A total of 46 participants representing diverse stakeholders were involved in three ToC workshops. All of the participants were working age adults. The academic backgrounds of participants ranged from non-literate (in the community group) to higher level mental health professionals including clinical psychologists, public health professionals, social workers and psychiatrists (in the policy makers’ group). Except the participants of the policy makers ToC workshop and the PRIME team members, all of the participants were based in the district.
The following section describes details of the ToC map including the key pre-conditions, the pathways at the different levels of care, the interventions and the indicators. Figure 3 presents abridged version of the ToC map for the MHCP in Sodo.
Key pre-conditions in the ToC map
Four distinct dimensions comprising the community, health care facility, district and higher (federal) level health care administration were identified. Various distinct pre-conditions were identified for these levels. These different pre-conditions were identified by stakeholders as the essential milestones in the path towards integrated mental health care at the primary care level. Achieving these pre-conditions would lead to the targeted long-term outcome: improvement in health, social and economic status of people using mental health services. The long-term outcome of the programme was established during the cross-country workshop. Later, it was presented as a discussion point during the in-country ToC workshops and approved by all stakeholders. The broader impact (for which PRIME would not be held accountable) included a reduction in crime, domestic violence and unnatural deaths in the community. The pre-conditions at the different levels are described below. The required pre-conditions were mapped following the three intervention lines. These included the community, health facilities, district healthcare administrations and higher health care administration (Zonal health bureau, regional health bureau and the Federal Ministry of Health.
Community level pathways
The baseline situation in Sodo was discussed in all the ToC workshops. The existing coverage of mental health services in the community was reported to be very low. As identified during the workshops, most people with severe mental disorders in the district were reported to have been chained up or shackled at home. The underlying assumption in the district is that mental disorders were caused by possession by evil spirits. Therefore, the common practice is that they remain untreated or often receive help only from traditional healers. The few people known to seek care travelled to urban centres notwithstanding high costs of transportation and accommodation.
Findings from the situational analysis and exploratory interviews suggested that there was no mental healthcare service in the district. Yet, as a long-term outcome, the programme aspires to see improvement in the health, social and economic status of people with priority disorders. Hence, the ToC workshops with the community were aimed at filling out the empty space between the current state and the long-term outcome with possible short-term pre-conditions, indicators and assumptions. At some points during the workshop, differences in opinion and divergence in recommendations were observed. In those cases, both ideas were forwarded to the group for discussion until consensus was reached. Disagreements also emerged where there was lack of information. Such topics were recorded for further exploration after the ToC process.
Participants were requested to list assumptions, interventions and indicators. These three were numbered written in a separate flipchart. Numbers and letters representing the assumptions, interventions and indicators were used to link one pre-condition to the next one. Possible interventions and indicators to measure success of the project were jointly set with the community workshop participants. Details of the process are illustrated in Fig. 4.
To achieve the long-term outcomes, the current lack of awareness about mental health at the community level was mentioned as being problematic. Therefore, raised mental health awareness and increased help seeking behaviour among people with priority disorders were identified as possible short-term outcomes. The provision of adherence support by families, HEWs and community volunteers was also suggested to strengthen service delivery. The current situation also indicated that HEWs did not have the skills to detect and refer cases they suspected to be mental disorder. Therefore, improving their skills to detect and refer people with potential mental disorders was recommended as crucial. As stated during the workshops, HEWs may be helpful in improving adherence, detecting relapse and providing family support.
Apart from reliance on HEWs for detection and referral, sensitizing and engaging with broad range of community stakeholders was also mentioned essential. To this end, working with community based organisations (CBOs), community leaders, teachers, health development army (a group of community members who work as health volunteers), other extension workers (e.g., agricultural extension workers), traditional healers, non-governmental organisations (NGOs) and faith based organisations (FBOs) was mentioned instrumental in achieving community level pre-conditions.
Strengthening the existing community initiatives to increase mental health awareness and support persons with mental disorders was indicated as an important intervention to achieve these pre-conditions. Engaging with persons with mental disorders and their families in different community activities and providing community based rehabilitation (for people with more severe disorders) were reported to be vital. Involvement of CBOs, FBOs and NGOs in different social and economic activities was reported to have a direct bearing on stigma reduction and the promotion of social inclusion of people with mental disorders.
