Strengthening Human Resources Through Development of Candidate Core Competencies for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary (2013)

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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 

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 

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 

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 

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. 

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. 

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 

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 

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. 

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 

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. 

14 12 Other health worker 12 Occupaonal therapist Social worker 10 Psychologist Nurse 8 Other doctor Psychiatrist 6 FTE per 100,000 population 4 2 0 Cô te d’ Iv oi re FIGURE 1 Current mental health worker head count across sub-Saharan Africa (expressed as total full-time equivalent per 100,000 population). CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA SOURCE: Chisholm presentation, citing WHO, 2011a. 

WORKSHOP SUMMARY 13 Psychiatrist, Occupational Other worker, 676, 4% therapist, 185, 1% 2,295, 12% Other doctor, 766, 4% Social worker, 474, 2% Psychologist, 453, 2% Nurse, 14,526, 75% FIGURE 2 Current mental health workers in sub-Saharan Africa by profession (expressed as total number and percent of total). SOURCE: Chisholm presentation, citing WHO, 2011a. To provide a modest level of care, but not full coverage, for most of the eight SSA countries contained in the analysis, the psychiatrists needed were calculated to be about 1 per 100,000 people. Nurses and broader psychosocial care providers (e.g., social workers, community health workers) needed was around 7 or 8 per 100,000 people for each category. The authors calculated that the total gap is around 15 of these health workers missing for every 100,000 people. Chisholm noted that modeling current levels of providers is useful for human resource planning, and can provide information about different scenarios for scaling up the workforce and predicting the budgetary implications. Bridging Human Resources Gaps for MNS Disorders One approach to bridging the human resources gap for MNS disorders is to strengthen the health system from within by mobilizing financial resources, establishing a plan for monitoring and evaluation, and developing intervention packages. A second approach is to develop strategies to address human resource issues across different diseases area 

14 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA (e.g., cardiovascular disease, diabetes). Chisholm pointed out that most fields have chronic shortages of health workers and it is important to think not just about the shared competencies within MNS disorders, but also to look for shared competencies with other non-communicable diseases. In addition, because many of the same issues that impact mental health resources have been extensively studied and reviewed in other fields, Chisholm suggested that there are lessons to be learned by looking to other areas of health care. CHALLENGES FACING MNS CARE PROVIDERS IN SSA Using alcohol use disorders as a case example, Muthoni Mathai, a psychiatrist from the Department of Psychiatry at the University of Nairobi in Kenya, suggested that two of the biggest challenges in SSA are delayed diagnosis and misdiagnosis. Patients may carry on for years before a correct diagnosis is made. Denial is a significant hindrance to seeking help, which is compounded by the social stigma related to MNS disorders. In the primary health care system, stigmatizing attitudes among health workers are common, she said. Many people with MNS disorders do not know where to go to find help, Mathai continued. There is lack of public knowledge that these disorders are treatable conditions. Economic priorities of families and communities may also have a negative influence on whether patients seek treatment. For those that are diagnosed and do seek care, Mathai expressed concern about inadequate provider skills for disorder management, lack of specialized facilities, and no funding for treatment. Health workers may feel a sense of helplessness, she noted. Sebolelo Tseeke, a senior social worker with the South African National Council on Alcoholism and Drug Dependence (SANCA), concurred, adding that a particular challenge for substance use disorders is the limited number of registered rehabilitation centers. In addition, an increasing number of community-based organizations lack properly trained personnel. Tseeke observed that professionally trained personnel usually handle high caseloads, and there is often confusion by some treatment professionals with regard to referral protocols. For example, medical staff often refer comorbid patients to social workers before stabilization of their MNS disorder. Tseeke also expressed concern about delayed diagnosis, noting that a challenge for the treatment of substance use is that many patients seek interventions in the late stages of addiction. 

WORKSHOP SUMMARY 15 Gerald Vitus Kihwele, a nursing officer at the Mirembe National Mental Hospital in Tanzania, explained that MNS care in Tanzania is provided free of charge but adequate financial support for the costly treatments and facilities is needed from governments and other sources. Kihwele noted that sometimes patients might experience unfriendly therapeutic environments that contribute to physical problems and negatively impact both the general health and mental status of patients. Health facilities are often a “dumping place” for MNS patients, he added, and family members sometimes do not come to retrieve patients when they are in remission. Anthony Mulenga Zimba, a clinical officer in Zambia and vice president of the International Bureau for Epilepsy, Africa Region, noted that many challenges are the result of the lack of defined programs to care for patients with these conditions, despite the high prevalence of MNS disorders in SSA countries. Another challenge from a treatment perspective is that many patients suffer from the extrapyramidal side effects (i.e., movement disorders) associated with antipsychotic drugs. In addition, many health care workers lack the skills to handle the unpredictability of the actions and behavior of MNS patients. Challenges highlighted by Zimba and others are summarized in Box 4. BOX 4 Challenges of Caring for Patients with MNS Disorders in SSA Treatment Challenges  Delayed diagnosis and/or misdiagnosis  Stigma and discrimination  Self-denial  Lack of public awareness about MNS disorders and treatment options Resource Challenges  Insufficient resources allocated to MNS disorders  Mental health professionals are mainly concentrated in urban areas hindering treatment of patients in rural areas  Limited diagnostic tools (e.g., advanced imaging technologies)  Lack of specialized facilities 

