Working together to close gaps in mental health care delivery: innovating community health approaches, priming health systems and strengthening partnerships consistent with the SDGs
Paul Farmer and Giuseppe Raviola
Partners in Health
Working together to close gaps in mental health care delivery: innovating community health approaches, priming health systems and strengthening partnerships consistent with the SDGs
In the early 1980s, I (Paul Farmer) met Marie-Thérèse: a brilliant, remarkable young woman from a poor family in Haiti’s Central Plateau. A couple of years after we began working together, she was diagnosed by psychiatrists at the Mars and Kline national psychiatric hospital as having manic-depressive disorder. For years she struggled with keeping appointments and purchasing medications. Like many people with major mental illness, then and today, Marie-Thérèse lived in a constant state of insecurity, not knowing whether or not she would receive regular care for her illness.
In those formative years of our medical work in Haiti, we learned about the importance of co-morbidities and of the social determinants of medical conditions, including mental disorders, the ways in social forces (like gender inequality) become embodied as disease, and the lethality of broken health systems. I interviewed Haitian psychiatrists who taught us that attention to sociology and anthropology must inform good practice and service delivery. But they could not help Marie-Thérèse unless she was able to pay their fees. Critical analysis of the history of psychiatry (for example, as related to longstanding efforts to create a scientific psychiatric nosology), and of stigma and fear, as they reverberate today in dilapidated government mental hospitals and in settings where formal mental health services still do not exist, merits ongoing attention. This must be appreciated in the context of scientific evidence regarding the neurobiological, genetic and medical elements contributing to the etiology of the major mental illnesses.
We remain convinced that attention to history, culture, political economy, and structural violence must inform the provision of holistic, community-based and comprehensive care for problems related to mental health. This is not simply an academic exercise.[1] There is no health—nor sustainable development—without mental health. We fully endorse the increased focus of the Lancet Commission on global mental health and sustainable development, on social determinants, on wellbeing rather than solely illness, on unique contextual experience, and on invoking human rights frameworks. We also reassert the relevance of psychiatry as a basic and essential field of medicine. We need to think hard about the role of mental-health specialists in the care of severe presentations of mental and neurologic illness, while acknowledging that psychiatrists are too tiny a part of the workforce to directly address the world’s leading cause of illness and suffering. Engaging psychiatrists, psychologists, and clinical social workers in efforts to link inpatient services to those delivered in communities, primary-care centers, and general hospitals remains a ranking challenge. So does avoiding the mistake of dismissing the significance of inpatient facilities in addressing severe mental illness. The crude deinstitutionalization of previous eras has often served to turf the care of the most stricken patients back to beleaguered facilities—or to the streets.
Partners In Health, founded in 1987, initially focused on delivering primary health care to a population shut out of it. Working in understaffed and underfunded public clinics in Haiti, we linked care and prevention, aggressive case finding and treatment, and made health services available to those who lacked them, relying primarily on community health workers, rather than physicians or nurses, to provide the bulk of care that extended far beyond clinic walls.[2] (When we began, there were more Haitian psychiatrists in the city of Montreal than all of Haiti.) We learned how the integration of preventive and clinical approaches represents a valuable public good which, when combined with effective partnerships with the public sector, can strengthen health systems. We started small, but hoped for scale.
Tuberculosis and AIDS, both chronic infections, forced us to sharpen our focus on further strengthening health systems. Care for HIV/AIDS and tuberculosis called for transforming primary care by demanding we pay attention to chronic infections; diabetes and mental disorders posed the same demands. We also learned that this model of global health delivery maximizes the spillover effects that foster economic growth and sustainable development.[3] Rwanda presents one such example, where such integration of approaches has led to significant health improvements, including large reductions in maternal mortality, under-five mortality, and deaths secondary to infectious diseases such as HIV/AIDS, tuberculosis and malaria—an illustration of health care delivery as an engine itself for sustainable development.[4]
By obvious extension, given the lessons learned over decades of fruitful progress in global health delivery, and an evidence base that has become established regarding the effectiveness of interventions delivered by non-specialists for mental health conditions,[5][6][7][8][9] it is clear that the opportunity exists for the integration of mental health care (preventive and clinical) to strengthen health systems and promote sustainable development.
Are the aims of the Lancet Commission—around innovative strategies, “balanced” care models, and universal health coverage—overambitious or misguided? We think not. During one of Marie-Thérèse’s psychotic flares, she faced the acute peril of childbirth. Since we sought to provide health services to any acutely ill patient, we sought to make sure Marie-Thérèse was delivered safely of her baby while treated for what was manifestly a psychotic break. But good intentions and a refusal to turn away the sick, regardless of their diagnosis, did not an effective program make.
