Strengthening Human Resources Through Development of Candidate Core Competencies for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa

Workshop Summary

INTRODUCTION1

Sub-Saharan Africa (SSA) has one of the largest treatment gaps for mental, neurological, and substance use (MNS)2 disorders in the world. An estimated four out of five people with serious MNS disorders living in low- and middle-income countries do not receive needed health services (WHO, 2004, 2006, 2011a). The ability to provide adequate human resources for the delivery of essential interventions for MNS disorders has been identified as a critical barrier to bridging the treatment gap (Kakuma et al., 2011).

In 2009, the U.S. Institute of Medicine (IOM) Forum on Neuroscience and Nervous Systems Disorders and the Uganda National Academy of Sciences (UNAS) Forum on Health and Nutrition convened

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1 This workshop was organized by an independent planning committee whose role was limited to identification of topics and speakers. This workshop summary was prepared by the rapporteurs as a factual summary of the presentations and discussions that took place at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the Institute of Medicine and they should not be construed as reflecting any group consensus.

2 The phrase “MNS disorders” is used throughout this summary to refer broadly to the wide range of mental, neurological, and substance use disorders. This terminology was first adopted by the participants at the 2009 IOM workshop on reducing the treatment gap for MNS disorders in SSA (IOM, 2009) and has been retained for the current workshop.



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Strengthening Human Resources Through Development of Candidate Core Competencies for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa Workshop Summary INTRODUCTION1 Sub-Saharan Africa (SSA) has one of the largest treatment gaps for mental, neurological, and substance use (MNS)2 disorders in the world. An estimated four out of five people with serious MNS disorders living in low- and middle-income countries do not receive needed health services (WHO, 2004, 2006, 2011a). The ability to provide adequate human resources for the delivery of essential interventions for MNS disorders has been identified as a critical barrier to bridging the treatment gap (Kakuma et al., 2011). In 2009, the U.S. Institute of Medicine (IOM) Forum on Neuroscience and Nervous Systems Disorders and the Uganda National Academy of Sciences (UNAS) Forum on Health and Nutrition convened 1 This workshop was organized by an independent planning committee whose role was limited to identification of topics and speakers. This workshop summary was pre- pared by the rapporteurs as a factual summary of the presentations and discussions that took place at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or veri- fied by the Institute of Medicine and they should not be construed as reflecting any group consensus. 2 The phrase “MNS disorders” is used throughout this summary to refer broadly to the wide range of mental, neurological, and substance use disorders. This terminology was first adopted by the participants at the 2009 IOM workshop on reducing the treatment gap for MNS disorders in SSA (IOM, 2009) and has been retained for the current workshop. 1

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2 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA an international workshop to bring together stakeholders from across SSA and to foster discussions about improving care for people suffering from MNS disorders and what steps, with potential for the greatest impact, might be considered to bridge the treatment gap. The develop- ment of a diverse, well-trained network of MNS health care workers in SSA was identified during the workshop and in subsequent stakeholder conversations as a feasible step toward meeting the needs of the people in the region. Given the broad interest to further examine this particular treatment gap; the IOM Forum convened a second workshop in Kampala, Uganda, on September 4 and 5, 2012. The goal of the workshop was to bring together key stakeholders to discuss candidate core competencies that providers might need to help ensure the effective delivery of services for MNS disorders (see Box 1, Statement of Task). The workshop focused on candidate competencies for four MNS disorders that account for the greatest burden in low- and middle-income countries: depression, psychosis, epilepsy, and alcohol use disorders (Collins et al., 2011). Some high burden disorders identified at the workshop and in 2009 (IOM, 2009), but not addressed at this workshop, that have a significant burden include mental disorders such as bipolar depression, anxiety, and attention deficit hyperactivity disorder; neurological disorders such as stroke, dementia, Alzheimer’s disease, and Parkinson’s disease; and other substance use disorders such as cocaine addiction. Organization of the Workshop and Report In addition to a series of overview presentations, the workshop was organized around a series of breakout sessions (Appendix E, Agenda). The breakout sessions were designed for participants to discuss a series of draft materials that were prepared, and distributed, before the meeting. The materials included a set of templates that identified candidate core competencies, with one template for each disorder (depression, psychosis, epilepsy, alcohol use), listing characteristics for the different provider types to be discussed, including treatment environments; candidate core competencies relative to screening and identification, diagnosis, and treatment and care; and relationship roles with other providers. Prior to the workshop, these draft templates were shared with individual members of the working groups assigned to facilitate workshop discussions (Appendix F). Following the workshop, working group members checked the updated templates for clarity and to ensure

