Meeting People Where They Are
CHAG Integrates Mental Health Services for Greater Impact
Mental health services are often kept in silos away from other health services. Inaccessibility, compounded with the stigma surrounding mental health issues, means many people do not get the help they need. The Christian Health Association of Ghana (CHAG) received a five-year grant from the United Kingdom’s Department for International Development (DFID) spanning from 2013 to 2018 to improve accessibility to mental health services, increase awareness and reduce stigma. CHAG Executive Director Peter Yeboah does a deep dive into the project, including what they achieved and learned, the challenges that remain, and next steps.
Can you tell us why CHAG undertook this mental health program?
In Ghana, the general practice has been that specialized psychiatric facilities provide mental health services, which are highly inadequate in meeting the country’s mental health needs. Before the year 2013, there was a huge treatment gap of about 98%, largely attributed to inadequate funding, limited trained personnel, and facilities inequitably distributed resulting in inaccessible and over-crowded facilities. Stigma, discrimination and prejudice against persons living with mental illnesses were rife in Ghana. The level of stigma led to the situation where persons treated for mental illness were not readily accepted by their families or communities. Consequently, there were many cases of relapse. In the late 2000s, in response to the growing needs for mental health services, the Government of Ghana began planning the integration of mental health services into the mainstream health service delivery package to address the challenge of limited access to mental health services.
CHAG received this grant to introduce a series of interventions to bridge the accessibility and awareness gap in mental health in Ghana from 2013 to 2018 to improve the lives of persons suffering from mental illnesses.
What were the main objectives of the project?
The objectives were to increase access to treatment, care and support; reduce stigma and discrimination towards persons with mental illness; and re-integrate those treated for mental illness back into their communities.
What were the main components?
CHAG integrated mental health services into the continuum of care in its facilities. We realized training health professionals in mental health was indispensable, so CHAG trained cadres of professionals to diagnose and treat mentally ill persons. These staff included Medical Officers, Nurses and Physician Assistants for basic diagnosis and treatment. Other cadres included mid-level staff who were trained for three years to become Clinical Psychiatric Officers (CPOs). As of 2013, Ghana had only 18 psychiatrists in the country. So, the CPOs who were already practicing Physician Assistants were trained to complement the work of those 18 Psychiatrists to help fill the skills gap. Additionally, a lower grade called Community Mental Health Officers (CMOs) were trained for one year. This cadre took mental health services to the community level. They followed clients who visited the facilities to the community level and administered medication and provided education where necessary. They linked up with a fourth group: community volunteers who were opinion leaders trained at the community level to identify and connect clients to care.
Within the healthcare setting, we created physical space (consulting rooms and detention rooms) in CHAG facilities for care and treatment.
What would you say is the Christian aspect of the program? How do you think it differs from a secular-run program?
The commitment of the health staff and health managers of the various CHAG facilities are unmatched. The enthusiasm with which the facilities embraced this project is a demonstration of living out CHAG’s core values. The partnerships – the interfaith platform created with fetish priests and Muslim clerics – made so much difference in this project.
How did you reach people in marginalized communities?
In order to improve access to mental health services in the communities, CHAG provided motorbikes to 218 out of the 238 districts in Ghana to help CMOs reach community members. Additionally, CHAG realized the need for targeted services to marginalized segments of the population, so seven specialized centres were created to provide Day Care services for adults, as well as adolescents and children who are often ignored in mental health service provision.
To promote effective management of mental illnesses, the project also produced pocket-sized guidelines in diagnosing simple Mental Health conditions. These guidelines were produced for Medical Officers, Nurses and Physician Assistants who did not have thorough training in mental health.
Where do most people in Ghana get information on mental health? And are there gaps in their knowledge?
Our assessment revealed the most trusted sources of information on mental health are health workers at health facilities, public health authorities and television. Respondents revealed that social media (37%) and television (56%) provide easily accessible information on mental health as compared to information from chiefs and elders (29%). People had very low awareness and knowledge of mental health laws and policies, including healthcare workers and managers. More information is needed on mental health and its laws for all. Overall, two-thirds (65%) of respondents were not aware of community mental health structures such as daycares, rehabilitation centers and vocational centers.
Who were your partners in the project?
CHAG member facilities who integrated mental health services into their continuum of care were the key partners in this project. In order to train community volunteers and enhance service provision at community level, CHAG worked with BasicNeeds Ghana, an organization with immense skill in community entry skills for mental health services. CHAG also leveraged its access to social spaces to promote mental health. Churches, prayer camps and traditional healing centers, which are often the first port of call for many families with mental illness, were collaborators in this project. To obtain access to these groups, CHAG engaged religious leaders, including well-known pastors, Muslim clerics and fetish priests that served as conduits or gatekeepers to unreached groups who would otherwise not be reached or served through health facilities.