16 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA BOX 4 Continued  Poor and inadequate infrastructure for MNS disorders, lack of funds to repair existing facilities or build new ones  Lack of access to affordable medicines Training Challenges  Shortage of trained human resources to manage MNS disorders  Resistance in some countries for the training of mid-level providers (e.g., clinical officers)  Inadequate provider skills for disorder management, including skills to handle the unpredictable behavior of MNS patients  Confusion about referral protocols, problematic or non-existent referral systems  Lack of training in leadership, advocacy, and fundraising Systems-Level Challenges  Lack of space and resources within hospitals for the provision of MNS services  Integrating MNS services into existing health systems  Lack of policy, legislative framework, and strategic plans for the management of MNS disorders in many SSA countries  Lack of plans for monitoring and evaluation of MNS disorder programs  Lack of evidence-based information on the extent of the MNS disorder burden in many SSA countries  Lack of political commitment to addressing MNS disorders in many SSA countries  Concerns by leadership that new or revised core competencies will lead to the expectation to be paid more SOURCES: Adapted from Kihwele, Mathai, Tseeke, and Zimba presentations and participant discussion. Developing Candidate Core Competencies In preparation for the breakout sessions, panel participants discussed a variety of questions to consider when developing candidate core com- petencies (see Box 5). Kihwele suggested that capacity building around competencies be based on the needs of MNS patients and emphasized a 

WORKSHOP SUMMARY 17 BOX 5 Questions to Consider When Developing MNS Provider Candidate Core Competencies  What types of treatment and care are available?  Do existing guidelines and policies address treatment and care?  How could new guidelines and policies be developed?  What type of training is currently available?  Would it be cost-effective in developing and training around core competencies?  What is achievable?  What is sustainable?  What priorities have been integrated by key stakeholders (e.g., government, donors, and community members)?  Could MNS treatment and care be integrated into primary health care programs?  What providers are available in different treatment environments?  How could a wide array of community members be trained to identify those who need care? SOURCES: Adapted from Kihwele, Mathai, Tseeke, and Zimba presenta- tions and participant discussion. community approach. MNS health care is applicable everywhere, includ- ing maternity settings, home, school, social settings, and elsewhere. Tseeke noted that providers could benefit from being aware of legislation and policies governing prevention and treatment of MNS disorders. Regular in-service training for social workers and other professionals is important to keep abreast of new developments. Some community-based organizations do not have social workers and rely on lay counselors and volunteers. Tseeke also noted that it could be helpful if the government provided information for community members about services and resources available in the area. Tseeke suggested that participants consider how patients might bene- fit from multidisciplinary team approaches and comprehensive treatment plans that include skill development for patients, to occupy them after treatment and help prevent relapse. Mathai noted that a variety of providers and community members can play a role in getting patients into care including pharmacy techni- cians and drug dispensers, because many patients first visit a pharmacist or dispenser when they have a medical problem. Others who might help 

18 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA to identify individuals with MNS disorders include teachers; grassroots administrators, including chiefs and subchiefs, who are often approached when there is a disorderly type of behavior in the community; religious leaders; and law enforcement agents, probation officers, and correctional officers. MNS DISORDER PROVIDERS For discussion and for purposes of providing a summary of the candidate core competencies, the various providers who care for patients with MNS disorders were grouped into four main categories: (1) community/lay workers; (2) non-specialized, non-prescribing prac- titioners; (3) non-specialized prescribing practitioners; and (4) spe- cialized practitioners (see Table 1). Definitions for each type of provider were modified from the WHO health worker classification chart7 based on various participant comments throughout the plenary and breakout sessions (Appendix C). The definitions include potential relationship roles with other providers as discussed by workshop participants. Workshop discussions also included potential treatment environments where providers might be found in SSA. The list of treatment environments was compiled by the workshop rapporteurs based on individual participants comments during the breakout sessions and is not meant to be comprehensive (see Table 2). Traditional and Faith Health Practitioners Workshop discussions included the role of traditional and faith health practitioners in the treatment and care of patients with MNS dis- orders. Unlike other provider types, traditional health practitioners were not able to participate in all breakout sessions, and no faith health practi- tioners were able to attend the workshop. Without this voice represented more widely during the discussions, many participants were concerned that inclusion of candidate core competencies for traditional and faith health practitioners would be inappropriate. Therefore, these providers have not been included in the list of candidate competencies presented in this summary. 7 See http://www.who.int/hrh/statistics/Health_workers_classification.pdf. 

