horizontal

approaches are necessary in order to have success. The pyramid can be

turned upside down with the community lead and putting pressure on top.

Incremental Vs Comprehensive Approach

‐ Learning from primary health care, the initial plan was incremental but then

other centres were pro-active about it so the governmental then changed into

comprehensive approach

‐ Better start one and do it well so that it serves as an example and an

inspirational to all. This has also been observed with other medical services

provided in Zambia such ART. Centres were targeted where this was started

in a particular area and then rolled out to other places later.

‐ It is important for us to define exactly what services we are talking about.

For example, stigma and awareness can be done comprehensively right

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away and others, such as primary health care may use strategic incremental

approach with defined time frames.

‐ Incremental approach can be taken but for a centre in each province

‐ It is important that there is coordination with the community because there

is pressure from the community organisations to get things started and

advanced.

Concluding remarks:

The concept of integration is a must and should not just be at service delivery level but also on training level.

The review of various curricular would have to be done. It seems to be state that there is lack of quality

control mechanisms on what kind of mental health is taught when teaching medical staff. Attitudes of trained

mental health staff that are in general centres but do not practice mental health but instead keep referring

cases to ‘specialists’ need to change. They need to actively call upon their skills and practice.

There is need to include consumers of mental health services in these plans and making headway.

Communities need to be motivated to support mental health programmes.

A focal group to put all these ideas together and make a way forward will be needed this group should also

set up a model. Both incremental and comprehensive approach on different levels and in different issues can

still work.

* A questionnaire was administered (Appendix C) before the official closing of the day’s activities.

CLOSING

Dr Joseph Kasonde:

Acknowledged the efforts of donors such as the Alliance for Health Policy and Systems Research (AHSPR)

and the EU (through SURE project). Also, the Zambian government (through MoH) and stated how glad he

was that the permanent secretary could come and officiate the deliberations of the day. He thanked the

chairman, Mr John Mayeya, who was also in the place of a policy maker. Mr Mayeya has had many break-

throughs, has worked with Dr Mwape and others for a long time. He came forward and wanted to know the

research evidence before proceeding with options. Dr Kasonde also thanked Dr Lonia Mwape, presenter of

the policy brief, who worked on this brief for one and half years. He thanked Moderator who facilitated well.

The ZAMFOHR team of organisers – Derrick Hamavhwa, Nkunda Vundamina and Alicia Cundall were also

acknowledged including all others in attendance for a very productive day.

Mr John Mayeya:

29

Introduced the Provincial Medical Officer (PMO) for North-western province to do the official closing. Their

province is the first to have a provincial mental health facility and it is hoped that others will emulate this.

Dr George Liabwa:

Thanked ZAMFOHR for co-sponsoring the policy dialogue meeting and for also bringing an element of

research based policies and activities. He noted that the Issue of input of mental health into the HMIS needs

to be revised. He also advised all PMOs to take advantage of planning cycle which starts in 2 months time to

include mental health activities. He advised that a comprehensive plan be made that even other stakeholders

can buy into.

Finally, he thanked all in attendance and officially closed the meeting at 17:03hrs.

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APPENDIX A

17 février 2012

An Evidence-Based Policy Brief

Strengthening the health system

for mental health in

Zambia

Included:

- Description of a health system problem

- Viable options for addressing this problem

- Strategies for implementing these options

Not included: recommendations

This policy brief does not make recommendations

regarding which policy option to choose

Who is this policy brief for? Policymakers, their support staff, and other stakeholders with an interest in the problem addressed by this policy brief

Why was this policy brief prepared? To inform deliberations about health policies and programmes by summarizing the best available evidence about the problem and viable solutions

What is an evidence-based policy brief? Evidence-based policy briefs bring together global research evidence (from systematic reviews*) and local evidence to inform deliberations about health policies and programmes *Systematic Review: A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from this research

This policy brief was prepared by the Zambia Forum for Health Research

2

Authors

Lonia Mwape, BSc(N), PhD, Lecturer, University of Zambia

Prudencia Mweemba, BSc(N), PhD, Lecturer, University of Zambia

Joseph M. Kasonde, MD, Zambia Forum for Health Research

Address for correspondence

Joseph M Kasonde, MD, Executive Director, Zambia Forum for Health Research

23 Chindo Road, Woodlands

PostNet 261, Crossroads

Lusaka 10101

Zambia

Contributions of authors

All of the authors contributed to drafting and revising the policy brief.

Competing interests

None known.

Acknowledgements

This policy brief was prepared with support from the “Alliance for Health Policy and Systems Research (AHPSR) and

Supporting the use of research evidence (SURE) for policy in African health systems project. Health Policy and Systems

Research is funded by the Alliance (Project ID number ID‐ EIP ‐12). SURE is funded by the European Commission’s Seventh

Framework Programme (Grant agreement number 222881). The funders did not have a role in drafting, revising or

approving the content of the policy brief. Andy Oxman, principal investigator of the SURE project, guided the preparation of

the policy brief.

We would like to thank the following people for providing us with input and feedback: John Mayeya, Eddie Mbewe, Paul

Chungu , and The Mental Health Research‐to‐Action Group

The following people provided helpful comments on an earlier version of the policy brief: Margaret Maimbolwa, Dr.

Mukonka and Dr. Chipoya

Suggested citation

Mwape L, Mweemba P.. Strengthening the health system for mental health in Zambia (policy brief). Lusaka, Zambia: The

Zambia Forum for Health Research, 2010.

3

The Zambia Forum for Health Research (Zamfohr) is a Knowledge Translation institution that aims to promote evidence-informed decision-making among researchers and research users. It is not a funder of research but rather an institution designed to bring together the key producers and users of knowledge, serving researchers, institutes, the Ministry of Health, Cooperating Partners, practitioners and civil society. www.zamfohr.org

Since its inception in 1999, the Alliance’s overall goal has remained unchanged – promoting the generation and use of health policy and systems research (HPSR) as a means to improve health and health systems in developing countries. The Alliance pursues this goal by developing and harnessing existing methods and approaches to improve both the quality of research and its

ultimate uptake. www.who.int/alliance-hpsr/en/

SURE – Supporting the Use of Research Evidence (SURE) for Policy in African Health Systems – is a collaborative project that builds on and supports the Evidence-Informed Policy Network (EVIPNet) in Africa and the Regional East African Community Health (REACH) Policy Initiative. SURE is funded by the European Commission’s 7th Framework Programme. www.evipnet.org/sure

The Evidence-Informed Policy Network (EVIPNet) promotes the use of health research in policymaking. Focusing on low and middle-income countries, EVIPNet promotes partnerships at the country level between policymakers, researchers and civil society in order to facilitate policy development and implementation through the use of the best scientific evidence available. www.evipnet.org

4

Key messages

The problem:

Although mental illness constitutes a large

proportion of the burden of disease in Zambia, it

receives inadequate attention.

• Mental health was not among the twelve priority areas in the National

Health development plan and was not provided for in the basic

package of services defined by the Ministry of Health.

• Only 0.38% of health care funding was directed towards mental illness

in 2008.

• Mental health services are lacking in general in general health care,

including secondary and primary care levels.

Policy options:

An incremental versus a comprehensive option for

integrating mental health into primary care

An incremental option

This option would start with a pilot project introducing mental

health services into primary care with a well-designed evaluation

prior to scaling up. Key advantages of this option are:

It is possible to make improvements in the plan, if needed, prior to

scaling up.

The pilot would help ensure that full implementation of the plan

achieves its intended objectives and could provide better data

for estimating the costs of scaling up.

It may be more feasible than rapidly scaling up throughout the

country.

A comprehensive option

This option would entail implementation of a comprehensive plan

to introduce mental health services into primary care in all nine

provinces of Zambia. Key advantages of this option are:

Scaling up could occur more rapidly.

5

Monitoring and evaluation could be used to ensure that the

implementation of the plan is working as intended.

It may be less likely to stall and than an incremental approach.

