Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya Workshop Summary (2016) / Chapter Skim
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Appendix F: Providing Sustainable Mental Health Care in Ghana: A Demonstration Project
Appendix F: Providing Sustainable Mental Health Care in Ghana: A Demonstration Project
Pages 183-232
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From page 183... ...
"Knowing is not enough; we must apply. Willing is not enough; we must do." Goethe "No condition is permanent." Popular Ghanaian saying a CBM International.
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, a reflection of the substantial efforts made by a growing civil society sector interested in mental health. These efforts, over the past decade, have also seen the emergence of one of the strongest service user movements in Africa, new cadres of trained personnel, and a greater awareness of mental health issues in the country.
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NOTE: GDP = gross domestic product; HDI/R = human development index and rank; MICS = Multi-Indicator Cluster Survey (UNICEF) ; UNDP = United Nations Development Program; UNICEF = United Nations Children's Fund; USD = United States dollar.
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Each district has a District Health Management Team headed by a district director, who reports to the regional director. Every region has a regional hospital, and each district should have a district hospital, although the facilities available in some are limited.
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2444 Regio hospitals onal 1 10 Distri hospitals ict 1330 Health centers h 810 Comm munity-based health plannin and service h ng e compounds 1,5 562 Persoonnel Docto (total) ors 2,2 200 Physician assistants 2,2 280 Regisstered nurses 17,,322 c As def fined by the Ab Declaratio of 2001.
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Since the Mental Health Act was enacted in 2012, a new Mental Health Authority has been charged with managing mental health issues, though it is still in its formative stages. The governing body of the Mental Health Authority is an 11-member board with a number of committees under it.
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Prisons have high rates of mental illness, with inadequate care provided. Given this lack of services, particularly in more rural areas, it is not surprising that there is a large treatment gap.
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This is particularly the case for severe mental disorders such as schizophrenia, bipolar affective disorder, mod erate and severe depression, and epilepsy. Such evidence-based medical interventions are advised in the mhGAP Intervention Guide, a publication by the WHO Mental Health Gap Action Program (mhGAP)
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The Mental Health Act has seen some collabora tive work across agencies. Health Management Information Systems Recent years have seen a significant investment in improving the way that information is gathered and managed, both for recordkeeping and data collections for individual patients, and for service-level information.
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The indicators in the WHO Comprehensive Mental Health Action Plan6 are a good example. Health Promotion, Prevention of Ill Health, and Surveillance In general, health surveillance is strongest in child and maternal health services that have been a focus of government health efforts, largely driven by the Millennium Development Goals.
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- of which are community psychiatric nurses 160 Clinical psychologists 100 - of which work in health facilities 20 Occupational therapists 1 Psychiatric social workers 0 * Many of whom do not work in mental health.
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The Mental Health Society of Ghana works to support these groups, not only for the potential therapeutic benefit, but for advocacy purposes. Financing At the individual and family levels, a chronic mental illness can have a catastrophic effect on financial security.
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Human Rights Wat n tch publish a compre hed ehensive repo on human rights in the formal and tr ort raditiona sectors in 20124 that gained wide international attention. T al g The new Mental Health Act provides some powe to the Men Health A M h ers ntal Authority to enforce ri y ights, and it will be interes w sting to see to what extent it o t will im mpact the expperience of pe eople being suubject to hum rights abu man use in institutions and communities across the cou c a untry.
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The new law has been seen as a model for reform of mental health legislation in other parts of Africa. It is particularly strong in recognizing and upholding human rights of people with mental illness and emphasizes community care.
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Research Ghana has a strong history of research in mental health, going back many decades.13 Well-established local research institutions like the University of Ghana and the Kintampo Project have participated in important international collaborations such as the Mental Health and Poverty Project. International NGOs such as BasicNeeds and CBM International have a strong philosophy of evaluation and research within their projects, and have published examples of good practice.14,15 The WHO is collaborating on an important demonstration project related specifically to improving services in the field of epilepsy using the evidence base of mhGAP.