In other words, having good and compassionate clinicians on hand is not the same as creating effective and sustained mental-health programs. Reflecting on practice-based experience of implementation in challenging circumstances, Partners In Health has been working over the past decade to integrate the four innovations for scaling interventions which have been endorsed by the Lancet Commission: task-sharing of psychosocial interventions; coordination with primary and specialist care; adoption of digital platforms; and implementation of community-based interventions. In close partnership with ministries of health, we have cared for tens if not hundreds of thousands of people living with mental disorders. We have responded to disasters and conflict from Peru and Guatemala to Rwanda, from the 2010 Haiti earthquake to the 2014-16 West Africa Ebola outbreak, and have sought to “build back better” with regard to mental health as a component of strengthening health systems.[10]
In Haiti and Rwanda, with public-health authorities, we are serving thousands of people living with mental disorders across a range of conditions, effectively offering national demonstrations of decentralizing care to communities, including primary care integration of mental health.[11][12][13] Several of our sister organizations, including those in Haiti, Peru, Siberia, Rwanda and Mexico, have innovated in mental health care delivery in a number of ways since their establishment in 1985, 1993, 1999, 2005 and 2012, respectively, and are currently expanding their capacity to serve at the community level. In other places in which we’ve been privileged to work—including Lesotho, Liberia, Malawi and Sierra Leone—we’ve been expanding care delivery in mental health. For example, in the city of Harper, Liberia, a small, and largely local, implementing team, working within the government hospital, has been providing care to several hundred homeless former combatants of Liberia’s civil wars through mobile community health workers. This approach helps to get them off the street, and will be adapted to address a broader range of problems.
We hope to expand community-based mental health care delivery in the places we work by focusing on psychological treatments for common mental disorders, improving supply chains for pharmacologic therapy for severe mental disorders, and integrating preventive interventions such as early child development and school-based therapies that can reduce the risk for the development of mental disorders. Longer-term work will consolidate efforts to integrate specific care packages for common and severe mental disorders, increase use of approaches consistent with the Lancet Commission recommendations of a staging approach; evaluate clinical outcomes and local systems changes; share knowledge and experience with public-health authorities working with our local affiliates; partner with ministries to increase investments in mental health; and support expansion and scale of mental health services in context.
Marie-Thérèse died in 1988 of puerperal sepsis, a preventable, infectious complication of childbirth. “You see,” her mother said at the time, “she died not from being crazy. It’s this country that killed her.”[14] Ten years after her death, her youngest brother would repeat exactly the same words to me. Marie-Thérèse’s infant son survived, and now works with Partners In Health in central Haiti. Today, while there are mental health services available and people such as Marie-Thérèse have a fighting chance to survive the assaults of poverty, endemic disease and the risk of developing problems related to mental health, there is a long road ahead for all those seeking to prevent major mental illness from dragging more people under.
The Lancet Commission offers a concise review of a complex literature and a tragically consistent story of unnecessary suffering. The parallels between the movement to bring mental health care to the world, and the experience of the successful development of community-based approaches to integrating prevention and care of and for AIDS—including the emphasis on sustainable development—are readily apparent. These parallels should encourage those who have been working in the neglected area of mental health care delivery—in any and all settings—for significant progress can be made.
[1] Kleinman A. The art of medicine: Four social theories for global health. The Lancet. 2010;375:1518-19
[2] Walton D, Farmer PE, Lambert W, Leandre F, Koenig SP, Mukherjee JS. Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti. Journal of Public Health Policy.25(2):137-158.
[3] Kim JY, Porter M, Rhatigan J, Weintraub R, Basilico M, Van Der Hoof Holstein C, Farmer P. Scaling Up Effective Delivery Models Worldwide. In Reimagining Global Health: An Introduction. Farmer P, Kim JY, Kleinman A, Basilico M, eds. Berkeley: University of California Press, 2013: 194.
[4] Binagwaho A, Farmer PE, Nsanzimana S, Karema C, Gasana M, de Dieu Ngirabega J, et al. Rwanda 20 years on: investing in life. The Lancet. 2014;384(9940):371–5.
[5] Hoeft TJ, Fortney JC, Patel V, Unützer J. Task-Sharing Approaches to Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic Review. The Journal of RuralHealth. 2018;34: 48–62.