Implementation strategies:

Strategies to implement either option must address a

number of barriers, including:

Insufficient funding for mental health services due to inadequate

advocacy, inadequate mental health indicators, inadequate

public awareness of mental illnesses, social stigma attached to

mental illnesses, mental health care not being perceived as cost-

effective or affordable, and resources that are allocated to

mental health at the district level not being earmarked

Lack of collaborative efforts between mental health workers in the

tertiary care hospital and provincial units, primary care

workers and community health workers and organizations

Primary care workers already being overburdened due to low

numbers and limited types of health workers trained and

supervised in mental health care, poor working conditions in the

public health service, lack of incentives to work in rural areas,

and inadequate training of the general health workforce in

mental health

Insufficient funding for mental health services due to inadequate

advocacy, inadequate mental health indicators, inadequate

public awareness of mental illnesses, social stigma attached to

mental illnesses, mental health care not being perceived as a

serious problem.

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Executive summary

The problem Mental illness constitutes a large proportion of the burden of disease in Zambia. Although

data regarding the burden of mental disorders in the country are lacking, there are some

indicators of the magnitude of the problem. For example, Mayeya et al (2004) found a

prevalence of 36 and 18 per 100 000 for acute psychotic states and schizophrenia

respectively, based on hospital figures. Acute psychotic states refer to mental illnesses which

present in an acute state and do not normally exceed a period two weeks for resolution while

schizophrenia refers to a chronic state of psychotic illness. Further, according to the Mental

Health and Poverty Project (MHaPP) Country Report of 2008, about 2667 patients per

100,000 population are admitted annually to the only tertiary referral psychiatric hospital

and units around the country. It is expected that mental health problems in general will

increase, taking into account the extent of predisposing factors like HIV/AIDS, poverty and

unemployment. It is recognised that this is a very high incidence when compared to expected

prevalence of about 3 percent for severe mental disorders and 19 percent for mild to

moderate disorders. This observation would support the proposition that there is lack of

provision for mental health at the primary and secondary level and that mental health

services mostly accessed at tertiary level.

By contrast, mental health care services have continued to receive inadequate attention:

mental health was not among the twelve priority areas in the National Health development

plan; mental health was not provided for in the basic package of services defined by the

ministry of Health; and only 0.38% of health care funding was directed towards mental

illness in 2008. Moreover, legislation related to mental health care, not updated since 1951,

fails to mention basic human rights related to the mentally ill.

The current system of mental health care is based largely on secondary and tertiary health

institutions. Mental health services at the primary health care level are either inadequate or

lacking due to several factors, the main one being the low level and misplacement of mental

health professionals.

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Policy options

In considering the way forward the government was confronted with two options for improving

mental health services. The first is strengthening of the status quo by making the “vertical” system

work more efficiently. This would imply investment in secondary and tertiary institutions to increase

the number and competencies of human resources as well as the physical structures and logistics.

Secondly, there was the option of investing in integrating mental health in primary health care

services. The government decided on the latter.

Integrating mental health into primary health care: strategic options

The two strategic options that are considered here focus on integration of mental health into primary

health care using (1) an incremental approach or (2) a comprehensive approach. In the incremental

system, it is envisaged that a few centres will be selected for implementation with a view to scaling

up at a later stage. In the comprehensive system an effort is made to initiate a process widely across

the country without a need for extending to other centres at a later date. The important distinction

between these two options is the implication for resource allocation in specific context of Zambia. It

is important to take into account the country’s ability to fulfil the resource allocation implications of

these options before adopting one or the other or both. The two options, how they would differ and

their advantages and disadvantages are summarized in Table 1 in relation to the ten WHO/WONCA

principles for integrating mental health into primary care.

Table 1. Key characteristics of two options for integrating mental health into primary care

Principles The status quo Option 1

Incremental implementation starting with a pilot project

Option 2

A comprehensive plan for scaling up

1. Policy and plans need to incorporate primary care for mental health

The Ministry of Health is committed to integrating mental health in primary care. Implementation of this policy has been slow, nonsystematic and uncoordinated

A systematic and coordinated plan for integrating mental health in primary care

The plan will initially be implemented in a small number of districts

A comprehensive plan for scaling up the integration of mental health in primary care will be implemented throughout the country

2. Advocacy is required to Several independent A voluntary coalition of A mental health advisory

8

Principles The status quo Option 1 Option 2

shift attitudes and behaviour organizations (e.g. MUHNZA, MHAZ) are working largely independently

organizations will collaborate in advocating for change

board will be established to ensure input into the plan and its implementation and to help monitor and coordinate implementation of the plan, as well as to advocate for change

3. Adequate training of primary care workers is required

Limited training for specialised skills at the only tertiary care mental health hospital, limited mental health training in the curricula for general health workers, and limited efforts and resources for in service training

A pilot project in a small number of districts including systematically planned and coordinated training and supportive supervision for primary care workers

A cascade approach for training relevant cadre of primary care workers throughout the country

4. Primary care tasks must be limited and doable

Treatable mental health problems commonly go unrecognised, minimal mental health services provided in primary care, lack of follow-up for discharged psychiatric patients

Improved recognition of high priority mental illnesses, diagnosing and treating high priority conditions that are optimally managed in primary care, improving referrals and communication with specialized mental health workers, and follow-up of discharged psychiatric patients

Implemented initially in a small number of districts focusing on a minimal number of high priority conditions and tasks

Implemented throughout the country and the prioritised conditions and tasks may be expanded to include all priorities that are best provided in primary care

5. Specialist mental health professionals and facilities must be available to support primary care

Inadequate specialist mental health professionals, they do not have responsibility or time to provide adequate support, and the referral process is ineffective and inefficient

Increased supply of mental health professionals, posts providing support as a key component of the job description, and an effective and efficient referral process

Implemented initially in a small number of districts with a minimal sufficient increase in capacity

Implemented throughout the country and may include additional expansion of the specialist mental health service to increase its capacity to handle referrals as well as to provide outreach, supervision and

9


support for primary care workers

6. Patients must have access to essential psychotropic and other mental health medications in primary care

No psychotropic drugs included in the primary health care kit or available in private pharmacies, and inappropriate drugs are being used

Include appropriate psychotropic and other drugs for mental health problems (e.g. depression) in the primary health care drug kit

Implemented initially in a small number of districts for a minimal number of high priority conditions

Implemented throughout the country and the prioritised conditions may be expanded to include all priorities for which drugs are needed in primary care

7. Integration is a process, not an event

The process of integrating mental health into primary care does not have a timeline and is uncoordinated

Stage by stage changes building on experience, beginning with a pilot project, including rigorous evaluation of both impacts and processes

A plan for achieving comprehensive mental health care over a defined period of time with ongoing monitoring, evaluation and adaptation

8. A mental health service coordinator is crucial

Currently there is a National Mental Health Services Unit with a small number of staff

Strengthen the National Mental Health Services Unit and ensure that it has a clear mandate and capacity for coordinating the integration of mental health into primary care

Initially focusing on ensuring a clear mandate and capacity for coordinating the pilot project

In addition establishing establish coordinators at the provincial level and focal point persons at the district level

9. Collaboration with key stakeholders is required

Not currently coordinated The National Mental Health Services Unit will be responsible for indentifying key stakeholders and working with them

An advisory board with key stakeholders will be established (see 2 above)

10. Financial resources are needed

No earmarked funds allocated to integrating mental health in primary care

Earmarked funds for the pilot project and other elements of this option outlined above, including for training, drugs, mental health professionals to support primary care

Earmarked funds for mental health professionals to support an advisory board, training, additional tasks undertaken by primary care workers, drugs, mental health professionals to

10


workers, evaluation, and strengthening coordination

support primary care workers and to manage increases in referrals, and coordination

Implementation considerations There will be several barriers to the implementation of either option. Inconsistent and unclear

advocacy may result in unclear messages. It will be necessary to establish mechanisms for common

approaches among stakeholders for either approach. It will also be necessary to devise

comprehensive indicators that do not give a skewed view of the burden of mental illness.

Lack of general public awareness of mental illnesses and the social stigma that is attached to mental

illnesses are bound to undermine efforts to provide mental health services in primary care.

Moreover, mental health care and provision of psychotropic drugs may not be perceived as cost‐

effective or affordable. Finally, and most importantly, allocation of resources earmarked for mental

health may continue to be scarce despite the adoption of either policy option for integrating mental

health care in primary care.

