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1.  Mental health policy in Kenya -an integrated approach to scaling up equitable care for poor populations 
Background
Although most donor and development agency attention is focussed on communicable diseases in Kenya, the importance of non-communicable diseases including mental health and mental illness is increasingly apparent, both in their own right and because of their influence on health, education and social goals. Mental illness is common but the specialist service is extremely sparse and primary care is struggling to cope with major health demands. Non health sectors e.g. education, prisons, police, community development, gender and children, regional administration and local government have significant concerns about mental health, but general health programmes have been surprisingly slow to appreciate the significance of mental health for physical health targets. Despite a people centred post colonial health delivery system, poverty and global social changes have seriously undermined equity. This project sought to meet these challenges, aiming to introduce sustainable mental health policy and implementation across the country, within the context of extremely scarce resources.
Methods
A multi-faceted and comprehensive programme which combined situation appraisal to inform planning, sustained intersectoral policy dialogue at national and regional level; establishment of a health sector system for coordination, supervision and training of at each level (national, regional, district and primary care); development workshops; production of toolkits, development of guidelines and standards; encouragement of intersectoral liaison at national, regional, district and local levels; public education; and integration of mental health into health management systems.
Results
The programme has achieved detailed situation appraisal, epidemiological needs assessment, inclusion of mental health into the health sector reform plans, and into the National Package of Essential Health Interventions, annual operational plans, mental health policy guidelines to accompany the general health policy, tobacco legislation, adaptation of the WHO primary care guidelines for Kenya, primary care training, construction of a quality system of roles and responsibilities, availability of medicines at primary care level, some strengthening of intersectoral liaison with police, prisons and schools, and public education about mental health.
Conclusions
The project has demonstrated the importance of using a multi-faceted and comprehensive programme to promote sustainable system change, key elements of which include a focus on the use of rapid appropriate assessment and treatment at primary care level, strengthening the referral system, interministerial and intersectoral liaison, rehabilitation, social inclusion, promotion and advocacy to mobilize community engagement.
doi:10.1186/1752-4458-4-19
PMCID: PMC2907308  PMID: 20584266
2.  Developing and implementing mental health policy in Zanzibar, a low income country off the coast of East Africa 
Background
The Zanzibar Ministry of Health and Social Welfare, concerned about mental health in the country, requested technical assistance from WHO in 1997.
Aims
This article describes the facilitation over many years by a WHO Collaborating Centre, of sustainable mental health developments in Zanzibar, one of the poorest countries in the world, using systematic approaches to policy design and implementation.
Methods
Based on intensive prior situation appraisal and consultation, a multi-faceted set of interventions combining situation appraisal to inform planning; sustained policy dialogue at Union and state levels; development of policy and legislation, development of strategic action plans, establishment of intersectoral national mental health implementation committee, establishment of national mental health coordination system, integration of mental health into primary care, strengthening of primary-secondary care liaison, rationalisation and strengthening of secondary care system, ensuring adequate supply of medicines, use of good practice guidelines and health information systems, development of services for people with intellectual disability, establishment of formal mechanism for close liaison between the mental health services and other governmental, non-governmental and traditional sectors, mental health promotion, suicide prevention, and research and development.
Results
The policy and legislation introduced in 1999 have resulted in enhanced mental health activities over the ensuing decade, within a setting of extreme low resource. However, advances ebb and flow and continued efforts are required to maintain progress and continue mental health developments. Lessons learnt have informed the development of mental health policies in neighbouring countries.
Conclusions
A multi-faceted and comprehensive programme can be effective in achieving considerable strengthening of mental health programmes and services even in extremely low resource settings, but requires sustained input and advocacy if gains are to be maintained and enhanced.
doi:10.1186/1752-4458-5-6
PMCID: PMC3045977  PMID: 21320308
3.  Health system challenges to integration of mental health delivery in primary care in Kenya- perspectives of primary care health workers 
Background
Health system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness.
Methods
Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training).
Results
These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues.
Conclusion
Generic health system weaknesses in Kenya impact on efforts for horizontal integration of mental health into routine primary care practice, and greatly frustrate health worker efforts.
Improvement of medicine supplies, information systems, explicit inclusion of mental health in district level targets, management and supervision to primary care are likely to greatly improve primary care health worker effectiveness, and enable training programmes to be followed by better use in the field of newly acquired skills. A major lever for horizontal integration of mental health into the health system would be the inclusion of mental health in the national health sector reform strategy at community, primary care and district levels rather than just at the higher provincial and national levels, so that supportive supervision from the district level to primary care would become routine practice rather than very scarce activity.
Trial registration
Trial registration ISRCTN 53515024
doi:10.1186/1472-6963-13-368
PMCID: PMC3852631  PMID: 24079756
Health system challenges; Health sector reform; Mental health; Primary care; Kenya
4.  Mental health care in Nepal: current situation and challenges for development of a district mental health care plan 
Background
Globally mental health problems are a serious public health concern. Currently four out of five people with severe mental illness in Low and Middle Income Countries (LMIC) receive no effective treatment. There is an urgent need to address this enormous treatment gap. Changing the focus of specialist mental health workers (psychiatrists and psychologists) from only service delivery to also designing and managing mental health services; building clinical capacity of the primary health care (PHC) workers, and providing supervision and quality assurance of mental health services may help in scaling up mental health services in LMICs. Little is known however, about the mental health policy and services context for these strategies in fragile-state settings, such as Nepal.
Method
A standard situation analysis tool was developed by the PRogramme for Improving Mental health carE (PRIME) consortium to systematically analyze and describe the current gaps in mental health care in Nepal, in order to inform the development of a district level mental health care plan (MHCP). It comprised six sections; general information (e.g. population, socio-economic conditions); mental health policies and plans; mental health treatment coverage; district health services; and community services. Data was obtained from secondary sources, including scientific publications, reports, project documents and hospital records.
Results
Mental health policy exists in Nepal, having been adopted in 1997, but implementation of the policy framework has yet to begin. In common with other LMICs, the budget allocated for mental health is minimal. Mental health services are concentrated in the big cities, with 0.22 psychiatrists and 0.06 psychologists per 100,000 population. The key challenges experienced in developing a district level MHCP included, overburdened health workers, lack of psychotropic medicines in the PHC, lack of mental health supervision in the existing system, and lack of a coordinating body in the Ministry of Health and Population (MoHP). Strategies to overcome these challenges included involvement of MoHP in the process, especially by providing psychotropic medicines and appointing a senior level officer to facilitate project activities, and collaboration with National Health Training Centers (NHTC) in training programs.
Conclusions
This study describes many challenges facing mental health care in Nepal. Most of these challenges are not new, yet this study contributes to our understanding of these difficulties by outlining the national and district level factors that have a direct influence on the development of a district level mental health care plan.
Electronic supplementary material
The online version of this article (doi:10.1186/s13031-014-0030-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13031-014-0030-5
PMCID: PMC4331482
Mental health; Situation analysis; Integration of mental health into PHC; Mental health care plan; Nepal
5.  Integrating mental health into primary care in Sverdlovsk 
Introduction Mental disorders occur as frequently in Russia as elsewhere, but the common mental disorders, especially depression, have gone largely unrecognised and undiagnosed by policlinic staff and area doctors.
