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Blog post 2: How to Tackle Serious Public Health Issues in Resource-Poor Countries?

Hello again everyone, after providing an overview of mental illness and potential causes, I am back to describe what I think are viable financial strategies to tackle mental illnesses in resource-poor countries. Financial strategies are essential in tackling mental illness in resource-poor countries because as indicated in the chart in my first blog, many individuals in these countries struggle to pay for the care they require because they are either uninsured and/or have to pay out of pocket. Thus, this blog intends to focus on viable financial strategies that can be used to combat mental illness in African countries. Because if not addressed, the issue will only continue to flourish.

Influence of PPP or 3P’s in mental health care:

With today’s complex health challenges, especially those attributed to mental illnesses in resource-poor countries, sometimes governments cannot or do not have the financial means to tackle these issues on their own. This is where the public-private partnerships (PPPs) or 3P’s are emerging as viable strategies. A significant strength of this strategy is the ability to provide services to low- and middle-income countries (LMICs) (Nakimuli-Mpungu et al., 2013). Moreover, although many have heard of non-governmental institutions or organizations (NGOs) and their subsequent ability to provide public assistance to such countries; they have been increasingly interested in more social and humanitarian efforts on a larger scale, leaving health issues such as mental illness management on a lower priority tier (Nakimuli-Mpungu et al., 2013). PPPs or 3Ps differ from organizations such as NGOs because their scope of activities and partners tend to be more locally based (Nakimuli-Mpungu et al., 2013). For instance, the first ‘P’, stands for public partnerships, which includes governments at the National and local levels, and/or organizations such as academic institutions and/or community groups (Nakimuli-Mpungu et al., 2013). The second ‘P’ stands for local private organizations or partners, which can either be for-profit companies and/or not-for-profit companies such as donors (Nakimuli-Mpungu et al., 2013). However, although PPPs have not had much exposure in strengthening mental health services in LMICs, there is evidence to suggest that they can deliver low-cost or more financially feasible options in the provision of mental health care. Additionally, it has been found in the literature that successful PPPs have proven to mobilize a significant amount of financial resources (Nakimuli-Mpungu et al., 2013). Further, since we know that LMICs suffer tremendously from a lack of resources and mental illnesses such as depression—which remains a leading cause of morbidity and mortality— potential strategies such as the utilization of PPPs need to be entertained whenever possible.

An example of a PPP in action to tackle mental illness in an LMIC can be found in a study involving four private partnership trauma clinics known as the Peter C. Alderman Foundation (PCAF) in Northern Uganda (Nakimuli-Mpungu et al., 2013). For instance, in the past decade, this PPP has managed to train physicians and other health care providers in LMICs— 1,000 mental health professionals from 22 countries to be exact (Nakimuli-Mpungu et al., 2013). This PPP has also worked to enhance Uganda’s Ministry of Health’s efforts to integrate mental health into its primary health care system, enabling the government to offer holistic care to its war-affected population (Nakimuli-Mpungu et al., 2013).

In terms of other partners of the PPP, the Makerere University College of Health Science Department of Psychiatry is one, and it assists in networking with trained mental health professionals as well as provides culturally competent screening tools (Nakimuli-Mpungu et al., 2013). Partnering with the Department of Psychiatry, also made it possible for the PPP to work with local experts to develop a monitoring and evaluation system to track clinical outcomes; which provides a demonstrable impact on improving the mental health of the affected population. The Ministry of Health and the Butabika National Mental Health Referral Hospital are other key partners in the PCAF PPP (Nakimuli-Mpungu et al., 2013). The Ministry of Health ensures effective supervision, coordination, and monitoring of the PPPs activities, as well as links it with other local governments, private and government hospitals, health training and religious institutions and other key stakeholders (Nakimuli-Mpungu et al., 2013). Moreover, the Butabika National Mental Health Referral Hospital works with the PPP by providing specialists who train, support and supervise PCAF staff (Nakimuli-Mpungu et al., 2013). Thus, the above represents how PPPs can pool resources to tackle such health issues, especially when resources are minimal such as the case in LMICs.

To further exemplify the impact this PPP has had on decreasing mental illness burden— as indicated by a reduction in symptomology, Nakimuli-Mpungu and colleagues (2013), devised a cohort study, wherein around three-hundred and seventy-five men and women with a history of war-related traumatic experiences were followed over a six-year period (2005 to 2011) (Nakimuli-Mpungu et al., 2013). During this time, participants were enrolled in PCAF trauma clinics, which involve a series of group counselling sessions (Nakimuli-Mpungu et al., 2013). The first session involves participants sharing their trauma stories, the next two involved discussing their positive and negative coping skills, and in the fourth session, participants receive psycho-education on common mental, neurological, and substance use (MNS) disorders and their complications (Nakimuli-Mpungu et al., 2013). The expertise of social workers and traditional or faith healers were also utilized for home visits in hopes to improve symptom outcomes (Nakimuli-Mpungu et al., 2013). At three and six months, participants were asked to partake in follow-up assessments so that their symptoms of mental illness could be measured (Nakimuli-Mpungu et al., 2013).

