Eight-year project’s lessons for mental health care

After eight years, the Programme for Improving Mental Health (PRIME), a global consortium led by the University of Cape Town (UCT), is wrapping up. Crick Lund, PRIME CEO and professor of Public Mental Health at UCT, looks back at some of the programme’s insights into how to create effective mental health care in low- and middle-income countries.

Mental illness, including substance abuse, makes up 13% of the global burden of disease, yet four out of every five people with mental illness in low- and middle-income countries go without treatment.

“PRIME was set up as a way to find solutions to this huge treatment gap through research into the implementation and scaling up of treatment programmes for mental illness in low-resource settings,” explains Lund.

“From the outset, PRIME was exciting because it was global, southern-led and intrinsically collaborative in nature.”

The programme was made up of research institutions and health ministries in five countries in Africa and Asia. Over the course of the programme, a team of 30 researchers and partners in Ethiopia, India, Nepal, South Africa and Uganda developed evidenced-based health plans for the district level. These they implemented at 37 facilities and then scaled up the plans at a further 94 facilities.

Mental illness, including substance abuse, makes up 13% of the global burden of disease, yet four out of every five people with mental illness in low- and middle-income countries go without treatment.

Almost a decade after the first PRIME meeting was held in 2011, the programme has influenced policy, demonstrated the power of collaboration across institutions, provided essential training for both primary caregivers and a new cohort of young researchers, and resulted in more than 100 papers published in peer-reviewed journals.

Form and function

At the heart of PRIME lies the question: how can mental health care be integrated into primary health care? Or as Lund explains it, how do you train non-specialist nurses and community health care providers to deliver interventions to people living with complex conditions?

To answer this question, the programme differentiated between form and function.

“The core functions of a health system must remain constant but the form these functions take can differ widely,” Lund says. To illustrate this, he explains that one of the core functions of a health care system is detection.

“How do you detect someone who is clinically depressed when they have sought care for an apparently unrelated health concern, for instance?

At the heart of PRIME lies the question: how can mental health care be integrated into primary health care?

“With PRIME, detection was a core element of the programme, but it might happen in different ways in different countries. In Nepal, for example, they trained community health workers to detect people with mental disorders using a screening tool with case vignettes based on locally produced idioms of distress.”

Taking it to scale

The district-health plans PRIME developed covered areas with populations ranging from 170 000 to 1.3 million people. By 2015, the programme started to evaluate the progress of these plans using a variety of methods: from community-based surveys to individual case studies and cohorts of individuals tracked over time.

“Mary de Silva of the London School of Tropical Medicine did amazing work in leading the design of these studies,” says Lund. “From there, we were able to scale up these district plans to other areas. These then also ran in parallel with some exciting national policy work that we were able to do.”

In the Indian state of Madhya Pradesh, for example, PRIME set up a mental health care model in all 52 state hospitals that together serve between 70 and 80 million people. In South Africa, Professors Inge Petersen and Arvin Bhana from the University of Kwazulu-Natal took a model developed in the Kenneth Kaunda district, North West province, and scaled it up to several other provinces.

PRIME also had a strong influence on national policy in several cases. “PRIME team members were instrumental in Ethiopia developing its first national mental health strategy. And in Nepal, a national training programme for community health care workers was rolled out in part due to PRIME’s work.”

Asking the right questions

Lund believes one reason for the programme’s success was building collaboration into the design of the project – from the start.

“We had some stormy discussions about which disorders to include and what was feasible in each country.”

“Even before the official launch, PRIME’s research director, Professor Vikram Patel from the London School of Hygiene and Tropical Medicine, and the rest of the team got everyone around a table to discuss the aims of the project and the form it would take,” says Lund. “This included the health ministries in all five countries. Instead of being prescriptive, we asked them, ‘How can this be useful?’

“This set the tone for a very equitable partnership while ensuring the programme’s research goals were relevant. It also fostered trust between partners.”

These foundations proved crucial in the first years of the programme during which time the district-health plans were designed. “It was at times very difficult to get everyone pulling in the same direction as we were working in vastly different contexts. We had some stormy discussions about which disorders to include and what was feasible in each country.

“I’m proud to say that – in the end – we were able to create a common framework, which still allowed for customised implementation. Also, almost 10 years on, virtually all of the people who first sat round the table stayed with the project.”

A population-based approach

“During the programme’s two-year extension, we reached out to other countries, from Fiji to Madagascar and the national government of India. It is exciting to see the tools created in the programme being used elsewhere,” says Lund.

PRIME has also helped to grow a new cohort of young researchers. “We expected four to five PhDs from the programme. In the end, we had 20 PhDs,” says Lund.

“We have shown that it is possible to integrate mental health into primary care in a way that leads to significant improvements in symptoms and functioning for people living with psychosis, depression, alcohol-use disorder and epilepsy.”

“In looking at impact, I think we have shown that it is possible to integrate mental health into primary care in a way that leads to significant improvements in symptoms and functioning for people living with psychosis, depression, alcohol-use disorder and epilepsy.

“There has been recent global advocacy for mental health care, and national governments – while committed to putting such structures in place – do sometimes neglect mental health in resource-scarce environments where health systems are already very stretched.

“Overall, I think PRIME has made a strong case for how to think about mental health using a population-based approach as opposed to an individual approach, which of course is also at the heart of the work we do at the Centre for Public Mental Health at UCT.”