Methods This paper describes the impact and sustainability of a multi-component programme to facilitate the integration of mental health into primary care, by situation appraisal, policy dialogue, development of educational materials, provision of a training programme and the publication of standards and good practice guidelines to improve the primary care of mental disorders in the Sverdlovsk region of the Russian Federation.
Results The multi-component programme has resulted in sustainable training about common mental disorders, not only of family doctors but also of other cadres and levels of professionals, and it has been well integrated with Sverdlovsk's overall programme of health sector reforms.
Conclusion It is possible to facilitate the sustainable integration of mental health into primary care within the Russian context. While careful adaptation will be needed, the approach adopted here may also hold useful lessons for policy makers seeking to integrate mental health within primary care in other contexts and settings.
PMCID: PMC2777595  PMID: 22477885
depression; primary care; Russian Federation; training
6.  Developing European guidelines for training care professionals in mental health promotion 
BMC Public Health  2012;12:1114.
Background
Although mental health promotion is a priority mental health action area for all European countries, high level training resources and high quality skills acquisition in mental health promotion are still relatively rare. The aim of the current paper is to present the results of the DG SANCO-funded PROMISE project concerning the development of European guidelines for training social and health care professionals in mental health promotion.
Methods
The PROMISE project brought together a multidisciplinary scientific committee from eight European sites representing a variety of institutions including universities, mental health service providers and public health organisations. The committee used thematic content analysis to filter and analyse European and international policy documents, scientific literature reviews on mental health promotion and existing mental health promotion programmes with regard to identifying quality criteria for training care professionals on this subject. The resulting PROMISE Guidelines quality criteria were then subjected to an iterative feedback procedure with local steering groups and training professionals at all sites with the aim of developing resource kits and evaluation tools for using the PROMISE Guidelines. Scientific committees also collected information from European, national and local stakeholder groups and professional organisations on existing training programmes, policies and projects.
Results
The process identified ten quality criteria for training care professionals in mental health promotion: embracing the principle of positive mental health; empowering community stakeholders; adopting an interdisciplinary and intersectoral approach; including people with mental health problems; advocating; consulting the knowledge base; adapting interventions to local contexts; identifying and evaluating risks; using the media; evaluating training, implementation processes and outcomes. The iterative feedback process produced resource kits and evaluation checklists linked with each of these quality criteria in all PROMISE languages.
Conclusions
The development of generic guidelines based on key quality criteria for training health and social care professionals in mental health promotion should contribute in a significant way to implementing policy in this important area.
doi:10.1186/1471-2458-12-1114
PMCID: PMC3553026  PMID: 23270332
Mental health promotion; Training; Best practice guidelines
7.  An assessment of mental health policy in Ghana, South Africa, Uganda and Zambia 
Background
Approximately half of the countries in the African Region had a mental health policy by 2005, but little is known about quality of mental health policies in Africa and globally. This paper reports the results of an assessment of the mental health policies of Ghana, South Africa, Uganda and Zambia.
Methods
The WHO Mental Health Policy Checklist was used to evaluate the most current mental health policy in each country. Assessments were completed and reviewed by a specially constituted national committee as well as an independent WHO team. Results of each country evaluation were discussed until consensus was reached.
Results
All four policies received a high level mandate. Each policy addressed community-based services, the integration of mental health into general health care, promotion of mental health and rehabilitation. Prevention was addressed in the South African and Ugandan policies only. Use of evidence for policy development varied considerably. Consultations were mainly held with the mental health sector. Only the Zambian policy presented a clear vision, while three of four countries spelt out values and principles, the need to establish a coordinating body for mental health, and to protect the human rights of people with mental health problems. None included all the basic elements of a policy, nor specified sources and levels of funding for implementation. Deinstitutionalisation and the provision of essential psychotropic medicines were insufficiently addressed. Advocacy, empowerment of users and families and intersectoral collaboration were inadequately addressed. Only Uganda sufficiently outlined a mental health information system, research and evaluation, while only Ghana comprehensively addressed human resources and training requirements. No country had an accompanying strategic mental health plan to allow the development and implementation of concrete strategies and activities.
Conclusions
Six gaps which could impact on the policies' effect on countries' mental health systems were: lack of internal consistency of structure and content of policies, superficiality of key international concepts, lack of evidence on which to base policy directions, inadequate political support, poor integration of mental health policies within the overall national policy and legislative framework, and lack of financial specificity. Three strategies to address these concerns emerged, namely strengthening capacity of key stakeholders in public (mental) health and policy development, creation of a culture of inclusive and dynamic policy development, and coordinated action to optimize use of available resources.
doi:10.1186/1478-4505-9-17
PMCID: PMC3090369  PMID: 21477285
8.  Medico-Legal Findings, Legal Case Progression, and Outcomes in South African Rape Cases: Retrospective Review 
PLoS Medicine  2009;6(10):e1000164.
Rachel Jewkes and colleagues examine the processing of rape cases by South African police and courts and show an association between documentation of ano-genital injuries, trials commencing, and convictions in rape cases.
Background
Health services for victims of rape are recognised as a particularly neglected area of the health sector internationally. Efforts to strengthen these services need to be guided by clinical research. Expert medical evidence is widely used in rape cases, but its contribution to the progress of legal cases is unclear. Only three studies have found an association between documented bodily injuries and convictions in rape cases. This article aims to describe the processing of rape cases by South African police and courts, and the association between documented injuries and DNA and case progression through the criminal justice system.
Methods and Findings
We analysed a provincially representative sample of 2,068 attempted and completed rape cases reported to 70 randomly selected Gauteng province police stations in 2003. Data sheets were completed from the police dockets and available medical examination forms were copied. 1,547 cases of rape had medical examinations and available forms and were analysed, which was at least 85% of the proportion of the sample having a medical examination. We present logistic regression models of the association between whether a trial started and whether the accused was found guilty and the medico-legal findings for adult and child rapes. Half the suspects were arrested (n = 771), 14% (209) of cases went to trial, and in 3% (31) of adults and 7% (44) of children there was a conviction. A report on DNA was available in 1.4% (22) of cases, but the presence or absence of injuries were documented in all cases. Documented injuries were not associated with arrest, but they were associated with children's cases (but not adult's) going to trial (adjusted odds ratio [AOR] for having genital and nongenital injuries 5.83, 95% confidence interval [CI] 1.87–18.13, p = 0.003). In adult cases a conviction was more likely if there were documented injuries, whether nongenital injuries alone AOR 6.25 (95% CI 1.14–34.3, p = 0.036), ano-genital injuries alone (AOR 7.00, 95% CI 1.44–33.9, p = 0.017), or both nongenital and ano-genital injuries (AOR 12.34, 95% CI 2.87–53.0, p = 0.001). DNA was not associated with case outcome.