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WORKSHOP SUMMARY 3 BOX 1 Statement of Task  Assess the future needs of MNS health care workers based on provider type, treatment environment, and MNS disorder. o Examine human resource needs for effective delivery of treatments in a typical African district health care system. o Consider core competencies and performance requirements necessary to improve human resource capabilities for MNS disorders (e.g., diagnosis, prescribing of medicines, patient monitoring).  Discuss potential mechanisms for task shifting and task sharing among human resources and across treatment locations.  Explore education and training opportunities for acquiring and maintaining core competencies. o Consider existing and potential partnerships for:  Developing programs to train current providers to reach core competencies.  Implementing training programs.  Consider tangible next steps for the dissemination of identified hu- man resource core competencies and performance requirements. that all candidate core competencies discussed by workshop participants were included. Finally, the templates were edited again to ensure consistency. The following report summarizes the presentations and discussions by the expert panelists and participants during the plenary sessions of the workshop. Included is a summary table of candidate core competencies for providers treating patients with depression, psychosis, epilepsy, or alcohol use disorders (Appendix A). It is based on an expanded list of candidate core competencies discussed by the working groups (Appendix B). These candidate core competencies, as discussed by workshop participants, could potentially apply to the general population; however, specific populations (e.g., children, adolescents) were not discussed. It is important to note that the workshop was not designed or conducted as a consensus process, and the candidate core competencies described in this report and appendixes are not a formal consensus product of the workshop or the working groups. Rather, they are a compilation of all comments by workshop participants, and should be attributed to the rapporteurs of this summary as informed by the workshop. Throughout the workshop, many speakers and participants employed the phrase “mental health” in reference to health care systems, treatment

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4 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA and care, and candidate competencies. Many of the same speakers and participants commented that their use of the term “mental health” as it related to the workshop discussions and how care is delivered in SSA, could be broadened to include mental and neurological and substance use disorders. STRENGTHENING HUMAN RESOURCES The human resource shortage spans the entire range of providers involved with mental health care in SSA and throughout the developing world. Meeting this critical need involves not only increasing the number of providers involved in health care of individuals with MNS disorders, but also increasing the capabilities of providers, explained Vikram Patel of the London School of Hygiene and Tropical Medicine and workshop co-chair. This includes both specialized and non-specialized providers working within a task-sharing environment, each with the competencies needed to deliver on those tasks. In health care, competency is an attribute of an individual human resource that is engaged in the delivery of an intervention, Patel explained. It is the ability of the individual worker, based on his or her acquired knowledge and skills, to deliver an intervention to a desired performance standard. The first step toward defining human resources core competencies for MNS disorders, Patel said, is to understand the tasks necessary for delivering evidence-based interventions. What does it take, for example, to assess a patient, or to prescribe a particular drug therapy, or to deliver a psychological treatment? The next step is to define the candidate core competencies needed to perform those tasks to an expected standard, acknowledging that there might be certain limits to what a particular human resource category may be able to do, or is permitted to do in a particular context. The last step is to define how individual health care workers can acquire and maintain these competencies and how to evaluate them. General competencies are needed to be an effective health care worker, along with specific competencies for addressing MNS disorders. Some mental health care–specific competencies may be common across the many human resource categories that deliver health care interventions. Patel suggested that basic candidate competencies could include, for example, engaging patients, assessing mental and neuro- logical health and suicide risk, providing accurate information, making appropriate treatment decisions, and knowing when to refer to a higher

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WORKSHOP SUMMARY 5 level of care. Other more advanced candidate competencies may vary by MNS disorder or within a particular treatment context. Patel noted that this distinction is useful when considering task sharing because certain tasks may only be relevant to specific categories of human resources due to the advanced nature of the competencies that those tasks entail. Task sharing or task shifting involves taking a complex intervention (e.g., psychological treatment) and breaking it down into smaller skill sets that have sequential levels of mastery. When a provider masters a basic competency, he or she can build upon that to acquire more sophisticated levels of competency. In a collaborative framework, more complex competencies might need to be handled by more specialized providers. Depending on context, competencies may require different sets of skills, knowledge, and attitudes. Competency-based education is focused on the knowledge and skills of providers, with the ultimate goal of improving patient outcomes. Medical education is, by and large, competency based, Patel noted. He emphasized that moving from a knowledge-based approach to a competency-based approach requires the application of more diverse forms of evaluation. In knowledge-based education, evaluation is often in the form of a written examination, but assessment of competencies requires a more mixed-methods approach. WHY FOCUS ON DEPRESSION, PSYCHOSIS, EPILEPSY, AND ALCOHOL USE? The focus of workshop discussions was depression, psychosis, epi- lepsy, and alcohol use disorders, explained Seggane Musisi, professor of psychiatry at Makerere University and workshop co-chair. Together, the- se disorders affect about 10 percent of the population at any point in time, and have a significantly negative socioeconomic impact, account- ing for about 13 percent of disability-adjusted life years (DALYs) (Collins et al., 2011).3 Another reason to focus on these four conditions to start is that they are treatable, and in some cases are preventable. Musisi provided a brief overview of each disorder (see Box 2). 3 DALY is a measure of the overall burden of a disease or condition, calculated as the sum of years of life lost to premature mortality (YLL) plus years of life living in a state of disability (YLD). As defined by the World Health Organization, “one DALY can be thought of as one lost year of ‘healthy life’ and ‘the sum of these DALYs across the population … can be thought of as a measurement of the gap between current health sta- tus and an ideal health situation.’” See http://www.who.int/healthinfo/global_burden_ disease/metrics_daly/en/index.html for further information.

