Integrating mental health in primary health care: part 4. toolkit for monitoring and evaluation

Integrating mental health in primary health care PART 4. Toolkit for monitoring and evaluation

Integrating mental health in primary health care PART 4. Toolkit for monitoring and evaluation WHO Library Cataloguing in Publication Data Names: World Health Organization. Regional Office for the Eastern Mediterranean Title: Integrating mental health in primary health care: part 4. toolkit for monitoring and evaluation / World Health Organization. Regional Office for the Eastern Mediterranean Description: Cairo: World Health Organization. Regional Office for the Eastern Mediterranean, [2023] Identifier: ISBN 978-92-9274-097-9 (pbk.) | ISBN 978-92-9274-098-6 (online) Subjects: Mental Health Services - organization & administration | Primary Health Care | Delivery of Health Care, Integrated | Program Evaluation | Health Policy | Emergencies | World Health Organization | Eastern Mediterranean Region Classification: NLM WM 30 © World Health Organization 2023 Some rights reserved. 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However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. iii PART 4. Integrating mental health in primary health care Contents Target audience iv 1. Introduction 1 2. Core set of reporting forms 3 3. System level monitoring and evaluation 4 3.1. WHO mental health policy and service guidance package on monitoring and evaluation of mental health policies and plans 4 3.2. Emerald programme mental health indicators within information systems 5 3.3. WHO Service availability and readiness assessment (SARA) 5 3.4. WHO Assessment Instrument for Mental Health Systems (AIMS) 5 3.5. Mental health atlas 20209 6 3.6. Additional Indicators developed for the regional framework to scale up action on mental health in the Eastern Mediterranean Region 6 3.7. Patient outcome measures 7 4. Monitoring and evaluation at the locality level 8 4.1. mhGAP operations manual 8 4.2. Other indicators relevant for locality-level monitoring 8 4.3. IFRC Project/programme monitoring and evaluation (M&E) guide 9 5. Monitoring and evaluation in humanitarian emergencies 10 5.1. IMC toolkit for the integration of mental health into general health care in humanitarian settings 10 5.2. Inter-Agency Standing Committee: A common monitoring and evaluation framework for mental health and psychosocial support in emergency settings 10 iv Integrating mental health in primary health care Toolkit for m onitoring and evaluation PART 4. Target audience The target audiences for PART 4. of this package are country-level policy-makers, health managers and representatives of primary health care, specialist mental health care and other relevant stakeholder groups. 1PART 4. Integrating mental health in primary health care 1. Introduction The ultimate measures of success of the integration of mental health in primary health care (PHC) are improvements in the mental health of the nation, reduced disability and the burden associated with mental illness, and increased productivity. However, since there are so many complex steps on the way to achieving these outcomes and impacts, it is crucial to regularly monitor and evaluate the inputs and processes that are changed and enhanced in order to achieve integrated mental health care. Monitoring is a continuous process of collecting and analysing information about the inputs and outputs of a programme. Monitoring is done routinely: monthly, quarterly or annually, etc. The findings can be used to inform immediate decisions and adjustments to implementation as they arise. Countries should be in a position to summarize mental health needs, service inputs, processes and outcomes every year for parliament to encourage debate and national prioritization of mental health, and integration across sectors to the lowest levels. Key monitoring indicators should be built into the routine mental health information systems. If there is an annual work plan, it should have inputs, processes, outputs and sometimes outcomes. A strategic plan may also have impacts. Monitoring will include how these are all routinely measured and by whom (e.g. workshop reports to determine numbers trained; pre- and post- tests to measure change in knowledge). “Policy-makers and planners should never assume that the plan, as accepted, is being implemented as intended. Ongoing monitoring is essential so that where problems are identified corrective actions can be taken. If activities have been planned on a monthly basis, monitoring should probably take place monthly. The longer the time lapse between monitoring the more difficult it is to get the plan back on track if problems are identified. The outputs need to be monitored on completion of each activity.” (WHO mental health and service guidance package: monitoring and evaluation of mental health policies and plans). Evaluation is a periodic systematic appraisal of the effectiveness and value of a policy, plan or programme. It can be carried out during (e.g. at mid-point) or at the end of a strategic plan period. It is used to assess and strengthen the programme by collecting and analysing information