Post a (200 Word APA Format) explanation of how you think you would be affected personally by the implementation of the mental heath integration model. Be specific, using the model and your situation to illustrate your points.

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Article

Integration of mental health into primary health care in Uganda: opportunities and challenges

Fred N Kigozi MBChB MMed (Psychiatry) MD, Senior Consultant Psychiatrist/Executive Director, Butabika National Referral and Teaching Mental

Hospital, Uganda

Joshua Ssebunnya BSc MSc (Clinical Psychology) Research Officer, Mental Health and Poverty Project, Makerere University, Butabika National Mental

Hospital, Uganda

Background

Worldwide, a number of reforms have been under-

taken with the intention of improving access to

mental health services. Notable among these is the

integration of mental health services into primary

health care (PHC), which has been one of the most

fundamental healthcare reform recommendations

globally.1–3

Providing mental health services in PHC involves

diagnosing and treating people with common mental

disorders within the general framework of available

health services, putting in place strategies to prevent

mental disorders, ensuring that primary healthcare

workers are able to apply key psychosocial and behav-

ioural science skills, as well as ensuring an efficient

referral system for those who require more special-

ised care.2 However, because of the inadequacy of

the referral services, the same system and human

resources are, from time to time, called upon to

ABSTRACT

Background Worldwide, a number of reforms

have been undertaken with the intention of im-

proving access to mental health services. Notable

among these is the integration of mental health

services into primary health care, which has been

one of the most fundamental healthcare reform

recommendations globally.

Objectives This paper describes the opportun-

ities for and challenges to the integration of men-

tal health into primary health care in Uganda, as

identified in a wider study, aimed at exploring

the policy interventions required to address the

vicious cycle of mental ill-health and poverty.

Methods Semi-structured interviews and focus

group discussions (FGDs) were conducted with

purposefully selected mental health stakeholders

from various sectors. The interviews and FGDs were

audio-recorded, and transcripts coded on the basis

of a pre-determined coding frame. Thematic anal-

ysis of the data was conducted using NVivo7,

adopting a framework analysis approach.

Results The participants identified a number of

opportunities that could be exploited to strengthen

the integration process. Notable among these was

the political will and prioritisation of mental

health at policy level. Poor appreciation of the

integration process and attitudinal problems

emerged as the most pressing challenges for inte-

gration of mental health into primary health care.

Conclusion Irrespective of the various oppor-

tunities in place, the integration of mental health

into primary health care has not yet been fully

realised, as it faces a number of challenges within

and outside the health sector. This calls for more

concerted efforts to scale up activities for effective

integration of mental health care into primary

health care.