In the end, it was found that not only did the PPP substantially increase access to mental health services for traumatized individuals living in several rural districts, but it also led to an overall decrease in mental illness symptoms (Nakimuli-Mpungu et al., 2013).

The graph below provides a visual depiction of the impact the PPP had on decreasing mental illness symptoms within the Uganda population. For instance, over six months after adjusting for covariates that were significantly associated with these outcomes, the decrease in the proportion of participants who had high depression and high PTSD scores also had a concomitant increase in high function scores, which is representative of a positive correlation between utilization of PPPs and a decrease in mental illness symptomology. 

To conclude, successful PPPs have shown to have an impressive record for being able to mobilize a significant amount of financial resources to tackle health issues that have been neglected, and/or funds are lacking to address (Nakimuli-Mpungu et al., 2013). This finding also appears to ring true with the PPP example provided in this section.

Other financial strategies mentioned in the literature include:

Albeit, Results-Based Financing (RBF) has received mixed reviews in the literature; there are still many who claim it is a viable financial strategy. It entails making sure funds are available for essential health services like mental health (Ssebunnya et al., 2018). For instance, an RBF approach that has proven to be effective in rural communities such as in Rwanda involves community members making regular payments to their local health care facility after which they access a set of services. Conditional cash transfer programmes are another potential strategy (Wiysonge et al., 2017). This type of program is interesting because it is set up to give money to recipients only if they take action to improve their health (Wiysonge et al., 2017). This strategy could be of significant benefit to those who have a mental illness because often it is the delaying or neglecting to take action to improve one's health that leads to a downward spiral. Vouchers—albeit, have demonstrated low-certainty evidence—may be another strategy to increase individuals’ utilization of mental health services, especially for those who have to pay out of pocket but cannot afford it (Wiysonge et al., 2017). Ssebunnya and colleagues (2018) have also mentioned a National Health Insurance Scheme (NHIS) as a potential option. Implementation of an NHIS would involve providing new resources by pooling resources from private sources, which would promote equity through cross-subsidies (Ssebunnya et al., 2018). For instance, the researchers proposed that citizens would contribute a portion of their income (i.e., four percent) and employers would match (Ssebunnya et al., 2018). Thus, this strategy would not only improve sustainability but also keep citizens in the work-force; therefore, improving countries overall financial well-being.

Advocacy strategies are also essential to acknowledge because they assist in reducing stigma towards mentally ill individuals; which, unfortunately, remain at high levels among policy/decision makers. Advocacy efforts are highly influential in financial approaches because it is the policy/decision makers that are deciding where to allocate health care funding (Ssebunnya et al., 2018). For instance, if these individuals deem mental health issues to be less critical than other non-communicable diseases, then they will continue to be pushed to the bottom of the health priority pyramid (Ssebunnya et al., 2018). Research has suggested that to maintain and/or advance mental health efforts, demonstration of societal costs (i.e., lost workforce production) attributed to mental illnesses versus the costs of interventions should be utilized to help strengthen the business case for mental health care (Ssebunnya et al., 2018). Furthermore, by convincing key stakeholders of the importance of treating mental illness via advocacy efforts, this could result in annual healthcare budgets to be redistributed so that mental health care remains an as high or higher priority as other illnesses (Ssebunnya et al., 2018).  

Therefore, the above represents several viable strategies that LMICs in Africa could potentially utilize to ensure their populations are receiving the mental health care they deserve and require.

Stay tuned…more strategies to follow!

-Shelley

 

References:

  1. Nakimuli-Mpungu, E., Alderman, S., Kinyanda, E., Allden, K., Betancourt, T. S., Alderman, J. S., Pavia, A., Okello, J., Nakku, J., Adaku, A., & Musisi, S. (2013). Implementation and Scale-Up of Psycho-Trauma Centers in a Post-Conflict Area: A Case Study of a Private–Public Partnership in Northern Uganda. PLOS medicine, 10, 4. Retrieved from https://doi.org/10.1371/journal.pmed.1001427
  2. Ssebunnya, J., Kangere, S., Mugisha, J., Docrat, S., Chisholm, D., Lund, C., & Kigozi, F. (2018). Potential strategies for sustainably financing mental health care in Uganda. International journal of mental health systems, 12, 74. :10.1186/s13033-018-0252-9
  3. Wiysonge, C.S., Paulsen E., Lewin, S., Ciapponi, A., Herrera, C.A., Opiyo, N., Pantoja, T., Rada, G., & Oxman, A.D. (2017). Financial arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database of Systematic Reviews, 9. doi: 10.1002/14651858.CD011084.pub2

 

 

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