Conclusions
This is the first study, to our knowledge, to show an association between documentation of ano-genital injuries, trials commencing, and convictions in rape cases in a developing country. Its findings are of particular importance because they show the value of good basic medical practices in documentation of injuries, rather than more expensive DNA evidence, in assisting courts in rape cases. Health care providers need training to provide high quality health care responses after rape, but we have shown that the core elements of the medico-legal response require very little technology. As such they should be replicable in low- and middle-income country settings. Our findings raise important questions about the value of evidence that requires the use of forensic laboratories at a population level in countries like South Africa that have substantial inefficiencies in their police services.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Sexual violence has significant short- and long-term mental and physical health consequences for the victim. Estimates of how common rape is vary within and between countries. The World Health Organization (WHO) estimates that between 1% and 12% of women aged 15 or over have experienced sexual violence by a nonpartner. It has also been used as a weapon of war.
The WHO recognises that rape may be committed by a spouse, partner, or acquaintance as well as a stranger, that men can be victims as well as perpetrators, and that coercion need not be physical. It advocates preventing sexual violence through better support for victims, legal and policy changes, educational programmes, and campaigns to change attitudes, and better health care services and training for health care workers.
Health services for victims of rape have two important roles: to assist the victim and to gather evidence for the police and courts. Nonetheless, health services for victims of rape are often poor. Over the last decade, the South African government has taken steps to reduce particularly high rates of sexual violence by broadening the legal definition of rape and improving health services.
Why Was This Study Done?
Previous studies into how useful expert medical evidence is for the police and courts have focused almost exclusively on high-income countries. It is not clear what interventions work best in countries with fewer resources. The researchers wanted to know the impact of medical evidence on how the South African criminal justice system handled cases of rape and attempted rape.
What Did the Researchers Do and Find?
The authors analysed data from police and court files of 1,547 cases of rape or attempted rape first reported in 2003 to a random sample of police stations in Gauteng province, South Africa. They looked for associations between case data and the arrest, charge, trial, and conviction or acquittal of the alleged perpetrator. They included only cases that were closed when they collected data in 2006 and only cases that contained a record of a medical examination of the victim. The researchers used South Africa's then legal definition of rape as “intentional and unlawful vaginal sex with woman without consent.” They analysed cases involving adults and children (aged 0–17 years) separately. They found that the overall conviction rate was very low, with only 3% of adult cases and 7.4% of children's cases resulting in a guilty verdict. Many cases were dropped at each stage of the legal process and DNA evidence was often not collected or, if collected, not analysed. DNA reports were rarely available for the courts. Injuries were not associated with arrests for either adult or children's cases; an arrest took place in 40% of cases without injuries. Child cases were more likely to come to trial if injuries were present, although a guilty verdict was not more likely. The reverse was true in adult cases: the presence or absence of injury was not linked to cases being brought to trial, but if injuries were present, whether genital, nongenital, or both, a conviction was more likely.
What Do These Findings Mean?
One limitation of the research is that the researchers identified statistical associations of events, but this does not prove that one event caused the other. Other possible limitations of the study are that the researchers had access only to cases closed by the police, which may have biased their results, and the quality of the recorded data was very variable. In addition, the research did not consider other factors that may have affected case outcomes, such as how witnesses are perceived in court.
The system to collect and analyse DNA was rarely effective in making evidence available to the courts. It is known from other countries with effective systems that DNA evidence is of no value if the basis of defence is consent; for instance in cases where the accused is an intimate partner of the victim. Injuries appear not to be necessary to secure a conviction but may be seen as useful by the South African courts in corroborating the victim's testimony, at least in adult cases.
The authors conclude that in poor countries, training for nurses and/or doctors who act as forensic medical examiners in how to record injuries and present their evidence in court will be more effective than investing in costly systems for DNA analysis. However, they argue that in South Africa, as a middle-income country with a high proportion of nonintimate partner rapes, there would be benefit in improving the system to collect and analyse DNA evidence rather than abandoning it entirely.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000164.
Further information on rape in South Africa is available from the Tshwaranang Legal Advocacy Centre
Information on rape is also available from the Rape Crisis Cape Town Trust
Emergency rape information, facts about rape, events, legal services, and medical care can be found at the Speakout Web site
The World Health Organization publishes a factsheet on sexual violence, a report on violence and health, as well as guidelines on medico-legal care for victims of sexual violence
doi:10.1371/journal.pmed.1000164
PMCID: PMC2752115  PMID: 19823567
9.  The Role of Health Systems Factors in Facilitating Access to Psychotropic Medicines: A Cross-Sectional Analysis of the WHO-AIMS in 63 Low- and Middle-Income Countries 
PLoS Medicine  2012;9(1):e1001166.
In a cross-sectional analysis of WHO-AIMS data, Ryan McBain and colleagues investigate the associations between health system components and access to psychotropic drugs in 63 low and middle income countries.
Background
Neuropsychiatric conditions comprise 14% of the global burden of disease and 30% of all noncommunicable disease. Despite the existence of cost-effective interventions, including administration of psychotropic medicines, the number of persons who remain untreated is as high as 85% in low- and middle-income countries (LAMICs). While access to psychotropic medicines varies substantially across countries, no studies to date have empirically investigated potential health systems factors underlying this issue.
Methods and Findings
This study uses a cross-sectional sample of 63 LAMICs and country regions to identify key health systems components associated with access to psychotropic medicines. Data from countries that completed the World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS) were included in multiple regression analyses to investigate the role of five major mental health systems domains in shaping medicine availability and affordability. These domains are: mental health legislation, human rights implementations, mental health care financing, human resources, and the role of advocacy groups. Availability of psychotropic medicines was associated with features of all five mental health systems domains. Most notably, within the domain of mental health legislation, a comprehensive national mental health plan was associated with 15% greater availability; and in terms of advocacy groups, the participation of family-based organizations in the development of mental health legislation was associated with 17% greater availability. Only three measures were related with affordability of medicines to consumers: level of human resources, percentage of countries' health budget dedicated to mental health, and availability of mental health care in prisons. Controlling for country development, as measured by the Human Development Index, health systems features were associated with medicine availability but not affordability.
Conclusions
Results suggest that strengthening particular facets of mental health systems might improve availability of psychotropic medicines and that overall country development is associated with affordability.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Mental disorders—conditions that involve impairment of thinking, emotions, and behavior—are extremely common. Worldwide, mental illness affects about 450 million people and accounts for 13.5% of the global burden of disease. About one in four people will have a mental health problem at some time in their life. For some people, this will be a short period of mild depression, anxiety, or stress. For others, it will be a serious, long-lasting condition such as schizophrenia, bipolar disorder, or major depression. People with mental health problems need help and support from professionals and from their friends and families to help them cope with their illness but are often discriminated against, which can make their illness worse. Treatments include counseling and psychotherapy (talking therapies), and psychotropic medicines—drugs that act mainly on the brain. Left untreated, many people with serious mental illnesses commit suicide.
Why Was This Study Done?
About 80% of people with mental illnesses live in low- and middle-income countries (LAMICs) where up to 85% of patients remain untreated. Access to psychotropic medicines, which constitute an essential and cost-effective component in the treatment of mental illnesses, is particularly poor in many LAMICs. To improve this situation, it is necessary to understand what health systems factors limit the availability and affordability of psychotropic drugs; a health system is the sum of all the organizations, institutions, and resources that act together to improve health. In this cross-sectional study, the researchers look for associations between specific health system components and access to psychotropic medicines by analyzing data collected from LAMICs using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). A cross-sectional study analyzes data collected at a single time. WHO-AIMS, which was created to evaluate mental health systems primarily in LAMICs, is a 155-item survey that Ministries of Health and other country-based agencies can use to collect information on mental health indicators.