about its delivery, coverage and changes in health status. “Evaluation of the plan’s implementation should include an assessment of whether the targets set for each strategy have been realized. For example, if one of the targets is to increase the number of people being treated in the community by 50%, an evaluation needs to be conducted to determine whether this target has been reached. Generally, if a plan has been carefully thought through and if all the outputs have been achieved, it might be expected that the targets set will be realized; however, this may not always be the case. Evaluation of the plan may thus include an assessment of why the targets have not been met.” (WHO mental health and service guidance package: monitoring and evaluation of mental health policies and plans). 2 Integrating mental health in primary health care Toolkit for m onitoring and evaluation PART 4. Monitoring and evaluation are needed to: ■ confirm that the planned changes and interventions have actually occurred and/or to what extent they have occurred; ■ identify areas of weakness or inequity, and barriers that require further review and revision of plans; ■ provide feedback on and reinforce areas that have successfully implemented planned changes; ■ demonstrate what has been achieved to stakeholders and funders, including the government, collabo- rating organizations, health care staff, service users and their families, and the general population. Detailed guidance on how to develop, organize and analyse monitoring and evaluation at the system and locality levels is already available. This guidance summarises the relevance of the existing guidance and provides links to guidance and other supporting tools and materials. Countries can select from these the methodology and indicators that will best monitor their own circumstances and targets. Steps in monitoring and evaluation: ■ Decide what to measure – relate to the goals, targets and processes of the implementation plan. ■ Decide when and where to measure the selected indicators. ■ Decide how to measure the selected indicators. ■ Identify data sources to measure. ■ Plan for analysis of data and preparation of the report. ■ Plan for dissemination of data. 3PART 4. Integrating mental health in primary health care 2. Core set of reporting forms A set of essential core information recording forms is included in the box below specifically to monitor the implementation of mental health in PHC. The main arguments for the integration of mental health in PHC are improved access, improved accessibility, better outcomes and cost-savings. These reporting forms attempt to capture information that can be used to monitor these issues. ■ Improved access to care can be monitored by monitoring consultation and treatment rates by diagnosis, age and sex. ■ Improved access to medication can be monitored by monitoring availability of supplies by medication type and prescriptions. ■ Costs per capita can be estimated and monitored. ■ Treatment coverage and discharged patients can be used as a proxy for outcome, or a specific survey of outcome can be carried out. ■ Data collected at facility level should be aggregated at district, regional and national level. Likewise, data collected at district or regional level should be aggregated at the national level. In most countries, acceptability will be assessed by a specific survey of satisfaction rather than by routine data collection. Likewise, it may not be possible to include direct measurement of health outcomes in routine data collection. These may be assessed using specific surveys designed to allow the findings to be generalized to the whole population (i.e. by employing a representative sampling methodology). Possible instruments are included in section 3.7. Patient outcome measures. Core set of reporting forms Reporting forms 4 Integrating mental health in primary health care Toolkit for m onitoring and evaluation PART 4. 3. System level monitoring and evaluation 3.1. WHO mental health policy and service guidance package on monitoring and evaluation of mental health policies and plans The WHO mental health policy and service guidance package: monitoring and evaluation of mental health policies and plans provides guidance for policy-makers and health planners and other stakeholders to monitor and evaluate the implementation of policies and plans and to assess whether they have achieved their intended objectives. It includes a five-step framework for policy-makers and health planners to use when setting up and conducting an evaluation of policy and plans: Step 1: clarifying the purpose and scope of the monitoring and evaluation; Step 2: identifying the evaluators and funding for the evaluation; Step 3: assessing and managing ethical issues; Step 4: preparing and implementing the operational plan for the evaluation; Step 5: analysis of evaluation data, including unintended outcomes, and reporting of results. The strengths and weaknesses of different experimental and nonexperimental designs are briefly presented, including randomized controlled trials, quasi-experimental designs, surveys, case studies, phenomenology, participant observation, focus