WORKSHOP SUMMARY 19 TABLE 1 Provider Classifications and Abbreviations Provider Category Type Abbreviation Peer/service user PR Community/Lay Worker Community health care worker/health extension CHW worker Pharmacist PH Non-specialized, Social Worker SW Non-prescribing Occupational Therapist OT Clinical/health officer CO Non-specialized, Nurse RN Prescribing Medical doctor/general MD practitioner Psychiatric Nurse PRN Psychologist PY Specialized Neurologist NE Psychiatrist PS Several participants emphasized that these providers play an im- portant health care role throughout SSA but that no formal relationship between the health system and traditional health practitioners currently exists. The need to engage traditional health practitioners, and the need for functional referral pathways in all directions between the peer/service users, community health workers, and traditional practitioners was stressed by many participants. A large number of participants, including Lydia Matoka, a traditional health practitioner from Kenya, noted that in SSA, most rural area patients turn to traditional health practitioners first. It was noted by several participants that traditional health practition- ers can play an important role in encouraging treatment-seeking behav- iors by providing community members with examples of how treatment has been helpful. For epilepsy, these providers might be able to offer counseling to help patients deal with perceived supernatural elements they may believe have a role in their disease (e.g., through mediation with ancestors). Elliot Makhatini, a participant from South Africa, said one of the tertiary institutions in his area holds an annual forum for doctors, special- ists, and traditional health practitioners to interact and give presentations 

20 TABLE 2 Provider Treatment Environments Compiled Based on Suggestions from Individual Workshop Participantsa Treatment Environment PR CHW PH SW OT CO RN MD PRN PY NE PS Provincial hospital, clinic, ward             District/state hospital, clinic, ward             Sub-district/state hospital, clinic, ward             Psychiatric hospital, clinic, ward             Community clinicb            Community-based settingsc          Nursing homes           Private practice          Rehabilitation centers      Criminal justice system          Military settings          Mobile clinics or outreach centers       Out-patient treatment centersd   

Home setting     Military setting    Pharmacies  Free-standing chemists/dispensaries  Independent drug stores  Market places  Refugee camps    a This table presents provider treatment environments discussed by one or more workshop participants. During the workshop, all participants engaged in active discussions of treatment environments. In some cases, participants expressed differing opinions. However, because this is a summary of workshop comments and not meant to provide consensus recommendations, workshop rapporteurs endeavored to include all provider treatment environments discussed by workshop participants. This table and its content should be attributed to the rapporteurs of this summary as informed by the workshop. b Providers may work full time or in a supportive role in this environment. c Examples include, but are not limited to, faith-based facilities/groups, mental health society buildings, rehabilitation centers, schools, halls, nongovernmental organization (NGO) facilities, and community-based organization facilities. d With or without a dispensary. 21 

22 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA on different kinds of illnesses. This helps to foster communication, mu- tual understanding, and respect. Another participant noted that in his ex- perience, traditional health practitioners want to work with clinicians. To improve patient care, Matoka urged participants to integrate traditional medicine into the management of MNS disorders in SSA. CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS A summary table of candidate core competencies can be found in Appendix A. During the breakout sessions, all participants engaged in active discussions of the candidate core competencies. In some cases, participants expressed differing opinions whether a particular core com- petency could be useful and included in the list of candidate competen- cies. However, because this is a summary of workshop comments and not meant to provide consensus recommendations, workshop rapporteurs endeavored to include all candidate core competencies discussed by workshop participants across providers and disorders. As previously mentioned the candidate core competencies discussed are a compilation of all workshop participant comments and should be attributed to the rapporteurs of this summary as informed by the workshop. For each provider type, candidate competencies are listed for screening/ identification (SI), formal diagnosis/referral (DR), and treatment/care (TC), relative to each of the four MNS disorders discussed. An expanded view of the candidate core competencies can be found in Appendix B. This table also includes additional comments by participants specific to disorders and provider types. During the workshop breakout group discussions many participants commented that there appeared to be some candidate competencies that might be applied across providers and another group of candidate compe- tencies that might be applied to providers who prescribe or are special- ized. In addition, numerous participants noted that these subsets of can- didate competencies might apply beyond the four disorders discussed during the workshop to all MNS disorders. Based on the candidate core competencies presented here, the following two tables highlight can- didate competencies for all providers (see Table 3) and for non- specialized prescribing and specialized providers (see Table 4) across MNS disorders. 

WORKSHOP SUMMARY 23 TABLE 3 Candidate Core Competencies Discussed for All Provider Types Across MNS Disordersa Screening/Identification (SI) SI.1 Demonstrates awareness of common signs and symptoms SI.2 Recognizes the potential for risk to self and others SI.3 Demonstrates basic knowledge of causes SI.4 Provides the patient and community with awareness and/or education SI.5 Demonstrates cultural competence SI.6 Demonstrates knowledge of other mental, neurological, and substance use (MNS) disorders Formal Diagnosis/Referral (DR) DR.1 Demonstrates knowledge of when to refer to next level of care/other provider/specialist DR.2 Demonstrates knowledge of providers for specialized care within the community Treatment/Care (TC) TC.1 Provides support for patients and families while in treatment and care TC.2 Identifies and assists patients and families in overcoming barriers to suc- cessful treatment and recovery (e.g., adherence, stigma, finances, accessi- bility, access to social support) TC.3 Demonstrates ability to monitor mental status TC.4 Demonstrates knowledge of how to offer emergency first aid TC.5 Initiates and/or participates in community-based treatment, care and/or prevention programs TC.6 Demonstrates knowledge of treatment and care resources in the community TC.7 Promotes mental health literacy (e.g., to minimize impact of stigma and discrimination) TC.8 Communicates to the public about MNS disorders TC.9 Monitors for adherence to and/or side effects of medication TC.10 Practices good therapeutic patient interactions (e.g., communication, relationship, attitude) TC.11 Provides links between patients and community resources TC.12 Identifies available resources to support patients (e.g., rehabilitation, medication supplies) 

