Global mental health: transformative capacity building in Nicaragua

Abstract

Background: Mental health is increasingly recognised as integral to good public health, but this area continues to lack sufficient planning, resources, and global strategy. It is a pressing concern in Latin America, where social determinants of health aggravate existing inequities in access to health services. Nicaragua faces serious mental health needs and challenges. One key strategy for addressing gaps in mental health services is building capacity at the primary healthcare and system levels.

Objective: Using the framework of best practice literature, this article analyses the four-year collaborative process between the National Autonomous University of Nicaragua in León (UNAN-León) and the Centre for Addiction and Mental Health (CAMH) in Canada, which is aimed at improving mental healthcare in Nicaragua.

Design: Based on a critical analysis of evaluation reports, key documents, and discussion among partners, the central steps of the collaboration are analysed and main successes and challenges identified.

Results: A participatory needs assessment identified local strengths and weaknesses, expected outcomes regarding competencies, and possible methodologies and recommendations for the development of a comprehensive capacity-building programme. The partners delivered two international workshops on mental health and addiction with an emphasis on primary healthcare. More recently, an innovative Diploma and Master programme was launched to foster interprofessional leadership and effective action to address mental health and addiction needs. Collaborative activities have taken place in Nicaragua and Canada.

Discussion: To date, international collaboration between Nicaragua and CAMH has been successful in achieving the jointly defined goals. The process has led to mutual knowledge sharing, strong networking, and extensive educational opportunities. Evidence of effective and respectful global health capacity building is provided. Lessons learned and implications for global health action are identified and discussed.

CAPACITY BUILDING

Global mental health: transformative capacity building in Nicaragua

Jaime C. Sapag1,2,3*, Andrés Herrera4, Ruth Trainor1, Trinidad Caldera4 and Akwatu Khenti1,5

1Office of Transformative Global Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada; 2Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada; 3Department of Family Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile; 4Centre for Demographic and Health Research (CIDS), National Autonomous University of Nicaragua in León (UNAN-León), León, Nicaragua; 5Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada

Abstract

Background : Mental health is increasingly recognised as integral to good public health, but this area continues to lack sufficient planning, resources, and global strategy. It is a pressing concern in Latin America, where social determinants of health aggravate existing inequities in access to health services. Nicaragua faces serious mental health needs and challenges. One key strategy for addressing gaps in mental health services is building capacity at the primary healthcare and system levels.

Objective : Using the framework of best practice literature, this article analyses the four-year collaborative process between the National Autonomous University of Nicaragua in León (UNAN-León) and the Centre for Addiction and Mental Health (CAMH) in Canada, which is aimed at improving mental healthcare in Nicaragua.

Design : Based on a critical analysis of evaluation reports, key documents, and discussion among partners, the central steps of the collaboration are analysed and main successes and challenges identified.

Results : A participatory needs assessment identified local strengths and weaknesses, expected outcomes regarding competencies, and possible methodologies and recommendations for the development of a comprehensive capacity-building programme. The partners delivered two international workshops on mental health and addiction with an emphasis on primary healthcare. More recently, an innovative Diploma and Master programme was launched to foster interprofessional leadership and effective action to address mental health and addiction needs. Collaborative activities have taken place in Nicaragua and Canada.

Discussion : To date, international collaboration between Nicaragua and CAMH has been successful in achieving the jointly defined goals. The process has led to mutual knowledge sharing, strong networking, and extensive educational opportunities. Evidence of effective and respectful global health capacity building is provided. Lessons learned and implications for global health action are identified and discussed.