What Did the Researchers Do and Find?
The researchers used WHO-AIMS data from 63 countries/country regions and multiple regression analysis to evaluate the role of mental health legislation, human rights implementation, mental health care financing, human resources, and advocacy in shaping medicine availability and affordability. For each of these health systems domains, the researchers developed one or more summary measurements. For example, they measured financing as the percentage of government health expenditure directed toward mental health. Availability of psychotropic medicines was defined as the percentage of mental health facilities in which at least one psychotropic medication for each therapeutic category was always available. Affordability was measured by calculating the percentage of daily minimum wage needed to purchase medicine by the average consumer. The availability of psychotropic medicines was related to features of all five mental health systems domains, report the researchers. Notably, having a national mental health plan (part of the legislation domain) and the participation (advocacy) of family-based organizations in mental health legislation formulation were associated with 15% and 17% greater availability of medicines, respectively. By contrast, only the levels of human resources and financing, and the availability of mental health care in prisons (part of the human rights domain) were associated with the affordability of psychotropic medicines. Once overall country development was taken into account, most of the associations between health systems factors and medicine availability remained significant, while the associations between health systems factors and medicine affordability were no longer significant. In part, this was because country development was more strongly associated with affordability and explained most of the relationships: for example, countries with greater overall development have higher expenditures on mental health and greater medicine affordability compared to availability.
What Do These Findings Mean?
These findings indicate that access to psychotropic medicines in LAMICs is related to key components within the mental health systems of these countries but that availability and affordability are affected to different extents by these components. They also show that country development plays a strong role in determining affordability but has less effect on determining availability. Because cross-sectional data were used in this study, these findings only indicate associations; they do not imply causality. They are also limited by the relatively small number of observations included in this study, by the methods used to collect mental health systems data in many LAMICs, and by the possibility that some countries may have reported biased results. Despite these limitations, these findings suggest that strengthening specific mental health system features may be an important way to facilitate access to psychotropic medicines but also highlight the role that country wealth and development play in promoting the treatment of mental disorders.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/ 10.1371/journal.pmed.1001166.
The US National Institute of Mental Health provides information on all aspects of mental health (in English and Spanish)
The UK National Health Service Choices website provides information on mental health; its Live Well feature provides practical advice on dealing with mental health problems and personal stories
The UK charity Mind provides further information about mental illness, including personal stories
MedlinePlus provides links to many other sources of information on mental health (in English and Spanish)
Information on WHO-AIMS, including versions of the instrument in several languages, and WHO-AIMS country reports are available
doi:10.1371/journal.pmed.1001166
PMCID: PMC3269418  PMID: 22303288
10.  Analysis of the ‘reformpool’-activity in Austria: is the challenge met? 
Aim
The purpose of our study is to analyse the activities initiated by the foundation of the reformpools on the regional level. We wanted to see not only what projects have emerged from these funds, but also how the incentives of this special way of funding influence the activity and what overall impact can be expected on health services delivery in the future.
Context
In Austria, all expenses in the outpatient sector are borne by the statutory health insurance. But in the inpatient sector, SHI just co-finances about 45% of all costs incurred by patients, with the rest contributed by the federal, regional and municipal level. This, however, leads to a number of problems in today's epidemiological situation with patients in need of many different interventions in the course of their chronic disease.
Originally with the aim of finding solutions to these interface problems between inpatient and outpatient care, the healthcare reform 2005 instated the instrument of the reformpool. The reformpool unites funds from social health insurance and regions to finance projects that develop new ways of health services delivery across the sectors. In the course of recent reforms, it became explicitly possible to sponsor projects of integrated care, which had de facto already been the case before.
Theory
The reform pool has various disincentives or wrong incentives compared to e.g. the German ‘Anschubfinanzierung’ for IC-contracts, which was probably a role-model for the Austrian reformpool, because of the underlying differences in the healthcare system and the distinct differences in the regulation. For example, the ‘Anschubfinanzierung’ in Germany withdraws money from the available funds for contract physicians to finance IC-projects, whereas in Austria, their fees are fixed. So in Austria, there is no incentive to retrieve money by participating in such projects. For the stakeholders supplying the pool, mainly the sickness funds and the regions, many projects inflict additional costs on the one or on the other in the future. So as both parties have to agree on projects, there is a strong basic disincentive to grant funds in the present. If a project is in both their interest because it is reducing costs, the care providers might not be interested to participate, as this would diminish their revenues in the future. What is more, the federal control over the (region-based) funds and projects is poor, which might lead to duplication of efforts and missing scale-efficiency in some regions.
Methods and data
For our analysis, we conducted a survey with a standardised questionnaire sent to the management of the regional health funds, which are responsible for the reformpool funds. The questionnaire was checked by experts of the federal association of social security institutions. We also conducted an on-site visit of the reformpool-manager, a programme which can be used to evaluate the reformpool-projects. In addition, we used all available evaluation reports of projects to assess the situation of evaluation of the projects. Furthermore, we used financial data from the regional health funds, the federal association of social security institutions, from the ministry of health and the regional health funds to assess the usage of the reformpool.
(Preliminary) Results
The qualitative results are mixed. Some projects are promising with regard to improvements of the current situation and are well evaluated. Many projects neglect the requirement of the reformpool to be such as to yield a monetary benefit for the system but only focus on improving service delivery. Some evaluations are not well operationalised and thus, arguments why these projects should be transformed to ordinarily financed services will be lacking. The reformpool activity set on very slowly, with only one project already started in 2005, the first possible year. In 2007 we see the highest number (23) of new projects granted and the highest monetary volume, €11 Mio total for 21 of them 1, with activity subsiding in 2008 (6 projects with a volume of € 2.5 Mio total for 5 of them 1) and most certainly in 2009 (with diminishing tax revenues and health insurance contributions) with only one project granted in the first quarter of the year. Of all funds (theoretically) available, only about 16% have been put to use in a reformpool project per year, with high variation (e.g. in the region of Styria over 30%, in Tyrol only 1.5%).
(Preliminary) Conclusions
From our study we can tell that the instrument of reformpool was not devised well concerning its incentive structure, and the interest to conduct such projects is diminishing. Stricter control of the requirements by the federal level, more pronounced requirements, a dedication of the funds to projects instead of a virtual budget and more cooperation between regions could improve the effectiveness of the instrument. Conflicts of interest: The project was funded by the federal association of social security institutions. All authors are researchers at the IHS and hold no commercial interests in the subject. Additional information: Founded by the economist Oskar Morgenstern and the sociologist Paul Lazarsfeld, the IHS (Institute for Advanced Studies) is a non-profit post-graduate teaching and research facility in the fields of economics, sociology and politology, and one of the two Austrian institutes preparing the official economic forecast for Austria. For more than a decade, it has been one of the major research facilities in the fields of health economics and health policy in Austria.
