Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya Workshop Summary (2016) / Chapter Skim
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Appendix E: Providing Sustainable Mental Health Care in Kenya: A Demonstration Project
Appendix E: Providing Sustainable Mental Health Care in Kenya: A Demonstration Project
Pages 137-182
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a Visiting Scientist, Kenya Medical Research Institute. b Assistant Professor, Department of Neurology, School of Medicine, Yale University.
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150 Overview of the Existing Health Information Systems in Kenya ............................................................................................. 151 Existing Resources for Selected MNS Disorders ..............................
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181 E-4 Burden of disease due to substance use disorders in Kenya, 2010 .................................................................................. 181 E-5 Demonstration project structure…………………………… ......
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synergies exist in developing community-based interventions using laypersons or non-specialist health workers for these disorders. We propose several key components for this demonstration project (see Figure E-5)
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Strengthening and expansion of existing information systems infrastructure for MNS disorders In collaboration with key stakeholders, such as the county governments, and in partnership with the Ministry of Health (MoH) , Republic of Kenya, we propose a 4-year demonstration project that includes a planning phase and implementation phase and culminates with an evaluation phase in which ownership and management of the program is passed to the Ministry of Health or county government as appropriate.
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Most are based within Nairobi, the capital city.8 Outside of Nairobi, there is one psychiatrist per million population.9 There are 12 neurologists in Kenya and all practice primarily in the urban settings of Nairobi, Kisumu, and Mombasa and are primarily available in private settings.10 Furthermore, there is substantially lower usage of health services for mental health disorders11 and epilepsy12−15 in low- and middle- income countries as compared to high-income countries. For example, the treatment gap for mental health services ranged from 76−85 percent in less developed countries,16 and was 23–100 percent for epilepsy in lowincome countries.12 Finally, people with MNS disorders experience stigma, discrimination, and human rights abuses worldwide.17−21 Prevalence of MNS Disorders in Kenya and Sub-Saharan Africa Mental Disorders Mental disorders are highly prevalent and a leading cause of the global burden of disease.22 Mental disorders pose an increasing challenge to the global health care system.1 According to the World Health Organization (WHO)
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has a huge burden of mental disorders. This picture takes a darker shade when one considers that increasingly more and more children and young people suffer from mental illness.
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The 20 years between 1990 and 2010 saw an increase of nearly 40 percent in the global burden of substance use disorders.1 SSA is not left behind, and in some respects, the region is one of the leading contributors of the current upward trend seen in substance use.22 Considering the sky-rocketing rates of earlyonset alcohol and substance use in the region, there is a serious cause for concern.36 Studies done in Kenya indicate high substance use rates.4 The most recent rapid assessment carried out by the National Authority for the Campaign against Alcohol and Drug Abuse (NACADA) shows that while tobacco use rates are on the decline, the age of onset for any substance use has fallen to 10 years of age and the prevalence of alcohol use is now at 13.3 percent.
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The vast majority of Kenyans believe that mental health disorders are caused by supernatural powers like evil spirits. Many believe that those who develop mental disorders do so to atone for sins committed against ancestors or as a result of being bewitched.43 Such stigma pervades society and hinders health-seeking behavior among mentally ill patients.
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TFHs fear repudiation by the ancestors, spirits, or God, who bequeathed the skill on them.46 This is especially true for mental illness; traditional healers are the first to be contacted for mental illness in many parts of Africa.47,48 This is because they are not only available and accessible in the community, but they form part of the community's cultural belief system, making them an integral part of the community.45 This makes them acceptable to the community.45 Indeed, though modern medicine may exist side by side with such traditional and/or spiritual practice, many patients in SSA still prefer traditional and spiritual therapies.49,50 Moreover, the deficiency of doctors, clinical officers, and nurses in Kenya, together with the urban clustering of these practitioners51 and the need to seek holistic treatment results in a significant proportion of patients consulting TFHs. However, the larger scientific community and modern medicine have remained critical and skeptical of the efficacy of such spiritual and traditional practices.52,53 Despite this, it is imperative to appreciate the critical role that TFHs can play in the health care system.
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For example, an intervention focused on HIV/AIDS and tuberculosis and collaboration reported that 99 percent of participants reported a "willingness" to collaborate, but only 43 percent were actually referring.54 Identifying factors associated with traditional healer referral practices of their mentally ill patients is central for developing and designing interventions to ensure that traditional healers refer more frequently and appropriately. Educating traditional healers on the fundamentals of mental disorders, including mood and anxiety disorders, is therefore important in this regard.58 Target MNS Disorders for Kenya We chose three priority conditions for the purposes of this demonstration project: depression, epilepsy, and alcohol abuse.
