5

Perspectives on Potential Next Steps

Participants at each workshop developed ideas for demonstration projects that were specific to either Kenya or Ghana, taking into consideration the unique health care systems, mental health burdens, traditional belief systems, and policies and laws in each country. However, a number of themes persisted throughout both workshops and seemed to have broad support from many stakeholders in attendance. Many participants identified similar challenges in both countries and developed similar overarching concepts that should be part of any demonstration project designed to improve mental health in Ghana or Kenya. In addition, practical sequential steps for carrying out such a project were identified, based on participant discussion and the draft demonstration projects included in Appendixes E and F.

OVERARCHING CONCEPTS IDENTIFIED BY
INDIVIDUAL PARTICIPANTS

Integrating Mental Health Care into the
Primary Care System

Many participants repeatedly cautioned that any mental health project must not create a “parallel system,” but be integrated into the general health system. They added that this would efficiently capitalize on available resources, improve patient access to care and treatment, and reduce stigma, both among the community and among health workers. There are few mental health specialists in either Kenya or Ghana, and this is a major barrier to care in both countries, according to many participants. By

providing the training and support necessary for mental health to be integrated into primary care—so that “every provider thinks of himself as a mental health provider” [Sodzi-Tettey]—patients will be able to access care in their communities and do so without the stigma associated with seeking care from a psychiatric hospital. Patient care will be improved, said several participants, because patients often have both physical and mental ailments. With an integrated system, providers will be able to offer holistic and coordinated care. They added that the overall readiness of the primary and general health care system to handle this demand will be important. In addition, a few participants said that treating patients with MNS disorders in primary care facilities will allow health care workers to see that treatment and recovery are possible, which has been shown to reduce stigma. One participant at the Kenya workshop stated, “Mental health is part of health” and should be treated in that manner.

Aligning Mental Health Care Efforts with Existing Priorities

Governments, NGOs, and funders manage competing priorities, limited resources, and pressing health needs. To get mental health the attention and funding it deserves, several participants said, mental health advocates must align efforts with the issues that these stakeholders already prioritize. For example, if maternal and child health is important to the MoH, Tedla Wolde-Giorgis said, mental health care must be presented as a way to decrease maternal mortality or increase children’s quality of life. Wolde-Giorgis said that ministers and NGOs are now heavily focused on international efforts such as the MDGs. The MDGs do not explicitly mention mental health, and several participants stressed that mental health advocates must demonstrate the links between mental health and a specific MDG such as poverty, HIV/AIDS, and gender equality. While the MDGs will end in 2015, several participants noted the importance of making mental health a priority for the newly developed Sustainable Development Goals (SDGs).¹ In addition, there are already a number of international efforts to improve mental health care, such as WHO’s mhGAP. One participant said there is no need to “reinvent the wheel” by deviating from such efforts. Although demonstration projects must be tailored for each country, they should be aligned with existing priorities and efforts in order to make efficient use of resources and to be sustainable.

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¹See https://sustainabledevelopment.un.org/?menu=1300 (accessed September 3, 2015).

Community Buy-in and Involvement

If the community is not involved in setting priorities and deciding on strategies, a project has little chance of success, several participants asserted. One participant in Kenya told the story of a donor who decided to build toilets in a community in order to combat cholera, and after 8 months returned to find that no one had used the toilets. Another participant emphasized the importance of involving opinion makers, such as faith leaders and tribal chiefs, in community discussions from the start. He cautioned that if these people do not support a project, for whatever reason, the project will not achieve its goals. Finally, schools, prisons, social workers, NGOs, and other community organizations can be valuable partners in carrying out a mental health project by providing referrals, resources, or education. Several participants stressed that these organizations must be involved from the beginning to gain their support and maximize their potential to contribute.

Considering the Mental Health Care System in Its Entirety,
Rather Than as Separate Components

Although discussions at the workshops were divided into four distinct topics—diagnosis and treatment, access to medicines, stigma, and health information systems—it became clear to many participants that no one part of the system could be addressed without simultaneous efforts directed at the other parts. Franҫois Bompart, while discussing how to improve access to essential medicines, stated, “Access to medicines only makes sense if there is first access to diagnosis.” Relatedly, if a project greatly improved the availability of diagnosis and treatment, but did not address stigma, participants noted that patients might not be willing or able to access the care that has been made available. A robust MHIS is ineffective if providers are not consistent in patient diagnosis and treatment. Each part of the health care system cannot be improved in isolation from the others; many participants emphasized that any demonstration project must account for these intersections and make an effort to address multiple challenges simultaneously.