11

MAIN REPORT

Table of contents

Preface 8 The problem 9 Policy options 16 Implementation considerations 27 Next steps 28 Appendix 29 Abbreviations 30

References 31

12

Preface

“The problem of under‐diagnosis and under‐treatment of mental health problems cannot be

remedied by simple provision of guidelines and protocols, no matter how elegant; it will require a

reordering of the actual structure and process of primary care” (deGruy, 1997).

The purpose of this report

The purpose of this report is to inform deliberations among policymakers and stakeholders. It

summarises the best available evidence regarding integration of mental health into primary healh

care. It was prepared as a background document to be discussed at meetings of those engaged in

developing mental health and primary health care policies and stakeholders. In addition, it is

intended to inform other stakeholders and to engage them in deliberations about those policies. It is

not intended to prescribe specific options or implementation strategies. Rather, its purpose is to

introduce systematic and transparent consideration of the available evidence of the likely impacts of

different options into deliberations about mental health care.

How this report is structured

This policy brief has a list of key messages, an executive summary, and a full report to present policy‐

relevant research evidence about the impacts of integrating mental health into primary health care.

Although this entails some replication of information, the key messages and summary address the

concern that not everyone for whom the report is intended will have time to read the full report.

How this report was prepared

We searched for relevant evidence describing the problem, the impacts of options for addressing the

problem, barriers to implementing those options, and implementation strategies to address those

barriers. We searched particularly for systematic reviews describing the effects of policy options and

implementation strategies. Reviews that we assessed as being most relevant were used to extract

key findings and information that facilitates interpretation of those findings in the Zambian context.

We supplemented information extracted from the included systematic reviews with information

13

from other relevant studies and documents. The report was revised iteratively based on feedback

from the Mental Health Research to Action Group, key informants and external reviewers.

Limitations of this report

Because this policy brief is based largely on previously completed systematic reviews and research,

there may be important gaps in addressing options for which we did not find relevant evidence. We

have attempted to address this limitation in three ways: by relying on other documents to fill in the

gaps, through personal contact with experts, and through external review of the report.

14

The problem Background

A large proportion of the burden of disease in Zambia and around the world is due to mental illness

(WHO 2005). The common mental disorders are depression (42%) and schizophrenia (21%) while the

diagnosis of acute transient psychoses is rare. The majority of people with mental illness do not have

access to mental health services in Zambia [Mental Health Atlas, 2005]. The World Health

Organization (WHO) and the Ministry of Health, along with non‐governmental organizations dealing

with mental health advocate integrating mental health into primary care to address this problem. In

a survey conducted to explore attitude of health workers towards integrating mental health into

primary health care in Zambia revealed that over 98.2 percent of the health workers were of the

view that such integration was either extremely important (71.2%) or just important (27.0%) and this

ranged from a high of 88.5 percent among Zambian Registered Nurses to 25.1 percent among

Environmental Health Technologist who indicated that it was extremely important (Mwape, et. Al.,

2010). Although the Ministry of Health has made some strides towards integrating mental health into

primary health care, the process of integration to address the inadequacy of mental health service

provision has been slow and has not been systematically planned or implemented.

The decision to focus this policy brief on mental health care was influenced by the Mental Health and

Poverty Project conducted in four African countries (Ghana, South Africa, Uganda and Zambia) to

investigate policy level interventions required to break the vicious cycle of human poverty and

mental illness. This project was undertaken in order to generate lessons for a range of low and

middle‐income countries. Subsequently, discussions with key policymakers in the Ministry of Health,

mental health professionals and mental health organizations’ staff revealed that integration of

mental health into primary health care is a priority of current policy interest. Further, it was evident

that there was need for research evidence to inform decisions about how to effectively integrate

mental health into primary health care.

Over the past two decades the focus of care in mental health has been through the provision of

curative care, situated in big third level provincial hospitals (Petersen 1999). However, in the Mental

Health Policy document (2005), the Ministry of Health has committed to integrating mental health

into primary care. This integration is expected to address a full range of services so that continuity of

care and a balanced mix of community and inpatient services are ensured. The process was also

planned to be sensitive to prevailing cultural beliefs and practices. Further, the Ministry of Health has

included mental health in the current National Health Services Strategic Plan which is as part of the

Fifth National Development Plan (2006 – 2010) and has integrated it in Clinical Technical Guidelines,

15

as they pave the way to integrating mental health at primary health care level (Mental Health Unit,

MoH, 2008).

Reasons for integrating mental health into primary health care, as outlined by the World Health

Organization (WHO 2008), include:

• The burden of mental disorders is great.

• Mental and physical health problems are interwoven.

• The treatment gap for mental disorders is enormous.

• Primary care for mental health enhances access.

• Primary care for mental health promotes respect of human rights.

• Primary care for mental health is affordable and cost effective.

• Primary care for mental health generates good health outcomes.

Size of the problem

Treatment for mental illness is either lacking or provided in a fragmented manner at the primary

health care level for an estimated 200 000 people with mental disorders (of an adult population of 5

million) in Zambia [WHO, 2004; MHaPP, 2008; Mental Health Atlas, 2005]. It is cause for concern that

mental health at the primary care level has been largely overlooked in Zambia [Mayeya et al., 2004].

It is not one of the top ten priorities and has not been included within the Zambian Basic Health Care

Package. Consequently, psychotropic medications are not included in the primary care health kit and

are generally unavailable in primary care.

Because mental health is omitted from the health package, mental health care services are

unavailable throughout most of Zambia. There is currently only one mental care specialist in each of

the nine provinces. There are only three psychiatrists in the country, for a population of 12 million,

and none working in public health care (MHaPP, 2008; Mental Health Atlas. 2005). Mental health

services are mainly hospital based with Chainama Hills Hospital, located in the capital city of Lusaka,

as the only third level inpatient, long‐term care facility in Zambia. It is supported by a network of

psychiatric units in seven provincial general hospitals and three general psychiatric rehabilitation

units (Mental Health Policy Document, 2005). However, the Mental Health Policy Document (2005)

reports that the rehabilitation centres are not funded by the Ministry of Health, are inadequate, and

are located far away from patients. The document further notes that there are scant mental health

services for vulnerable groups such as children, young people, women, single parents, terminally ill,

unemployed, prisoners, retrenchees, widows, divorcees and the homeless.

16

Although data regarding the burden of mental disorders in Zambia are lacking, some indicators are

available. Mayeya et al (2004), for example, found a prevalence rate based on hospital figures of 36

and 18 per 100 000 population for acute psychotic states and schizophrenia respectively, with

alcohol and drug misuse cases accounting for 10 percent of acute psychotic states. This prevalence is

slightly higher than global burden which when measured by years lived with disability and years lost

as a result of premature death in disability‐adjusted life years, accounted for 13% of the global

disease burden in 2002 (WHO, 2002). However both the global and the Zambian prevalence do not

capture other types of burden associated with mental disorders, including the burden of care giving

for family members, financial costs, stigma, and human rights violations (Saxena, 2007). In addition,

and mentioned earlier, it is recognised that this is a very high incidence when compared to expected

prevalence of about 3 percent for severe mental disorders and 19 percent for mild to moderate

disorders. This observation would support the proposition that there is lack of provision for mental

health at the primary and secondary level and that mental health services mostly accessed at tertiary

level.

Further, the burden of mental disorders is likely to have been underestimated because of inadequate

appreciation of the connectedness between mental illness and other health conditions (Prince, Patel,

Saxena, Maj, Maselko, Phillips, & Rahman, 2007). The WHO’s 2005 (Mental Health Atlas, 2005)

estimates of the global burden of disease provide evidence on the relative effect of health problems

worldwide. WHO’s 2005 report attributed 31∙7% of all years lived‐with‐disability to neuropsychiatric

conditions: the five major contributors to this total were unipolar depression (11∙8%), alcohol‐use

disorder (3∙3%), schizophrenia (2∙8%), bipolar depression (2∙4%), and dementia (1∙6%).

According to the Mental Health and Poverty Project (MHaPP) Country Report [2008], about 2667

patients per 100 000 population are admitted to Chainama and psychiatric units around the country.