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6 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA BOX 2 MNS Disorders with the Greatest Disease Burden in Low- and Middle-Income Countries Depression  The most common mental disorder in low- and middle-income countries with a lifetime prevalence of 11 percent (Kessler and Bromet, 2013).  Complicates treatment of other disorders and increases morbidity and mortality (e.g., HIV/AIDS, diabetes, cancer, heart disease, posttraumatic stress disorder).  Often unrecognized and untreated.  Resources can be wasted in unnecessary testing and treatment before the patient gets to a mental health professional.  Causes premature deaths through suicides and homicides or through increased mortality with other disorders.  Associated with low socioeconomic production through decreased work output and increased absenteeism.  Responds well to treatment (pharmacological, psychological, social).  Many of the causes are preventable. Psychosis  Affects up to 1 percent of the general population, regardless of social class, race, ethnicity, or religion.  Gradual deterioration to chronicity, downward shift in social class, numerous social deficits.  Third most disabling condition worldwide.  Accounts for 1 percent of DALYs and 3 percent of YLDs in low- and middle-income countries (Farooq, 2013).  The most costly psychiatric disorder to treat is schizophrenia; most psychiatric hospital beds are occupied by patients with schizophrenia.  Associated with premature death via suicide or decreased life expectancy.  When diagnosed and treated early, prognosis is better.  Most modern drugs (e.g., atypical antipsychotics) are too expensive for routine use in developing countries; older drugs often have significant side effects (e.g., tardive dyskinesia). Epilepsy  The most common brain disorder in the general population.  Highly stigmatized in low- and middle-income countries.  Untreated, it can cause brain damage or lead to early death from asphyxia, drowning, burns, or accidents.

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WORKSHOP SUMMARY 7 Alcohol Use  Most commonly abused substance in low- and middle-income countries.  Accounts for 2 percent of deaths and 4 percent of DALYs worldwide.  Causes extensive end organ damage (e.g., liver, pancreas, brain).  Increases morbidity and mortality, especially through suicide.  Cost of care can be very high.  Associated with other health problems (e.g., cancer, domestic violence).  Increasingly a problem of youth.  Negatively impacts human capital.  Difficult to treat, but is preventable. SOURCE: Musisi presentation. OVERVIEW OF THE 2009 JOINT IOM AND UNAS WORKSHOP As background, Edward Kirumira, deputy principal of the College of Humanities and Social Sciences at Makerere University, provided an overview of the 2009 workshop, Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Reducing the Treatment Gap, Im- proving Quality of Care (IOM, 2009) (see Box 3). It was noted at the 2009 workshop that MNS disorders produce a very substantial disease burden in the developing world, but much of the focus has been on infec- tious diseases (e.g., HIV/AIDS, malaria, tuberculosis). Many discussions at the 2009 workshop emphasized the need for sustainable and feasible strategies for lasting change, multidisciplinary collaborations, research to guide evidence-based policies and practices, and engagement of the pub- lic and policymakers through advocacy and communication. Among the opportunities discussed for decreasing the treatment gap was increasing the number of trained professionals with expertise in MNS disorders. The 2012 workshop was designed to expand the discussion further. PROGRESS SINCE 2009 Pamela Collins, director of the Office for Research on Disparities and Global Mental Health at the U.S. National Institute of Mental Health (NIMH) and workshop co-chair, noted that over the 3 years since the 2009 workshop, much has happened to highlight MNS disorders around

