The challenges
Low- and middle-income countries have limited resources to support mental health
services. Our research found that 85-98% of people experiencing mental health
conditions in Ghana cannot access the treatment they need due to the lack of
service provision, lack of trained mental health professionals, inaccessible
services and the stigma surrounding mental health.
While national plans do extend to the regional level of government and community
self-help groups do organise around visible needs, the lack of a coordinated plan
means that mental health support at district level is lacking.
Our own situational analysis on district-level health services done in 2021 confirmed
a lack of District Mental Healthcare Plans in primary care. The analysis, which was
conducted in five districts, confirmed there was an unmet need for mental health
services, with underdeveloped mental health infrastructure and systems, and only
0.5% of those in need getting access to mental health services.
The solution
Poor access to mental health services can be addressed by integrating mental
health services in primary healthcare. District mental healthcare plans have been
shown to be a critical component in improving case detection, reducing the treatment
gap in mental healthcare and addressing the burden of mental illness in districts and
communities.
District Mental Healthcare Plans not only treat symptoms and illness, but can bring
services together to improve the economic and social empowerment of people with
mental health conditions, help with their recovery, reintegration into society and help
realise their full potential.
What we did
We worked in consultation with the Mental Health Authority, the Ghana Health Service
and the district assemblies to agree a framework for District Mental Healthcare Plans.
We implemented a district mental healthcare plan in three pilot districts, Anloga,
Asunafo North and Bongo in Volta, Ahafo and Upper East Regions. We used existing
structures in the districts to establish a district mental health operations team using the
guidance cited in the Mental Health Act for district mental health subcommittees.
The operations team comprised representatives from
- Commission for Human Rights and Administrative Justice,
- Ghana Health Service,
- District Assemblies,
- Ghana Education Service,
- Social Welfare,
- and community members,
- including service users.
The operations teams were supported to develop District Mental Healthcare Plans,
which were focussed on: healthcare organisation, health facilities, and the community.
Tools were also developed to support implementation, analysis and monitoring.
We provided in-person and remote support and provided financial support for specific
health worker and community volunteer training activities.
Training
A key component of the district plans was training general health workers who are
employed by the Ghana Health Service, to help increase access to mental health
A key component of the district plans was training general health workers who are
employed by the Ghana Health Service, to help increase access to mental health
services in communities. We trained 84 healthcare workers from 15 health
facilities across three districts, in mhGAP (the WHO Mental Health Gap Action
Programme aimed at scaling up services for mental, neurological and substance use
disorders in low- and middle-income countries) as well as 87 Community Health
Volunteers
How we made a difference
By implementing the district mental healthcare plans we trained 84 primary healthcare
providers to ensure better identification and management of mental health conditions.
Community Health Volunteers who received training successfully identified and
referred 144 individuals (as of August 2024) with probable mental health issues to
mental health professionals working at local healthcare facilities.
Early identification and awareness
Based on data from the District Health Information Management System, there was a
significant increase in new cases treated in all three districts, comparing the periods
before and during the implementation.
Government stakeholders such as the Ghana Health Service, the Mental Health
Authority, and members of the regional and district health structures, highlighted the
value and their acceptance of the mental healthcare plans. They indicated success
in early case identification and integration with primary healthcare. Different levels
of health personnel sought out training, indicating a level of buy-in within health
practitioners.
Pre- and post-training assessments showed improvements in knowledge and
increased confidence in clinical skills for managing mental health problems, which
increased from a 9% score at baseline to 99% post-training.
Collaborating to connect services
As a result of implemented district mental healthcare plans, there is now integration of
mental health services in primary healthcare, meaning that more primary healthcare
workers, not just mental health specialists, are able to identify whether someone might
need referral for mental health support.
Examples of collaboration and referrals include:
- Three districts identified mental health service users in need of support and
submitted their names to the Department of Social Welfare and Community
Development for enrolment onto the LEAP cash transfer programme and
the National Health Insurance Scheme. - Examples of collaboration and referrals include:
Vocational training institutions and social services collaborated to help
people with mental health conditions gain skills. The team in Anloga
District, in collaboration with the social welfare department and a vocational
institution, organised a training session on soap-making for 80 participants,
which five mental health service users attended. - A District Assembly used the collaboration to allocate additional funds
specifically for mental health services in the district. - District teams collaborated with Ghana Education Service and helped raise
awareness amongst students on mental health and stigma.
Lessons learned
- District mental healthcare plans can have a positive impact on reducing the
treatment gap for mental health services through an integrated approach to the
detection, treatment, and management of mental health conditions. - Training and supportive supervision are required to ensure that district-level
mental health service providers have the skills and knowledge to deliver highquality mental healthcare. Focus areas for training and supervision include
identification, assessment, and management of mental health conditions. - It is important to engage all relevant stakeholders in the planning and
implementation of the plans to ensure ownership. Committed leadership
plays an important role in the successful implementation of District Mental
Healthcare Plans. - Standard Operating Procedures are essential to ensure that mental healthcare
plans are effective and sustainable. - Community support systems, including Community Health Volunteers,
are crucial in facilitating the successful implementation of District Mental
Healthcare Plans. They are well positioned to bridge the gap between formal
healthcare services and the community, make it more accessible to use
services, can identify early signs of mental distress, and link affected persons
Resources produced on this topic
- Policy brief: Scaling up mental health services in Ghana: Preliminary evidence
from district demonstration sites. 2023 - Towards implementation of context-specific integrated district mental healthcare
plans: A situation analysis of mental health services in five districts in Ghana.
2023 DOI: 10.1371 - Prevalence of probable mental, neurological and substance use conditions and
case detection at primary healthcare facilities across three districts in Ghana:
findings from a cross-sectional health facility survey. 2023 DOI: 10.1186 - Development and Implementation of Mental Healthcare Plans in Three Districts
in Ghana: A Mixed-Method Process Evaluation Using Theory of Change (awaiting
publication, 2024) - Care delivery in the context of district mental healthcare plans in Ghana: experiences
of primary health care workers and service users (awaiting publication, 2024)