PMCID: PMC2807071
evidence-based guidelines; quality of care
11.  Development of Mental Health Indicators in Korea 
Psychiatry Investigation  2012;9(4):311-318.
Objective
Promoting mental health and preventing mental health problems are important tasks for international organizations and nations. Such goals entail the establishment of active information networks and effective systems and indicators to assess the mental health of populations. This being said, there is a need in Korea develop ways to measure the state of mental health in Korea.
Methods
This paper reviews the mental health indicator development policies and practices of seven organizations, countries, and regions: WHO, OECD, EU, United States, Australia, UK, and Scotland. Using Delphi method, we conducted two surveys of mental health indicators for experts in the field of mental health. The survey questionnaire included 5 domains: mental health status, mental health factor, mental health system, mental health service, and quality of mental health services. We considered 124 potential mental health indicators out of more than 600 from indicators of international organizations and foreign countries.
Results
We obtained the top 30 mental health indicators from the surveys. Among them, 10 indicators belong to the mental health system. The most important five mental health indicators are suicide rate, rate of increase in mental disorder treatment, burden caused by mental disorders, adequacy of identifying problems of mental health projects and deriving solutions, and annual prevalence of mental disorders.
Conclusion
Our study provides information about the process for indicator development and the use of survey results to measure the mental health status of the Korean population. The aim of mental health indicator development is to improve the mental health system by better grasping the current situation. We suggest these mental health indicators can monitor progress in efforts to implement reform policies, provide community services, and involve users, families and other stakeholders in mental health promotion, prevention, care and rehabilitation.
doi:10.4306/pi.2012.9.4.311
PMCID: PMC3521105  PMID: 23251193
Mental health; Mental health indicator; Development
12.  Mental health priorities in Vietnam: a mixed-methods analysis 
Background
The Mental Health Country Profile is a tool that was generated by the International Mental Health Policy and Services Project to inform policy makers, professionals and other key stakeholders about important issues which need to be considered in mental health policy development. The Mental Health Country Profile contains four domains, which include the mental health context, resources, provision and outcomes. We have aimed to generate a Mental Health Country Profile for Vietnam, in order to highlight the strengths and weaknesses of the Vietnamese mental health situation, in order to inform future reform efforts and decision-making.
Methods
This study used snowball sampling to identify informants for generating a Mental Health Country Profile for Vietnam, and the data gathering was done through semi-structured interviews and collection of relevant reports and documents. The material from the interviews and documents was analysed according to qualitative content analysis.
Results
Marked strengths of the Vietnam mental health system are the aims to move toward community management and detection of mental illness, and the active involvement of several multilateral organizations and NGOs. However, there are a number of shortages still found, including the lack of treatment interventions apart from medications, the high proportion of treatments to be paid out-of-pocket, prominence of large tertiary psychiatric hospitals, and a lack of preventative measures or mental health information to the public.
Conclusions
At the end of this decade, mental health care in Vietnam is still characterised by unclear policy and poor critical mass especially within the governmental sector. This initial attempt to map the mental health situation of Vietnam suffers from a number of limitations and should be seen as a first step towards a comprehensive profile.
doi:10.1186/1472-6963-10-257
PMCID: PMC2942883  PMID: 20813036
13.  Mental health policy in Eastern Europe: a comparative analysis of seven mental health systems 
Background
The objective of this international comparative study is to describe and compare the mental health policies in seven countries of Eastern Europe that share their common communist history: Bulgaria, the Czech Republic, Hungary, Moldova, Poland, Romania, and Slovakia.
Methods
The health policy questionnaire was developed and the country-specific information was gathered by local experts. The questionnaire includes both qualitative and quantitative information on various aspects of mental health policy: (1) basic country information (demography, health, and economic indicators), (2) health care financing, (3) mental health services (capacities and utilisation, ownership), (4) health service purchasing (purchasing organisations, contracting, reimbursement of services), and (5) mental health policy (policy documents, legislation, civic society).
Results
The social and economic transition in the 1990s initiated the process of new mental health policy formulation, adoption of mental health legislation stressing human rights of patients, and a strong call for a pragmatic balance of community and hospital services. In contrast to the development in the Western Europe, the civic society was suppressed and NGOs and similar organizations were practically non-existent or under governmental control. Mental health services are financed from the public health insurance as any other health services. There is no separate budget for mental health. We can observe that the know-how about modern mental health care and about direction of needed reforms is available in documents, policies and programmes. However, this does not mean real implementation.
Conclusions
The burden of totalitarian history still influences many areas of social and economic life, which also has to be taken into account in mental health policy. We may observe that after twenty years of health reforms and reforms of health reforms, the transition of the mental health systems still continues. In spite of many reform efforts in the past, a balance of community and hospital mental health services has not been achieved in this part of the world yet.
doi:10.1186/1472-6963-14-42
PMCID: PMC3908346  PMID: 24467832
Mental health policy; Health financing; Eastern Europe
14.  An overview of Uganda's mental health care system: results from an assessment using the world health organization's assessment instrument for mental health systems (WHO-AIMS) 
Background
The Ugandan government recognizes mental health as a serious public health and development concern, and has of recent implemented a number of reforms aimed at strengthening the country's mental health system. The aim of this study was to provide a profile of the current mental health policy, legislation and services in Uganda.
Methods
A survey was conducted of public sector mental health policy and legislation, and service resources and utilisation in Uganda, in the year 2005, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS) Version 2.2.
Results
Uganda's draft mental health policy encompasses many positive reforms, including decentralization and integration of mental health services into Primary Health Care (PHC). The mental health legislation is however outdated and offensive. Services are still significantly underfunded (with only 1% of the health expenditure going to mental health), and skewed towards urban areas. Per 100,000 population, there were 1.83 beds in mental hospitals, 1.4 beds in community based psychiatric inpatient units, and 0.42 beds in forensic facilities. The total personnel working in mental health facilities were 310 (1.13 per 100,000 population). Only 0.8% of the medical doctors and 4% of the nurses had specialized in psychiatry.
Conclusion
Although there have been important developments in Uganda's mental health policy and services, there remains a number of shortcomings, especially in terms of resources and service delivery. There is an urgent need for more research on the current burden of mental disorders and the functioning of mental health programs and services in Uganda.
doi:10.1186/1752-4458-4-1
PMCID: PMC2831025  PMID: 20180979
15.  Acceptability and feasibility of using non-specialist health workers to deliver mental health care: Stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda 
Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.
Highlights
•Task sharing in mental health requires improved training, support, compensation and supervision.•Overburdening health workers is a risk for task-sharing mental health care.•Task-sharing requires clearly defined roles and the use of recognized and trusted trainers.•Socio-cultural context is fundamental for effective task sharing strategies in mental health.•Cultural brokers can be important stakeholders to identify local cultural idioms of distress.
doi:10.1016/j.socscimed.2014.07.057
PMCID: PMC4167946  PMID: 25089962
Task-sharing; Task-shifting; Global mental health; Mental health services; Low- and middle-income countries; Acceptability; Feasibility
16.  Urban Mental Health Services in India : How Complete or Incomplete? 
Indian Journal of Psychiatry  2004;46(3):195-212.