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8 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA the world and to educate the global health community on the importance of addressing these disorders. WHO mhGAP Intervention Guide The publication in 2011 of the World Health Organization (WHO) mhGAP Intervention Guide, Collins noted, provided guidelines for implementing evidence-based interventions for several MNS disorders in low- and middle-income countries (WHO, 2011b). Also in 2011, as part of its Global Health Series, the Lancet published its second article series focused on global mental health (Eaton et al., 2011; Kakuma et al., 2011; Patel et al., 2011; Raviola et al., 2011). These papers highlighted, among many other topics, the status of the workforce in low- and middle-income countries and progress on scaling up interventions to reduce the treatment gap. BOX 3 Highlights from the 2009 Workshop Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Reducing the Treatment Gap, Improving Quality of Care Workshop Topics  Need to consider all nervous system disorders  Benefits through leveraging skills, expertise, and networks of other health fields (e.g., HIV/AIDS, malaria)  Include a focus on treatment and prevention  Improve the available medication formulary  Expand the use of high-quality, community-based care, and the training of community health workers Opportunities for Decreasing the Treatment Gap  Recognize the interconnected nature of MNS disorders  Establish comprehensive policies  Promote high-quality research that will provide evidence to inform health policy  Improve the integration of basic diagnosis and treatment into primary care  Leverage established infrastructures  Increase the number of trained professionals with expertise in MNS disorders  Formalize community health care providers as an integral component of the health system  Improve the formulary of medications to treat MNS disorders

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WORKSHOP SUMMARY 9 Next Steps Sustainable and Feasible Strategies  To make lasting change, a system of supervision and support may be necessary  Improving care for MNS disorders in SSA will require a strategic plan Collaboration  Cooperation with researchers and health care providers around the continent and across disease specialties  Integration of MNS care into programs that support other diseases (e.g. HIV/AIDS, malaria, tuberculosis) Research  Need for data that would help guide the development and imple- mentation of MNS policies (e.g., cost-effectiveness) Advocacy and Public Communication  Increase the audience that is aware of issues related to treating and caring for patients with MNS disorders  Engagement and involvement of policy makers NOTE: These statements are based on individual participant comments at the 2009 workshop and do not reflect group consensus. SOURCE: IOM, 2009, as summarized in Kirumira presentation. Grand Challenges in Global Mental Health The Grand Challenges in Global Mental Health Initiative, launched by NIMH and collaborators, identified priorities for research on MNS disorders and highlighted 25 research priorities needing immediate atten- tion to help reduce the treatment gap (Collins et al., 2011). Collins noted that the top five challenges ranked by disease-burden reduction, impact on equity, immediacy of impact, and feasibility are 1. Integrate screening and core packages of services into routine primary health care. 2. Reduce the cost and improve the supply of effective medications. 3. Provide effective and affordable community-based care and rehabilitation. 4. Improve children’s access to evidence-based care by trained health providers in low- and middle-income countries. 5. Strengthen the mental health component in the training of all health care personnel.

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10 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA Provider Education Education is receiving greater attention, with regard to both increasing the number of educated health professionals and examining how training is provided. Collins highlighted a report from the Commission on Education of Health Professionals for the 21st Century. It concluded that professional education courses have not kept up with the increasing complexity of health systems around the world, rapid demographic and epidemiologic transitions, and the need to diminish major inequities in health care around the world, both within and between countries (Frenk et al., 2010). The report also emphasized the importance of balancing individual patient care with population health. Collins summarized some of the issues with professional education highlighted in the report, including a mismatch between competencies and patient or population needs; poor teamwork among providers; narrow technical focus of training that does not afford providers with an understanding of the broader context in which they work; a focus on hospital-based care over primary care; and a focus on episodic encounters with the health care system instead of continuity of care. These issues are relevant to the delivery of MNS health services in many parts of the world, she added. Collins charged workshop participants to discuss the draft candidate core competencies for the management of depression, epilepsy, alcohol use disorders, and psychosis, focusing on candidate competencies that might be needed for each kind of provider to be able to manage MNS disorders, from community health workers through psychiatrists and neurologists, and all other levels. “What is at stake,” Collins emphasized, “is alleviating suffering for the many people who experience these disorders.” STATUS OF MNS HUMAN RESOURCES IN SUB-SAHARAN AFRICA Daniel Chisholm, a health economist at the WHO, shared data from the WHO Mental Health Atlas 2011 on the state of mental health human resources in SSA (WHO, 2011a). SSA has a total population of approximately 800 million. The WHO survey identified that there are approximately 20,000 mental health workers across all SSA countries, with a staff-to-population ratio of about one mental health worker for 40,000 people. This can also be expressed as 2.5 mental health workers