The total number of beds at Chainama is 210, excluding 167 (floor beds) which are not officially

recognised by the Ministry of Health. Primary health care units (health centres) form the first level in

terms of the structure of health care provision. They are expected to refer complex cases to district

hospitals (second level) and the district hospitals are expected to refer to third level (tertiary)

hospitals. However, neither health centres nor district hospitals have mental health plans. Both are

fragmented and uncoordinated in their provision of mental health services [Mental Health Policy

Document, 2005; Gleisner, 2001; Gleisner, 2002].

Mental health care providers at the primary care level are generally clinical officers who have

undergone three years of training. They are able to diagnose mental illness and they illegally provide

prescriptions for psychotropic drugs, meanwhile medical officers are generally not available at the

primary care level, especially in rural areas, yet they are the ones that have the legal provision to

prescribe drugs for mental illness (MHaPP, 2008). Training of nurses and general practitioners about

17

mental illness is limited. This may be attributed to the lack of knowledgeable trainers for mental

illness and care (MHaPP, 2008). Generally, research in mental health in Zambia is scarce, with no

research, apart from the MHaPP project, having been conducted on issues around integration of

mental health within primary health care [MHaPP, 2008; Mayeya et al., 2004; Gleisner, 2001;

Gleisner, 2002].

Factors underlying the problem

Key factors underlying the failure to integrate mental health into primary care are a lack of

legislation, inadequate financing and an inadequate mental health information system.

Legislative challenges

Legislation related to mental health care in Zambia is an appendage of a colonial legacy. Created in

1951 the policy discusses how the general population needs to be protected from the mentally ill but

fails to mention basic human rights related to those living with mental illness (MHaPP, 2008). Zambia

is still under the guidance of this legislation, which does not recognize nor provide for the protection

of the human rights of mentally ill patients or involvement of communities in the provision of mental

health care. The National Mental Health Bill, which will repeal the Mental Health Ordinance of 1951,

has been in under review for about 10 years. This has delayed repealing the Mental Health Ordinance

of 1951 and enacting the new bill. The Mental Health Policy was ratified in 2005, still based on the

Mental Health Ordinance of 1951, and has not been fully implemented. This has perpetuated the

slow pace at which integration of mental health services into primary health care is progressing,

despite the good intentions of the Ministry of Health’s vision of ‘providing equity of access to quality

health care as close to the family as possible’.

Inadequate financing

Only 0.38% of health care funding is directed towards mental illness (MHaPP, 2008). The Zambia

Mental Health Policy (2005) makes it clear that this is insufficient. The Ministry of Health’s Annual

Action Plan (2010) with a total of K756 billion (app. $151 million) shows Mental Health as having

been allocated only K889 million (app. $178 000) under six activities: strengthening coordination of

mental heal services in the provinces; support to tobacco control activities; training and research in

mental health; creation of public awareness in mental health; the prevention of alcohol and drug

abuse and facilitation of the provision of community mental health services in provinces. In

comparison, STI/HIV was allocated K8.6 billion (app. $1.7 million) and K2.4 billion (app. $478 000)

was allocated for tuberculosis and leprosy activities. This situation is similar to other states in the

world despite the huge burden of mental illness and the availability of effective interventions; few

resources are directed toward mental health care. Mental health spending in many countries in the

world is less than 1% of health expenditures (which are already very low in most middle‐ and low‐

18

income countries), 31% percent of countries have no separate mental health budget, and the

number of mental health professionals is grossly deficient (Mental Health Atlas, 2005; Saxena,

Sharan, Saraceno, 2003).

Inadequate mental health information system

The Zambian Ministry of Health collects health information from health facilities in the country

through a data capture form that clinicians complete by tallying conditions of patients seen each day.

The data capture form has a list of conditions from which clinicians select. However, there are only

two categories (psychosis and neurosis) through which mental health problems are captured leaving

all others unrecorded. This has significantly contributed to under reporting of mental health

disorders. It has further contributed to patients being referred to the only tertiary level hospital

without being treated at the primary care level. The Mental Health and Poverty Project survey (2008)

reports that patients with mental disorders are sent to a tertiary level hospital right away without

being screened and in most cases, without a provisional diagnosis. This is done regardless of the

distance the patient should cover to the hospital or the cost of transportation.

Other factors underlying the need for improving the integration of mental health into primary care

can be summarised in relationship to the reasons for integrating mental health into primary health

care listed above.

The burden of mental health problems is immense

Mental health problems are increasing in the Zambian population, mostly arising from the socio‐

economic difficulties that exist in the country. These include: HIV/AIDS, poverty, and joblessness.

With the population of 12 million people, an HIV prevalence of 17 percent and only about 400 000

formal jobs, over 68 percent of the population live on one US Dollar per day or less (CSO, 2007). Amid

all the mental health problems arising from socio‐economic difficulties, the health system in Zambia

considers a disease as a priority if it represents a large burden (in terms of mortality, morbidity or

disability), has high economic costs, or is associated with violations of human rights (Mental Health

and Poverty Project, 2008). Although WHO has identified depression, schizophrenia and other

psychotic disorders, suicide, epilepsy, dementia, disorders due to use of alcohol, disorders due to use

of illicit drugs, and mental disorders in children as priority conditions, these did not fit the criteria

that were used to prioritize conditions in Zambia. Disability and the economic burden imposed by

these disorders includes loss of gainful employment, with the attendant loss of family income; the

requirement for care giving, with further potential loss of wages; the cost of medicines; and the need

for other medical and social services. These costs are particularly devastating for poor populations

[Mweemba, et al, 2009; WHO/WONCA, 2008].

19

However there have been almost no epidemiological studies conducted in Zambia to determine the

exact burden of mental health problems. Few isolated studies have been undertaken and the

findings have indicated prevalence rates among various groups. A study that was undertaken to

determine mental distress among primary care attendees reported a prevalence rate of 12.4 percent

and 15.4 percent in men and women respectively (Chipimo & Fylkesnes, 2009). Another study which

was conducted to explore psychological distress among women in the perinatal period reported a

prevalence rate of 48 percent during the antenatal period and 37 percent during the postnatal period

(Mwape, 2010)

Mental and physical problems are interlinked

Consistent associations have been have reported between physical conditions and mental health

problems in both low and high‐income countries (Chipimo & Fylkesness, 2009). Further, an

association has been found between mental health problems and epilepsy (Lee & No, 2010; Gilliam,

2006); pregnancy (Mwape, 2010) and HIV/AIDS (Chipimo & Fylkesness, 2009). The WHO in the 2010

world report shows that between 11% and 63% of HIV‐positive people in low‐ and middle‐income

countries have depression. People with the condition also are prone to anxiety due to the

unpredictable nature of AIDS progression. Stress has been reported to impair immunity, and

depression is likely to affect adherence to antiretroviral therapy. A study conducted in Tanzania

revealed that 57 percent of HIV‐positive women experienced depression and that depression was

associated with disease progression and death. Further, in both the general population and in

general medical‐care settings, at least, a third of all somatic symptoms (commonly pain, fatigue, and

dizziness) remain medically unexplained. although, at least a third of those with somatisation have

no comorbid mental disorder medically unexplained somatic symptoms and syndromes are strongly

associated with common mental disorders (Prince, Patel, Saxena, Maj, Maselko, Phillips, & Rahman,

2007). In recognition of the relationship between mental health problems and physical conditions,

some international agencies have supported mental health through programmes that support

physical health problems. Mental health was integrated in round four and eight of the Global Fund

with a component on mental health and Anti Retroviral Treatment, and mental health and alcohol

and substance abuse in the context of HIV/AIDS included respectively. In addition, the United Nations

Office for Drugs and Crime has provided support capacity building for service delivery in relation to

substance abuse.

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The treatment gap for mental health is enormous and respect of human rights is lacking

Mental Health did not qualify to be one of the six main health thrusts, and subsequently was left out

in the first (1995‐1998) and second (1998‐2000) National Health Strategic Plans (Ministry of Health,

2005). Table 2 shows the priority area ranking in Zambia in what forms the Basic Health Care

Package.