The information about Urban Mental Health Services has been nearly nonexistent in India, although the developed countries have been focusing on programmes for “Healthy Cities”. The initiative taken as part of the WHO-ICMR Pilot Project on Urban Mental Health Services, with a public health perspective is being shared. The objectives of the Health Services Research (HSR) Arm of the project were to study the distribution and the availability of tertiary Mental Health Services, availability of human resources, average service load, mental health service gap, and perceptions of the users and the service providers, regarding the barriers in accessibility of mental health services, unmet service needs and strategies for improvement.
The Research Methods involved Mapping Exercises with estimation of Service Loads and Qualitative Research Methods (QRM) like In-Depth Interviews (IDIs), Key Informant Interviews (KIIs), Free Listing and Focused Group Discussions (FGDs). The results indicate uneven availability of mental health services, human resource deficit specially for non-medical mental health professionals and mental health service gap (82% to96%). The average service load in the specialist mental health services is largely carried by the Govt. sector (half to two thirds), followed by the private sector (one third to half), with only a small portion by the NGO sector. The average mental health service load in the primary care general health services is largely carried by the private sector, with significant contribution from the non-formal service providers. The barriers to access, unmet needs and possible strategies as perceived by the community, users and service providers have been identified. The findings are discussed in the context of the mental health programmes and the public policy issues. The implications of the conclusions which suggest that Urban Mental Health Services are far from complete are highlighted.
PMCID: PMC2951645  PMID: 21224901
Urban Mental Health; Health Services Research; Service Utilization Indicators; Public Health Policy
17.  Perceived challenges and opportunities arising from integration of mental health into primary care: a cross-sectional survey of primary health care workers in south-west Ethiopia 
Background
The WHO’s mental health Gap Action Programme seeks to narrow the treatment gap for mental disorders by advocating integration of mental health into primary health care (PHC). This study aimed to assess the challenges and opportunities of this approach from the perspective of PHC workers in a sub-Saharan African country.
Methods
A facility-based cross-sectional survey of 151 PHC workers was conducted from 1st to 30th November 2011 in Jimma zone, south-west Ethiopia. A structured questionnaire was used to ask about past training and mental health experience, knowledge and attitudes towards mental disorders and provision of mental health care in PHC. Semi-structured interviews were carried out with 12 heads of health facilities for more in-depth understanding.
Results
Almost all PHC workers (96.0%) reported that mental health care was important in Ethiopia and the majority (66.9%) expressed interest in actually delivering mental health care. Higher levels of general health training (degree vs. diploma) and pre-service clinical exposure to mental health care were associated with more favourable attitudes. Knowledge about mental disorder diagnoses, symptoms and treatments was low. Almost half (45.0%) of PHC workers reported that supernatural factors were important causes of mental disorders. Health system and structural issues, such as poor medication supply, lack of rooms, time constraints, absence of specialist supervision and lack of treatment guidelines, were identified as challenges. Almost all PHC workers (96.7%) reported a need for more training, including a clinical attachment, in order to be able to deliver mental health care competently.
Conclusions
Despite acceptability to PHC workers, the feasibility of integrating mental health into PHC in this sub-Saharan African setting is limited by important gaps in PHC worker knowledge and expectations regarding mental health care, coupled with health system constraints. In addition to clinically-based refresher mental health training, expansion of the specialist mental health workforce may be needed to support integration in practice.
doi:10.1186/1472-6963-14-113
PMCID: PMC3946769  PMID: 24602215
Mental health; Mental disorders; Mental health care; Primary health care; Task shifting; Scale-up; Sub-Saharan Africa; Low-income country
18.  Integrating mental health into primary health care in Zambia: a care provider's perspective 
Background
Despite the 1991 reforms of the health system in Zambia, mental health is still given low priority. This is evident from the fragmented manner in which mental health services are provided in the country and the limited budget allocations, with mental health services receiving 0.4% of the total health budget. Most of the mental health services provided are curative in nature and based in tertiary health institutions. At primary health care level, there is either absence of, or fragmented health services.
Aims
The aim of this paper was to explore health providers' views about mental health integration into primary health care.
Methods
A mixed methods, structured survey was conducted of 111 health service providers in primary health care centres, drawn from one urban setting (Lusaka) and one rural setting (Mumbwa).
Results
There is strong support for integrating mental health into primary health care from care providers, as a way of facilitating early detection and intervention for mental health problems. Participants believed that this would contribute to the reduction of stigma and the promotion of human rights for people with mental health problems. However, health providers felt they require basic training in order to enhance their knowledge and skills in providing health care to people with mental health problems.
Recommendations
It is recommended that health care providers should be provided with basic training in mental health in order to enhance their knowledge and skills to enable them provide mental health care to patients seeking help at primary health care level.
Conclusion
Integrating mental health services into primary health care is critical to improving and promoting the mental health of the population in Zambia.
doi:10.1186/1752-4458-4-21
PMCID: PMC2919445  PMID: 20653981
19.  Integrating mental health services: the Finnish experience 
Abstract
The aim of this paper is to give a short description of the most important developments of mental health services in Finland during the 1990s, examine their influences on the organisation and provision of services, and describe shortly some national efforts to handle the new situation. The Finnish mental health service system experienced profound changes in the beginning of the 1990s. These included the integration of mental health services, being earlier under own separate administration, with other specialised health services, decentralisation of the financing of health services, and de-institutionalisation of the services. The same time Finland underwent the deepest economic recession in Western Europe, which resulted in cut-offs especially in the mental health budgets.
Conducting extensive national research and development programmes in the field of mental health has been one typically Finnish way of supporting the mental health service development. The first of these national programmes was the Schizophrenia Project 1981–97, whose main aims were to decrease the incidence of new long-term patients and the prevalence of old long-stay patients by developing an integrated treatment model. The Suicide Prevention Project 1986–96 aimed at raising awareness of this special problem and decreasing by 20% the proportionally high suicide rate in Finland. The National Depression Programme 1994–98 focused at this clearly increasing public health concern by several research and development project targeted both to the general population and specifically to children, primary care and specialised services. The latest, still on-going Meaningful Life Programme 1998–2003 which main aim is, by multi-sectoral co-operation, to improve the quality of life for people suffering from or living with the threat of mental disorders. Furthermore, the government launched in 1999 a new Goal and Action Programme for Social Welfare and Health Care 2000–2003, in which mental health has been chosen as one of the eight priority areas.
PMCID: PMC1484394  PMID: 16896401
mental health; integration of mental health services; decentralisation; de-institutionalisation; R&D programmes
20.  Mental health problems in Pakistani society as a consequence of violence and trauma: a case for better integration of care 
Objectives
This paper discusses the increasing incidence of mental health problems in Pakistan, and specifically in the Swat Valley, in relation to the growing insurgency and current violence in Pakistani society. The paper argues that the health care system’s response in Pakistan is not adequate to meet the current challenges and that changes in policy are needed to build mental health care services as an important component of the basic health package at primary care level in the public sector.
Method
This paper reviews the existing mental health situation in Pakistan with reference to the findings of a case study in the Swat Valley in Khyber Pukhtoonkhwa Pakistan. The figures presented in the case study are used to support the need for an integrated national mental health policy.