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WORKSHOP SUMMARY 11 or “full-time equivalents” (FTEs)4 per 100,000 population. For perspective, Chisholm noted that the WHO estimates the minimum number of health workers across all specialties required in order to deliver on the goals and commitments of the health-related Millennium Development Goals (MDGs) to be 2.5 health workers per 1,000 population, which means that current levels are 100 times below what is needed. The total mental health workforce count varies by country. South Africa and Botswana each report around 11 or 12 FTE per 100,000 population, however, close to half of SSA countries report one or less FTE per 100,000 population (see Figure 1). Nurses make up the vast majority of the mental health workforce in SSA at 75 percent, while psychiatrists and psychologists combined comprise only a small fraction at 6 percent (see Figure 2). Defining the Gap Efforts have been made over the years to estimate the number of health workers needed to provide comprehensive mental health services in SSA. Chisholm described one case study for South Africa, which estimated full coverage as 38.4 mental health workers per 100,000 people and 13 workers as the minimal number for acceptable coverage (Petersen et al., 2012). Another study by Chisholm and colleagues considered workforce re- sources for eight key disorders included in the WHO mhGAP Inter- vention Guide5 across 58 low- and middle-income countries around the world, including 8 SSA countries6 (Bruckner et al., 2011). They attempted to map out services and staffing that would be needed for dif- ferent populations with various demographic and epidemiological char- acters. For this particular study, the authors looked specifically at nurses, psychosocial care providers, and psychiatrists. First, service need was calculated based on the population of the country, the prevalence of the eight key disorders, coverage or the proportion of people in need who will actually receive care, and the typical care package provided. The number of health workers needed in each country was then calculated using the estimated service need and staffing ratios. 4 Full-time equivalent is the number of working hours corresponding to one full-time employee during a fixed year. 5 “Depression, schizophrenia and other psychotic disorders, suicide, epilepsy, de- mentia, disorders due to use of alcohol, disorders due to use of illicit drugs, and mental disorders in children” (WHO, 2008). 6 Benin, Burundi, Congo, Eritrea, Ethiopia, Nigeria, South Africa, and Uganda.

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38 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA maintaining their registration. In the current program, professionals no longer only see patients in private practices, but instead also support community programs and provide supervision to community lay workers. In summary, Chibanda said, Zimbabwe has adopted a more holistic approach to MNS issues and is increasingly using modern technology to teach and deliver interventions. Regular visiting lecturers and an ex- change program help to maintain interests of students and professionals. He added that as more students travel on exchange programs they are less likely to permanently leave when they finish their education. Encouraging and funding regular travel and providing opportunities to link with other specialties is important. Ethiopia Tedla Wolde-Giorgis, mental health advisor to the Federal Ministry of Health in Ethiopia, described the released Ethiopian National Mental Health Strategy for 2012/2013 to 2015/2016.10 This strategy will leverage the already existing health system while integrating MNS health care at all levels. All health care professionals will receive training to provide care appropriate to their role within the health care system. The system will be decentralized, but Wolde-Giorgis stressed it will be fully integrated and will not result in new silos. The Ethiopian health system consists of the Federal Ministry of Health, Regional Health Bureaus, zonal health offices, district health centers, local health extension posts, and community health extension workers. A new approach to community engagement has been developed, referred to as the “health development army,” Wolde-Giorgis explained. “Model families” are recruited for the health army and, with the support of paid health extension workers, help to disseminate information and influence healthy habits in other families throughout the community. Health extension workers train model families in health- related activities. The model families are then attached to five other households. Their role is to encourage and to support these five families to become models as well. Wolde-Giorgis described the National Mental Health Strategy as one of contextual integration. For example, similar to how general nurses 10 See http://www.globalmentalhealth.org/sites/default/files/Ethiopia%20MH%20 Strategy.pdf.

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WORKSHOP SUMMARY 39 have learned to provide antiretroviral therapy to HIV/AIDS patients, they can also be trained to provide psychotropic medications. There are HIV case managers who are already trained in basic counseling skills and do AIDS-related counseling such as ART adherence counseling. Their expertise can be leveraged and their competency expanded to be able to identify MNS disorders and provide appropriate care, referral, and follow-up. Wolde-Giorgis stressed that this is not the introduction of a whole different system, but building on existing infrastructure. One challenge to progress is how best to capitalize on minimal financial resources allocated for MNS disorders. Most of the funds for the MDGs are allocated to the designated priorities such as malaria, tuberculosis, and family planning. Wolde-Giorgis suggested that this will require integration of care for MNS disorders into the already existing system through task sharing. This process will meet resistance because providers are already overwhelmed and are concerned about “task dumping.” There are different levels of competence, Wolde-Giorgis noted. For example, informational competence is where one has knowledge about a topic area; interpersonal competence is where one is able to communicate effectively and engage the patient, or may be able to communicate with external organizations; and cultural competence is where one has an understanding of the community. There is also interventional com- petence, in other words, can you go out and work with patients? Can you intervene? Wolde-Giorgis emphasized that the acquisition of core competencies cannot take place in one training session. Training is a process that requires continual reinforcement to ensure providers reach interventional competence. This can be a costly venture, he acknowledged, and finding balance between obtaining those competencies and providing supervision, coaching, mentoring, and in-service training is important. For example, the Ethiopian National Mental Health Strategy specifically discusses periodic supervision, mentoring, and coaching as important for attaining and retaining core competencies. The strategy also identifies different functions, core requirements, and competencies for different providers. Uganda Sheila Ndyanabangi, national coordinator of mental health services at the Ministry of Health in Uganda, focused her comments on strengthening human resources for MNS disorders in primary care. In

