Delivering Mental HeaLth Care In India Via Non-specialist Health workers

In India, the gap between the people who need mental health treatment and personnel who are capable of providing this treatment is wide. In the light of the huge treatment gap, trained non-specialists become important.
The DELIVER programme aims to explore the roles of these non-specialist health workers, (primary level doctors, nurses, lay health workers, and other generalist paraprofessionals) and how they can provide mental health services in India. The team is working towards informing policy makers by describing programmatic achievements and failures and understanding the role of non-specialist health workers, and also recommending effective, acceptable and sustainable measures to scale-up community mental health services in India and other lower-middle income countries.

To explore the acceptability, feasibility and effectiveness of non-specialist health workers in primary and community mental health care in India

Specific objectives –

  1. Explore the history and development of the roles of non-specialist health workers in mental health care provision in India
  2. Describe and compare the current perceived roles of Indian non-specialists and the actual roles in mental health care in south India. This also includes highlighting issues (e.g. acceptability, feasibility) that affect the integration of mental health care within the primary health system
  3. Examine how the roles of non-specialists, and their scaling-up and integration within the health system, may evolve in the future so as to inform policy development in this area

The study is now drawing to a close. The team has published a systematic review and is due to do the same with the oral history soon. A qualitative study of the project is also in progress.

The preparatory phase began in London in 2009 as part of Dr Nadja van Ginneken’s PhD, during which time a research and project strategy were developed to meet academic and practical targets. The project then moved to south India, from where it now works, based at its office in Bangalore.
The team began work on several complementary research activities. The Cochrane Collaboration accepted DELIVER’s topic for a systematic review on the effectiveness of non-specialist health workers in delivering mental health care in low- and middle- income countries and published its protocol in 2011. The team sourced relevant articles and completed data extraction, before conducting outcome analyses (meta-analyses and narrative summaries). The final draft will soon be sent to the Cochrane Collaboration for peer review.
Oral history interviews were conducted with individuals mainly from India, and three from abroad, who all had experience either designing policy or implementing care by non-specialist health workers in mental health care in India. The team hopes to draw a picture of the history of how non-specialist health workers have been incorporated into mental health policy. Preliminary results from the collected data were presented at a Wellcome Trust meeting in Arusha, Tanzania, and at the Anglo-American History Conference in London, UK, in 2011. The results also contributed to an article in the Lancet’s series on global mental health (Kakuma et al. 2011).
Much work has also gone into the qualitative component of the project, which studies the current models of delivering mental health care through non-specialist health workers in India. Projects and initiatives which demonstrated different models of delivering rural mental health care (such as different types of non-specialist health workers, different systems of support or models of delivery. As many as 37 organisations, both government and non-government, were selected. Two primary health centres under Karnataka’s District Mental Health Program were chosen – one solely run by the government, and one in which an NGO had a public-private partnership – as in-depth case studies using ethnographic approaches.
Following approved Memoranda of Understanding, the team conducted several stakeholder meetings, in-depth interviews, site visits and the two case studies. Preliminary findings of the qualitative study were presented by Meera S M and Sarah Ghani at the International Congress of Rural Health and Medicine in Goa in December 2012.

Latest achievements

  • Three conference presentations
  • Human Resources For Mental Health Care: Current Situation And Strategies For Action published in the Lancet
  • Non-specialist health worker interventions for mental health care in low- and middle-income countries (Protocol). Cochrane Collaboration. 2011. Cochrane Review ID: 501210041309211330

Future course of action
As a final outcome of the study, the team is now synthesising evidence to back up recommendations on scaling up emerging models of task shifting mental health care to non-specialist workers. The results will suggest what elements of these models are likely to be feasible, acceptable and effective, and the contextual factors which determine the scalability of such interventions within routine health care programmes in India.