Conclusion
Mental health care needs to be incorporated as a core service in primary care and supported by specialist services. There is a strong need to provide adequate training for general practitioners and postgraduate training for mental health professionals to meet the current demands. A collaborative network between stakeholders in the public and private sector, as well as non-governmental organisations are required that promotes mental health care and advocates for changes in mental health policy.
PMCID: PMC3225239  PMID: 22128277
mental health; primary care; Pakistan; health policy; conflict; post-traumatic stress disorder
21.  Integration of mental health into primary health care in Uganda: opportunities and challenges 
Background Worldwide, a number of reforms have been undertaken with the intention of improving access to mental health services. Notable among these is the integration of mental health services into primary health care, which has been one of the most fundamental healthcare reform recommendations globally.
Objectives This paper describes the opportunities for and challenges to the integration of mental health into primary health care in Uganda, as identified in a wider study, aimed at exploring the policy interventions required to address the vicious cycle of mental ill-health and poverty.
Methods Semi-structured interviews and focus group discussions (FGDs) were conducted with purposefully selected mental health stakeholders from various sectors. The interviews and FGDs were audio-recorded, and transcripts coded on the basis of a pre-determined coding frame. Thematic analysis of the data was conducted using NVivo7, adopting a framework analysis approach.
Results The participants identified a number of opportunities that could be exploited to strengthen the integration process. Notable among these was the political will and prioritisation of mental health at policy level. Poor appreciation of the integration process and attitudinal problems emerged as the most pressing challenges for integration of mental health into primary health care.
Conclusion Irrespective of the various opportunities in place, the integration of mental health into primary health care has not yet been fully realised, as it faces a number of challenges within and outside the health sector. This calls for more concerted efforts to scale up activities for effective integration of mental health care into primary health care.
PMCID: PMC2777598  PMID: 22477886
integration; mental health; policy; primary healthcare; Uganda
22.  Experiences with Policing among People Who Inject Drugs in Bangkok, Thailand: A Qualitative Study 
PLoS Medicine  2013;10(12):e1001570.
Using thematic analysis, Kerr and colleagues document the experiences of policing among people who inject drugs in Bangkok and examine how interactions with police can affect drug-using behaviors and health care access.
Please see later in the article for the Editors' Summary
Background
Despite Thailand's commitment to treating people who use drugs as “patients” not “criminals,” Thai authorities continue to emphasize criminal law enforcement for drug control. In 2003, Thailand's drug war received international criticism due to extensive human rights violations. However, few studies have since investigated the impact of policing on drug-using populations. Therefore, we sought to examine experiences with policing among people who inject drugs (PWID) in Bangkok, Thailand, between 2008 and 2012.
Methods and Findings
Between July 2011 and June 2012, semi-structured, in-depth interviews were conducted with 42 community-recruited PWID participating in the Mitsampan Community Research Project in Bangkok. Interviews explored PWID's encounters with police during the past three years. Audio-recorded interviews were transcribed verbatim, and a thematic analysis was conducted to document the character of PWID's experiences with police. Respondents indicated that policing activities had noticeably intensified since rapid urine toxicology screening became available to police. Respondents reported various forms of police misconduct, including false accusations, coercion of confessions, excessive use of force, and extortion of money. However, respondents were reluctant to report misconduct to the authorities in the face of social and structural barriers to seeking justice. Respondents' strategies to avoid police impeded access to health care and facilitated transitions towards the misuse of prescribed pharmaceuticals. The study's limitations relate to the transferability of the findings, including the potential biases associated with the small convenience sample.
Conclusions
This study suggests that policing in Bangkok has involved injustices, human rights abuses, and corruption, and policing practices in this setting appeared to have increased PWID's vulnerability to poor health through various pathways. Novel to this study are findings pertaining to the use of urine drug testing by police, which highlight the potential for widespread abuse of this emerging technology. These findings raise concern about ongoing policing practices in this setting.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
In many countries, the dominant strategy used to control illegal drugs such as heroin and methamphetamine is criminal law enforcement, a strategy that sometimes results in human rights abuses such as ill-treatment by police, extrajudicial killings, and arbitrary detention. Moreover, growing evidence suggests that aggressive policing of illicit drug use can have adverse public-health consequences. For example, the fear engendered by intensive policing may cause people who inject drugs (PWID) to avoid services such as needle exchanges, thereby contributing to the HIV/AIDS epidemic. One country with major epidemics of illicit drug use and of HIV/AIDS among PWID is Thailand. Although Thailand reclassified drug users as “patients” instead of “criminals” in 2002, possession and consumption of illicit drugs remain criminal offenses. The 2002 legislation also created a system of compulsory drug detention centers, most of which lack evidence-based addiction treatment services. In 2003, the Thai government launched a campaign to suppress drug trafficking and to enrol 300,000 people who use drugs into treatment. This campaign received international criticism because it involved extensive human rights violations, including more than 2,800 extrajudicial killings of suspected drug users and dealers.
Why Was This Study Done?
Drug-related arrests and compulsory detention of drug users are increasing in Thailand but what is the impact of current policing practices on drug users and on public health? In this qualitative study (a study that aims for an in-depth understanding of human behavior), the researchers use thematic analysis informed by the Rhodes' Risk Environment Framework to document the social and structural factors that led to encounters with the police among PWID in Bangkok between 2008 and 2012, the policing tactics employed during these encounters, and the associated health consequences of these encounters. The Risk Environment Framework posits that a range of social, political, economic, and physical environmental factors interact with each other and shape the production of drug-related harm.
What Did the Researchers Do and Find?
Between July 2011 and June 2012, the researchers conducted in-depth interviews with a convenience sample (a non-random sample from a nearby population) of 42 participants in the Mitsampan Community Research Project, an investigation of drug-using behavior, health care access, and drug-related harms among PWID in Bangkok. Respondents reported that policing activities had intensified since rapid urine toxicology screening became widely available and since the initiation of a crackdown on drug users in 2011. They described various forms of violence and misconduct that they had experienced during confrontations with police, including false accusations, degrading stop and search procedures, and excessive use of force. Urine drug testing was identified as a key tool used by the police, with some respondents describing how police caused unnecessary humiliation by requesting urine samples in public places. It was also reported that the police used positive test results as a means of extortion. Finally, some respondents reported feeling powerless in relation to the police and cited fear of retaliation as an important barrier to obtaining redress for police corruption. Others reported that they had adopted strategies to avoid the police such as staying indoors, a strategy likely to impede access to health care, or changing their drug-using behavior by, for example, injecting midazolam rather than methamphetamine, a practice associated with an increased risk of injection-related complications.
What Do These Findings Mean?
These findings suggest that the policing of PWID in Bangkok between 2008 and 2012 involved injustices, human rights abuses, and corruption and highlight the potential for widespread misuse of urine drug testing. Moreover, they suggest that policing practices in this setting may have increased the vulnerability of PWID to poor health by impeding their access to health care and by increasing the occurrence of risky drug-using behaviors. Because this study involved a small convenience sample of PWID, these findings may not be generalizable to other areas of Bangkok or Thailand and do not indicate whether police misconduct and corruption is highly prevalent across the all police departments in Bangkok. Nevertheless, these findings suggest that multilevel structural changes and interventions are needed to mitigate the harm associated with policing of illicit drug use in Bangkok. These changes will need to ensure full accountability for police misconduct and access to legal services for victims of this misconduct. They will also need to include ethical guidelines for urine drug testing and the reform of policies that promote repressive policing and compulsory detention.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001570.