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40 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA 2002, upon realizing the low numbers of professionals trained in MNS disorders and the lack of MNS care at the primary health care level, the Ministry of Health started an in-service training program. At that time, MNS in-service training was done centrally, with the health workers coming from their districts to the tertiary hospital for lectures and some practical sessions, however there was no follow-up or supervision of trainees. Many of the trainees were not frontline prescribers. In addition, training was led by experts who used complex terminology. Therefore many of the health workers did not or could not practice what they had learned when they went back to their districts. Since then, many changes have been made and the program continues to be evaluated and improved. Now, training about MNS disorders is provided as part of pre- service training for all health workers. Ndyanabangi highlighted some of the lessons learned and achievements. Among the approaches that worked well was the development of training materials with a cross-section of providers, including psychiatrists, psychologists, social workers, psychiatric clinical officers, and nurses. Another important component, she explained, was the inclusion of trainees for whom the materials were being developed, which ensured the relevance and appropriateness of language and expected competencies. The language in the manuals was simplified to help demystify neuropsychiatric terminology and training was con- centrated on common conditions that are managed in primary care. Methods for adult learning were used, including group discussions, role play, and practical sessions. The training also included providers, including psychiatric clinical officers and the nurses, who would carry out future supervision of the trainees. This helped to bridge the gap between primary care and specialists. In addition, formation of networks for follow-up, referrals, supervision, and mentoring are encouraged. The training process now includes orientation of district political leaders, the district health management team, the chief administrative officers of the district, the health managers of the health facilities, and others in key sectors such as education, social development, religion, and law enforcement, to provide supportive mechanisms for change. Such mechanisms include, for example, recruitment of the appropriate providers, a referral system, access to essential medicines, and resettlement and reintegration of patients after referral. The process also provides for supervision and mentoring on a monthly basis, by either regional or district-based mental health professionals. This helps to build the confidence of trainees. In addition, the use of modern technology is

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WORKSHOP SUMMARY 41 encouraged, such as consultation by mobile telephone with expert trainers. Achievements Ndyanabangi noted that this training system has served to achieve political commitment and awareness of stakeholders about MNS disorders, which are critical for successful integration of MNS disorders into primary care. MNS health care is for everybody, she said, and is not just about patients, but the whole community. In practical terms, the training system has led to increased attendance and care, as shown by Uganda’s health management information system. For example, between 2009 and 2011, there was an increase of 17,000 more patient visits at the primary care level. The success of the training program has also helped attract more general health workers to train as mental health professionals, Ndyanabangi said, and many now view MNS health care as a good area in which to specialize. Moving Forward Ndyanabangi stressed that to engage policy makers and the public, it is necessary to raise awareness of the importance of mental health in day- to-day life, and not focus only on the treatment of MNS disorders. Linking MNS health care to popular issues such as education, poverty eradication, sexual- and gender-based violence, conflict and disaster, and alcohol and substance abuse helps to make treating MNS disorders relevant to the general population. Ndyanabangi highlighted the importance of mid-level providers, such as psychiatric clinical officers, to bridge the gap between specialists and general health care workers. Investment in comprehensive processes to secure buy-in and support of MNS human resource training, starting with a policy change at the national level, integration of MNS guidelines in Ministry of Health guidelines, and orientation of district structures, will be important for the success of any effort. Finally, Ndyanabangi stressed that competencies for leadership, advocacy, and resource mobilization would need to be incorporated into all training programs to be able to successfully integrate MNS into general care. Most training programs are about the “what” (i.e., the knowledge), but little about the “how.” We need to concentrate it on the “how,” she suggested.