Keywords: Global mental health; primary healthcare; capacity building; Nicaragua; Latin America

*Correspondence to: Jaime C. Sapag, Office of Transformative Global Health, Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Office 4002-C, Toronto, Ontario, Canada M5S 2S1, Tel: Tel:+[phone] ext. 6790, Fax:+[phone], Email: [email protected]

Received: 8 May 2013; Revised: 1 September 2013; Accepted: 3 September 2013; Published: 30 September 2013

Global Health Action 2013. © 2013 Jaime C. Sapag et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Citation: Glob Health Action 2013, 6 : 21328 - http://dx.doi.org/10.3402/gha.v6i0.21328

Mental health is increasingly recognised as integral to good public health (1, 2), but this area continues to lack sufficient planning, resources, and global strategy (3). The issue is particularly problematic in low- and middle-income countries (LMICs), where an estimated four out of five people with a serious mental illness do not receive appropriate treatment (4). It is a pressing concern in Latin America, where social determinants of health aggravate existing inequities in access to health services.

A global movement is emerging in response to the mental health service gap (1). International organisations are involved in this movement; the World Health Organization (WHO) launched its Mental Health Gap Action Programme (mh-GAP) in 2008 (5) and in May 2013 approved the Global Mental Health Action Plan 2013-2020 (Sixty Sixth World Health Assembly, May 27, 2013: http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R8-en.pdf). The response focuses on the burden of mental illness, access to mental health services, and the wellbeing of individuals living with mental illness (6).

One key strategy for addressing gaps in mental health services is building capacity at the system level (1). Capacity building is an on-going, collaborative process involving education and practical applications; it aims to foster systemic, policy, and structural change in diverse contexts. It incorporates best practices and action research, and progress depends on the strength of relationships, level of knowledge exchange, and communication between partners (7-9).

In many LMICs, little or no mental health training is available for primary healthcare (PHC) professionals. Strengthening PHC services, particularly those serving vulnerable populations, is an effective way to improve access to mental healthcare (10). Successful initiatives foster human resource capacity through comprehensive and on-going education for health and social service professionals. Several studies have demonstrated the importance of having strong, well-trained local PHC teams to better address the mental health and addiction needs of the population (11-14). Research has confirmed the success of previous mental health capacity-building initiatives in Latin America (15).

Nicaraguan context

Nicaragua faces serious mental health needs and challenges (16-21), as shown in Table 1. The country has a population of about six million inhabitants, but less than 25% of it has access to mental healthcare. A complex political history, coupled with repeated natural disasters, has slowed progress towards modern treatment for mental health conditions, such as community-based care, instead maintaining organisational and service structures centred in psychiatric hospitals (22). Another major obstacle to progress is the lack of psychiatrists and well-trained PHC professionals in the country.

[Table omitted -see PDF.]

Complementary activities in Canada

The collaboration leader from Nicaragua participated in two events in Toronto, which were organised by PAHO and CAMH.

* March 2009: International Mental Health & Addiction Leadership Training Programme

Aimed at improving the ability to formulate and apply innovative and viable strategies for improving mental health systems, services, and practices in various countries.

* March 2010: Symposium on Strengthening Mental Health Plans and Services in the Americas: Scaling Up Care for Mental and Substance Use Disorders

Aimed at improving mental health and substance use plans and services in Latin America and the Caribbean, with a particular focus on capacity building for PHC and mental health among indigenous populations.

Diploma and Master's programmes

The Diploma programme is part of an overarching strategy entitled 'An Advanced Educational Capacity Building Strategy in Mental Health and Addictions in Central America and Beyond', which is being developed collaboratively by CAMH, UNAN-León, and the Ministry of Health of Nicaragua (MINSA). This multi-level community-based capacity-building strategy will foster interprofessional leadership and effective action to address mental health and addiction needs in PHC in the region (Fig. 5). The programme began in November 2012 and aims at fostering professional and research competencies and capacities of healthcare workers in order to more effectively address the mental health and addiction needs in primary healthcare in Nicaragua, Central America, and beyond. The programme has three key levels of training and engagement that are interrelated: (a) Continuing Education Courses; (b) Diploma; and (c) Master of Health Sciences. The initiative is directed primarily to those professionals involved in public health practice such as: physicians, dentists, nurses, psychologists, and social workers. Furthermore, to those working in planning, management, research, and evaluation in different health units and other public health agencies with main concern is related to mental health and addictions in PHC.

