Ayiti Government -Full Presentation- Scaling up care
Mental health is central to health and social development
Design a system that lives up to these needs
This is very possible to do
Evidence and goals point to a needed systematic approach– using a community health-worker based “pyramid” of care
Leading innovation in community health: Scaling up mental health care in Haiti
Gary S Belkin MD, PhD
New York University
Richard Douyon, MD
University of Miami
Key Messages
• Mental health is central to health and social development
• Design a system that lives up to these needs
• This is very possible to do
• Evidence and goals point to a needed systematic approach– using a community health-worker based “pyramid” of care
• Such an approach is being modeled in Zanmi Lasante for potential scale-up
• Hospitals, conceived differently, have a critical role in this
• Any “model”– as this one- has to logically lead to clear benchmarks and planning tasks so thatGoH leads otherwise fragmented actors
• There are emerging networks eager to support this
The Vicious Cycle of Social Challenges and Mental Conditions
World Health Organization: World Mental Health Report, 2001: p. 30
Mental health– Burden but also critical
mediator Think innovatively about structure: Deliver care in ways that follow the causal paths
Income-Employment
A Systematic Planning “Model”
• Starting point is to describe the skillsets needed to provide a range of evidence-based care pathways, and thendescribe the kinds of workers across whom those skillsets are distributed, provided that:
– As many of those skills as possible are arranged so they can be done by the least specialized worker, as close to the community as possible, with the right supports for them to be able to do so.
• This allows for as much overlap as possible within the roles and design of overall primary health care (which should also follow a health worker-based design).
• This allows a rapidly accessible career path entry opportunity and rapid workforce expansion
• This allows for adaptation along local practice and a basis for prevention and “cross-sector” work
• This specifies the tasks and expectations to align actors and develop benchmarks for GoH action
How?
Adhere to 2 guiding tasks:
• Get the skill-sets right- Establish a core “Pyramid of Care” as a flexible foundation for multiple care pathways and to coordinate largescale implementation
• Follow 4 “Implementation Rules”
Skill Set “Packages”
A few evidencesupported skill sets can provide a foundation that carries a range of care pathways to span needed range of action
Effective and integrated mental health care, needs effective, rational design and staffing of primary health care
Hospitals as anchors
National Centers of Excellence and Referral (rehabilitated, staffed, and re-defined missions for Mars & Kline and Beudet) and Department primary designated general hospitals with 5-10 inpatient psychiatric beds each will host key leadership functions of referral, quality review/ monitoring, and training/supervision for these pyramids.
Inside the Pyramid of Care
• Staffing and budgeting assumptions will vary depending on actual functional unit of organization, parallel development of a primary care health worker (CHW) –based capability, and on inclusion of preventive functions and a broadened initial layer of pyramid-eg to teachers, etc as providers/partners
• The ZL pilot can provide valuable information along with select large NGO experiences to date in specifying the resources needed for this model- and expected ZL-MSPP workshops could be an opportunity to explore first-step spread of that model to other areas
• Assuming hospital-”anchors” at the Department level and mobile and other “pyramid” staff estimated through population ratios at arrondissement levels, and based on experience in skilled health worker use and population coverage, a minimum target of 1:200 skilled CHW:household ratio, and 1:10- 1:20 ratio of mid-level mental health provider to CHW, and ~20-40 psychiatrists initially.
• Regionalization of small inpatient psychiatric beds/units within general hospitals and rehabilitation of Mars and Kline /Beudetand their staffing
• This does not include human resource needs for: institutionalizing training capacity in current Haitian teaching faculties, enhancing Monitoring & Evaluation infrastructure, adoption of quality improvement and services management and program evaluation practices and roles.
Aligning change and leadership
• This framework of delivery provides a set of tasks and targets that can align the fragmented work of multiple stakeholders around mental health
• These functions and elements can be translated into national and local level benchmarks as appropriate (eg % target worker type/population ratio-met, % CHW-referred cases- treated, etc) to enforce accountability and focus actions and expectations towards systems-building across actors and geographies
Supports to Achieve a Pyramid Model
• Ministry office for mental health integration
• Capable Haitian university/training faculties especially for training “mid-levels”
• Huge pool for potential Haitian workforce expansion
• ZL pilot
• Specific NGOs with broad, well organized primary care structure and reach, and/or mental health capacity agreeing to shared model
• International organizations for adoption and use of quality improvement/M&E methods and tools
• Rebati Sante Mental
• Caribbean Hub for Community Mental Health
• Partners for use of cellular other innovative mhealth technologies
Model Scale-up Planning Scenario
Steering Group– Intergovernmental (key planning ministries, institutions)
Aligns with budget and other-sector and national planning
Addresses obstacles of Planning and Implementation group (P&I) Oversees and gets reports from P&I
P&I Group– MSPP, key providers of mental health and primary care, training institutions and other-sector allied with model (egEducation)
Within this Model- identifies gap areas and recommends and then coordinates implementation of Workplan with:
– Targets-timelines
-Staging of implementation
-Identifies proven health implementation and improvement methods for the 10 Department
Teams to use
Recommends benchmarks for success and implementation, quality, oversight
-Department MSPP, elected and community leaders, area health, etc
Department Teams
-Department MSPP, elected and community leaders, area health, etc
Department Teams
-Department MSPP, elected and community leaders, area health, etc