The Importance of Affordability and Insurance Coverage
of Mental Health Services

Many participants stressed that even the best efforts to improve mental health care would fail if mental health care continues to fail to be covered by insurance and remain unaffordable to most people in Ghana and Kenya. While the insurance schemes and financing of care in each country differ, several participants said neither system is adequate. In Kenya, mental health services are excluded from the insurance fund, leaving people to pay costs out of pocket. In Ghana, there is conflict between what the law says—that mental health care is free—and the reality on the ground, which is that because no funding is coming from the government for this care, treatment and medicines are either not available or must be paid for out of pocket. Several participants from both countries appealed to their governments for sustainable, clear financing systems for mental health care, and they called for universal health coverage for all people and all conditions.

POTENTIAL NEXT STEPS

The workshops in Ghana and Kenya generated an enormous number of suggestions for how to improve mental health care in these countries, including detailed strategies that could be employed. The draft demonstration projects, as well as participant discussion, provided a framework of the general sequential steps necessary to turn these ideas into on-the-ground demonstration projects.²

1. Collect baseline data. In both Ghana and Kenya, there is a lack of available data about mental health care demand and services. Before undertaking an effort to improve the system, many participants stated that baseline data must be collected to have a better understanding of, for example, the burden of MNS disorders; resources currently available; how existing partnerships and key stakeholders engage; and the priorities of community members, stakeholders, and the government. This can be done through data collection methods such as surveys, focus groups, resource map-

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²This section draws on a commissioned paper, “Providing Sustainable Mental Health Care in Ghana: A Demonstration Project,” by Julian Eaton and Sammy Ohene (see Appendix F).

2. ping, and meetings with community and government leaders. According to several participants, the data collected can be used to help determine how a project will proceed: on which conditions it will focus, the areas of the country in which it will operate, and the initial goals and strategies of the project.

3. Obtain buy-in. Buy-in from the government, communities, health care managers, and industry must be procured before a project begins, according to many participants. As previously discussed, buy-in is critical to ensure that a project is efficient, successful, and sustainable. The baseline data that have been collected might help these leaders see the importance of a project, while the leaders can provide valuable input into how a project should be structured. This is also an opportunity to form partnerships that can greatly strengthen a project by adding local wisdom, additional resources, and capacity to provide services.

   Goal:	Reduce stigma in the community in the Ashanti region of Ghana.
   Strategy:	Small targeted meetings with peer educators.
   Objective:	Hold 10 community meetings in Adansi North district, reaching at least 100 community members.
   Tactics:	Partner with health care workers, chiefs, traditional healers, and other community members to identify and invite at least 10 at-risk individuals or families in each community.

4. Develop a strategic plan. Although several ideas were discussed to provide sustainable mental health care in Ghana and Kenya, many participants stressed that it will be important to further extrapolate from these opportunities goals, strategies, objectives, and tactics in order to be implemented and evaluated. In addition, several participants said key stakeholders and partners should be identified for each step. For example, for the goal of reducing stigma in the community, a strategic plan might look like this:

4. Find a private space to hold a meeting—partner with a local NGO or a school. Identify an MNS-affected peer educator who is willing to lead the meetings. Train the peer educator. Identify and assemble resources (e.g., handouts, refreshments) for the meetings. Hold the meetings.

5. Monitor and evaluate. Many participants noted that the success of a project must be monitored and evaluated in order to determine if it should be altered, replicated, or discarded. Evaluation metrics should be determined before a project begins so that baseline data can be collected. Evaluation metrics might include process measures (e.g., the number of people reached, the number of meetings held, or the number of guidelines distributed), use of services (the number of people seeking and receiving care before and after the start of the project), retention rate (patient adherence to treatment and services), or scales that measure knowledge, attitudes, beliefs, behaviors, or stigma. Several participants stated that timely and accurate evaluation of a project can save resources, improve patient care, and facilitate expansion of a successful project.
6. Scale up. Finally, if evaluation shows that a demonstration project has been successful, it can be scaled up and implemented in other areas of the country. A project may have to be adjusted to local context: the strategies and tactics may differ significantly depending on local priorities and resources available. However, a well-evaluated, well-planned demonstration project should be successful when appropriately replicated and scaled up, several participants said.

CLOSING COMMENTS

In the final sessions of the workshops, participants expressed hope that “a new era [for mental health] is dawning,” as Akwasi Osei, acting chief executive officer of the Ghana Mental Health Authority, put it. Osei urged participants to move forward with optimism, rather than “the

pessimism of the old times.” He said the ideas generated by these workshops could create a blueprint for governments, NGOs, and funders who wish to make significant changes to the mental health system. Leshner noted that in addition to the blueprint, resources and political will are necessary to move forward. For political will and resources to materialize, Leshner added, mental health advocates must “continuously remind” policy makers and the public that “we know what we are doing … we do have treatments that work.” Bompart concluded: “There is an opportunity now, today, to bring mental health … to the attention of political decision makers. The window of opportunity may be fairly narrow, so let’s seize it.”

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