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42 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA Rwanda Jeanne d’Arc Dusabeyezu, director of the Unit of Drug Abuse Prevention and Treatment at the Ministry of Health, Rwanda, explained that much of the MNS health care focus in the country is focused on psychological suffering and emotional distress associated with the Rwandan genocide. In the after-genocide period, Dusabeyezu explained, people are facing posttraumatic stress disorder (PTSD), severe depression, and psychosis along with other conditions and are in need individual medical psychological interventions and community shelters. Dusabeyezu explained that MNS health care operational services have been established at several district hospitals and at the community level. Regular refresher sessions are held for specialists and nurses who work in district hospitals and referral hospitals. General medical doctors and general nurses from district hospitals and health centers are trained in MNS disorders twice yearly. Community health workers who deal with non-communicable diseases are now being trained in MNS disorders. In addition, members of some genocide survivor associations and other associations are being trained in basic management of PTSD or emotional crisis and Red Cross volunteers are given the appropriate training module on PTSD management. As noted by others, Dusabeyezu said there was some resistance among non-specialist health care providers toward integrating MNS health care into general care. However, as the training progressed, there was increased understanding and more active involvement in the management of MNS programs. Referral of MNS cases also improved. For example, a patient who is referred to the specialty hospital for the management of a psychological crisis can now be referred back to the district hospital that has a psychiatric nurse, and follow-up care can be provided at the local level. Dusabeyezu noted growing demand for MNS disorders training by general nurses working at the health center level and their respective hospital managers. As a sign of the success of the training programs, Dusabeyezu said there has been better recognition and management of MNS disorders as well as a remarkable involvement by non-specialized professionals. The number of people accessing MNS health services has improved, in part because many can now seek services near their home. In addition, everyone in Rwanda has “Mutual Health Insurance” that covers the care they receive at all levels.

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WORKSHOP SUMMARY 43 Panel Overview Speakers highlight significant challenges but also successful programs concerning the integration of services for patients with MNS disorders (see Box 7). PERSPECTIVES ON NEXT STEPS In the final session, the workshop co-chairs and participants discussed practical next steps for dissemination and implementation of the candidate core competencies identified at the workshop and identified potential partners to continue efforts around this topic. Collins suggested integrating what was discussed at the workshop with larger ongoing efforts, such as MEPI discussed earlier, which is focused on designing competencies for medical education. She reiterated the points made by Chibanda regarding research as a way of making training exciting and interesting. She noted that MEPI provides opportunities for research exchange programs, allowing investigators to have mentors outside of their countries. NIMH is investing in building research capacity through a program of collaborative hubs for research in international mental health, she said. How can these research capacity-building platforms be used to streng- then what countries are doing regarding medical education? For example, can they provide opportunities for trainees to become involved in research locally? Collins also raised the question of how professional as- sociations could be engaged in issues of MNS human resources and com- petencies. As noted by many participants, a critical key for buy-in is engaging stakeholders at all levels. Musisi raised several issues for consideration. The first is the importance of engaging governments to consider the development of MNS health policies, and to improve funding for the integration of MNS health services into general health care and for training programs. Musisi next suggested that overcoming the stigma associated with MNS disorders and the care of patients would be important for long-term change. Identification of allies in training, collaboration, and service delivery could be one mechanism for reducing stigma. Another concern is the lack of career paths for many providers. Musisi left the audience with this question: How can training be revised to offer degrees and career groups, and thereby retain providers?

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44 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA BOX 7 Challenges and Opportunities for Integration Challenges  Establishment of a need for integration  Attracting individuals into MNS care specialties  Sustaining providers within the region once trained  Lack of defined roles and responsibilities around integration  Minimal human and financial resources for capacity building  Overwhelmed providers Opportunities  International funding for development of training and research opportunities  Greater willingness of community/lay workers to be involved in treatment and care initiatives  Modern technology to deliver training and interventions  Examples of successful programs integrating MNS disorder treatment and care into the general health care system  Development of candidate core competencies for other diseases (e.g., HIV) that can be leveraged  Development of training materials by a cross-section of providers  Increasing engagement of policy makers and the public SOURCE: Adapted from Sahabo, Chibanda, Wolde-Giorgis, Ndyanabangi, and Dusabeyezu presentations. Patel reflected on the workshop discussions, including his ex- periences as a member of two breakout groups. He noted that a large portion of the discussion focused on how the numerous human resource categories were classified, organized, and defined. Many discussions focused on prescription practices, country differences, and relationship roles. The discussion of candidate competencies focused primarily on clinical aspects, but Patel noted the importance of system level competencies, such as supervisory skills. Teaching and supervision do not always come naturally and are skills to be learned, much as surgical skills are learned. Patel stressed the importance of recognizing that specialists and other professionals high in the system would benefit from competencies in capacity building, supervision, advocacy, and leader- ship. Patel asserted that system level competencies would need to be considered separately from clinical competencies.

