A Multi-state Digital Initiative in India Aimed at Improving Primary Mental Healthcare Through Planning,Execution,and Gathering Insights

Discussion

This project was funded by a Corporate Social Responsibility grant of the Indian counterpart of a multinational company (the identity of which is withheld at their behest). This company had approached the National Institute of Mental Health and Neurosciences (NIMHANS) in mid-2021 with the intention of donating funds to support the cause of mental health. The second wave of COVID-19 was raging at that time. Moreover, mental health consequences were one of the major fallouts of the COVID-19 pandemic, with lockdowns leading to widespread disruption of daily life, affecting children and older people alike.

Mental health issues paralleled the pandemic, some observed.^1,2 While children were forced to attend online classes, with severe disruption of their play and other outdoor activities, the elderly got stuck in the confines of their homes, restricting their mobility, social networks, including health checkups and morning/evening strolls, all resulting in mental distress.^3,4 Widespread increase in domestic violence, coupled with increased substance abuse, was among the manifestations. ⁵ Another sector that got severely affected was the migrant population, particularly in bigger cities, who got stuck, without proper shelter and resources to sustain and survive even for a week or so. ⁶ Finally, that was the time when digital interventions were taking the upper hand, particularly in mental health. ⁷

On the other hand, NIMHANS has had pioneering experience in telepsychiatry since 2007 and has been implementing digitally driven capacity-building initiatives in states such as Bihar, Uttarakhand, Karnataka, and Chhattisgarh since 2015, particularly in task-shifting approaches to integrate mental health into primary healthcare delivery systems. Some critical lessons already learned included leveraging digital technology to improve skills in carrying out mental health work in primary care settings. Even grassroots community health workers can be engaged meaningfully through digital means (notwithstanding a few barriers), but the uptake is slow and requires sustained mentoring and monitoring. Bottom-up approaches are more effective for adult learning than traditional top-down approaches in training primary healthcare workers. Some changes in both the content and the training modalities are required for relatively better outcomes. For example, clinical training that occurs in real-time in the presence of patients is likely to result in better translation quotients compared to classroom settings. Additionally, the curriculum should be tailored to ground-level realities and not perceived as daunting, as primary healthcare workers are already overburdened. Finally, a couple of administrative aspects: the success of the training initiative will depend on the active involvement of the health administration.^8–11 Their involvement is directly proportional to the amount of success of the initiative. The moment administrative oversight and mentoring support cease, the outputs decline rapidly and dramatically. We had a prior idea about the digital infrastructure that is necessary to mount such a project, the curricula, the screening tools, and other instruments required to engage the primary healthcare workforce were already, as were the monitoring means and other logistic elements, including administrative approvals and mechanisms starting from the highest level to local level health systems.

The Implementation

With the above context in mind, we proposed a capacity-building project that leverages digital expertise to strengthen primary care settings in India, enabling them to deliver mental healthcare more effectively. The same was agreed upon, and to execute the program, a Memorandum of Understanding (MOU) was signed by the authorities. The choice of the states was purposive: Karnataka, Telangana, and Maharashtra were requested by the funders as they have their main offices in these states, while NIMHANS finalized the others. The latter included Bihar, Uttarakhand, Tripura, West Bengal, Kerala, and Goa. We completed the tasks in the nine states mentioned above within the stipulated timeframe. Our outreach to Arunachal Pradesh, Andhra Pradesh, and Jammu and Kashmir did not fructify.