The Basic Health Care Package consists of interventions for the prevention and management for each

of the priority conditions, on the basis of evidence about the effectiveness and feasibility of scaling

up these interventions. An intervention has been defined as an agent or action (biological,

psychological, or social) that is intended to reduce morbidity or mortality (Mental Health and Poverty

Project, 2008), and could be directed at individuals or communities. The interventions were

identified on the basis of their effectiveness, cost effectiveness, equity, ethical considerations

including human rights, feasibility or deliverability, and acceptability.

As a consequence of not including mental health in the basic health care package, psychotropic drugs

are not included in the primary care drug kit. (Mental Health and Poverty Project, 2008; Ministry of

Health Strategic Plan 2005‐2011). This was confirmed by the Mental Health and Poverty Project

survey that was conducted in 2009, which found that out of the twenty three health centres in

Lusaka, only two had psychotropic drugs in stock. Further, although the process of integration is

slowly commencing, there has not yet been an attempt made to review the basic health care

package in order to incorporate mental health. Yet mental health services delivered in primary care

minimise stigma and discrimination. They also remove the risk of human rights violation

(WHO/WONCA, 2008).

If the gaps in mental health services, resources, and policies are not addressed, the basic human

rights of the mentally ill (including the right to treatment) will continue to be neglected, and the

mentally ill will continue to suffer.

Table 2: National Health Priorities (Basic Health Care Package)

No Priority Area/Condition Strategic Intervention

1 Child health and nutrition To reduce the mortality rate among children under five

2 Integrated reproductive Health To reduce the maternal mortality ratio

3 HIV/AIDS, TB, and STIs To halt and begin to reduce the spread of HIV, TB, STIs

4 Malaria To reduce incidence and mortality due to malaria

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5 Epidemics To improve public health surveillance and control of epidemics

6 Hygiene, sanitation and Safer water To promote and implement appropriate interventions aimed at improving hygiene and access to acceptable sanitation and safer water

7 Human resources To train, recruit, and retain appropriate and adequate staff at all levels

8 Essential drugs and medical supplies To ensure availability of essential drugs and medical supplies at all levels

9 Infrastructure and equipment To ensure availability of appropriate infrastructure and equipment at all levels

10 Systems strengthening. To strengthen existing operational systems, financing mechanisms, and governance arrangements for effective delivery of health services

Source: Mental Health Poverty Project Country Report (2008).

Primary health care for mental health enhances access

Mental health services at the primary health care level are either inadequate or lacking due to

several factors, including low levels and misplacement of mental health professionals. Human

resources for mental health in Zambia have been declining over the past years. This has been largely

attributed to low numbers of health care providers being trained in mental health, retirement, death

due to HIV/AIDS, and migration. As of 2001, Zambia had a total of about 132 mental health workers

for an estimated population of 12 million people. After the reintroduction of the Registered Mental

Health Nursing and the Clinical Medicine Psychiatry programmes in 2006, the numbers are slowly

increasing.

In addition to being scarce, mental health workers are often misplaced and end up being assigned

duties in the provision of general health care because of the low priority given to mental health

problems as well as the decrease in human resource for health. For example, none of the mental

health workers in the urban clinics within the capital city were providing mental health care because

they had been placed outside the mental health care system (Mental Health and Poverty Project,

2008).

22

Primary care for mental health is affordable, cost effective, and generates good health outcomes

Evidence shows that mental health services at the primary health care level are less expensive than

psychiatric hospitals for both patients and government [Mwape, et al, 2010; Mweemba, et al, 2009].

In Zambia, due lack of integration of mental health services at the primary health care level, patients

are neither screened nor treated for mental illness. Generally, patients with mental illness are

referred to the only tertiary hospital in the country without being screened (Mwape et al, 2010). This

imposes a financial burden on patients, most of who are living in poverty, which is perpetuated by

their mental disability (Flisher, 2007). Integrating mental health services that are affordable and cost

effective into primary care can lead to improvements in health seeking behaviour that ultimately

lead to better health outcomes (Chisholm et al, 2007).

Policy options Globally, mental health has been integrated into primary health care across a range of

circumstances, including difficult economic and political circumstances. The specific models of

integration vary due to differences in socioeconomic situations, health care systems and health care

resources. Generally, success is achieved through leadership, commitment, and clear policies

(WHO/WONCA, 2008). As has been highlighted earlier, in Zambia integration of mental health into

primary health care has been slow and there is therefore, a need to carefully select an option that

will be compatible and that will yield the intended results within a short period of time. The two

policy options that are discussed in this section focus on integration of mental health into primary

health care using WHO/WONCA’s (2008) ten principles for integrating mental health into primary

health care: (1) an incremental approach and (2) a comprehensive approach. We describe the

current situation of mental health in primary health care before describing two options for

addressing challenges to integrating mental health into primary care.

The Current Zambian Mental Health and Primary Health Care Situation

According to MHaPP (2008) access to basic health services was affirmed as a fundamental human

right by the Declaration of Alma‐Ata in 1978. The goal of the Alma Ata declaration was to enable

people to receive a basic health care package as close to their residence as possible. However, this

goal has not been realised, especially in low‐income countries (MHaPP, 2008). In the Zambian

context, as stated earlier the integration of mental health into primary health care has been slow.

There is a critical shortage of human resources at the primary care level. Frontline mental health care

workers are inadequate. According to Mental Health Policy (2005) there were less than 260 mental

health workers working in mental institutions. Gleisner (2001) revealed that apart from declining

23

numbers, there is misplacement of mental health workers into areas where they are unable to

provide mental health services.

There are a number of challenges that must be addressed in order to effectively integrate mental

health into primary care. These are described in relationship to WHO/WONCA’s (2008) ten principles

for integrating mental health into primary care.

l. Policy and plans need to incorporate primary care for mental health

The current mental health policy, which commits the Ministry of Health to integrating mental health

into primary care, came into effect in 2005. However, it has taken over ten years to review the

mental health bill needed to repeal the Mental Disorders Act, Cap 305 enacted in 1951. Further,

there is not yet a coordinated plan or efforts to implement the policy.

2. Advocacy is required to shift attitudes and behaviour

There are several non‐governmental organisations (NGOs) working in the area of mental health.

These organizations will play an important role in shifting the attitude and behaviour for scaling up of

mental health services in primary care.

3. Adequate training of primary care workers is required

The government recently re‐introduced the training of specialist mental health workers in primary

care ‐ the Clinical Officer Psychiatry (COP) and Registered Mental Health Nurse (RMN). It will take a

long time to produce required numbers of staff for all primary health care facilities. Currently, the

Ministry of Health has been undertaking capacity building workshops for general health workers

from primary health care facilities in identification and management of mental health problems.

However, there is no systematic plan to scale up training and it is not clear who or how many should

be trained over a specific period of time.


Currently there is lack of integration of mental health into primary health care and as such tasks have

not been specified.

5. Availability of Specialist mental health professionals and facilities to support primary care

As described above, there is a critical shortage of mental health specialists in Zambia. Specialised

mental health care is concentrated at the one tertiary hospital (Chainama Hills College Hospital) and

there is a scarcity of specialist mental health workers in primary care facilities. Hence, those requiring

mental health services are referred to the tertiary hospital and there is no provision of mental health

care at primary care level.

24

6. Access to essential psychotropic medications in primary care

There is a central procurement unit that ensures regulation of dangerous drugs, including

psychotropic medications to allow for easy accountability and tracking of consumption patterns.

However, psychotropic medications are not included in the essential drug kit and are in limited

amounts at the tertiary hospital (Mwape, et al., 2010).


Important steps that have been taken towards integrating mental health in primary care include the

development and launch of the mental health policy in Zambia. The mental health bill is currently

undergoing review.


The directorate of Public Health and Research at the Ministry of Health is responsible for the mental

health unit. The mental health unit has a coordinator and an officer responsible for policy

development, implementation and coordination of mental health services in Zambia. There is

inadequate coordination of mental health services at primary care level.

9. Collaboration with key stakeholders

Due to lack of integration of mental health into primary health care, collaborative activities have not

been implemented.

10. Financial resources

As earlier stated, financial resources for mental health services are inadequate.