24 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA TABLE 3 Continued TC.13 Promotes activities that aim to raise awareness and improve the uptake of interventions and the use of services TC.14 Protects patients and identifies vulnerabilities (e.g., human rights) TC.15 Demonstrates respect, compassion, and responsiveness to patient needs TC.16 Demonstrates knowledge and skills to use information technology to improve treatment and care a This table presents candidate core competencies discussed by one or more workshop participants. During the workshop, all participants engaged in active discussions of candidate competencies. In some cases, participants expressed differing opinions about whether a particular competency could be useful and included in the list. However, because this is a summary of workshop comments and not meant to provide consensus recommendations, workshop rapporteurs endeavored to include all candidate core competencies discussed by workshop participants across providers and disorders. This table and its content should be attributed to the rapporteurs of this summary as informed by the workshop. TABLE 4 Candidate Core Competencies Discussed for Non-Specialized Prescribers and Specialized Providers Across MNS Disordersa Screening/Identification (SI) SI.1 Demonstrates awareness of common signs and symptoms SI.2 Recognizes the potential for risk to self and others SI.3 Demonstrates basic knowledge of causes SI.4 Provides the patient and community with awareness and/or education SI.5 Demonstrates cultural competence SI.6 Demonstrates knowledge of other mental, neurological, and substance use (MNS) disorders SI.7 Demonstrates the ability to screen for and use screening tools SI.8 Demonstrates knowledge and skills in taking patient history SI.9 Demonstrates the ability to conduct a mental status exam SI.10 Recognizes patients who are relapsing and require inpatient care Formal Diagnosis/Referral (DR) DR.1 Demonstrates knowledge of when to refer to next level of care/other pro- vider/specialist 

WORKSHOP SUMMARY 25 TABLE 4 Continued Formal Diagnosis/Referral (DR) DR.2 Demonstrates knowledge of providers for specialized care within the community DR.3 Demonstrates skills in assessment of relative levels of social, cognitive, and physical functioning DR.4 Demonstrates knowledge of required information for effective referral DR.5 Demonstrates skills in using various functional assessment tools DR.7 Demonstrates an understanding of and ability to apply contextually ap- propriate diagnostic systems (e.g., DSM, ICD)b DR.8 Demonstrates knowledge and skills to make a formal diagnosis and for- mulation of differential diagnosis DR.9 Demonstrates ability to determine severity level DR.10 Demonstrates ability to make a diagnosis according to an algorithm (not considered a clinical diagnosis) Treatment/Care (TC) TC.1 Provides support for patients and families while in treatment and care TC.2 Identifies and assists patients and families in overcoming barriers to suc- cessful treatment and recovery (e.g., adherence, stigma, finances, accessi- bility, access to social support) TC.3 Demonstrates ability to monitor mental status TC.4 Demonstrates knowledge of how to offer emergency first aid TC.5 Initiates and/or participates in community-based treatment, care, and/or prevention programs TC.6 Demonstrates knowledge of treatment and care resources in the community TC.7 Promotes mental health literacy (e.g., to minimize impact of stigma and discrimination) TC.8 Communicates to the public about MNS disorders TC.9 Monitors for adherence to and/or side effects of medication TC.10 Practices good therapeutic patient interactions (e.g., communication, relationship, attitude) TC.11 Provides links between patients and community resources 

26 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA TABLE 4 Continued Treatment/Care (TC) TC.12 Identifies available resources to support patients (e.g., rehabilitation, medication supplies) TC.13 Promotes activities that aim to raise awareness and improve the uptake of interventions and the use of services TC.14 Protects patients and identifies vulnerabilities (e.g., human rights) TC.15 Demonstrates respect, compassion, and responsiveness to patient needs TC.16 Demonstrates knowledge and skills to use information technology to improve treatment and care TC.17 Demonstrates ability in general counseling skills TC.19 Demonstrates ability to select appropriate treatment based on an under- standing of diagnosis TC.21 Provides brief advice on symptom management TC.28 Demonstrates knowledge of and ability to apply relevant legislation and policies and access to appropriate services TC.34 Reports information to relevant health management systems TC.36 Assists patients with access to other providers and helps coordinate ef- forts TC.38 Documents medical records TC.39 Demonstrates knowledge and skills to consult with other providers in the treatment/care team TC.40 Demonstrates knowledge and skills to provide proactive follow-up and monitors outcomes of care TC.41 Demonstrates knowledge of standard drug regimens TC.42 Provides mentoring and support to other health care providers a This table presents candidate core competencies discussed by one or more workshop participants. During the workshop, all participants engaged in active discussions of candidate competencies. In some cases, participants expressed differing opinions about whether a particular competency could be useful and included in the list. However, because this is a summary of workshop comments and not meant to provide consensus recommendations, workshop rapporteurs endeavored to include all candidate core competencies discussed by workshop participants across providers and disorders. This table and its content should be attributed to the rapporteurs of this summary as informed by the workshop. b DSM: Diagnostic and Statistical Manual of Mental Disorders; ICD: Inter- national Statistical Classification of Diseases and Related Health Problems. 