Fig 5

Fig. 5. Educational pyramid for mental health and addiction in primary healthcare.

The strategic planning process was carried out between November 2008 and June 2011. In November 2008, CAMH and UNAN-León completed a thorough assessment and analysis of local contextual factors, identifying local strengths, needs, gaps, and opportunities for improving mental health and addictions treatment. The assessment revealed several key strengths among professionals in the region: a high level of interest in mental health; a commitment to primary healthcare; and local academic capacity and interest in international collaboration. The assessment also revealed several key areas of need: inadequate mental health services in PHC; significant challenges in suicide prevention; and insufficient mental health promotion. Based on the results of this assessment and the 2009 Participatory Needs Assessment, the organisational team developed a curriculum uniquely tailored to the demands and context of the Nicaraguan and Central American populations. The core curriculum focuses on clinical and research competencies, as well as system change regarding mental health and addictions.

The first session of the Diploma programme was held from February to September 2012, with positive results. (Data analysis is being conducted for a future article.) To ensure sustainability, the training model is designed to be easily replicated by participants, who are encouraged to train colleagues in their PHC settings. This process will further strengthen local capacity to engage in collaborative, on-going work to improve mental health and addictions services and research in PHC.

The first session of the Master's programme was launched in November 2012; it is still underway and will be evaluated upon completion in late 2013.

Additionally, the collaborative team is actively seeking out further opportunities and funding through grants and partnerships to strengthen the various components of the programme, as well as to ensure sustainability.

Discussion

Throughout the four-year collaborative process, CAMH and UNAN-León have developed programmes that are mutually beneficial, based on knowledge exchange, sustainability, and shared respect. Together, the two centres are making long-term systemic changes that are already generating increased capacity in mental health and addictions care in PHC. Strengthening knowledge, skills, and attitudes regarding mental health and addictions will improve rates of detection and treatment, as well as reduce stigma (32, 33). Evaluating the programme thus far offers important guidelines and considerations for future capacity-building initiatives, particularly in similar contexts. The results are of interest to the international mental health and addictions community as they shed light on how to build and maintain the long-term collaborative relationship necessary for sustainable capacity building.

The conducted needs assessment process provided critical information to develop a sustainable and effective programme, which is also appropriate for Nicaragua. Some of the identified needs are similar to those addressed in other capacity-building initiatives (12, 34) and are aligned with the WHO Mental Health Gap Action Programme (mhGAP) (35). However, the high interest of participants in areas such as mental health promotion and research, as well as addiction treatment modalities, was somehow surprising. The hereby-presented capacity-building initiative addresses those areas. For instance, the focus of the 2011 workshop was on addictions. The currently implemented Diploma/Master programme covers both research and clinical practice and includes fieldwork as well as a thesis according to the particular needs and interests of each student.

Two of the learning areas that were identified by the participants are particularly important to better integrate mental health/addiction services into primary health: (i) effective interprofessional team work in healthcare; and (ii) strategies for preventing stigma towards people with mental health and/or substance use issues among health providers. Those areas are essential to enhance health systems and reach better global mental health and equity outcomes (6, 11, 27, 36).

Capacity building is an effective strategy for improving mental health and addiction treatment in PHC, encouraging sustainable change at both clinical and systemic levels. Previous research demonstrated its efficacy in a similar collaborative project between CAMH and Chilean partners (15). In the Nicaraguan context, the collaborative process between UNAN-León, CAMH, and MINSA has successfully begun to develop sustainable capacity building among health and social service professionals working in primary healthcare. The capacity-building framework employed by CAMH and Nicaraguan partners fosters a strong sense of local ownership, as it is a bottom-up rather than top-down strategy (12, 37, 38). Based on the objectives set out in the PAHO Strategy and Plan of Action on Mental Health for the Americas (39), the programme will likely serve as a model for other countries in Central America. It is also effective in terms of addressing previously identified PHC mental health challenges and training needs for Nicaragua (32, 33).