Incremental and Comprehensive Options

1) An incremental option for integrating mental health into primary care

The first option for addressing the challenges to integrating mental health into primary care

(described above) is incremental implementation of a plan for integrating mental health into primary

care. It will start with a pilot project introducing mental health services into primary care with a well‐

designed evaluation prior to scaling up.

2) A comprehensive option for scaling up the integration of mental health into primary care

25

The second option is comprehensive implementation of a plan for scaling up the integration of

mental health into primary care. It will introduce mental health services into primary care in all nine

provinces of Zambia.

These two options are summarized in Table 1 in the Executive Summary and described here using the

same ten principles for integrating mental health into primary health that were used above to

describe the current situation.

l. Policy and plans need to incorporate primary care for mental health

Both options build on having a systematic and coordinated plan for implementing the current policy

of integrating mental health into primary care. The need for a plan is based largely on lessons from

other countries where mental health has been successfully integrated into primary care [WHO 2008;

WHO, 2007; Prince, Patel, Saxena, Maj, Maselko, Phillips, & Rahman, 2007)]. Other lessons learned

from case studies of experiences in other countries include:

• National directives can be fundamental in encouraging and to shaping local activities and

improvements

• It may be essential to ensure that all stakeholders are involved in local identification of needs

and possible solutions, planning and implementation of the identified solutions

• The policy and plan must be embraced by local‐level health managers, not only those

involved in mental health. This includes both health and local authority managers

The incremental option will initially implement the plan in a small number of districts; e.g. two rural

and two urban districts. The impacts of integrating mental health into primary care in these districts

will be evaluated in comparison to similar districts in which the plan is not implemented. Lessons

learned from the pilot project will guide any necessary revisions to the plan and inform strategies for

scaling up. In addition, success in a small number of districts may encourage other districts to

implement changes [WHO 2008].

The comprehensive option will begin with a comprehensive plan for scaling up the integration of

mental health in primary care that will be implemented throughout the country.

2. Advocacy is required to shift attitudes and behaviour

Both options would use information in deliberate and strategic ways. This is likely to be important to

change attitudes and behaviour [WHO 2008, Prince, Patel, Saxena, Maj, Maselko, Phillips, & Rahman,

2007]. Estimates of the prevalence of mental disorders, the burden they impose if left untreated, the

existence of effective primary care‐based treatments, and lack of access to those treatments are

26

important arguments to persuade health authorities and stakeholders. Time and effort is required to

sensitize government and health system leaders, mental health specialists, primary care workers and

the public about the importance of mental health integration. Lessons learned from case studies in

other countries include [WHO 2008]:

• Discussions with policy makers and others in advance of major changes are likely to be

important

• Advocacy may be required to overcome initial resistance and shift attitudes of mental health

specialists and general health workers

The incremental option will involve civil society and other stakeholders in mental health through

collaborative efforts together in their advocacy for integrating mental health into primary health

care. A voluntary coalition of these organisations will also serve to strengthen community

participation in the integration process.

The comprehensive option will establish an advisory board that will engage key stakeholders,

including community representatives and leaders from other sectors. In addition to providing a

formal forum for coordinating and helping to ensure effective advocacy for change, the advisory

board will

• Ensure input into the plan and its implementation and

• Help monitor and coordinate implementation of the plan

In addition, a team will be organising at the district level to work with the advisory board and help to

ensure that there is coordinated and effective advocacy locally as well as nationally.

3. Adequate training of primary health care workers is required

Both options need to address challenges due to limited

• Training for specialised skills at the only tertiary care mental health hospital ()

• Mental health training in the curricula for general health workers

• Efforts and resources for in service training in mental health for general health workers

Appropriate and adequate training of primary health care workers is essential to effectively integrate

mental health into primary care [WHO 2008, Mental Health Policy, 2005, Mwape, et al, 2010]. Other

lessons learned from case studies of experiences in other countries include:

• Improvements in pre‐service and in‐service training of primary care workers on mental

health issues is often needed

• Training should provide

27

• Basic education on the epidemiology, identification, and treatment of major mental

disorders

• Relationships between mental and physical health and illness

• Communication skills, including active listening, showing empathy, using open and closed

questioning techniques, and manage nonverbal communication

• Knowledge and skills to discuss information with patients and families in a patient‐

centred and positive manner, to negotiate treatment plans, and to motivate and prepare

patients to self‐manage and follow their treatment plans at home

• In‐service training is essential to

• Provide basic education to health workers that have not been exposed previously to

mental health care

• Consolidate existing knowledge

• Ensure that changes in practice based on new research are disseminated and

implemented

• Ongoing support and supervision from mental health specialists are essential

• Collaborative or shared care models, in which joint consultations and interventions take

place between primary care workers and mental health specialists are especially promising

[Patel, Flisher, Hetrick, & McGorry, 2007]

The incremental option will start with systematically planned and coordinated training in a pilot

project in a small number of districts. It will also include supportive supervision for primary care

workers. The training will be targeted at nurses and clinical officers who are already working in

primary care. Initially, they will be trained to identify and manage common mental health problems

at this level of care and to recognise other mental health problems that should be referred to mental

health specialists. Additional training will be targeted at

• Mental health specialists to provide supportive supervision

• Traditional healers and community health workers to recognize and refer people with

mental health problems

• District managers to recognise

• The burden of disease from mental illnesses

• The existence and importance of cost‐effective treatments

• Organisational changes that are needed to enable primary care workers to provide

mental health care and collaboration among general health care and specialist mental

health care workers

The comprehensive option will use a cascade approach for training the same cadre of primary care

workers throughout the country [Chisholm D, Lund C, Saxena S., 2007]. In addition, it will implement

28

a plan for expanding the capacity of specialist mental health workers throughout the country to

provide supportive supervision to primary care health workers. It will also include and implement a

plan for strengthening mental health in the pre‐service curricula of general health workers, and for

strengthening training for providing supportive supervision in the curricula of specialized mental

health workers.


Both options will focus on

• Improved recognition of high priority mental illnesses

• Diagnosing and treating high priority conditions that are optimally managed in primary care

• recognition and referral of patients with other mental health problems

• Follow‐up of discharged psychiatric patients

It is essential that the focus is on a limited number of additional tasks that is doable by already

overburdened primary care workers. Caution is needed to ensure that primary care tasks for mental

health do not impede the delivery of other prioritized tasks. Primary care providers, mental health

specialists, policy makers and stakeholders need to agree on which conditions are best managed in

primary care and which specific tasks should be undertaken in primary care [WHO 2008; Patel,

Flisher, Hetrick, & McGorry, 2007]. Other lessons learned from case studies of experiences in other

countries include:

• Decisions about which mental health conditions and tasks to priortize in primary care must

be taken after careful consideration of local circumstances

• This requires consultation with policy‐makers and health care workers, as well as users of

mental health services and their families

• Functions may be expanded as practitioners gain confidence. In Chile, practitioners

progressed

• It may be cost‐effective to develop specialized primary care services for mental health that

target particular population subgroups such as children

The incremental option will be implemented initially in a small number of districts focusing on a

minimal number of high priority conditions and tasks.

The comprehensive option will Implemented throughout the country and the prioritised conditions

and tasks may be expanded to include all priorities that are best provided in primary care.

29

5. Specialist mental health professionals and facilities must be available to support primary care

Both options need to address

• The inadequate capacity of specialist mental health professionals

• Their lack of responsibility and time to provide adequate support

• Ineffective and inefficient referral arrangements

To address these challenges they will both

• Increase the supply of mental health professionals

• Create mental health posts that include the provision of support to general health workers as

a key component of the job description

• Develop and implement effective and efficient referral processes

Specialist mental health professionals and facilities must be available to support primary health care

[WHO 2008]. Making mental health services accessible at primary health care level will have a

multiplier effect on the demand for services. Therefore, supply of mental health professionals should

be accelerated to meet the demand. According to WHO [2008] other lessons learned from case

studies of experiences in other countries include:

• Providing support to mental health workers in form of resources and supervision is a vital

component of the job description of specialist mental health professionals

• An effective and efficient referral process is needed

• Specialized mental health professionals may interact in a variety of ways, including

• Referral and backreferral

• Telephone consultation

• Outreach visits that include supportive supervision

• Regular meetings

• Collaborative or shared care models

• Onsite mental health workers

Primary care providers, mental health specialists, policy makers and stakeholders need to agree on

how best to ensure adequate support from specialist mental health professionals and facilities, and

how to ensure effective and efficient referral arrangements. Decisions about how best to do this

must be taken after careful consideration of current arrangements and circumstances.