WORKSHOP SUMMARY 27 Participant Comments from Breakout Group Discussions Following the small group breakout sessions, the subsequent plenary sessions provide an opportunity for group facilitators to provide brief reviews of each discussion. The plenary session discussions focused on commonalities and differences across all four MNS disorders, the treatment roles of different providers and review of some of the candidate core competencies. All breakout group facilitators reported having spirited discussions and participants were eager to share their experiences and comments. Overall a large number of workshop participants who spoke agreed that the treatment and care of patients with MNS disorders would benefit from cooperative and collaborative relationships among all providers. Many participants raised concerns about the probability that a provider might be able to perform any or all of the candidate competencies dis- cussed given limits on time and resources. Instead, several participants proposed that providers might not actively engage in performing specific candidate competencies, although training about and knowledge of the indicated candidate competency could still be considered. Facilitators noted that several questions reoccurred across the different breakout group discussions. First, how can strategies for incorporating MNS programs be developed to address country and/or regional differences? What are mechanisms for governments and nongovernment organizations to increase funding for MNS programs? For countries with competencies already integrated into government plans, how can additional implementation occur with low availability of human resources? Also discussed were mechanisms for determining current provider competencies and developing training programs to increase competency levels across all providers. One participant noted that it is not sufficient to simply train people and then expect them to be able to exercise additional core competencies without supervision, evaluation, and continuing education. Several participants reiterated that some of the specialist provider candidate competencies were discussed based on an understanding that these providers already have years of specific medical training including knowledge of MNS disorders. Many participants indicated that health systems would need to change, such as making use of tools such as telemedicine and eHealth technologies for training and supervision. Many participants commented on referral pathways; who refers to whom and at what level? Pathways can differ from country to country 

28 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA and depend on the combination of human resources available. There can be both upward referral and downward referral. For example, specialists can refer patients for management at the community level while community health workers can refer patients to the hospital level for specialized care. Several participants noted that patients at remote centers would need appropriate screening and referral early to a specialist, before treatment and care becomes too complicated to be treated at these health care centers. It was recognized that the candidate core competencies discussed may not necessarily be applicable to all countries’ current laws, policies, and practices, but many participants expressed hope that candidate core competencies could be used as benchmarks, contextualized to suit each county. The section that follows highlights some of the main topics of conversation from the breakout group discussions as reported by the facilitators. Community/Lay Workers Adesola Ogunniyi, professor of medicine at the University of Ibadan in Nigeria and group facilitator, noted that providers in this category might be trained to detect probable cases of MNS disorders, provide early interventions, and handle case management including monitoring, follow up, and continuity of care, such as adherence to treatment regimens and recognition of side effects of medicines. Community/lay workers could refer patients to the next level of care. A few breakout group participants discussed that addressing stigma through support groups, raising awareness, and providing psychosocial education might also be important roles for this group of providers. These providers could convey to the community that MNS disorders are true medical conditions. Ogunniyi said many participants discussed that basic prerequisites for a community or lay worker might include literacy and cultural competency. Community health care workers and health extension workers generally will have a more clinical approach to management of MNS disorders than peer/service users. A few participants noted that, although they might not provide a formal diagnosis, community health workers could do some level of screening. For psychiatric disorders, these providers could detect and recognize psychosis and perform a mental status examination. Community health care workers would likely need supervision from a higher level of provider. 

WORKSHOP SUMMARY 29 Many participants noted that the role of peer/service users is mainly supportive and not generally clinical, but that basic recognition of MNS diseases is important. Peer/service users have personal experience with MNS disorders and would need support, but not supervision, from the community health care workers. Ogunniyi summarized the relationship of these community agents to patients and other providers in four words: support, engage, integrate, and complement. Non-Specialized, Non-Prescribing Providers One issue that was the topic of spirited discussion in this breakout and other breakouts was prescribing, noted Musisi as facilitator of this group. Currently, the legality of a provider to prescribe medications varies by country; in some countries there are no laws governing nurses and thus many nurses will prescribe medications, while in other countries it is illegal for a nurse to prescribe any medications. Pharmacists dispense, and although they do not usually prescribe, a few participants noted that sometimes pharmacists will dispense medications without a prescription. Pharmacists can also give advice on what medicines they are dispensing. Several participants raised questions regarding who could be allowed to prescribe in emergency situations. Many participants noted that non-specialized, non-prescribing providers could be able to recognize, identify, and refer individuals needing further evaluation for MNS disorders. Pharmacists, for example, might be able to recognize patterns of drug use and be alert to signs of addiction. Social workers interacting with families could recognize signs of alcohol use. One participant suggested that more technical screening might be done by social workers. Several participants indicated that formal diagnoses would need to be made with care by those qualified, as an MNS diagnosis has long-term implications. Non-specialized, non-prescribing providers work in various treatment settings, for example, in a rehabilitation center or inpatient wards. Social workers and occupational therapists often work in concert, both working toward recovery. One somewhat controversial topic of discussion was the extent to which non-specialists could administer certain specific treatments if they had specialized training, for example, electroconvulsive therapy (ECT). A few participants asked whether administration of such therapies would need to be restricted to medical doctors. Many participants noted that a potentially important role for social workers could be to demystify and reduce the stigma of MNS disorders 