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WORKSHOP SUMMARY 45 When considering candidate competencies for MNS disorders across SSA, Patel suggested it is important to consider that resource levels are highly variable, even within an overall low resource context. A large number of participants noted during the workshop that in many areas there are no health professionals trained in MNS disorders. Patel emphasized that a full, multi-level human resource framework laid out during the workshop might be non-existent in some places, and that the candidate competencies would need to be adapted relative to the most highly trained provider available. This is a work in progress, Patel emphasized, and he offered several guiding principles to consider going forward:  Care of MNS disorders is guided by a framework of collaborative stepped care that implies a team effort of different providers, with different levels of competencies, delivering different kinds of interventions, according to their complexity and the needs of individual patients.  The purpose of developing candidate core competencies is empowerment, giving MNS care providers more skills to make them more effective and efficient, within a collaborative framework of active support and supervision that includes incentives and career paths. Additional tasks are not being “dumped” on the person at the next lower level; rather, they are becoming fully integrated within a system of relationships.  A key feature of developing candidate core competencies would be finding a common language to communicate across the many different efforts geared toward improving access to MNS health care. Competencies are a uniting feature of these diverse programs and will likely have similarities with other programs and disease areas. Practical Considerations for Moving Forward Numerous individual comments were made during the final discussion regarding how best to move forward with the development and integration of candidate core competencies. Many of these final comments reiterated points made by participants throughout the workshop. The following list highlights recurring topics and is provided here as part of the factual summary of the workshop. These should not be construed as reflecting any consensus of the workshop participants or any endorsement by the Forum or the IOM.

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46 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA  MNS health care as a complement of general health. Many participants noted that linking the treatment and care of patients with MNS disorders to general health and to improved outcomes for other diseases (e.g., HIV) might facilitate integration of MNS health care into the larger health care system, encourage development of MNS health policies and legislation and increase funding for MNS health care.  Community-driven public education. Many participants stressed the need for education about MNS disorders geared toward the public. Increased knowledge about the causes of MNS disorders might reduce stigma and misperceptions. A few participants noted that peer-to-peer education driven from the community level might be more successful because community members would be more familiar with cultural differences.  Training and career paths. Many participants suggested that training of mid-level providers (e.g., clinical officers) be revised to offer degrees and career growth. One participant noted that incentives, such as research opportunities and degrees, might also improve retention of providers. While training would be a critical component of any next steps around developing additional candidate core competencies, many participants noted that mentoring, post-training evaluations, and continual education are just as important as initial provider trainings.  System-level competencies. Many participants noted that training in supervision, teaching, leadership, and advocacy is lacking at all curriculum levels. Several participants noted that increasing training in these and other areas, such as resource mobilization and fundraising, might lead to greater ease of integration of MNS care into general health care.  Information technology. Several participants noted that nurses and medical officers are sometimes put in challenging situations where access to support or other health professionals is limited. With new technologies, support might no longer require that other providers be physically present; instead, remote con- sultations with experts can take place via telemedicine. These new avenues of engagement might also deliver increased as- sistance to providers in rural areas or other remote locations. Technology might also be used to enhance training and mentoring.

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WORKSHOP SUMMARY 47  Lessons learned from other areas. Throughout the workshop, examples of integration of MNS health care into established health systems and approaches to training and engagement were discussed. Many participants stressed the importance of examining successful sustained efforts around candidate core competencies, integration, training, and continuing education. One participant noted that efforts to reduce the treatment gap for MNS disorders need not start from “square one.”  Collaboration and engagement. A large number of participants indicated that developing partnerships with a diverse array of stakeholders will be critical for improving care for MNS disorders across SSA. Participants suggested that partners with the technical expertise to help further develop the candidate core competencies into a plan of action would be valuable. In addition, many participants indicated that collaborations might focus on governments and NGOs that can help identify financial resources, engage policy makers, and create collaborations across disease areas with shared competencies.  Evidence-based research. Many participants noted that a challenge to securing government, private-sector, and public support for MNS-related initiatives is the lack of evidence-based information on the burden of MNS disorders in many SSA countries. Throughout the discussions, participants urged investments in research to extend the evidence base for task shifting and task sharing as an approach to the provision of services for patients with MNS disorders. One participants noted that the treatment gap for MNS disorders might be reduced through a greater understanding of the evidence base for integrating MNS health services into other platforms of care. Closing Remarks Ndyanabangi of the Uganda Ministry of Health suggested that upon returning home, participants review their different approaches to capacity building and look for potential mechanisms to improve on programs that are delivering competencies needed for MNS health workers. Collins of NIMH stressed the need for accountability, both for governments to be accountable in terms of what they do for patients with MNS disorders, and for the workshop participants to be accountable for taking this process forward.

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48 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA Alan Leshner, chief executive officer at the American Association for the Advancement of Science and workshop planning committee member, encouraged participants to use the workshop discussions and candidate core competencies as tools, adapting them for use in their own local policy-making systems.