The incremental option will be implemented initially in a small number of districts with a minimal

sufficient increase in capacity.

30

The comprehensive option will be implemented throughout the country and may include additional

expansion of the specialist mental health service to increase its capacity to handle referrals as well as

to provide outreach, supervision and support for primary care workers.

6. Patients must have access to essential psychotropic medications in primary care

Both options need to address the following challenges:

• Psychotropic drugs are not included in the primary health care kit or available in private

pharmacies

• Inappropriate drugs are being used

To address these challenges both will include appropriate psychotropic and other drugs for mental

health problems (e.g. depression) in the primary health care drug kit. For both options, after

appropriate training, regulations will need to be modified to authorize primary care workers to

prescribe medications for the agreed upon range of conditions [WHO 2008]. Primary care providers,

mental health specialists, policy makers and stakeholders need to agree on which drugs should be

available and prescribed in primary care. Problems are likely to exist in procuring and distributing

these medications and these will need to be identified and addressed.

The incremental option will be implemented initially in a small number of districts for a minimal

number of high priority conditions.

The comprehensive option will be implemented throughout the country and the prioritised

conditions may be expanded to include all priorities for which drugs are needed in primary care.


Both options need to address the lack of a timeline and coordination of developing and

implementing the current government policy, which supports integration of mental health into

primary care. Integration is not a single or one‐off event. It is a gradual process [WHO 2008]. Other

lessons learned from case studies of experiences in other countries include:

• Meetings with a range of concerned parties are likely to be essential

• There may be considerable scepticism or resistance that must be overcome

• Training manuals and clinical guidelines are likely to be needed and implemented [National

Health Policy, 2005]

• Health workers will need training and additional staff will likely need to be employed

• For any of this to occur, budgets typically will require agreement and allocation

• Problems inevitably arise that must be addressed

31

The incremental option will use a process that can be characterised as a stage by stage approach to

changes that builds on experience. It will begin with a pilot project and might include subsequent

pilot projects. To maximise the ability to learn from experience pilot projects should include rigorous

evaluations of both desirable and undesirable impacts of the changes that are being implemented

and costs. In addition, process evaluations should examine how and why the strategies that are used

worked or did not work as intended.

The comprehensive option will develop and implement a plan for achieving comprehensive mental

health care over a defined period of time (e.g. 5 to 10 years) with ongoing monitoring, evaluation

and adaptation.


Both options will strengthen the National Mental Health Services Unit and ensure that it has a clear

mandate and capacity for coordinating the integration of mental health into primary care. Case

studies have found that primary care for mental health is usually most effective where a coordinator

is responsible for overseeing integration [WHO 2008]. Other lessons learned from case studies of

experiences in other countries include:

• Both anticipated and unexpected problems can sometimes threaten the success of efforts to

integrate mental health into primary care

• Coordinators may be crucial in steering programmes around these challenges and driving

forward the integration process

• Coordinators are important at both national and local levels

The incremental option will initially strengthen the National Mental Health Services Unit and ensure

that it has a clear mandate and capacity for coordinating the pilot project.

The comprehensive option, in addition to strengthening the National Mental Health Services Unit,

will in establish coordinators at the provincial level and focal point persons at the district level. This

will help to ensure coordination at the provincial and local levels as well as at the national level.

9. Collaboration with key stakeholders is required

Both options will address the current lack of ongoing collaboration among the Ministry of Health,

other sectors of the government, NGOs, community health workers and volunteers. Government

sectors outside health can work effectively with primary care to help patients with mental disorders

access the educational, social and employment initiatives required for their recovery and full

integration into the community [WHO 2008]. NGOs, community health workers and volunteers also

often play an important role in supporting primary care for mental health.

32

The incremental option will ensure that the National Mental Health Services Unit has a clear

responsibility for indentifying key stakeholders and working with them.

The comprehensive option will establish an advisory board with representatives from key sectors of

the government and other stakeholders.

10. Financial resources are needed

Both options will require earmarked funds allocated to integrating mental health into primary care.

For the success of the integration process, financial resources need to be made available to support

training and other activities. The additional time required to address mental health issues means that

more primary care workers might be needed and incentives may be needed to motivate primary care

workers. Mental health specialists who provide support and supervision also must be employed or

paid for these activities. [WHO 2008; Ducharme, Knudsen, & Roman, 2006]. Other lessons learned

from case studies of experiences in other countries include:

The incremental option will require earmarked funds for the pilot project and other elements of this

option outlined above, including for training, drugs, mental health professionals to support primary

care workers, evaluation, and strengthening coordination.

The comprehensive option will require earmarked funds for mental health professionals to support

an advisory board, training, additional tasks undertaken by primary care workers, drugs, mental

health professionals to support primary care workers and to manage increases in referrals, and

coordination

Costs

The key costs for each option and rough estimates were based on Chisholm D, Lund C, Saxena S

[2007] who have estimated that the cost per capita of providing a core package at target coverage

levels ranged from $1.85 to $2.60 (USD) per year in low‐income countries. Although significant new

resources need to be invested, the absolute amount is not large when considered at the population

level and against other health investment strategies. These estimates included training costs, but

may not have included all of the costs of scaling up. Nonetheless, they provide a good indication of

the likely recurrent costs once target levels of coverage have been achieved. Since the cost of

coverage would be less while scaling up, the total cost while scaling up is likely to be less, or at least

no greater than the yearly costs once target levels of coverage have been reached. In Zambia, with a

population of 12 million, this corresponds to a total yearly cost of $22.2 to 31.2 million (USD) (K114

to 161 billion), or roughly 15 to 21% of the Ministry of Health’s Annual Action Plan for 2010. This is

budget to big for the Zambian economy, but it can either be adjusted to fit into available funds.

Therefore, the most ideal scenario is to adjust the current core package to make it affordable and

33

gradually increase the core package to include latest psychotropic medications. The ministry of

health will need to identify additional sources of funds during a transition phase.

Equity considerations

Epidemiologic research over the last 20 years indicates that the social and economic conditions of

poverty are linked with common mental disorders in low and middle‐income countries [Lund C,

Breen A, Flisher AJ, et al., 2010]. The mechanisms by which the cycle of poverty and common mental

disorders is maintained are complex and multi‐dimensional. An importand conclusion that can be

drawn for a systematic review of this is that efforts to address the burden of common mental

disorders will be limited if they only target individual‐level interventions. The relatively consistent

association between common mental disorders and poverty, in addition to the large burden of

disease caused by mental illness, strengthens the case for the inclusion of mental health as a priority.

Improving recognition and treatment of mental illness by integrating mental health in primary care is

likely to reduce inequalities.

Monitoring and evaluation

Although there is high quality evidence of the effectiveness of many clinical interventions for mental

disorders, evidence of the effects of strategies for integrating mental health into primary care is

limited and, to a large extent, comes from case studies. Consequently, the impacts and costs of both

options are uncertain.

The incremental option addresses this uncertainty primarily by piloting implementation of the plan

for integration and evaluating the impacts (both desired and undesired) and costs. It also

incorporates process evaluations to examine how and why the strategies used to integrate mental

health into primary care worked or did not work as intended. The key advantage of this approach ‐ in

terms of evaluation ‐ is that it makes it possible to make improvements in the plan, if needed, prior

to scaling up [Supporting the Use of Research Evidence (SURE) Guides, 2010]. The key disadvantage is

that, to the extent that the plan is effective and works as intended, it delays scaling up and the

anticipated benefits of integrating mental health into primary care.

The comprehensive option addresses uncertainty about the impacts and costs of integrating mental

health into primary care through monitoring and evaluation. Monitoring of financial, material and

human resources as inputs can address uncertainties about the magnitude of the resources that are

required and allow for adjustments to the budget, if needed [SURE) Guides, 2010]. Monitoring of

impacts is unlikely to provide strong evidence that any changes in outcomes such as changes in the

burden of disease from mental illness are attributable to integrating mental health into primary care.