Keywords: integration, mental health, policy,

primary healthcare, Uganda

Mental Health in Family Medicine 2009;6:37–42 # 2009 Radcliffe Publishing

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FN Kigozi and J Ssebunnya38

manage severe mental disorders such as psychoses

and manic-depressive illness. The training of PHC

workers has therefore involved empowering them to

handle some of the key aspects of the severe mental

disorders to some extent.4 The advantages of inte-

grating mental health services into PHC include,

among others: reduced stigma for people with men-

tal disorders and their families, improved access to

care, human rights protection, reduced chronicity

and improved social integration, as well as improve-

ment in the human resource capacity for mental

health.5 Mental health treatment in primary care,

compared with the previous institutional care model,

has been noted to improve access, availability and

affordability of services, thereby producing better

outcomes.6

Various initiatives and strategies have been adopted

by countries to operationalise the integration of

mental health into PHC. In Uganda, cluster 4 of

the framework for delivery of the Minimum Health

Care Package comprises the non-communicable dis-

eases, of which mental health and substance abuse

are key elements.4 Primary care is the basic philos-

ophy and strategy for national health development

in Uganda, and the ministry of health has an elab-

orate decentralised structure for the delivery of

health services, which provides a conducive envir-

onment and increased access to mental health ser-

vices.6 The activities that have been undertaken in

Uganda include, among others: inclusion of mental

health as one of the components of the National

Mental Health Care Package, training and recruitment

of mental health professionals, in-service training of

general health workers in mental health, and mak-

ing psychotropic medicines readily available. How-

ever, despite the efforts, effective integration of mental

health into PHC has been noted to still be weak, with

a number of barriers.7,8

In this paper, we explore the opportunities and

challenges to integration of mental health into PHC,

as identified by various stakeholders in Uganda. The

paper is based on findings of a wider study that

explored the policy interventions required to address

the vicious cycle of mental ill-health and poverty in

Ghana, South Africa, Uganda and Zambia, through

the Mental Health and Poverty Research Project.9

Methods

Semi-structured interviews (SSIs) and focus group

discussions (FGDs) were conducted with a variety of

mental health stakeholders in Uganda. Individual

SSIs were used as they are an effective qualitative

method for learning about the perspectives of indi-

viduals in relation to a particular topic.10 These

interviews also allowed for detailed exploration of

a particular individual’s point of view. The FGDs

were conducted with some relatively homogenous

groups of participants (such as nurses or teachers), in

order to capture a range of opinions within these

groups, using the limited time and resources that

were available.

Selection of the participants was done purpose-

fully, based on a number of principles: participants

represented a range of key mental health organis-

ations in Uganda; they held specialised knowledge

or had specific experience related to mental health

policy, mental health services and poverty. In total,

62 semi-structured interviews and six FGDs (each

consisting of 5–9 participants) were conducted over

a six-month period.

The FGDs and interviews were conducted in

English, except for two interviews. The two users

who could not speak English freely were interviewed

in the local language, and the interviews were

translated to English. As required for this sort of

research, ethical approval was provided by the ethics

committee and the office of the Director General of

Health Services in the Ministry of Health. Written

informed consent was obtained from all the partici-

pants. The interviews and FGDs were audio-recorded

and transcribed verbatim. The transcriptions were

then coded and entered into NVivo7 qualitative

data-analysis software.

Thematic analysis of the data was conducted

using a framework analysis approach. This approach

was explicitly developed in the context of applied

research, and is gaining popularity in health policy

and systems research.10 Using this approach, certain

themes and sub-themes were collectively agreed upon

by the investigators at all the research sites, based on

the objectives of the study. A single framework for

analysis was thus developed, and the transcripts were

coded on the basis of this pre-determined coding

frame. Thereafter, specific themes emerging from

the interviews were added into the framework in the

process of conducting the analysis, and transcripts

were coded accordingly.

Findings

Opportunities for integration of mental health care

In this section, we present the findings in relation to

the opportunities for and challenges to the inte-

gration of mental health into primary health care.

It was noted that there is growing recognition of

mental health as an important public health and

development issue in Uganda. Mental disorders have

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Integration of mental health care into primary care in Uganda 39

been recognised to be not only a clinical problem

but also a serious public health problem in the

country, resulting in the inclusion of mental health

as one of the components of the National Minimum

Health Care Package.

The presence of political will and commitment at

the policy level were noted to provide an environ-

ment conducive for the integration process. Over

the last decade, the government of Uganda has made

attempts to formulate a mental health policy after

recognising an increase in mental health-related

problems in the country. The policy strongly em-

phasises the integration of mental health into gen-

eral health care up to the community level as one of

the strategies to strengthen mental health services

in the country. Furthermore, integration is a policy

requirement and the process is driven directly from

national level. This therefore provides a conducive

framework for integration even at the lower levels.

It was noted that the national health policy rec-

ognises mental health care as a key component of

the National Minimum Health Care Package. This is

backed by the fact that mental health has a separate

budget line within the Ministry of Health budget.

Some of the Ministry of Health officials identified

good leadership in mental health, to which they

attributed significant achievements that have been

realised in mental health service delivery over the

past few years.

It emerged that there is wide availability of general

health workers and physicians who can be trained in

a well-co-ordinated plan. In addition to this, there

has been improved training and recruitment of

specialised and other allied health workers in mental

health to facilitate the integration process. The cur-

ricula for medical training institutions were reviewed

to increase the number of hours of exposure to

mental health issues. A well-co-ordinated arrange-

ment for both pre-service and in-service training of

staff in mental health has greatly contributed to the

smooth progress of the integration process.

It was reported that there has been an improved

system of supply of medicines for the past decade,

enabling the provision of psychotropic medicines.

The Ministry of Health’s guidelines allow general

health workers to prescribe and administer psycho-

tropic medicines on the Uganda Essential Drug List.

It was further noted that at the Ministry of Health

headquarters, there is a ring-fenced budget for men-

tal health medicines.