groups, ethnography and various types of economic evaluation, along with an overview of commonly used data collection methods using routine data, standardized instruments, interviews and expert documentation review. This is followed by a detailed case example (86 pages) evaluating the national mental health policies and plans of a hypothetical country. This example uses checklists that are included as Annexes. Within this case example, there are several strategies and objectives directly pertinent to the implementation of mental health in PHC. For example, see the evaluation of the following items. ■ Strategy 3: Improve access to and utilization of mental health services throughout the country through decentralized mental health service delivery that is integrated into general health care. ■ Strategy 5: Undertake extensive mental health training programmes for all health staff, including general health workers and mental health specialists. ■ Strategy 7: Improve the supply and utilization of essential psychotropic medicines. ■ Objective 3: Integrate mental health into general health care. ■ Objective 5: Ensure the delivery of high quality, evidence-based interventions for mental health promotion, prevention, treatment and rehabilitation. Each country has its own unique policies and plans to address implementation of mental health in the context of its particular circumstances and will need to plan monitoring and evaluation to measure indicators related to their own goals, targets and processes. Although there is no single instrument that comprehensively covers the full range of monitoring and evaluation of the integration of mental health in PHC at system level that is applicable in all the varied countries of the Eastern Mediterranean Region, the following toolkits contain between them most of the key indicators that will be needed. It is suggested 5PART 4. Integrating mental health in primary health care that each country carefully reviews its own policies and plans to identify which indicators to use, and to determine whether additional indicators need to be developed to monitor strategies, objectives or processes that are not adequately addressed by these indicators. 3.2. Emerald programme mental health indicators within information systems The Emerald programme has published a series of papers in which they describe the development, feasibility, performance and utility of a set of indicators for the coverage of mental health care. ■ Jordans MJD, Chisholm D, Semrau M, et al. Indicators for routine monitoring of effective mental healthcare coverage in low- and middle-income settings: a Delphi study. Health Policy and Planning. 2016;31(8):1100–6. doi:10.1093/heapol/czw040. Note that there is a list of all 52 indicators included in the study and a list of the 15 most highly scored indicators that can be found by looking under the heading Article Contents and following the links to Supplementary data. ■ Jordans M, Chisholm D, Semrau M, et al. Evaluation of performance and perceived utility of mental healthcare indicators in routine health information systems in five low- and middle-income countries. BJPsych Open. 2019;5(5):E70. doi:10.1192/bjo.2019.22. Note there is a health facility data collection form that can be found under the Supplementary materials tab. ■ Ahuja S, Hanlon C, Chisholm D, et al. Experience of implementing new mental health indicators within information systems in six low- and middle-income countries. BJPsych Open. 2019;5(5):E71. doi:10.1192/bjo.2019.29. 3.3. WHO Service availability and readiness assessment (SARA) WHO’s Service availability and readiness assessment (SARA) provides the tools to measure and track health facility service delivery, including service availability, human and infrastructure resources, and provision of basic health-care interventions. The original version of SARA (2015) addresses the provision of general health care. A version of SARA has been adapted for mental health services, however, at the time of writing, publication of this version is pending. 3.4. WHO Assessment Instrument for Mental Health Systems (AIMS) The WHO Assessment Instrument for Mental Health Systems (WHO-AIMS) is a tool for collecting essential information on the mental health system of a country or region. It was developed to assess key components of a mental health system and to provide essential information to strengthen mental health systems. More than half (14) of the countries of the Region completed the assessment and reported using WHO-AIMS between 2006 and 2011 (see WHO-AIMS country reports). WHO-AIMS is structured into six domains: policy and legislative framework, mental health services, mental health in primary health care, human resources, public education and links with other sectors, and monitoring and research. Many, but not all, items in the WHO-AIMs are relevant to the integration of mental health in PHC. Domain 3 is specifically related to mental health in PHC, but items in other domains may be of interest depending on the national circumstances of implementing a whole-system approach. Data for several WHO-AIMS items are already collected in the Mental health atlas 2017. Therefore, it is not necessary to complete the whole WHO-AIMS. It should be used as a resource for items that will add to the mhGAP situation analysis and Mental health atlas to give a more comprehensive data set for analysis. The resource box i ncludes WHO-AIMS items that can be used to supplement the Mental health atlas 2017. 