[6] Barnett ML, Lau AS, Miranda J. Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care. Ann. Rev. Clin. Psychol. 2018;14:185-208.
[7] Singla DR, Kohrt BA, Murray LK, Anand A, Chorpita BF, Patel V. Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries. Ann. Rev. Clin. Psychol. 2017;13:149-81.
[8] Kohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJD, Mutamba BB, Nadkarni A, Pedersen G, Singla DR, Patel V. The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies. Int. J. Environ. Res. Public Health. 2018;15,1279.
[9] Kroenke K, Unützer J. Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care. J. Gen. Intern. Med. 2016;32(4):404-10.
[10] Epping-Jordan, J. E., Ommeren, M. V., Nayef Ashour, et al (2015), Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective, International Journal of Mental Health Systems, 9:15.
[11] Raviola G, Severe J, Therosme T, Oswald C, Belkin G, Eustache E. The 2010 Haiti Earthquake Response. Psychiatr Clin N Amer. 2013 September; 36:431-450.
[12] Smith S, Kayiteshonga Y, Misago CN, Iyamuremye JD, Dusabeyezu J, Mohand AA, Osrow R, Raviola G. Integrating Mental Health Care into Primary Care: the case of one rural district in Rwanda. Intervention. Intervention: July 2017 – Volume 15 – Issue 2 – p 136–150. doi: 10.1097/WTF.0000000000000148
[13] Smith S, Misago CN, Osrow R, Franke M, Iyamuremye JD, Dusabeyezu J, Mohand A, Anatole M, Kayiteshonga Y, Raviola G. Evaluating Process and Clinical Outcomes of a Primary Care Mental Health Integration Project in rural Rwanda: a Prospective Mixed-Methods Protocol. BMJ Open. 2017 Feb 28;7(2):e014067. doi: 10.1136/bmjopen-2016-014067.
[14] Farmer P. Birth of the Klinik: A Cultural History of Haitian Professional Psychiatry. In Ethnopsychiatry. Gaines A, ed. Albany: SUNY, 1992:251-272.
Working together to close gaps in mental health care delivery: innovating community health approaches, priming health systems and strengthening partnerships consistent with the SDGs
In the early 1980s, I (Paul Farmer) met Marie-Thérèse: a brilliant, remarkable young woman from a poor family in Haiti’s Central Plateau. A couple of years after we began working together, she was diagnosed by psychiatrists at the Mars and Kline national psychiatric hospital as having manic-depressive disorder. For years she struggled with keeping appointments and purchasing medications. Like many people with major mental illness, then and today, Marie-Thérèse lived in a constant state of insecurity, not knowing whether or not she would receive regular care for her illness.
In those formative years of our medical work in Haiti, we learned about the importance of co-morbidities and of the social determinants of medical conditions, including mental disorders, the ways in social forces (like gender inequality) become embodied as disease, and the lethality of broken health systems. I interviewed Haitian psychiatrists who taught us that attention to sociology and anthropology must inform good practice and service delivery. But they could not help Marie-Thérèse unless she was able to pay their fees. Critical analysis of the history of psychiatry (for example, as related to longstanding efforts to create a scientific psychiatric nosology), and of stigma and fear, as they reverberate today in dilapidated government mental hospitals and in settings where formal mental health services still do not exist, merits ongoing attention. This must be appreciated in the context of scientific evidence regarding the neurobiological, genetic and medical elements contributing to the etiology of the major mental illnesses.
We remain convinced that attention to history, culture, political economy, and structural violence must inform the provision of holistic, community-based and comprehensive care for problems related to mental health. This is not simply an academic exercise.[1] There is no health—nor sustainable development—without mental health. We fully endorse the increased focus of the Lancet Commission on global mental health and sustainable development, on social determinants, on wellbeing rather than solely illness, on unique contextual experience, and on invoking human rights frameworks. We also reassert the relevance of psychiatry as a basic and essential field of medicine. We need to think hard about the role of mental-health specialists in the care of severe presentations of mental and neurologic illness, while acknowledging that psychiatrists are too tiny a part of the workforce to directly address the world’s leading cause of illness and suffering. Engaging psychiatrists, psychologists, and clinical social workers in efforts to link inpatient services to those delivered in communities, primary-care centers, and general hospitals remains a ranking challenge. So does avoiding the mistake of dismissing the significance of inpatient facilities in addressing severe mental illness. The crude deinstitutionalization of previous eras has often served to turf the care of the most stricken patients back to beleaguered facilities—or to the streets.