It was further observed that there is considerable

involvement of other players, such as external de-

velopment partners, civil society organisations, tra-

ditional healers, and other relevant sectors. More

non-government organisations (NGOs) involved in

mental health work have facilitated the reduction

of stigma and discrimination against people with

mental illness, resulting in improved demand for

services.

The existence of a decentralised health system was

also believed to facilitate the integration process. It

provides for an improved supervisory system from

Ministry of Health headquarters to districts. Coupled

with all the above, there is an improved countrywide

acceptance of mental health and mental health

problems as an essential component of the diseases

to be handled in health facilities over the years.

It was further noted that there is increased com-

munity participation through selected community

resource personnel (village health teams). Training

of these resource personnel in mental health was

believed to be an excellent opportunity for strength-

ening community-based care as well as integration

of mental health into PHC.

Challenges

It was noted that integration, as a policy recommen-

dation, has been widely accepted and proclaimed,

but has not yet been fully institutionalised in a

guided manner at all levels of care. This was attrib-

uted to a number of challenges and barriers.

First, it emerged that there is limited appreciation

of integration, and what integration actually entails.

Some healthcare managers claimed to have inte-

grated mental health services into PHC but could

not identify any mental health aspects in their health

programme, further arguing that mental health fea-

tures indirectly in the general healthcare activities:

‘... if you look through my work plan here, you will not easily tease a bit of mental health; but it is integrated within. I mean we have the health sector strategic plan of which we are looking at how we really spell out which direction we should be taking for mental health. So, that is basically it. We have it in plan, but implementation may be rather different.’ (SSI, district health services manager)

A particularly striking finding was that even in the

absence of mental health personnel, PHC workers

trained in mental health, and explicit mental health

plans, some health managers maintained that men-

tal health care is part of the service delivery as an

integrated component; this point was echoed by

one of the context informants:

‘... as of now, I wouldn’t say that its activities are really teased out. They are completely integrated into our work of PHC. Well, as a district we don’t have a particular unit that handles mental health as such and I would say we don’t have many specialists. But by and large, it doesn’t mean that mental health is not completely taken care of ... in one way or another we may not be so specialised

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FN Kigozi and J Ssebunnya40

but we can do something about mental health.’ (SSI, district health services manager)

He added:

‘... indirect ... indirectly integrated within the network of treatment and care that we have. We may not be particularly targeting mental illness but we are treating a person holistically.’

The health managers further believed that all health

workers receive some training in mental health during

their pre-service training, and are therefore able

to attend to the mental health needs of patients,

although this was not clearly demonstrated in prac-

tice. This casts doubt as regards their understanding

of integration, and their enthusiasm to have mental

health services in place.

In relation to knowledge and skills in mental

health, most general health workers are ill-equipped,

with very few having had some training in mental

health care. With the limited knowledge on mental

health, many general health workers admitted know-

ing mental illness only by the severe forms – char-

acterised by psychotic features. They thus fail to

identify and attend to those whose mental health

problems do not present with obvious psychiatric

symptoms, resulting in fewer cases being reported.

This has implications regarding resource allocation,

to the disadvantage of mental health.

Furthermore, the general health workers exhibited

poor appreciation of what their role is in relation to

care for people with mental illness. It emerged that

most PHC workers with basic training in mental

health do not regard managing people with mental

illness as their primary role, other than identifi-

cation and referral to the mental hospital. Problems

of understaffing were noted to be further compli-

cated by the fact that there are still few experts to

provide technical support and supervision, particu-

larly to the health workers at the lower levels of care.

Even where support supervision is carried out, it has

been noted to be quite irregular.

The widespread negative attitude towards mental

health and mental disorders was noted to play a

significant role. It emerged that interest in mental

health among most general health workers was still

very low. Most of the general health workers who

received orientation in mental health never had an

interest in mental health, and never developed an

interest later, as they continue to disregard mental

health. One PHC doctor affirmed that although they

currently spend relatively longer time training in

mental health at the medical school than in the past,

their interest still remains low and the attitude

would take longer to change.

‘... Yes, we get the orientation in mental health but the attitude doesn’t change easily. The time is not

enough to change the attitude and develop interest.’ (SSI, PHC doctor, urban district)

Another important barrier that was either pointed

out directly or alluded to was the fact that mental

health care is still under-prioritised at the lower

levels, which is partly reflected by a reluctance to

recruit mental health professionals at lower levels,

and very limited or no financing of mental health

activities. Some of the health managers admitted

disregarding mental health when it comes to resource

allocation. This is further complicated by the fact

that there are limited resources for the health sector

generally, which makes it hard to balance com-

munity and hospital-based mental health care. At

district level, the small budgets intended to facilitate

mental health activities in some health facilities are

often not realised for that purpose. Some health

managers argued that mental health draws from

the general PHC budgets as an integrated com-

ponent, but with no pre-determined budgetary allo-

cations.