6 Integrating mental health in primary health care Toolkit for m onitoring and evaluation PART 4. WHO-AIMS items that provide additional information to supplement the Mental health atlas 2017 by health system building block WHO-AIMS items that supplement Mental health atlas 2017 3.5. Mental health atlas 2020 Since 2014, the Mental health atlas has been used globally to monitor the progress of countries towards the objectives and targets of the comprehensive mental health action plan 2013–2020. The most recent report was Mental health atlas 2020, which includes a new section on the integration of mental health in primary health care. Individual countries can use the Mental health atlas questionnaire to evaluate progress towards the integration of mental health in PHC at system level. The atlas was completed by most countries in 2020, therefore these are familiar indicators and there will be less duplication of effort than if other monitoring and evaluation tools are used. However, since the atlas has only a limited number of indicators focusing directly on mental health in PHC, it will be necessary to supplement it with additional system-level indicators from other sources. Mental health atlas 2020 Mental health atlas 2020 questionnaire Mental health atlas 2020 (global report) Mental health atlas 2020: Review of the Eastern Mediterranean Region Mental health atlas 2020: country profiles 3.6. Additional Indicators developed for the regional framework to scale up action on mental health in the Eastern Mediterranean Region Eleven additional indicators, in the format of Mental health atlas 2017 items have been developed to monitor the implementation of the regional framework to scale up action on mental health in the Eastern Mediterranean Region. These cover: 1. integration of mental health into emergency preparedness plans; 2. financial coverage for priority mental health conditions; 3. budgetary allocations for service delivery targets; 4. general hospitals with mental health units; 5. availability of non-pharmacological interventions; 6. training in priority mental conditions during emergencies; 7. psychological first aid training incorporated in emergency responder training; 8. schools implementing the whole-school approach to promote life skills; 9. training of personnel working in mother and child health care in parenting skills; 10. training of personnel working in mother and child health care in recognition and management of maternal depression; 11. national campaigns to improve mental health literacy and reduce stigma. 7PART 4. Integrating mental health in primary health care Additional indicators and metadata developed for the Regional framework to scale up action on mental health in the Eastern Mediterranean Region Questions to collect data for additional indicators Metadata for additional indicators 3.7. Patient outcome measures As stated above, the ultimate measures of success of the integration of mental health in PHC are improvements in the mental health of the nation, reduced disability and burden associated with mental illness and increased productivity. The indicators so far mentioned have largely concerned input and process, but policy makers, planners and those involved in delivering services may also want to know how effective implementation of plans has been in improving patient outcomes. Collecting patient outcome data will usually involve additional data collection activity, which needs careful planning and costing. Examples of brief assessments of well-being, mental health, disability and satisfaction are listed below: ■ The WHO-5 Well-Being Index is a 5-item questionnaire that measures current mental well-being (period: previous two weeks). ■ The Health of the Nation Outcome Scales (HoNOS) were created as a simple-to-use, brief measure that could be completed as a routine clinical indicator of change in mental health outcomes within a minimum data-set. See: Implementation of health of the nation outcome scale (HoNOS) in outpatient clinic, Sligo mental health services: feasibility and agreement with global assessment of functioning scale. ■ The WHO Disability Assessment Schedule 2.0 (WHO-DAS 2.0) is a short, generic assessment instrument for health and disability that can be used across all diseases, applicable across cultures, in all adult populations, including both clinical and general populations. It covers the dimensions of cognition, mobility, self-care, getting along, life activities and participation. ■ The IMC Client Satisfaction Scale was developed to measure satisfaction of clients receiving care and other services in a PHC setting. It can be used as a measure to improve services in access to care, facility, staff care and communication skills and confidentiality. 8 Integrating mental health in primary health care Toolkit for m onitoring and evaluation PART 4. 