Partners In Health, founded in 1987, initially focused on delivering primary health care to a population shut out of it. Working in understaffed and underfunded public clinics in Haiti, we linked care and prevention, aggressive case finding and treatment, and made health services available to those who lacked them, relying primarily on community health workers, rather than physicians or nurses, to provide the bulk of care that extended far beyond clinic walls.[2] (When we began, there were more Haitian psychiatrists in the city of Montreal than all of Haiti.) We learned how the integration of preventive and clinical approaches represents a valuable public good which, when combined with effective partnerships with the public sector, can strengthen health systems. We started small, but hoped for scale.
Tuberculosis and AIDS, both chronic infections, forced us to sharpen our focus on further strengthening health systems. Care for HIV/AIDS and tuberculosis called for transforming primary care by demanding we pay attention to chronic infections; diabetes and mental disorders posed the same demands. We also learned that this model of global health delivery maximizes the spillover effects that foster economic growth and sustainable development.[3] Rwanda presents one such example, where such integration of approaches has led to significant health improvements, including large reductions in maternal mortality, under-five mortality, and deaths secondary to infectious diseases such as HIV/AIDS, tuberculosis and malaria—an illustration of health care delivery as an engine itself for sustainable development.[4]
By obvious extension, given the lessons learned over decades of fruitful progress in global health delivery, and an evidence base that has become established regarding the effectiveness of interventions delivered by non-specialists for mental health conditions,[5][6][7][8][9] it is clear that the opportunity exists for the integration of mental health care (preventive and clinical) to strengthen health systems and promote sustainable development.
Are the aims of the Lancet Commission—around innovative strategies, “balanced” care models, and universal health coverage—overambitious or misguided? We think not. During one of Marie-Thérèse’s psychotic flares, she faced the acute peril of childbirth. Since we sought to provide health services to any acutely ill patient, we sought to make sure Marie-Thérèse was delivered safely of her baby while treated for what was manifestly a psychotic break. But good intentions and a refusal to turn away the sick, regardless of their diagnosis, did not an effective program make.
In other words, having good and compassionate clinicians on hand is not the same as creating effective and sustained mental-health programs. Reflecting on practice-based experience of implementation in challenging circumstances, Partners In Health has been working over the past decade to integrate the four innovations for scaling interventions which have been endorsed by the Lancet Commission: task-sharing of psychosocial interventions; coordination with primary and specialist care; adoption of digital platforms; and implementation of community-based interventions. In close partnership with ministries of health, we have cared for tens if not hundreds of thousands of people living with mental disorders. We have responded to disasters and conflict from Peru and Guatemala to Rwanda, from the 2010 Haiti earthquake to the 2014-16 West Africa Ebola outbreak, and have sought to “build back better” with regard to mental health as a component of strengthening health systems.[10]
In Haiti and Rwanda, with public-health authorities, we are serving thousands of people living with mental disorders across a range of conditions, effectively offering national demonstrations of decentralizing care to communities, including primary care integration of mental health.[11][12][13] Several of our sister organizations, including those in Haiti, Peru, Siberia, Rwanda and Mexico, have innovated in mental health care delivery in a number of ways since their establishment in 1985, 1993, 1999, 2005 and 2012, respectively, and are currently expanding their capacity to serve at the community level. In other places in which we’ve been privileged to work—including Lesotho, Liberia, Malawi and Sierra Leone—we’ve been expanding care delivery in mental health. For example, in the city of Harper, Liberia, a small, and largely local, implementing team, working within the government hospital, has been providing care to several hundred homeless former combatants of Liberia’s civil wars through mobile community health workers. This approach helps to get them off the street, and will be adapted to address a broader range of problems.
We hope to expand community-based mental health care delivery in the places we work by focusing on psychological treatments for common mental disorders, improving supply chains for pharmacologic therapy for severe mental disorders, and integrating preventive interventions such as early child development and school-based therapies that can reduce the risk for the development of mental disorders. Longer-term work will consolidate efforts to integrate specific care packages for common and severe mental disorders, increase use of approaches consistent with the Lancet Commission recommendations of a staging approach; evaluate clinical outcomes and local systems changes; share knowledge and experience with public-health authorities working with our local affiliates; partner with ministries to increase investments in mental health; and support expansion and scale of mental health services in context.
