Strengthening Human Resources Through Development of Candidate Core Competencies for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa Workshop Summary (2013) / Chapter Skim
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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
Strengthening Human Resources Through Development of Candidate Core Competencies for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Workshop Summary
Pages 1-48
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. 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)
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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)
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that all candidate core competencies discussed by workshop participants were included. Finally, the templates were edited again to ensure consistency.
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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.
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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)
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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.
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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.
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BOX 3 Highlights from the 2009 Workshop Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Reducing the Treatment Gap, Improving Quality of Care Workshop Topics Need to consider all nervous system disorders Benefits through leveraging skills, expertise, and networks of other health fields (e.g., HIV/AIDS, malaria) Include a focus on treatment and prevention Improve the available medication formulary Expand the use of high-quality, community-based care, and the training of community health workers Opportunities for Decreasing the Treatment Gap Recognize the interconnected nature of MNS disorders Establish comprehensive policies Promote high-quality research that will provide evidence to inform health policy Improve the integration of basic diagnosis and treatment into primary care Leverage established infrastructures Increase the number of trained professionals with expertise in MNS disorders Formalize community health care providers as an integral component of the health system Improve the formulary of medications to treat MNS disorders
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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 attention to help reduce the treatment gap (Collins et al., 2011)
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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)
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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.
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. CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA SOURCE: Chisholm presentation, citing WHO, 2011a.
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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)
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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.
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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
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Developing Candidate Core Competencies In preparation for the breakout sessions, panel participants discussed a variety of questions to consider when developing candidate core competencies (see Box 5)
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Would it be cost-effective in developing and training around core competencies? What is achievable?
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Unlike other provider types, traditional health practitioners were not able to participate in all breakout sessions, and no faith health practitioners 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.
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. Elliot Makhatini, a participant from South Africa, said one of the tertiary institutions in his area holds an annual forum for doctors, specialists, and traditional health practitioners to interact and give presentations
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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
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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.
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In some cases, participants expressed differing opinions whether a particular core competency could be useful and included in the list of candidate competencies. 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.
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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)
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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)
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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)
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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.
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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.
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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.
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Many participants noted that a potentially important role for social workers could be to demystify and reduce the stigma of MNS disorders
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Now, training about MNS disorders is provided as part of preservice training for all health workers. Ndyanabangi highlighted some of the lessons learned and achievements.
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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.
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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.
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. 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.
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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.
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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.
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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.
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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.
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48 CANDIDATE CORE COMPETENCIES FOR MNS DISORDERS IN SSA Alan Leshner, chief executive officer at the American Association for the Advancement of Science and workshop planning committee member, encouraged participants to use the workshop discussions and candidate core competencies as tools, adapting them for use in their own local policy-making systems.
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