Media houses, both print and electronic were very good partners in this project. CHAG also partnered with a local pharmaceutical company to produce psychotropic medicines which partially helped in reducing the gap in access to medicines. This partnership helped in setting up a revolving fund for medicines for selected CHAG facilities.
What did you achieve through the project? How many people were reached? And in what way?
By the end of December 2017, 180 of the 303 CHAG facilities had integrated mental health services into their continuum of care. One hundred and forty (140) of them had mental health units which provided services to mentally ill clients at the community level. Seventy-seven (77) mid-level staff (CPOs) were trained for three years at the Kintampo College of Health and Well Being. These were distributed in facilities that had set up mental health units as part of this program to provide mental health services. One hundred and eleven (111) CMOs were trained who are currently providing services at the facility and community levels. Community volunteers were also enlisted to help in connecting people identified with mental illness to care. Over 1200 medical officers, nurses and physician assistants took basic training in diagnosing and treating mental health conditions.
Every year since 2015, CHAG facilities collectively attend to about 30,000 clients. Between April 2018 and March 2019, CHAG facilities saw 35,466 mentally ill clients out of which 21,211 were insured by the National Health Insurance Scheme (NHIS). The CHAG network conducted 1100 community outreaches for mental health each year since 2015. In 2018, the CHAG network identified 238 clients who attempted suicide, and were supported by the trained CHAG staff in the various mental health units.
Through this project, mental health services became available in many primary healthcare facilities and are reachable at the community level. This is critical to achieving one of the Health Sector Medium Term Development Plan goals of making mental healthcare accessible to all. As an intervention, integrated services have improved access to mental healthcare at the communities, improved perception, and reduced stigma towards persons with mental illness. Our assessment also shows that membership in the NHIS increased financial accessibility, although it did not guarantee access to medication and cost for accessing care. Community interventions by health workers created opportunities for wider engagements, responsive healthcare and follow-up for mental health services.
What are your main takeaways from the project?
Overall, an assessment of the project proved that integrated mental health services are needed to improve access and to strengthen primary healthcare.
The six major findings of our assessment were:
-Awareness of mental health issues improved in communities with integrated services.
-Access to Mental Health Services increased in communities with integrated services.
-Access to mental health information increased in communities with integrated services, but more education is needed on policy and laws related to mental health.
-70% of people are satisfied with the quality of the care they receive, but the most challenging concern for people with mental health disorders is the availability and cost of psychotic medication for people who are not subscribers of the NHIS.
-The integrated mental health services were responsive to the needs of patients but waiting times must be reduced and patient engagement improved.
-Support from social networks and other community groups, especially churches, is important in integrating persons with mental health disorders back into their families and communities. Stigma is still a problem for people with mental health disorders and their families.
What challenges remain?
Affordability is still a challenge across the regions. Feedback from persons with mental illness and their families shows that the integration of mental healthcare into the service delivery package has still not addressed the financial and geographical barriers to mental health services. We need continuous mental health education to address the systemic knowledge gaps, stigma, prejudice and discrimination. Yet, in communities where extensive health education was undertaken, opportunities for re-integration of survivors back into their communities, vocations and social roles improved. CHAG health workers are requesting continuous support to enable them to strengthen their mental health services and community engagement.
What are the next steps?
Overall, CHAG’s integrated Mental Health services have strengthened primary healthcare while revealing areas that need to be improved. It has particularly increased knowledge and perception of and changed some attitudes towards mental health care, but has not reduced stigmatization for PMD and their relatives. Community interventions had improved access to health care, health education and community health personnel engagement and follow-up for health services. Areas requiring improvement are removing physical and financial barriers to care, improvement in resources such as medication, logistics, health workers and referral facilities and the reduction of stigmatization. It is evident that without the support of CHAG and UKAID, these facilities would not have provided mental health services.
CHAG is exploring funding from local and international partners to continue the gains made in this project. Gaps in skilled personnel in mental health services still exist. With further funding, CHAG will continue its training of mid-level personnel to complement the services of psychiatrists, particularly in deprived and unreached communities in Ghana. In essence, CHAG views mental health services as a neglected segment of the service delivery package, which requires sustained advocacy and commitment. Given the growing need for mental health services and the unrecognized socio-economic burden on humanity, CHAG will continue to explore effective partnerships and formulate innovative mechanisms for sustainable mental health services to populations in need.
In above photo a Senior Psychiatrist leads participants through mental health training modules. Photo courtesy of CHAG.
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