The collaborative partnership between CAMH and Nicaragua faces a number of limitations. The lack of resources committed to mental health and addiction training, service provision, and research is a significant barrier. The distance between Canada and Nicaragua also makes consistent collaborative work difficult. These challenges are not uncommon in international collaboration efforts (40, 41). Another limitation is related to contextual local will and resources: although Nicaragua has established a National Health Plan (2004-2015), the government's commitment to integrating mental health and addictions into PHC has yet to translate into extensive action. This is frequently a barrier to change in LMICs (3).

Despite these limitations, the process has achieved the objectives set out by the partners: (i) strengthening collaboration between Nicaragua and Canada to build capacity in mental health and addictions in PHC; (ii) promoting involvement of key stakeholders in the process of integration, according to existing strengths and needs; (iii) implementing the Diploma programme in mental health and addictions in PHC, with CAMH and UNAN-León faculty; and (iv) launching the sustainable, locally focused one-year Master's programme in mental health and addictions in PHC for professionals from all over Central America.

Participant evaluations of the International Workshops revealed high levels of satisfaction and evidence of concrete learning, with a strong focus on the contributions of local leaders. Participants stressed the benefits of being exposed to new perspectives like the client-centred approach, gaining technical skills for interventions, and working with an interdisciplinary team.

The collaborative team is looking forward to identifying future opportunities for capacity building and partnerships. One goal is to expand the Diploma programme into other Central American contexts. Because the model has proven to be effective in Nicaragua, it will likely also be beneficial in neighbouring countries. The design of the Diploma programme also allows alumni to deliver it to colleagues, increasing its impact. Other opportunities may include developing Master's programmes in other countries in Central America, as well as offering workshops on specific areas of mental health and addictions.

The International Workshops, the Diploma programme, and the Master's programme are all steps in the larger process of educational capacity building in Central America. By laying the groundwork for such programmes, as well as providing local professionals with the knowledge, skills, and attitudes necessary to provide effective care and to train colleagues, this process is fostering much-needed long-term systemic changes in the region.

Lessons learned

1. Begin with a foundational comprehensive needs assessment.

2. Establish clearly identified, step-by-step, common goals between partners.

3. Involve interdisciplinary participants and faculty in the whole process to ensure relevance.

4. Develop and conduct an effective evaluation process.

5. Ensure mutual responsibility and a horizontal decision-making structure.

6. Commit to mutual respect and the principles of mental health equity.

7. Be open to local expertise and previous experience in global mental health work.

Conclusions

To date, international collaboration between CAMH and Nicaragua has been successful. The process has led to mutual knowledge sharing, strong networking, and extensive educational opportunities. The project team is exploring opportunities for South-South partnerships, made possible by the sustainable capacity-building model that forms the foundation for the collaborative process. Gradually, CAMH will take a less active role, continuing to provide support when needed, but encouraging local partners to lead future initiatives.

Mental health is internationally recognised as a central feature of good overall health. The WHO's Millennium Development Goals set out in 2000 identified maternal health, child mortality rates, and HIV/AIDS as areas of focus for global health. All of these are closely linked with mental health, yet insufficient resources are being committed to making sustainable change in this area (42). Frichionne et al. (1) wrote, 'the development of mental health capacity, particularly in LMICs, requires collective action based on local and global partnerships' (p. 49). International collaboration, like that between Nicaragua and CAMH, is an essential part of fostering long-term development aimed at narrowing the mental health treatment gap. This article provides evidence of an effective and respectful global health capacity-building initiative to address a global and urgent public health issue.

Acknowledgments

This collaboration would not have been possible without the support, commitment, and participation of many people. We wish to express our deep thanks to many individuals, groups and institutions that have contributed to build and foster this capacity building process.

Conflict of interest and funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

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