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Periodic Report Summary 2 - EMERALD (Emerging mental health systems in low- and middle-income countries)

Project Context and Objectives:
Health systems the world over are facing ever greater demands and challenges. The health systems of low- and middle-income countries (LAMICs) are particularly strained due to the lower availability of resources and the higher overall burden of disease in these populations, compared to high-income countries. Many LAMICs face a double burden of diseases: While there are still extremely high, yet slowly decreasing levels of mortality due to communicable, maternal, perinatal and nutritional conditions, chronic non-communicable disease, including mental disorders increase.
Health systems in LAMICs are currently failing to meet the mental health needs of the populations they seek to serve. Starting from the premise that there can be 'no health without mental health' [1], a health system cannot be considered to be functioning properly if it is unable to protect and take care of the basic health rights and needs of the sick and the vulnerable – including the mentally ill. In the large majority of LAMICs, resources and services for mental health are extremely meagre, with low-income countries allocating 0.5% and lower-middle income countries 1.9% of their health budget to the treatment and prevention of these disorders, even though they represent over 10% of the overall disease burden [2]. In low-income countries, there is on average only one psychiatrist per 1.7 million people and one psychiatric inpatient bed per 42,000 people [2]. The result of this is a substantial treatment gap. A large multicountry survey supported by WHO showed that 76–85% of people with severe mental disorders in low-income countries did not receive any treatment in the previous year [3], often with devastating consequences [4-11].
In the past years much research has clarified how to tackle the growing burden of mental disorders. Landmark developments include the World Health Report in 2001 [12]; Lancet series on mental health in 2007 and 2011; the establishment of a Global Movement for Mental Health; the development of WHO's mhGAP programme for scaling up services for mental disorders [13,14]; the Grand Challenges in Global Mental Health review [15]; the establishment of ‘Collaborative Hubs for International Research in Mental Health’ by the National Institute of Mental Health (NIMH); the WHO Executive Board resolution in 2012 addressing the global burden of mental disorders [16]; as well as the on-going PRogramme for Improving MEntal health care (PRIME) [17].
What is still missing is how to translate this knowledge into practice within the health systems. This is the research gap that the EMERALD project is addressing to improve mental health outcomes in a fair and efficient way. Specifically, the EMERALD project aims to identify key barriers within the health system to, and solutions for, the scaled-up delivery of mental health services in LAMICs.
This shall be achieved through the following objectives:
Objective 1: Adequate, fair and sustainable resourcing (health system inputs): To identify health system resources, financing mechanisms and information needed to scale-up mental health services and move towards universal coverage.
Objective 2: Integrated service provision (health system processes): To evaluate the context, process, experience and factors of the health system which influence the implementation of mental health services.
Objective 3: Improved coverage and goal attainment (health system outputs): To develop, use and monitor indicators of mental health service coverage and the performance of the mental health system.
Underlying all of these health system objectives, there is a further fundamental need: To enhance local capacities and skills to plan, implement, evaluate and sustain system improvements.
The EMERALD consortium consists of 12 partners in Africa, Asia and Europe, who are working on the completion of these objectives to strengthen the mental health systems in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda.

Project Results:
The EMERALD Project is organized across 6 work packages (WPs).
In WP1 all relevant ethics approvals have been obtained. Phone conferences have continued on a monthly basis and the project consortium has met in full composition during 2 in-person meetings. A publication plan and protocol has been developed and an introductory paper has been published. The Scientific Advisory Board have convened and been consulted regarding EMERALD’s research approach, protocol and dissemination strategy. A consortium satisfaction survey has been conducted and the excellent results have been presented to the project group.
For WP2 an appropriate list of indicators for capacity-building within EMERALD has been established and a protocol for evaluating these has been developed and being implemented. 5 training for trainers’ workshops and capacity building short courses have been developed and taken place across sites. A Masters course in mental health systems strengthening has been developed. Currently, 9 PhD fellowships and 2 MSc students are being supported within EMERALD. 2 PhD fellows have successfully defended their protocols; 1 of which was published. 2 publications have been submitted to peer-reviewed journals and 2 papers have been drafted.
WP3’s new tool developed to assess the costs and impacts of scaled-up delivery of mental health services has been contextualised in each of the EMERALD countries and generated new estimates of the resources needed. A journal article describing the tool and it’s use has been submitted and other site-specific papers have been drafted. Baseline for the Household Survey has been collected on social and economic outcomes. Follow-up data collection is ongoing. A research protocol has been developed and finalised to address the task of sustainable financing for mental health, and ethical approval has been gained from all 6 sites. A situational analysis checklist was developed and has been finalised for 2 sites.
For WP4, strategies to address barriers to health care were identified and presented in all EMERALD countries. Strengthening mental health information systems (MHIS) has been addressed through communications with MHIS officials and related personal. 1 site has developed a community-based anti-stigma intervention, and quality improvement activities have taken place in 2 sites. Baseline facility and district profiles have been conducted, and baseline data for Assessment of Chronic Care Illness has been collected. Process evaluation interviews have been conducted in 2 sites and 1 country has identified strategies to address the bottlenecks. 1 paper has been published, 3 submitted for publication, and 4 drafted.
In WP5 the cross country results from the situational analysis were written up and a paper has been submitted to a peer reviewed journal. A panel of experts reviewed the list of indicators used for measuring service scale-up, coverage and performance, and refined the list to a final set of possible indicators; and a paper has been written and submitted to a peer-reviewed journal. A framework of how to integrate the mental health indicators into existing health information systems has been established. 2 forms for operationalization of prioritized indicators were developed and validation of indicators was achieved through a consultation process using workshops in 6 countries.
In WP6 a dissemination plan and protocol has been formulated and an additional social media platform is being used to present Emerald work. EMERALD has been presented at 5 international conferences, 2 project meetings have taken place with 1 press conference and two press releases. EMERALD was also mentioned in the press in partner countries. Video interviews of Emerald staff, students and associates have been created and are accessible via the website and the EMERALD YouTube channel. A 2nd project flyer has been created and distributed internationally. Since May 2014 , the EMERALD website has received over 10,000 hits.

Potential Impact:
The EMERALD programme seeks to strengthen mental health systems in six LAMICs in Africa and Asia by strengthening several components of the mental health systems in these countries, including health system inputs, system processes, and performance outputs. Based on the experience of the participating countries, the programme aims to achieve major positive impact by producing an evidence-based 'roadmap' for decision-makers in LAMICs on how to scale-up mental health services within the constraints of the broader health system. This will include to identify what human and budgetary resources are needed to meet local targets, health financing policy options, governance requirements and coverage/performance indicators. Furthermore, the EMERALD programme aims to map out and articulate the pathways used in the six local health systems to integrate mental health care within existing services. It will also document the impact of this integration on service inputs, processes and outputs. In so doing, the programme will produce workable and tested strategies for sustainable integration for health service providers, in the six countries and beyond. Another major impact of this programme will be to identify, train and support the career progression of a new cadre of health professionals and researchers in LAMICs with the information and skills needed to bring a health systems perspective to mental health planning, provision and evaluation, and one that complements existing knowledge, capacities and learning opportunities. Indeed, the shortage of technical know-how has been identified as a major barrier to the scale-up of mental health services in LAMICs, and EMERALD aims to address this. By taking this comprehensive approach, we plan to improve the evidence base on how to enhance health system performance in practice in LAMICs. Thereby we can ultimately reduce some of the mental health treatment gap that is prominent in LAMICs and improve the care for people with mental health problems in these countries.

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