30 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA in the community, in particular, epilepsy. Social workers could also support clients through advocacy and human rights protection and through other services such as helping patients in obtaining specialized care. Non-Specialized Prescribing Providers Communication between non-specialized prescribing providers and other providers for consultation and management of complex patients is key, whether by physical outreach or by telephone or other technology, noted Sylvia Kaaya, head of the Department of Psychiatry and Mental Health at the Muhimbili University College of Health and Allied Sci- ences in Tanzania and group facilitator. Like other groups, participants in this group discussed the importance of developing bidirectional referral systems. Such a system could allow efficient referral of complex cases to the next level of care, but once the patient is adequately managed referral back to non-specialists for follow-up and monitoring could occur. Many participants suggested that guidelines could be valuable tools for developing strong relationships between non-specialists and specialists and that these guides might be developed jointly. Kaaya noted that many participants discussed that disorders in which the outcome is critically dependent upon early intervention (e.g., psychosis, some forms of epilepsy) would need early referral to specialists, with generalists potentially assuming a leadership role in long-term care. Less complex disorders (e.g., depression, substance use disorders, non-refractory epilepsy) might remain in the purview of generalists and only be referred to specialists for crisis management. Another focus of discussion was task shifting among non-specialized providers, whether prescribing, non-prescribing, or lay workers. Evidence-based psychosocial interventions, for example, might be shifted to community health workers because they can often spend more time with patients and their families, and face less cultural dissonance. Similarly, follow-up care could be shifted to community health workers. However, several participants stressed that such task shifting would require support via regular communication, monitoring, guidance, and other tools developed together with specialists and prescribing generalists. Supportive supervision of non-specialized, non-prescribing providers, particularly at the community level, could be by non- specialized prescribing providers, assisted by specialists. 

WORKSHOP SUMMARY 31 In all relationships, teamwork was identified as being extremely important for the recognition, treatment, and management of MNS disorders. Participants discussed how a team approach could include joint training of nurses, clinical officers, and medical officers. Participants highlighted the importance of having clarity about roles among the different providers to ensure that nothing is overlooked in patient care. Guidelines and performance indicators could be employed to incentivize, monitor, and ensure quality improvement. In considering relationships among non-specialized prescribing providers themselves, it was pointed out that prescribing practices are likely to evolve over time. General nurses are performing a significant portion of patient care. Some participants suggested that access to care would benefit from the empowerment of nurses to allow initial prescribing, emergency prescribing, and re-prescribing. This would entail training of nurses by specialists, ensuring appropriate access of nurses to medical or clinical officers for consultation, and developing of a supporting legal framework. A participant pointed out that there is a precedent in prescribing of antiretroviral therapy (ART) where there is training and accreditation for practitioners who generally do not prescribe so they can prescribe ART. It was suggested that in-service training with accreditation of specific nurses to be able to prescribe for MNS disorders would be a more timely process than training and bringing nurse practitioners to a region. Specialized Providers Pamela Collins, who served as the group facilitator, said the discussion stressed the importance of defining both immediate needs, including stop-gap measures and long-term aspirations. There is an inherent tension between what to do now and what to aim for over the long term, she said. Supervisory structure for specialized practitioners is context dependent. In general, specialists can be involved in the administrative and clinical supervision of other specialists in training, as well as general practitioners, clinical officers, and nurses. A psychiatric nurse, for example, might supervise and train other psychiatric nurses as well as general nurses, and might also be involved in the training of clinical officers, social workers, community health workers, and peer/service users. Several participants noted that any of the specialized providers could be responsible for designing, setting up, or running a service. Many participants who spoke agreed there would need to be some 