Marie-Thérèse died in 1988 of puerperal sepsis, a preventable, infectious complication of childbirth. “You see,” her mother said at the time, “she died not from being crazy. It’s this country that killed her.”[14] Ten years after her death, her youngest brother would repeat exactly the same words to me. Marie-Thérèse’s infant son survived, and now works with Partners In Health in central Haiti. Today, while there are mental health services available and people such as Marie-Thérèse have a fighting chance to survive the assaults of poverty, endemic disease and the risk of developing problems related to mental health, there is a long road ahead for all those seeking to prevent major mental illness from dragging more people under.
The Lancet Commission offers a concise review of a complex literature and a tragically consistent story of unnecessary suffering. The parallels between the movement to bring mental health care to the world, and the experience of the successful development of community-based approaches to integrating prevention and care of and for AIDS—including the emphasis on sustainable development—are readily apparent. These parallels should encourage those who have been working in the neglected area of mental health care delivery—in any and all settings—for significant progress can be made.
[1] Kleinman A. The art of medicine: Four social theories for global health. The Lancet. 2010;375:1518-19
[2] Walton D, Farmer PE, Lambert W, Leandre F, Koenig SP, Mukherjee JS. Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti. Journal of Public Health Policy.25(2):137-158.
[3] Kim JY, Porter M, Rhatigan J, Weintraub R, Basilico M, Van Der Hoof Holstein C, Farmer P. Scaling Up Effective Delivery Models Worldwide. In Reimagining Global Health: An Introduction. Farmer P, Kim JY, Kleinman A, Basilico M, eds. Berkeley: University of California Press, 2013: 194.
[4] Binagwaho A, Farmer PE, Nsanzimana S, Karema C, Gasana M, de Dieu Ngirabega J, et al. Rwanda 20 years on: investing in life. The Lancet. 2014;384(9940):371–5.
[5] Hoeft TJ, Fortney JC, Patel V, Unützer J. Task-Sharing Approaches to Improve Mental Health Care in Rural and Other Low-Resource Settings: A Systematic Review. The Journal of RuralHealth. 2018;34: 48–62.
[6] Barnett ML, Lau AS, Miranda J. Lay Health Worker Involvement in Evidence-Based Treatment Delivery: A Conceptual Model to Address Disparities in Care. Ann. Rev. Clin. Psychol. 2018;14:185-208.
[7] Singla DR, Kohrt BA, Murray LK, Anand A, Chorpita BF, Patel V. Psychological Treatments for the World: Lessons from Low- and Middle-Income Countries. Ann. Rev. Clin. Psychol. 2017;13:149-81.
[8] Kohrt BA, Asher L, Bhardwaj A, Fazel M, Jordans MJD, Mutamba BB, Nadkarni A, Pedersen G, Singla DR, Patel V. The Role of Communities in Mental Health Care in Low- and Middle-Income Countries: A Meta-Review of Components and Competencies. Int. J. Environ. Res. Public Health. 2018;15,1279.
[9] Kroenke K, Unützer J. Closing the False Divide: Sustainable Approaches to Integrating Mental Health Services into Primary Care. J. Gen. Intern. Med. 2016;32(4):404-10.
[10] Epping-Jordan, J. E., Ommeren, M. V., Nayef Ashour, et al (2015), Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective, International Journal of Mental Health Systems, 9:15.
[11] Raviola G, Severe J, Therosme T, Oswald C, Belkin G, Eustache E. The 2010 Haiti Earthquake Response. Psychiatr Clin N Amer. 2013 September; 36:431-450.
[12] Smith S, Kayiteshonga Y, Misago CN, Iyamuremye JD, Dusabeyezu J, Mohand AA, Osrow R, Raviola G. Integrating Mental Health Care into Primary Care: the case of one rural district in Rwanda. Intervention. Intervention: July 2017 – Volume 15 – Issue 2 – p 136–150. doi: 10.1097/WTF.0000000000000148
[13] Smith S, Misago CN, Osrow R, Franke M, Iyamuremye JD, Dusabeyezu J, Mohand A, Anatole M, Kayiteshonga Y, Raviola G. Evaluating Process and Clinical Outcomes of a Primary Care Mental Health Integration Project in rural Rwanda: a Prospective Mixed-Methods Protocol. BMJ Open. 2017 Feb 28;7(2):e014067. doi: 10.1136/bmjopen-2016-014067.
[14] Farmer P. Birth of the Klinik: A Cultural History of Haitian Professional Psychiatry. In Ethnopsychiatry. Gaines A, ed. Albany: SUNY, 1992:251-272.