4. Monitoring and evaluation at the locality level 4.1. mhGAP operations manual The collection of monitoring and evaluation data at the locality level feeds into aggregated regional and national system-level information. It is also important that local information is reported and used to strengthen the delivery of mental health in PHC at the locality level. The processes for carrying out and reporting monitoring and evaluation are described in the WHO mental health policy and services guidance package and mhGAP operations manual. The integration of mental health in PHC is complementary with and supports WHO-mhGAP. The mhGAP resources are directly relevant to the whole process of implementation and have been frequently referred to and quoted throughout this guidance. The mhGAP is already being implemented in more than half the countries of the Region. Section 4 (Framework for monitoring and evaluating mhGAP operations) of the mhGAP operations manual provides guidance for district managers to use health information systems to generate and use data about their services and population. It includes key indicators (drawn from the mhGAP operations indicators in Annex 1), the process following the mhGAP model of plan, prepare, provide; and a case example from PRIME South Africa. 4.2. Other indicators relevant for locality-level monitoring Using the source documents in the previous section on monitoring and evaluation at the system level, the indicators that are likely to be of most use for locality level analysis and reporting are listed below. These are included as a resource of established indicators that may be selected for use in monitoring and evaluation at the locality level. The indicators from different sources in this list are not mutually exclusive, and where similar indicators are present, the one best meeting local needs should be selected. EMERALD PROGRAMME – FROM THE 15 MOST HIGHLY SCORED INDICATORS (Emerald references linked above in section 3.3) 1. Number of people diagnosed with severe mental disorders (all health system) 2. Number of days in last one month that psychotropic medicines were out of stock 3. Number of trained mental health workers at inpatient and outpatient service 4. Number of people with severe mental disorder who received mental health treatment 5. Rate of suicide deaths and attempts 6. Number of people diagnosed with any mental disorder (all health system) 7. Number of people receiving mental health care who are lost to follow-up (drop-out rate) 8. Number of people with any mental disorder who received mental health treatment (among diagnosed people) 9. Number of patients re-admitted to in-patient mental health care 10. Number of persons taking psychotropic drugs 11. Number of patients and caregivers expressing satisfaction with received services 12. Number of people with mental disorders who have some kind of financial protection or insurance against the cost of mental health care treatment 9PART 4. Integrating mental health in primary health care 13. Number of beneficiaries who are better, worse or unchanged post-treatment compared to pre-treatment, or at standard intervals after starting treatment 14. Number of serious complications or incidents associated with treatment WHO ASSESSMENT INSTRUMENT FOR MENTAL HEALTH SYSTEMS (WHO-AIMS) Domain 3 Mental health in primary health care 3.1.3 Assessment and treatment protocols in physician-based primary health care 3.1.4 Referrals between primary health care doctors and mental health professionals 3.1.5 Interaction of primary health care doctors with mental health services 3.1.6 Prescription by primary health care doctors 3.1.7 Availability of medicines to primary health care patients in physician-based primary health care 3.2.5 Assessment and treatment protocols in non-physician-based primary health 3.2.6 Mental health referrals from non-physician based primary health care to a higher level of care 3.2.7 Availability of medicines to primary health care patients in non-physician-based primary health care clinics 3.3.1 Interaction of physician-based primary health care clinics with complementary/alternative/traditional practitioners 3.3.2 Interaction of non-physician-based primary health care clinics with complementary/alternative/traditional practitioners 3.3.3 Interaction of mental health facilities with complementary/alternative/traditional practitioners MENTAL HEALTH ATLAS 2020 6.1 Guidelines for mental health integration into primary health care are available and adopted at national level 6.2 Pharmacological interventions for mental health conditions are available and provided at primary care level qualified by coverage) 6.3 Psychosocial interventions for mental health conditions are available and provided at primary care level (qualified by coverage) 6.4 Health workers at primary care level receive training on management of mental health conditions 6.5 Mental health specialists are involved in training and supervision of primary care professionals ADDITIONAL INDICATORS DEVELOPED FOR THE REGIONAL FRAMEWORK TO SCALE UP ACTION ON MENTAL HEALTH IN THE EASTERN MEDITERRANEAN REGION (numbered as in the document included in Section 3.6) 5. Availability of nonpharmacological