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.59 Antidepressants, individual psychoeducation, and group interpersonal therapy have demonstrated efficacy in low-income countries.60 Community-based treatment approaches using laypersons and non-specialist health workers have demonstrated efficacy. Epilepsy Although the burden of disease due to neonatal encephalopathies and meningitis are higher than epilepsy, these disorders are already addressed as part of maternal–child health initiatives and communicable disorders.
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; and support for self-help activities as well as for high-risk groups."63 Epilepsy Community-based treatment of epilepsy is cost-effective, does not require specialized equipment, and is effective.61 The Global Campaign Against Epilepsy began in 1997 as a partnership among the International League Against Epilepsy, the International Bureau for Epilepsy (IBE) , and the WHO.64 This effort included developing regional conferences and reports, an atlas for "Epilepsy Care in the World."6,65 Importantly, this initiative included several community-based demonstration projects in Brazil,66 China,67 Georgia,68 Senegal,69 and Zimbabwe.70 Additional demonstration projects are being planned or initiated in Cameroon, Ghana, India, and Vietnam.64
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Dispensary 6. Community health worker75 Basic primary care is provided at dispensaries and health centers.
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Further traditional midwives, pharmacists, and community health workers supplement the provision of health care. The migration of trained health workers from the public sector to higher paying positions in the private sector, or away from Kenya altogether, has made retaining qualified health personnel a persistent challenge.
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This department had three sections: Computing, Statistical and Medical Records, and the District HMIS.78 Data were collected at MoH facilities and then analyzed at a national level, but were not believed to be of high enough quality for planning and evaluation.78 Since then, there have been efforts to strengthen these data collection systems for various internationally funded initiatives on HIV/AIDS, malaria, child survival, and others. However, these were typically vertical initiatives with separate reporting tools, which increased the burden on health care workers.79 There have been several initiatives to streamline data collection and reporting and to improve the HMIS infrastructure via collaborative efforts with the MoH such as AIDS, Population, and Health Integrated Assistance; AfriAfya; the Community Based Health Information Management Project; and Afya Info.79−81 However, both the demographic and health information systems for much of the country are still based on handwritten, paper records.80 Continuing challenges include having too many indicators, with new indicators added by each international donor, a weak infrastructure for computing technologies, inadequate staffing and training, and little dissemination of existing information.80 Furthermore, over the past 15 years, several large population-based surveys have been conducted80: • Kenya Population and Housing Census 1999 • Kenya Demographic and Health Survey (KDHS)
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APPENDIX E 153 Both KAIS and KDHS collect minimal information on alcohol and drug abuse, but do not collect data on other mental health disorders. The HDSSs are complementary in that they observe populations with different environmental, epidemiological, and cultural back-grounds.84 However, there is little collaboration among HDSSs due to differing research concepts, objectives, and management systems84: • The Kilifi HDSS was established in 2000 by the Kenya Medical Research Institute (KEMRI)
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However, the situation is not all gloomy. Several key stakeholders are involved in the provision of care for MNS disorders.
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Training in neurology is limited and nurses and clinical officers posted to rural districts report significantly more discomfort with diagnosis, care, and treatment of neurological disorders as compared to medical disorders.92 Kenya has eight adult neurologists and four child neurologists, and only two in public service at Kenyatta National Hospital. The remainder are only available in private settings.10 Availability of essential drugs The drugs listed on the essential medication list are • Carbamazepine (tablet)
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KAWE also developed a feature film, "It's Not My Choice," which was awarded a gold medal at the International Audio-Visual Festival in New Delhi in 1989.98 KAWE promotes awareness of epilepsy by distribution of educational materials.99 In 2013, KAWE launched "FAFANUKA," a mobile health awareness project that provides epilepsy education and directions to epilepsy clinics.99 Their primary focus has been on training health personnel. Since 1999 KAWE has trained over 1,428 medical personnel of various cadres and 2,894 community health workers.99 KAWE also developed a training manual for clinical officers and nurses that
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We would like to highlight some key gaps that could be addressed by a demonstration project.
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Strengthen and expand existing information systems infrastructure for MNS disorders Study Site We propose an intervention targeted at the county level, encompassing at least one county or subcounty hospital and its surrounding primary care sites and community. The selected county should demonstrate a commitment and ownership of the project by contributing matching funds for service provision as well as participating fully as a partner in the design and execution of the demonstration project.