It can, however, inform decisions about whether changes are needed in the services that are

provided or how they are provided. More rigorous evaluation of the impacts of integration could be

34

incorporated into the comprehensive option by, for example, randomising the order in which it is

scaled up in different districts (using the districts where integration occurs later for comparison), or

sequentially introducing integration in different districts.

Advantages and disadvantages of the two options

Possible advantages of both options for integrating mental health into primary health care are that

they will:

• Bring mental health services closer to the community in line with the Ministry of Health

vision (1991)

• Help reduced travel costs for the patients and relatives who travel to Chainama hospital in

their effort to access mental health services

• Reduce stigma and discrimination considering that people with mental health problems will

be seen within the same setting as other patients

• Reduce the number of patients accessing the service at tertiary level, thus decongesting

tertiary and provincial level hospitals

Possible disadvantages of both options for integrating mental health into primary care are that they

will:

• Increase the workload for already overburdened primary health workers

• Compromise quality of care being provided due increase in workload

• Require deployment of more health care providers

• Increase the need for supervision

• Increase the need for financial resources.

• Waste of resources if integration is found not to be feasible

• Reduce the time available for primary care workers to attend to their usual patients

Possible advantages and disadvantages of the two options where compared to each other are

summarised in Table 3.

Table 3. Advantages and disadvantages of the two options

Favours Option 1

Incremental implementation starting with a pilot project

Favours Option 2

A comprehensive plan for scaling up

It is possible to make improvements in the plan, if needed, prior to scaling up and the pilot would help ensure that full

To the extent that the plan is effective and works as intended, it delays scaling up and the anticipated benefits of

35

implementation of the plan achieves its intended objectives integrating mental health into primary care and monitoring and evaluation could be used to ensure that the implementation of the plan is working as intended

Lower costs initially and the pilot could provide better data for estimating the costs of scaling up

• May be more feasible, affordable (initially) and acceptable to the government and others concerned about expanding the governments budget for health care

• It may be difficult to rapidly meet needs for more mental health specialists. Inadequate support for general health workers and capacity for increased referrals could have undesirable effects on the quality of care

More coverage initially. The incremental option is likely to take longer to achieve target leves of coverage and may stall

A voluntary coalition would require less government resources, but may give less of a voice to organizations and their members

An advisory board may provide a mechanism for ensuring better input into policy decisions, implementation of policies, and monitoring and evaluation. It might also strengthen engagement of stakeholders – provided there is a clear understanding of the role of the board and appropriate processes for involving stakeholders. An advisory board could also include community representatives and representatives from other sectors

May provide better coordination in early phases and therefore more effective implementation, provided coordination is is effective

Implementation considerations

Key barriers to integrating mental health into primary care and implementation strategies for

addressing these are summarised in Table 4. The same strategies and barriers are relevant for both

options.

36

Table 4. Barriers to implementing the policy options and implementation strategies

Barriers to implementing policy options Implementation strategies

Insufficient funding for mental health services [MHaPP 2008] due to

• Inconsistent and unclear advocacy

• Inadequate mental health indicators in the HMIS which currently capture only neurosis and psychoses and leave out other mental illnesses (particularly depression and schizophrenia)

• Lack of general public awareness of mental illnesses

• Social stigma attached to mental illnesses

• Mental health care, including psychotropic drugs, may not be perceived as cost-effective or affordable

• Establishment of a coalition (option 1) or an advisory board (option 2) with a mandate to coordinate advocacy efforts amongst key stakeholders

• Include an appropriate spectrum of mental illnesses in HMIS so as to provide a better picture of the burden of disease due to mental illnesses

• Mass media campaigns to increase awareness and understanding of mental illnesses, their recognition and treatment options, and to reduce the stigma attached to mental illnesses [Grilli 2002]

• Include guidance on strategies for reducing the stigma attached to mental illness in training targeted at primary care workers [Clement 2010; Mak 2007]

• Summarise and disseminate evidence of the cost-effectiveness of mental health care compared to other drugs and types of care currently included in primary care [Ducharme, Knudsen, & Roman, 2006]

• Undertake a detailed cost analysis of including psychotropic and other appropriate medications and other key costs of each option (see ’Costs’ in the description of the two options above)

• Based on the detailed cost analysis develop a plan for increasing funds for mental health over the next five to ten years, including transitional costs of a pilot project and scaling up

37


• Resources that are allocated to mental health at the district level are not earmarked for mental health

• Training for district managers to sensitize them to the need to priortise mental health and use funds allocated for mental health for that purpose rather than other purposes

• Regulations that make district managers accountable for using national funds that are earmarked for mental health for that purpose

• There is a lack collaborative efforts between mental health workers in the tertiary care hospital and provincial units, primary care workers and community health workers and organizations

• Setting up or refurbishing mental health units at health centres and at the district level

• Involve the community in the provision of mental health services [SURE 2010]

Primary care workers are already overburdened

• Low numbers and limited types of health workers trained and supervised in mental health care

• Poor working conditions in the public health service

• Lack of incentives to work in rural areas

• Inadequate training of the general health workforce in mental health

• Strategies for recruiting, redeployment and retaining health workers in underseverd areas

• Redeployment (some mental health specialists are curently misplaced and not providing mental health services

• Use of community health workers [Lewin 2010]

• Training, as a component of both options

• Strengthen mental health as a component of core curriculum for general health workers

• Lack of infrastructure to enable community-based supervision • Incorporate strategies for implementing community-based supervision in plans, as described for both options [Bosch-Capblanch 2008]

• Lack of continuous supply of psychotropic and other appropriate drugs in primary care

• Systematically review and improve the procurement and distribution of psychotropic drugs and include appropriate drugs in the primary care drug

38


kit

• Mental health leaders have limited public health skills and experience and public health leaders have limited mental health skills and experience

• Both options include coordinators to lead integration of mental health into primary care

• Leadership recruitment and training [refs], training for district managers in mental health, and public health training for mental health specialists who will be providing supervision [Ducharme, Knudsen, & Roman, 2006]

• Stengthen mental health in public health curriculum and public health in mental health curriculum

Next steps

The aim of this policy brief is to foster dialogue and judgements that are informed by the best

available evidence. The intention is not to advocate specific options or close off discussion. Further

actions will flow from the deliberations that the policy brief is intended to inform. These might

include:

• Deliberation amongst policymakers and stakeholders regarding the two options described in

this policy brief

• Refining the preferred option, for example by incorporating components of both options,

removing or modifying components

• Establish a coordinator with authority and accountability to lead the development and

implement of a plan and a team of people to work with that person in developing and

implementing the plan within an acceptable time frame

39

Appendix

How this policy brief was prepared

The methods used to prepare this policy brief are briefly described in the preface. The problem that

the policy brief addresses was clarified iteratively through discussion among the authors, review of

relevant documents and research, discussion within the Zambia Forum for Health Research

(Zamfohr) and external review of a preliminary description of the problem. Research describing the

size and causes of the problem was identified by reviewing government documents, routinely

collected data, searching Pub Med and Google Scholar, through contact with key informants, and by

reviewing the reference lists of relevant documents that were retrieved.

Strategies used to identify potential options to address the problem included considering

interventions described in systematic reviews and other relevant documents, considering ways in

which other jurisdictions have addressed the problem, consulting key informants and brainstorming.

We searched electronic databases of systematic reviews, including: the Health Systems Evidence

database of systematic reviews of delivery, financial and governance arrangements, and

implementation strategies (http://www.healthsystemsevidence.org/). This database includes

records of policy‐relevant systematic reviews that were identified through electronic searches of

MEDLINE, the Cochrane Database of Systematic Reviews (CDSR), the Database of Abstracts of

Reviews of Effectiveness (DARE) and EMBASE.

40

Abbreviations

AIDS - acquired immune deficiency syndrome

ART - antiretroviral therapy

CHW - community health workers

HIV - human immunodeficiency virus

MCH - maternal and child health

MHaPP - Mental Health and Poverty Project

WHO - World Health Organization

41

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