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Overall Objective "Persons with mental health needs and psychosocial disability are able to have access to good-quality mental health care through local mainstream health services, and to be included in community life." A demonstration project will be carried out and evaluated to inform replication. Principles Underlying Proposed Model As a demonstration project, we have aimed to follow best practice principles, established evidence, and stakeholder consensus, to meet the specific needs using the available resources in Ghana.
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• Accessible, made to be as easy to use as possible (taking into ac count proximity, cost, cultural acceptability) • Integrated into the existing systems, mainstreaming mental health into general services, and reducing barriers across sectors • Adapted for the local context and cultural norms of the people who would use the services • Developed in a participatory way, from future users of the ser vices to key decision makers whose buy-in at an early stage will facilitate future support • Sustainable and economically viable in the economic context of Ghana, and able to show good value for investment by potential donors • Replicable at scale; the project aims to inform possible scale up in Ghana and beyond • Well evaluated; as a demonstration project, results that will be taken seriously by health leaders and planners need to be backed up by data collected in a methodologically sound way Partnership This technical proposal for a demonstration project in Ghana is an initiative of the IOM and developed with the collaboration of local partners.
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. Catchment Area The overall objective of the project is to inform a process of reform of mental health services in Ghana with the aim of increasing coverage of accessible mental health services in the country.
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This includes situation analysis, planning and model development, awareness raising, initial capacity building and training, and the necessary evaluation and dissemination, etc.
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2. Mental health Ghana has three large Use evaluation of resources central- specialist hospitals, demonstration project to ized in and near big which are the main cen- show process and efficities and in large ters of care availability.
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model using existing health workers Positive development of workers. Add training (in trained and super- new mid-level profes- Mental Health Gap Acvised in mental sional grade in mental tion Program [mhGAP]
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Similarly, project oversight will be provided by a Steering Committee under the Mental Health Authority, but this will be made up not only of health system leaders, but a variety of professionals, persons with project management experience, and service users. Accountability will be ensured through inclusion of service users in the Steering Committee, with user satisfaction being a key indicator.
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Prior to implementation, there would also be need for a phase of more detailed situation analysis and baseline data collection. 3: Establish integrated Community Mental Health services in government health structures in two demonstration sites.
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These approaches will be used not only due to the limitation of available resources, but because much evidence supports their efficacy.25 The details of how this would be done in Ghana will depend on the situation analysis and planning process, but are likely to include tasks being done at certain levels, as summarized in Figure F-3. Among these different groups, there should be regular communication and supervision, and clear lines of referral.
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s structures, the ere is an important role for others involved in m i e i mental health care in Ghan na. They include servi users and their famili ice d ies; NGOs pr roviding heal lth and soocial care ser rvices; advoc cacy and cammpaigning org ganizations an nd umbre bodies; traditional and religious hea ella d alers; interna ational develoopment organizations and acade s; emic organiz zations intereested in men ntal health.
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Challenge myths and stigma. Changing Attitudes and Behavior The negative experiences of discrimination and human rights abuse are frequently identified by service users and others as major priorities for action, given the detrimental impact on quality of life.
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Addressing issues of human rights abuse and unhelpful negative myths will also be possible in the various multistakeholder forums that will be held to develop, oversee, and evaluate the program. The Ministry of Education has a Schools Health Education Program division.
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The results would not only be valuable in Ghana, but provide the guidance needed by many countries as they strive to meet the expectations to improve mental health services. There is growing international and local public pressure to bring mental health services into parity with physical health services, through local progressive legislation, and global agreements such as the Comprehensive Mental Health Action Plan.
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Sammy Ohene, who gratefully acknowledge the support of many experts in Ghana, particularly the Mental Health Board members.