32 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA minimum level of experience and expertise for a provider to assume a leadership role, but a leader need not necessarily be a psychiatrist or medical doctor; any person within the framework who has enough experience and knowledge could serve in a leadership role. One participant suggested that to achieve the goal of providing patients with the best access to care, a tiered system could be used in which specialists use their time to address situations that are beyond the ability of generalists. A specialist spending a lot of time seeing routine cases might not be an effective use of human resources. Specialists could be much more effective if they are influencing the care provided by 10 or 100 medical officers. Similarly, community workers instead of the busy generalists or specialists could address the day-to-day concerns of many patients. Several participants emphasized that for the delivery of psychosocial interventions, community health workers may be better positioned, more culturally in tune with the community, more skilled, and may have more time for the patient. It was suggested that a challenge to securing buy-in for core competencies is the shift in the type of work specialists may be doing. Several participants noted that many specialists enjoy direct contact with patients, but specialists are finding themselves doing less and less direct care, and more training, developing standards of care and standard operating procedures, and supervision. Some participants expressed concern about taking specialists away from their medical practice to do administrative work and noted a need for an additional group of individuals with expertise in managing health systems in SSA. THE PROCESS OF UPDATING AND INTEGRATING CORE COMPETENCIES Lessons Learned from Integrating Mental Health and HIV Care Integrating new or revised core competencies into the current system is one of the challenges facing mental health care that was highlighted by many participants. Lessons can be learned from training and capacity building in other global health programs, specifically lessons from the HIV/AIDS field. Ruben Sahabo, country director for the International Center for AIDS Care and Treatment Programs (ICAP)8 in Swaziland, 8 Established in 2004 by the Mailman School of Public Health at Columbia Univer- sity, ICAP is funded by the U.S. government under the President’s Emergency Plan for AIDS Relief (PEPFAR) and other U.S. government sources, in association with private 

WORKSHOP SUMMARY 33 shared his experiences in integrating new competencies at the district hospital level in Rwanda. The ICAP mission is to ensure the wellness of families and communities by strengthening health systems around the world. ICAP supports Ministries of Health and other in-country organizations in achieving national AIDS control program goals and other public health goals through central, provincial/district, health facility, and community-level support. The rationale for the integration of HIV care and mental health care is clear, Sahabo said. MNS disorders are associated with other health conditions. For example, Sahabo noted that there is a high rate of depression among patients with HIV and an increased risk of HIV acquisition in patients with depression. Depression is associated with HIV disease progression and increases mortality. Depression is also associated with poor adherence to antiretroviral treatment, and HIV treatment outcomes are improved when depression is treated. The first step in the process of updating competencies was to conduct a needs assessment, Sahabo explained. Based on that assessment, an integration framework concept was drafted and used in the advocacy efforts and negotiations with the government of Rwanda and the U.S. government agencies involved in funding, to convince them to shift or allocate HIV funds into mental health programs. This was followed by education of those who would be the trainers of others for integrating mental health into HIV counseling and testing. A framework was also created for the development and implementation of a national plan for mental health and HIV care integration. As part of the process, a technical working group was established, institutional roles and responsibilities were defined, and a focal person in each institution was designated. The technical working group helped to bring together professionals from both HIV and mental health programs. The group defined the key challenges for integration and conducted a review of HIV and mental health guidelines and other needed tools. The process for updating competencies also included introduction of quality improvement systems, including the establishment of formal multidisciplinary teams, referral systems, standards of care, and assessment tools. This step was very important, Sahabo said, because sponsors. ICAP supports HIV-related programs in 18 countries primarily in Africa (Cam- eroon, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Kenya, Lesotho, Ma- lawi, Mali, Mozambique, Nigeria, Rwanda, South Africa, South Sudan, Swaziland, Tan- zania, Thailand, Uganda, and Zambia). See http://icap.columbia.edu. 

34 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA HIV program managers did not see the need for integration, so it was critical to present a win/win approach to interest HIV managers in mental health, and vice versa. Nine district hospitals were then selected as pilot sites for collaborations. As noted above, a key issue was defining roles and responsibilities, in particular who should lead the integration process. It was decided that the national mental health program was responsible for coordinating and mobilizing resources for training, sensitizing district hospitals, and making sure there was a strategy for creating demand for mental health services at the district level. The HIV program was responsible for lobbying for the review of guidelines; for providing HIV trainers and training resources to mental health professionals; and ensuring that mental health tools are integrated in overall HIV management guidelines. The Ndera Neuropsychiatric Hospital was responsible for educating trainers and for proving mentors to the district hospitals. As a result of this collaborative approach, HIV care providers at district hospitals were trained in mental health, and other health care providers at district hospitals received training on the relevant aspects of HIV mental health. In 2010, Ndera Neuropsychiatric Hospital began to test for HIV and offer mental health counseling and treatment services. As a result, the Ndera mental health professionals gained the expertise in HIV needed so they could then offer themselves as qualified mentors to other hospitals in the integration of HIV care and mental health. Sahabo shared data showing the progress of mental health screening at one district hospital and how that has translated into patients receiving treatment with antidepressants. Sahabo noted the importance of defining indicators or metrics of mental health integration into HIV care, and promoting accountability among health care providers at the district level. In closing, Sahabo summarized the key principles for the rollout of HIV and mental health services integration from Ndera Neuropsychiatric Hospital to the district hospitals, and shared his perspective on the les- sons learned (see Box 6). Zimbabwe Psychiatrist Dixon Chibanda shared his experiences regarding building and sustaining MNS competencies in Zimbabwe. In 2005, there were just 7 psychiatrists in Zimbabwe compared to 72 physicians. Currently there are more than 1,000 general practitioners in private practice in the country and approximately 130 new junior doctors graduating from medical school each year. A survey of 68 randomly 