This study is further discussed in a PLOS Medicine Perspective by Burris and Koester
Human Rights Watch, a global organization dedicated to defending and protecting human rights, has information about drug policy and human rights, which includes information on Thailand
The Global Commission on Drug Policy published a report in June 2012 entitled “The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic” (available in several languages)
The Global Commission on HIV and the Law published a report in July 2012 entitled “HIV and the Law: Risk, Rights and Health” (available in several languages), the Open Society Foundations have prepared a briefing on this report
More information about the Mitsampan Community Research Project is available
doi:10.1371/journal.pmed.1001570
PMCID: PMC3858231  PMID: 24339753
23.  Implementing a knowledge application program for anxiety and depression in community-based primary mental health care: a multiple case study research protocol 
Background
Anxiety and depressive disorders are increasingly recognized as a health care policy priority. Reducing the treatment gap for common mental disorders requires strengthening the quality of primary mental health care. We developed a knowledge application program designed to improve the organization and delivery of care for anxiety and depression in community-based primary mental health care teams in Quebec, Canada. The principal objectives of the study are: to implement and evaluate this evidence-based knowledge application program; to examine the contextual factors associated with the selection of local quality improvement strategies; to explore barriers and facilitators associated with the implementation of local quality improvement plans; and to study the implementation of local quality monitoring strategies.
Methods
The research design is a mixed-methods prospective multiple case study. The main analysis unit (cases) is composed of the six multidisciplinary community-based primary mental health care teams, and each of the cases has identified at least one primary care medical clinic interested in collaborating with the implementation project. The training modules of the program are based on the Chronic Care Model, and the implementation strategies were developed according to the Promoting Action on Research Implementation in Health Services conceptual framework.
Discussion
The implementation of an evidence-based knowledge application program for anxiety and depression in primary care aims to improve the organization and delivery of mental health services. The uptake of evidence to improve the quality of care for common mental disorders in primary care is a complex process that requires careful consideration of the context in which innovations are introduced. The project will provide a close examination of the interplay between evidence, context and facilitation, and contribute to the understanding of factors associated with the process of implementation of interventions in routine care. The implementation of the knowledge application program with a population health perspective is consistent with the priorities set forth in the current mental health care reform in Quebec. Strengthening primary mental health care will lead to a more efficient health care system.
doi:10.1186/1748-5908-8-26
PMCID: PMC3614908  PMID: 23497399
Depression; Anxiety disorders; Primary care; Quality of care; Quality improvement; Mental health care; Quality indicators; Knowledge application
24.  Mental health research and evaluation in multicultural Australia: developing a culture of inclusion 
Introduction
Cultural and linguistic diversity is a core feature of the Australian population and a valued element of national identity. The proportion of the population that will be overseas-born is projected to be 32% by 2050. While a very active process of mental health system reform has been occurring for more than two decades - at national and state and territory levels - the challenges presented by cultural and linguistic diversity have not been effectively met. A key area in which this is particularly an issue is in the collection, analysis and reporting of mental health data that reflect the reality of population diversity. The purpose of this study was to examine: what is known about the mental health of immigrant and refugee communities in Australia; whether Australian mental health research pays adequate attention to the fact of cultural and linguistic diversity in the Australian population; and whether national mental health data collections support evidence-informed mental health policy and practice and mental health reform in multicultural Australia.
Methods
The study consisted of three components – a brief review of what is known about mental health in, and mental health service use by, immigrant and refugee communities; an examination of national data collections to determine the extent to which relevant cultural variables are included in the collections; and an examination of Australian research to determine the extent to which immigrant and refugee communities are included as participants in such research.
Results
The review of Australian research on mental health of immigrant and refugee communities and their patterns of mental health service use generated findings that are highly variable. The work is fragmented and usually small-scale. There are multiple studies of some immigrant and refugee communities and there are no studies of others. Although there is a broadly consistent pattern of lower rates of utilisation of specialist public mental health services by immigrants and refugees the absence of adequate population epidemiological data prevents judgments about whether the observed patterns constitute under-utilisation. There are virtually no data on quality of service outcomes. The examination of national data collections revealed multiple gaps in these data collections. The review of papers published in four key Australian journals to determine whether immigrants and refugees are included in mental health research studies revealed a high rate (9.1%) of specific exclusion from studies (usually due to low English fluency) and a much higher rate of general neglect of the issue of population diversity in study design and reporting.
Conclusions
While there are many positive statements of policy intent in relation to immigrant and refugee communities in national mental health policies and strategies there is virtually no reporting by Commonwealth or State and Territory governments of whether policies that are relevant to immigrant and refugee communities are effectively implemented. It is not possible, on the basis of the data collected, to determine whether immigrant and refugee communities are benefiting from the mental health system reforms that are being actively carried out. The majority of Australian mental health research does not adequately include immigrant and refugee samples. On the basis of the findings of this study eight strategies have been recommended that will contribute to the development of a culture of inclusion of all Australians in the national mental health research enterprise.
doi:10.1186/1752-4458-7-23
PMCID: PMC3852843  PMID: 24093216
25.  Integration of care systems in Portugal: anatomy of recent reforms 
Background
Integrated care is increasingly present in the agenda of policy-makers, health professionals and researchers as a way to improve care services in relation to access, quality, user satisfaction and efficiency. These are overarching objectives of most sectoral reforms. However, health care and social care services and systems are more and more dependent on the performance of each other, imposing the logic of network. Demographic, epidemiologic and cultural changes result in pressure to increase efficiency and efficacy of services and organisations in both sectors and that is why integrated care has become so relevant in the last years.
Methods
We first used concept maps to organise and systematise information that we had gathered through deep literature review in order to set a framework where to base the subsequent work. Then, we interviewed informants at several levels of the health and social care systems and we built a list of major recent reforms addressing integrated care in Portugal. In a third step, we conducted two independent focus groups where those reforms were discussed and evaluated within the context of the concepts and frameworks identified from the literature. Results were confronted and reconciled, giving place to a list of requisites and guidelines that oriented further search for documentation on those reforms.
Results
Several important health reforms are in course in primary and hospital care in Portugal, while a so-called third level of care has been introduced with the launch of the National Network of Long-Term Integrated Care (RNCCI – Rede Nacional de Cuidados Continuados Integrados). The social care sector has itself been a subject of alternative models springing from opposite political orientations. All these changes are having repercussions on the way the systems work with each other as they are leading to ongoing and ill-evaluated reformulations on the way they are governed, financed, structured and operated.
Conclusions
Care integration is not absent from policy-making and implementation endeavour in Portugal. However, recurrent issues seem to be consistently hampering the efforts regarding the integration of care in the country. It is urgent to assess current situation as experienced by those closely involved and directly affected.
PMCID: PMC4113913  PMID: 25114663
care systems integration; health care reform; social care reform; Portugal

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