Implementation of mhGAP in Mozambique: integrating epilepsy care into the primary health care system

Abstract

Background Epilepsy remains the most frequent diagnosis in Psychiatric and Mental Health Services in Mozambique. Because it is a major concern, in 2013 a Program for “ Reducing the Epilepsy Treatment gap ” was launched in 16 districts of five provinces covering a population of over 1.9 million. Using the WHO Mental Health Gap Program (mhGAP), a pilot Program was developed to provide effective quality care and treatment for people with epilepsy at primary health care level. Implementation was against a background of a shortage of human resources trained to address epilepsy and difficulties in the availability of antiepileptic medicines. Methods The first step for implementation was advocacy from the Government level to relevant stakeholders in the community. mhGAP training materials were translated and adapted to the local context. Non-specialists health providers and community health workers were trained and supervised regularly. Population awareness raising and community involvement were key for acceptance of the Program. Results After 4 years of implementation, 177 health professionals and 1161 community health workers were trained and ensured services delivery for people living with epilepsy (PwE). The implementation led to 89,869 consultations, representing an increase of 67% since the Program’s inception. From 2015 to 2017 a total of 13,563 new cases were attended and the treatment gap was reduced from 99 to 96%. More than 60% of the new cases are children and adolescents. Awareness actions reached more than 14,000 people per year using all available broadcast means. Preliminary positive results were used as evidence for the Ministry of Health (MoH) to increase the purchase of antiepileptic drugs and improve delivery at district level. Discussion mhGAP is an important tool for reducing the treatment gap in low-income countries. Adapting guidelines to the country context and involving community stakeholders are key for Program sustainability. As in other settings, the strategy was cost-effective resulting in an increase in new cases and follow-up consultations. Conclusions Implementation of an adapted mhGAP strategy and the involvement of community stakeholders and commitment of the MoH resulted in significant increase in the number of PwE attending outpatient services in primary health care facilities.

Process evaluation of a district mental healthcare plan in Nepal: a mixed-methods case study

“…The barriers and facilitating factors demonstrated by our study are consistent with those reported in Afghanistan, Nigeria and Mozambique. [28][29][30] The results show that the number of people receiving primarycare-based mental health services increased significantly after the introduction of the MHCP. On average, patients visited facilities 7.1 times for follow-up care despite a large variation in this number by disorder.…”

Development and Evaluation of a Pediatric Epilepsy Training Program for First Level Providers in Zambia

“…Additionally, a general positive impact on attitudes for providers in treating epilepsy was seen, similar to other epilepsy task-shifting efforts in the developing world, where increased care access for epilepsy was subsequently noted. 21,22,24 An additional benefit seen by implementation of our program was engagement of the community and Zambian health system. The referral hospitals, local clinics, district health offices, and Ministry of Health all acknowledged the gaps present for epilepsy care of children in the country and provided strong support for the success of our program.…”

“… 5 , 18 - 20 Beneficial impact in regards to recognition of epilepsy, reducing stigma, and improving health seeking behaviors and treatment adherence by people with epilepsy has been seen in both large and small programs targeting epilepsy at the community worker or primary provider level. 21 - 25 However, these programs typically focus on convulsive epilepsy in patients of all ages. Training for more subtle pediatric seizure management issues is more complex yet remains in high need in the developing world.…”

Effectiveness of Involvement of Community Health Workers in Identification and Referral of Persons Living With Epilepsy in Rural Rwanda

“…The impact of training of CHWs in epilepsy has only very rarely been documented [4,15]. More recently, a study described the use of the mhGAP and the impact of a successful engagement of CHWs on mental healthcare and epilepsy in Mozambique [16].…”