The key long-term outcomes (clinical, social and economic) described in the ToC map relate to the community pathways. Improved outcome for individual patients and their families in these areas would represent both individual, family and community outcomes. Although distinguishing between social and economic outcomes was considered difficult, change in one is likely to lead to change in the other. Reduced stigma in the community or in work places were identified as both social and economic outcomes. This is potentially because of the direct impact of reduced stigma on the social and economic conditions of people with mental disorders.
Facility level pathways
The situational analysis identified eight health centres and 58 health posts that were operating in the district during the time of the assessment. All of these health facilities were established by the government. Health centres were staffed by nurses, laboratory technologists, pharmacists, pharmacy technicians and supporting staffs. The health posts were staffed by HEWs. None of the facilities have trained mental health personnel. No mental health care provision was reported in any of these facilities. Cases with mental health problems in the community were referred to the capital city, Addis Ababa.
The key pre-conditions for clinical staff at the facility level were the attainment of adequate levels of competence in case detection, treatment and monitoring of care and the provision of inclusive care for persons with mental disorders. At the facility level, it was recommended that the health care staff should diagnose, treat, manage drug side-effects, and support adherence. Primary health care staff should also refer persons with mental disorders for community-based support, including income generating activities, provide psychosocial support, assess social needs and provide recovery education.
District health care administration level pathways
A proper reporting framework with clear mental health indicators did not exist at the district level. Psychotropic medications were not included in the current drug list of the district. The district officials also mentioned that lack of mental health awareness is common among the different officials in the district.
Allocation of budget, facilitation of resources and personnel for training, raised awareness and demonstration of political commitment were suggested as expected pre-conditions from the district health care administration. Developing non-stigmatising attitudes and engaging in advocacy initiatives which promote the inclusion of persons with mental disorders in different social activities within and beyond the district were also highlighted. Supporting the implementation of economic policies for persons with mental disorders and their families to improve their economic outcomes was emphasised as being essential for the MHCPs. In addition, it was emphasised that the district should encourage different development organisations to involve persons with mental illness in their activities. The importance of political commitment to support economic wellbeing of persons with mental illness and their families was also mentioned as significant. Although these activities are important for the successful rehabilitation programmes, the MHCP focused only on those activities that were feasible and affordable within the constraints of funding by the MoH.
Higher healthcare administration level pathways
At the national level, the national mental health strategy has been developed, endorsed and is pending its implementation . Most of the suggested outcomes at the health care organisation level are related to raising mental health awareness at the health care organisation level and budget allocation. The need for strong political commitment was also emphasised. The development of a national mental health strategy is taken as indicative of the political commitment of the Federal MoH of Ethiopia.
Raised awareness at the MoH was mentioned as having a direct impact on budget allocation and on the inclusion of mental health in the national Health Management Information System (HMIS). Obtaining political buy in was mentioned as vital for the development of a successful MHCP.
Assumptions and indicators
In addition to the causal pathway of pre-conditions leading to long-term outcomes, assumptions and indicators were also highlighted during the workshops. At the community level, the underlying assumptions included readiness to seek services among people with mental health problems, sensitivity of the general public towards the needs of people with mental disorders, and willingness to collaborate with HEWs and community health volunteers in awareness raising activities. Facility level assumptions included the availability and willingness of health workers to undergo mental health training and their readiness to provide mental health interventions. The political commitment of the district and health care administration, raised mental health awareness, and adequate budget allocation were cited as assumptions at the district and higher health care administration levels, which are necessary to make the MHCPs effective.
For all the pre-conditions outlined in the ToC, indicators were developed to enable a comprehensive evaluation of the process of implementation and the impact of the MHCP. Indicators were identified for the long-term outcomes of improved health, social and economic outcomes for people treated by the MHCPs. Health outcome indicators listed were improvement in symptom levels and in functional status. Indicators of improved social and economic outcomes included active engagement of people with mental disorders and their families in the different social affairs of their community, and improvement in the economic conditions of people with mental disorders and their families (Details are included in the ToC map, Fig. 3).
Additional facility and district level indicators of political commitment included the appointment of a separate mental health professional at the district level to coordinate mental health services in the district. Capacity building and ratification of policies for the inclusion of people with mental disorders at different development activities were also mentioned as policy level indicators.