It was noted that mental health drugs are included

on the essential drug list and efforts are made to

distribute these drugs. However, supply was reported

to be irregular, with frequent emptying of stocks,

which interferes with smooth service delivery. Re-

striction on prescription of psychotropic medicines

by the PHC nurses was also identified as an obstacle

to service delivery at the lower levels of care, which

greatly depends on these nurses.

Some of the participants, however, believed that

demand for mental health services also constitutes a

significant challenge as regards the integration of

mental health services. They cited poor help-seeking

behaviour, whereby many patients tend to seek help

from traditional healers or faith healers instead of

the health facilities. However, the problem of poor

help-seeking behaviour was also partly attributed to

the fact that the public believes that specialised

mental health services are not readily available in

all health facilities.

Discussion

According to the study findings, it was clear that

some health managers believe the integration of

mental health into PHC occurs automatically, even in

absence of deliberate efforts for its operationalisation.

It should be noted that integration of mental health

into PHC is a national health policy requirement,

with specific targets such as increasing community

access to mental health services by at least 50%,4

which calls for well-planned efforts and strategies.

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Integration of mental health care into primary care in Uganda 41

This was found to be lacking at various levels, where

it was nevertheless claimed that mental health is

integrated into PHC. For example, even in the

absence of any mental health activities, one health

manager at district level maintained that mental

health services were available, integrated into gen-

eral health care indirectly. The study findings suggest

an obvious need to educate healthcare managers

and workers on what integration entails and the

effective implementation strategies.

The findings further suggested that political will

and commitment as well as good leadership are a

pre-requisite for effective integration of mental health

into PHC. It was, however, noted that the strong

political will and commitment for mental health are

mostly at the central level, and less at district level.

This inadequate political support manifests in lim-

ited resource allocation as well as low priority for the

recruitment of human resources for mental health

at the lower centres.

It should be noted that although there is a system

in place for training general health workers in men-

tal health, the number of those who have received

this training is quite small. Furthermore, most health

workers trained before the inclusion of a mental

health component in the curricula for health workers.

Therefore, many health workers still lack knowledge

in mental health. The situation is further complicated

by the absence of regular supervisory visits from the

centre as well as a lack of continuous professional

development. Some of the health workers, including

those who had received training in mental health

care, confessed a lack of interest or a negative atti-

tude that still prevails in relation to mental health.

Training should therefore be tailored in such a way

that it is not only designed to impart mental health

knowledge, but also aims to change attitudes. Fur-

thermore, training arrangements need to take ac-

count of loss of knowledge over time among health

workers.

Inclusion of psychotropic drugs on the Essential

Drug List and a ring-fenced budget for mental health

drugs are positive aspects favouring improved men-

tal health care. However, besides the frequent emp-

tying of stocks, it is not clear to what extent the

medicines are readily available at the lower health

facilities. Given the strict restrictions on prescrip-

tion of psychotropic drugs by general nurses, avail-

ability of medicines would not have a significant

impact if they cannot be readily dispensed and used.

This emphasises a need to ensure that the drugs are

readily available and that health workers are able to

dispense them.

In line with the above, participants identified

poor help-seeking behaviour as one of the chal-

lenges. This implies a need for corrective measures

for effective service delivery and utilisation.

Furthermore, it should be noted that under the

decentralised system, authority lies with the man-

agement at district level to identify their priorities

and allocate resources accordingly. While some par-

ticipants believed that this system has also facilitated

the integration process, others viewed the decentra-

lisation system as one of the barriers. They argued

that mental health is well prioritised at the macro

level but not the district level, as evidenced by the

lack of mental health professionals in some districts.

A significant difference was evident in the mental

health systems of the rural and urban districts,

especially in relation to staffing for mental health;

this is attributable to the difference in prioritisation

by managers in rural and urban districts. This im-

plies that although mental health is a priority area at

policy level, the prioritisation has not moved down

to district level.

In view of the above, there is a need for the

Ministry of Health to closely monitor implemen-

tation of the various priority areas at the lower

levels.