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b. Adequate training and a supportive supervisory framework, including adequate numbers of community health workers, primary care health workers, and specialists in MNS disorders
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Individuals providing support to primary care facilities will generally be nurses and clinical officers who have responsibility over a district and can provide higher level services at the district hospital level. Innovative training models Prior efforts to train health care workers in Kenya to provide comprehensive mental health care have had modest success in improving health outcomes, but have not clearly improved diagnosis and treatment of mental health disorders.110,111 Diagnosis of mental and substance use disorders will have a foundation in a general psychosocial approach, and diagnosis of neurological disorders will be based on a comprehensive primary care approach.
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3. Strengthen existing infrastructure for distribution of essential drugs Our goal was to address several key challenges identified by the IOM, including inappropriate selection, ineffective supply chains, high pricing, and poor financing.25 KEMSA, the national authority charged with procurement and distribution of medications to MoH facilities, provides medications to county governments when requested.
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4. Strengthen and expand existing information systems infrastructure for MNS disorders The county governments and Department of Health Information Systems of the MoH will be key partners and stakeholders in this project.
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Below we describe the general activities over an initial 4-year period: • Year 1: o Select implementation site in consultation with county governments and key stakeholders o Develop training materials for health care providers aligned to the mhGAP-Intervention Guide (IG) o Evaluate and strengthen distribution of essential medications o Develop core set of variables for MNS disorders o Integrate training on mental health, using the mhGAP-IG, into existing training programs and with emphasis on existing service providers at county and subcounty health facilities • Year 2: o Begin training existing primary health care providers and community health workers in the participating county, integrating training into existing training programs as much as possible o Expand services across the county, with the goal of complete coverage by the end of the year o Continue to develop additional training modules • Year 3: o Provide services across the county • Year 4: Evaluation o Transfer management to the county government o Final evaluation
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These stakeholders should be engaged from the earliest phases of the project through to the monitoring and evaluation phase, and ultimately should extend beyond the life of the demonstration project and to scale up across the nation. The county government will also play a key role in national scale-up as a role model for other county governments.
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Our approach will require early engagement with and involvement of county governments and governors from the conceptualization of the demonstration through its implementation. We believe this will lead to local ownership of the process and a smooth transfer of ownership at the conclusion of the demonstration project -- and ultimately to the sustainability and scalability of these services across the country.
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Outputs and Outcomes Health facility assessment Health facility 1. Number of community health workers and health care workers trained to care for MNS disorders 2.
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Number of calls received by the hotline Community-Based Assessment Prevalence rates for MNS disorders 1. Prevalence of mental disorders a.
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168 MENTAL AND NEUROLOGICAL HEALTH CARE IN GHANA AND KENYA Disease-specific outcome metrics 1. Depression a.
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2014. Neurological disorders in the Global Burden of Disease 2010 Study.
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2004. Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys.
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2009. The global burden of mental disorders: An update from the WHO World Mental Health (WMH)
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2004. Structural levels of mental illness stigma and discrimination.
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2003. Common mental disorders among those attending primary health clinics and traditional healers in urban Tanzania.
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2008. Primary care treatment of epilepsy with phenobarbital in rural China: Cost outcome analysis from the WHO/ILAE/IBE global campaign against epilepsy demonstration project.
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2010. Demonstration project on epilepsy in Zimbabwe.
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2011. Training needs and evaluation of a neuro-HIV training module for non-physician healthcare workers in western Kenya.
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2014. Kenya national guidelines for the management of epilepsy: A practical guide for healthcare workers.
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2014. Training primary health care workers in mental health and its impact on diagnoses of common mental disorders in primary care of a developing country, malawi: A cluster-randomized controlled trial.
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2014. Supervising community health workers in low-income countries -- a review of impact and implementation issues.
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180 MENTAL AND NEUROLO A OGICAL HEALTH CARE IN GHA TH HANA AND KEN NYA FIGURES F (Autho analysis) .3 ors' FIGUR E-1 Burden of disease in Kenya, 2010.
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APPEN NDIX E 181 (Autho analysis) .3 ors' FIGUR E-3 Burden of disease du to neurologic disorders in Kenya, 2010.
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182 MENTAL AND NEUROLO A OGICAL HEALTH CARE IN GHA TH HANA AND KENYA N FIGUR E-5 Demon RE nstration projec structure.
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