SUPPORT-SYSTEMS (44) Meeting the information needs of health policy makers (2)

23 May, 2022

Dear HIFA Colleagues,

With regards to participation of community groups, patient associations, and professional associations in decision-making processes about UHC and for using evidence to improve health policy making, the ‘mental health’ space in Anglophone West Africa (Gambia, Ghana, Liberia, Nigeria, and Sierra Leone) provides lots of good practice for learning.

Like many developing countries, across West Africa, governance structures for mental health remain weak. Governance entails having a framework that includes mental health policy and legislation that protects and promotes human rights, as well as their effective implementation. In general, leadership and coordination are often lacking, as many Ministries of Health, either do not have a dedicated Mental Health Section or Desk Officer; or they are poorly empowered and financed.

For the countries under review with a common colonial legacy, they also inherited extant laws that tend to criminalise mental health. Despite better understanding of mental health as a health condition requiring considerable care and support, and after over 50 years of independence from British rule; many of these laws remained unrepealed largely due to poor understanding of health policy makers about mental health. Moreover, current knowledge that mental health is treatable and mental health services could be provided at community level by frontline health workers, was also lacking.

Supported by CBM International [https://en.wikipedia.org/wiki/CBM_(charity)], a regional Mental Health Leadership and Advocacy Programme (mhLAP) organised annual leadership and mental health advocacy training over a ten-year period starting in 2011, jointly for policymakers, stakeholders, service users, journalists, mental health professionals across the 5 anglophone countries of West Africa. Following this, participants in each country established a National Stakeholder Council to advance mental health advocacy and push for effective governance with a view to scaling up appropriate mental health services and improving the quality of life of people with lived experience of mental health conditions in the respective jurisdictions. In addition, individual National Stakeholder Councils were empowered to contextualise the WHO Mental Health Gap Action Programme, Intervention Guide (mhGAP-IG) used in training primary care workers on commuity mental health care for each country, as well as develop and implement quality improvement activities for mental health services in their countries using the WHO Quality Rights Toolkit.

As this author conducted the End-of-Programme Evaluation, here are few paragraphs taken from the conclusions of the evaluation report:

As the findings and analysis of this evaluation indicate, the views from most participants of the mhLAP training course on increasing policy attention by governments and implementing mental health services in the project countries, were very positive. The formation and maintenance of National Stakeholder Councils committed to advocating for improved mental health services in their respective countries is also seen to have influenced policies and practices and strengthened systems that have brought about definite changes in the national mental health system indicators. Both strategies working synergistically is considered to have led to increased access for mental health services at district level thereby reducing the treatment gap for mental illnesses, as well as promote the delivery of improved mental health services that respect patients’ rights and autonomy, in addition to reducing stigmatisation of mental illness.

The stakeholder councils also attempted to promote the establishment of service user groups in countries where they did not exist. This could have been an additional strategy that should have been used alongside the two main strategies to also meet the needs and priorities of the project’s beneficiaries. It has been suggested12 that other than the benefits of contact-based behavioral health anti-stigma interventions, whereby people with lived experience of mental illness interact with the public describing their challenges and stories of success; when integrated into service-provision teams, people with lived experience who work as health care team members are also able to foster the provision of nonjudgmental, nondiscriminatory services while openly identifying with their own experiences.

While the mhLAP National Stakeholder Councils where originally intended to direct governments’ attention towards appropriate mental health policies and resource allocation for mental health service delivery, during the course project implementation, they have become permanent features within government mental health coordinating structures. For example, the Mental Health Coalition of Sierra Leone is the designated Secretary of the Steering Committee for Mental Health that provides oversight and implementation of mental health projects and programmes by government and its partners in order to avoid duplication of efforts. In Liberia, the Technical Coordination Committee (TCC) is the highest governing body on mental health, which ensures that the efforts of donors and NGOs are coordinated and aligned with that of government. Set up by the Minister of Health, it has four sub-committees, two of which (Advocacy, and Substance Use Disorders) are headed by the mhLAP Stakeholder Council. Having influenced the establishment and/or strengthened structures within government to lead on mental health programmes, the other three National Stakeholder Councils were also noted to had played similar or related roles in their countries. Though an unintended positive change, there is a sense that national Ministries of Health in the project countries now look up to mhLAP National Stakeholder Councils and by extension their evolved counterparts (the indigenous Coalition of mental health NGOs/CSOs) to play a critical role in mental health governance of the respective countries.

12. "4 Approaches to Reducing Stigma." National Academies of Sciences, Engineering, and Medicine. 2016. Ending Discrimination Against People with Mental and Substance Use Disorders: The Evidence for Stigma Change. Washington, DC: The National Academies Press. doi: 10.17226/23442

And several useful lessons learned from the evaluation of this initiative were noted as outlined below:

1. The mhLAP has been successful as a pragmatic and context-specific model to develop capacity for mental health leadership and advocacy in the West African region.

2. It has proven to be efficient and cost-effective, way of raising a cohort of informed, motivated, and impactful mental health advocates for the sub-region. The diverse range of participants, from service users to mental health professionals and civil society actors strengthened mutual learning and richness of sharing.

3. Forming a range of technical partnerships such as WHO and civil society organisations ensured that programmes had a readily available source of international best practice examples and context specific frameworks and approaches.

4. The regional approach involving several countries with a focus on developing capacity in each country is a pragmatic and cost-effective means of scaling up mental health advocacy and improving mental health services.

And here are some publications that emerged from the implementation of mhLAP that fostered and maintained civil society actions for policy changes in mental health in West Africa:

1. Abdulmalik J, Fadahunsi W, Kola L, Nwefoh E, Minas H, Eaton J, Gureje O. The Mental Health Leadership and Advocacy Program (mhLAP): a pioneering response to the neglect of mental health in Anglophone West Africa. Int J Ment Health Syst. 2014 Jan 27;8(1):5. doi: 10.1186/1752-4458-8-5.

2. Esan O, Abdulmalik J, Kola L, Fadahunsi W, Gureje O. (2014): Mental Health Care in Anglophone West Africa. Psychiatric Services Vol. 65, 1084 – 1087

3. Rwafa-Madzvamutse C, Kidia K, Gureje O, Mangezi W, Jack HE. Leadership and management training for African psychiatrists in the era of task-sharing. Lancet Psychiatry. 2020 Jan 20. pii: S2215-0366(19)30529-2. doi: 10.1016/S2215-0366(19)30529-2.

4. Gureje, O. The Mental Health Leadership and Advocacy Programme (mhLAP) at the University of Ibadan – a pioneering effort to change the mental health service. The ACU Review [https://www.acu.ac.uk/the-acu-review/] (in press)

Best,

Tarry

HIFA Profile: Tarry Asoka is a consultant in health and development based in Nigeria. Besides assisting clients to meet their corporate objectives, Tarry is keen on searching for and implementing innovative solutions that address critical challenges that confront the world in health and development. He has experience with civil society participation in health policy processes in Anglophone West Africa (Ghana, Liberia, Nigeria, Sierra Leone, and The Gambia). In Nigeria, he has provided mentoring support and help to channel resources to the lead CSO (Health Reform Foundation of Nigeria – HERFON) both as UK DFID (now FCDO) Health Adviser over a 5-year period and later as an Independent Consultant. Tarry is a member of the HIFA working group on SUPPORT-SYSTEMS.

https://www.hifa.org/support/members/tarry

https://www.hifa.org/projects/new-support-systems-how-can-decision-makin...

Email address: tarry AT carenet.info