Overall, the study findings highlighted a number

of effective current strategies for the integration of

mental health into PHC in Uganda, similar to anec-

dotal individual experiences and perceptions on

integration of mental health into PHC as reported

in Integrating Mental Health into Primary Care: a global

perspective.6

Conclusion

The study findings implied that this important

policy requirement of integration has not yet been

fully realised, as a result of a number of challenges

within and outside the health sector. The fact that

mental health is a component of the Minimum

Health Care Package implies an obligation for all

health managers to ensure that mental health ser-

vices exist at various levels of care, which seems,

however, not to be happening. This therefore calls

for a deliberate strategy by the health departments

concerned to scale up activities for effective inte-

gration of mental health into PHC, in order to ensure

accessibility and equity in mental health service

delivery.

ACKNOWLEDGEMENTS

This paper reports on the findings from the first

phase of the Mental Health and Poverty Project

(MHaPP). MHaPP is a Research Programme Con-

sortium (RPC) funded by the UK Department for

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FN Kigozi and J Ssebunnya42

International Development (DfID) (RPC HD6 2005-

2010) for the benefit of developing countries. RPC

members among others include Alan J Flisher (Di-

rector) and Crick Lund (Co-ordinator) (University of

Cape Town, Republic of South Africa (RSA)); Therese

Agossou, Natalie Drew, Edwige Faydi and Michelle

Funk (World Health Organization); Arvin Bhana

(Human Sciences Research Council, RSA); Victor

Doku (Kintampo Health Research Centre, Ghana);

Andrew Green and Mayeh Omar (University of

Leeds, UK); Fred Kigozi (Butabika Hospital, Uganda);

Martin Knapp (University of London, UK); John

Mayeya (Ministry of Health, Zambia); Eva N Mulutsi

(Department of Health, RSA); Sheila Zaramba

Ndyanabangi (Ministry of Health, Uganda); Angela

Ofori-Atta (University of Ghana); Akwasi Osei (Ghana

Health Service); and Inge Petersen (University of

KwaZulu-Natal, RSA).

REFERENCES

1 Kigozi F. Integrating mental health into primary

health care – Uganda’s experience. South African

Psychiatry Review 2007;10:17–19.

2 World Health Organization (WHO). World Health

Report 2001, Mental Health: new understanding, new

hope. Geneva: WHO, 2001.

3 Sherer R. Mental health care in the developing

world. Psychiatric Times 2002;19:1–6.

4 Ministry of Health. Health Sector Strategic Plan II.

Kampala, Uganda: Ministry of Health, 2005.

5 WHO, 2007. Integrating Mental Health Services into

Primary Health Care. Mental Health Policy, Planning

and Service Development Information Sheet, Sheet

3). Geneva: World Health Organization, 2007.

www.who.int/mental_health/policy/services/en/

index.html (accessed 14 July 2009).

6 WHO and World Organization of Family Doctors

(Wonca). Integrating Mental Health into Primary Care:

a global perspective. Singapore: WHO and Wonca,

2008. www.who.int/mental_health/policy/Mental

%20health%20+%20primary%20care-%20final

%20low-res%20140908.pdf (accessed 14 July 2009).

7 Ssebunnya J, Kigozi F, Kizza D, Ndyanabangi S and

MHaPP. Integration of mental health into primary

health care: a case of one rural district in Uganda.

African Journal of Psychiatry (in press).

8 Kigozi F, Ssebunnya J, Ndyanabangi S et al. A

Situational Analysis of the Mental Health System in

Uganda. 2008 (unpublished)

9 Flisher AJ, Lund C, Funk M et al. Mental health

policy development and implementation in four

African countries. Journal of Health Psychology 2007;

12:505–16.

10 Ritchie J and Spencer L. Qualitative data analysis for

applied policy research. In: Bryman A and Burgess R

(eds) Analysing Qualitative Data. London and New

York: Routledge, 1994, pp. 172–94.

FUNDING

We thank the British Department for International

Development (DfID) for funding this RPC.

CONFLICTS OF INTEREST

None.

ADDRESS FOR CORRESPONDENCE

Fred N Kigozi, Executive Director, Butabika National

Referral Mental Hospital, PO Box 7017, Kampala,

Uganda. Tel: +256 414 504376; email: fredkigozi@

yahoo.com/[email protected]

Accepted 13 July 2009