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LAMIC low- and middle-income country (World Bank definition) MAKS Mental heAlth Knowledge Scale M&E monitoring and evaluation MGMH Movement for Global Mental Health MH mental health MH Authority Mental Health Authority mhGAP WHO Mental Health Gap Action Program MHIN Mental Health Innovation Network
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NCD noncommunicable disease NGO nongovernmental organization NHIS National Health Insurance Scheme PHC primary health care PWPD people with psychosocial disabilities SMD severe mental disorder (e.g., schizophrenia, bi polar affective disorder, severe depression) ToT Training of Trainers UNDP United Nations Development Programme UNICEF United Nations Children's Fund USD United States dollars WHO World Health Organization
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214 MENTAL AND NEUROLO A OGICAL HEALTH CARE IN GHA TH HANA AND KEN NYA Appendix 1 A Map of Fac cilities Providi Mental He ing ealth Care in Ghana = Specialist hospital = Regional hospital with psych unit h = Teaching hospital h = Nongovern nmental organiization providi mental care ing e
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APPENDIX F 215 Appendix 2 List of Civil Society Organizations Working in Mental Health National Organizations Name Field of Work National (multiple regions) Mental Health User movement for persons with mental illness Society of Ghana or epilepsy MindFreedom Human rights−based organization involved in Ghana advocacy and public education Ghana Mental Umbrella organization for all persons and orHealth Association ganizations with interest in mental health Psycho-mental Public education Health International Remar Drug rehabilitation Chosen Rehab Drug rehabilitation Presbyterian Church Community-based rehabilitation programs in of Ghana Upper East Region International Organizations Name Field of Work BasicNeeds Mental health and development CBM International Disability and development Department for International Development Bilateral donor European Union Multilateral donor
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216 MENTAL AND NEUROLOGICAL HEALTH CARE IN GHANA AND KENYA Name Field of Work Mental Health Educators in the Diaspora Training local mental health personnel World Health Organization UN agency Research Groups Active in Mental Health Research Name Area of Research National Christian Health Association of Maternal depression and epilepsy Ghana-Project Fives Alive! International collaborations Kintampo Health Research Centre Community mental health Fight Against Epilepsy Initiative Epilepsy
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cooperates demonstration sites are able to have tricts that will reach 20- Patient outcome data and provides support. access to quality mental health care 40% of people with collection and analysis.
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. Results 2: 2.1 Carry out detailed situation 2.1.1 Situation analysis Published reports on Assume information is analysis in identified demonstration carried out and report Ghana mental health available without need for Situation analy- sites to document needs and availa- written.
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Risk that staff will not want grated Communi- each level based on clearly defined 3.2 Relevant personnel Documentation of person- to work in rural areas (rety Mental Health tasks. identified and trained nel posted appropriately.
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4.3 Explore most appropri- willing to integrate MH to non-medical 4.4 Health management information ate model for making into their work. services.
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service users) who will ers, radio/TV programs.
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resources developed available. 6.3 Develop program, 6.4 Engagement with stakeholders materials (training, record in mental health (including gov- keeping, HMIS, referral, ernment structures)
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Meet with local leadership to gain Situation analysis and support. planning: Hold mapping exercise for needs Complete full situation and resources (national and in analysis in identified detail in demonstration sites)
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demonstration sites. Carry out TOT and trainings at each level.
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, ideally using service users and family members as advocates. Design of curriculum module for schools, testing, and evaluation.
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Results 2: 2.1 Carry out detailed Situation analysis and situation analysis in planning: Complete full identified demonstrasituation analysis in iden- tion sites. tified demonstration sites, 2.2 Use detailed situadesign implementation tion analyses to inform model, develop M&E development of a plan.
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Ensure good intersectoral 4.3 Lack of psychologlinks to facilitate access ical care. to non-medical services.
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228 Year 1 Year 2 Year 3 Year 4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Results 5: 5.1 Hold forums of Increase community traditional leaders and awareness of mental healers. health issues.
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229 APPENDIX F X App pendix 5: Organizational Diagram fo Ghana Dem r l or monstration Project
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2013. Mental health action plan 2013-2020.
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2006. Shunned: Discriminatio against peo 2 on ople with mental illness.
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New York, NY: UNDP. http://hdr.undp.org/sites/default/files/hdr14-report-en-1.pdf (accessed August 18, 2015)
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