interventions 6. Training in priority mental conditions during emergencies 9. Training of personnel working in mother and child health care in parenting skills 10. Training of personnel working in mother and child health care in recognition and management of maternal depression PATIENT OUTCOME MEASURES WHO-5 Well-being Index Health of the Nation Outcome Scales (HoNOS) WHO Disability Assessment Schedule 2.0 IMC Client Satisfaction Scale 4.3. IFRC Project/programme monitoring and evaluation (M&E) guide The IFRC Project/programme monitoring and evaluation guide, published by the International Federation of Red Cross and Red Crescent Societies (IFRC), is a desktop reference on understanding and reliable practice in monitoring and evaluation. It focuses on how to develop and implement project/programme monitoring, evaluation and reporting. Although not specifically about the integration mental health in PHC, it does contain relevant advice on principles and practice. 10 Integrating mental health in primary health care Toolkit for m onitoring and evaluation PART 4. 5. Monitoring and evaluation in humanitarian emergencies 5.1. IMC toolkit for the integration of mental health into general health care in humanitarian settings The IMC toolkit for the integration of mental health into general health care in humanitarian settings includes a cross-cutting theme on monitoring, evaluation, accountability and learning (MEAL). This describes a system for MEAL that includes situation analysis, programme design, baseline, implementation and review. There is guidance on selection of indicators and a range of resources including tools, publications and readings. 5.2. Inter-Agency Standing Committee: A common monitoring and evaluation framework for mental health and psychosocial support in emergency settings The Inter-Agency Standing Committee (IASC) have produced IASC Common Monitoring and Evaluation Framework for Mental Health and Psychosocial Support in Emergency Settings: with means of verification (Version 2.0). This covers a broad approach to mental health and psychosocial support, of which PHC is an integral part. It recommends monitoring a select number of outcomes including at least one impact indicator from the common framework goal to reduce suffering and improve mental health and psychosocial well-being, at least one goal impact indicator, plus at least one recommended means of verification related to that goal impact indicator, plus at least one outcome indicator from the common framework. The key impact indicators for the overall goal of reducing suffering and improving well-being include functioning, well-being, distress coping, social behaviour and social connectedness. These correspond with some of the patient outcome measures (above) and, depending on how the programme goals are formulated, they may be considered as outcome indicators. There are eight key outcome indicators in the IASC guidance, under heading (5) People with mental health and psychosocial problems use appropriate focused care (O5) (see pages 22 and 33). ■ O5.1 Percentages of medical facilities, social services facilities and community programmes which have staff trained to identify mental disorders and to support people with mental health and psychosocial problems. ■ O5.2 Percentages of medical facilities, social services facilities and community programmes which have staff receiving supervision to identify mental disorders and to support people with mental health and psychosocial problems. ■ O5.3 Percentages of medical facilities, social services facilities and community programmes that have and apply procedures for referral of people with mental health and psychosocial problems. ■ O5.4 Number of women, men, girls and boys who receive focused psychosocial and psychological care (such as psychological first aid, linking people with psychosocial problems to resources and services, case management, psychological counselling, psychotherapy or other psychological interventions). 11 PART 4. Integrating mental health in primary health care ■ O5.5 Number of women, men, girls and boys who receive clinical management of mental, neurological or substance use disorders through medical services (primary, secondary or tertiary health care). ■ O5.6 Number of people per at-risk group (for example, unaccompanied or separated children, children associated with armed groups, survivors of sexual violence) receiving focused care (such as psychological first aid, linking people with psychosocial problems to resources and services, case management, psychological counselling, psychotherapy or clinical management of mental disorders). ■ O5.7 Percentage of available focused mental health and psychosocial support programmes that offer evidence-based care relevant to the culture, context and age of target group. ■ O.5.8 Level of satisfaction of people with mental health and psychosocial problems and/or their families regarding the care they received. Annex 5 (page 41) is a sample framework for a health programme to treat people with mental disorders in primary health clinics. 12 Integrating mental health in primary health care Toolkit for m onitoring and evaluation PART 4.