WORKSHOP SUMMARY 35 selected new doctors found that only 2 percent were interested in psychiatry as a possible specialty after completing their internship compared to 28 percent who selected internal medicine. When asked what criteria they used to decide which specialty would be best for them, the most frequent responses were professional development, financial remuneration, respect, research opportunities, international travel, and service. In essence, Chibanda suggested that junior doctors believed that psychiatry was not an attractive discipline. The key question is how to interest general practitioners and new doctors in MNS health care. Among the specific objectives defined were building faculty expertise, modernizing undergraduate curriculum, building research capacity, developing community MNS health care services, and modernizing postgraduate training. Chibanda explained that a “marketing mix” of the components was needed to make psychiatry a more attractive specialty, including education, community, and private practice. BOX 6 Integration of HIV and Mental Health Services Principles  Integration allows streamlined care for people with dual diagnoses of HIV and mental health disorders.  When possible, co-localization of services at the same site can o increase adherence to care, o improve monitoring of psychiatric and HIV symptoms, and o ensure monitoring of response to treatment and adverse reactions to medications. Lessons Learned  Integration is most successful when mental health services are incorporated into health policy and the legislative frameworks, and are supported by senior leadership, adequate resources, and clear governance.  Primary care for mental health for HIV patients needs to be coordinated within a network of services at different levels of care and complemented by a broader health system development. SOURCE: Adapted from Sahabo presentation, September 5, 2012. 

36 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA Education For the education component, he noted that the University of Zimba- bwe was fortunate to receive a Medical Education Partnership Initiative (MEPI)9 award with two sub-grants. One was in mental health, the Im- proving Mental Health Education and Research Capacity in Zimbabwe (IMHERZ) Program. As a result of MEPI, there are now 11 Master of Medicine psychiatry students, as well as 8 in clinical psychology, 3 Mas- ter of Philosophy, 2 Ph.D., and 4 in subspecialties, including child psy- chiatry. This is a significant achievement for Zimbabwe, Chibanda noted. Compared to the old system, a variety of MEPI approaches have contributed to the success of this initiative (see Table 5). One approach that Chibanda highlighted was the mentoring triangles, where every stu- dent has both a local mentor and an external mentor from one of the part- ner institutions (e.g., University of Cape Town, Institute of Psychiatry- London, and Harvard University). Community The next component in the mix is the “Friendship Bench” project, which has interventions delivered by lay health workers in the community in a task-shifting approach. Since 2006 lay health workers in this program are supervised by senior counselors, who in turn are supervised by clinical psychologists and psychiatrists. The Friendship Bench is a physical bench that is placed within the grounds of the primary health care clinic. The lay health workers are usually elderly ladies—the current mean age is 58 years—who reside in the community, with literacy as the only requirement. The city health department pays the lay health workers, which contributes to the stability, Chibanda said. Since inception, more than 6,000 individuals and their families have used the Friendship Bench. More than 800 lay health workers work in 33 primary clinics throughout Harare. Chibanda said a cluster randomized controlled trial of this intervention was planned to begin in November 2012. 9 MEPI supports medical education and research at SSA institutions through grant awards. MEPI is coordinated by the Office of the U.S. Global AIDS Coordinator and supported by the National Institutes of Health and the Health Resources and Services Administration. See http://www.mepinetwork.org. 

WORKSHOP SUMMARY 37 TABLE 5 Comparison of Prior Educational Approach to the Current MEPI Approach Current Approach (MEPI) Previous Approach Mentoring triangles Group supervision Buddy system None Mental Health Resource center None Balance between research, clinical Purely clinical work, and service Community program No community program Local mentor/non-psychiatrists No mentoring Invite other specialties Restricted to psychiatry E-learning Textbook approach Master classes/invite non- Departmental only psychiatrists Fellowships No financial incentive These changes from the previous approach to the current Friendship Bench approach have resulted in a self-sustainable successful program. Chibanda pointed out that using clinic nurses to deliver interventions was not well received, and having interventions delivered by lay health workers who are part of the community has been better received. In addition, the approach works better when the lay health workers are carrying out a variety of health tasks within the community, rather than focusing solely on MNS disorders. For example, tuberculosis surveil- lance, treatment strategies, antiretroviral therapy adherence, and im- munization can all be improved by incorporating a MNS health care component. Perception is important, and Chibanda noted that “Friend- ship Bench” was more accepted than the old name “Community Mental Health Initiative.” Private Practice Chibanda said that private practice generally has been left out of efforts to develop capacity for MNS health care in the country. Now, Zimbabwe has a “Therapy Support Group” that consists of 34 MNS health professionals and general practitioners in private practice. These providers are encouraged to attend master classes in MNS disorders, for which they earn continued medical education points that go toward 

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. 

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 

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 

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. 

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. 

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? 

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. 

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. 

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. 

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. 

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.