Pillars of our primary healthcare system are three cadres: doctors, nurses (Community Health Officers), and field-level workers (Accredited Social Health Activists {ASHA}). Hence, they were chosen for the project. We started corresponding with the officials of the Health Departments to obtain the necessary approvals. Non-financial MOUs were signed between the states and NIMHANS for executing the project in their respective states. Liaison was established through a state-level point of contact with all district-level officials to obtain details of trainees in each cadre. Later, meetings were held to orient the trainees about the project’s purpose, their roles, the training objectives, and the time commitments required from them. Training timings were fixed based on their convenience. A bottom-up approach was employed, with each session featuring a case-based discussion in addition to covering a specific topic. Only fundamental must-know aspects were covered in a point-of-care format. Following the training, all cadres were provided with 24/7 support through collaborative audio/video consultations, designed to help them resolve clinical dilemmas and navigate challenging scenarios while on the job. This real-time support is like clinical supervision during care delivery. This support was continued until the time the project funding was available. Communications were through WhatsApp groups formed for each district that was engaged. Trainees were encouraged to complete a pre-post questionnaire to assess their knowledge, attitude, and practices, allowing for evaluation of the differences. Additionally, they were required to submit monthly reports detailing the number of mental health cases they had cared for during and after the training. Participants were given certificates as a token of appreciation for partaking/completing the training modules. The project staff comprised a technical team from psychiatry, clinical psychology, psychiatric social work, psychiatric nursing, psychology, social work, and general nursing. They were ably supported by a team of project coordinators who handled the backend preparation, session scheduling, collaboration with the project and accounts sections of NIMHANS, regular communication with trainees, data entry, and numerous other related tasks. Throughout the implementation phase, weekly updates were given to the funders on the progress. One additional point to note: initially, a small pilot was conducted, and the learnings were incorporated before expanding to the states mentioned above.

Finally, an impact evaluation was carried out. As this was not the primary aim, the review was primarily carried out using the available and accrued data from the implementation phase. This supplement comprises papers that analyze this data. Additionally, it includes the results of a practical implementation of hybrid research that was conducted to evaluate the impact of training and supporting primary care doctors in integrating mental healthcare into their day-to-day clinical work. This implementation research was registered with the Clinical Trial Registry of India (CTRI) and was also approved by the Institutional Ethics Committee, NIMHANS. In a nutshell, the program trained more than 42,000 primary healthcare workers across nine states in India, indirectly touching more than 50 million lives, at a training cost of ₹1,145 (approximately $14) per trainee. Further, though the range is wide, there was a 4%–58% increase in prescription practices of psychotropic medications post-training. 5%–43% increase in the practice of educating patients and family regarding mental illness. Primary care doctors improved their skills to diagnose and treat commonly prevalent psychiatric disorders. Patients treated in these settings showed noticeable clinical improvements. Contours of a successful digitally driven training program were identified, along with the implementation challenges, mitigation strategies, and the facilitatory role of implementation partners.

The Insights

This mammoth endeavor was draining, but in the end, enriching and gratifying. Above all, it gave us invaluable lessons, which we have captured to the best of our ability. We share the summary below.

Mental Health is a broad term encompassing not only illnesses but also a state of well-being, comprising the ability to cope with everyday life’s stressors. It is determined by a wide variety of factors, including biological, developmental, psychological, economic, and social. Provision of mental health services, therefore, should encompass preventive and promotive aspects in addition to treatment and rehabilitative components, and as such falls outside the scope of this training program and the supplement. Accordingly, we restrict ourselves to task-shifting approaches, which involve empowering non-specialist health professionals to deliver basic mental health care in the community. Globally, task-shifting is considered the cornerstone for integrating mental healthcare into primary care and as a path for meaningful reduction of the treatment gap.

We believe that the mental health sector requires repeated and relentless efforts, such as these projects, before task-shifting becomes an integral and seamless part of India’s primary healthcare delivery system. This training program, in summary, has demonstrated that digital technologies can be successfully leveraged for task-shifting approaches. In addition to the training, technology can be invaluable in supporting the workforce over extended periods of time, without increasing costs. Additionally, the program provides templates, schedules, formats, curricula, and an evidence base to cover all the above aspects. It also provides a sense of the time commitments required by both trainees and trainers. We believe that if these templates are consistently followed by the states/UTs, we will hopefully become self-sufficient within the next decade or so. This would also be a way of fulfilling states’ obligations as enshrined in the Mental Healthcare Act, 2017. Integrating mental health into primary care is also an accepted way of reducing the burgeoning treatment gap for mental illnesses. This project, in a sense, bolsters this assertion. However, the findings need to be replicated in other settings as well.

If the task-shifting concept is to be sustained and generalized across the country, permanent training systems must be established at the state and Union Territory (UT) levels. NIMHANS Digital Academy (NDA) is a prime example of an institution that, since its inception, has trained more than 175,000 individuals from across the nation in delivering mental healthcare. The NDA offers more than 30 digitally driven courses. ¹² Likewise, similar digital academies can be started within each state and UT. Indeed, Tele MANAS Mentoring Institutes can serve as state-level digital academies to plan, execute, mentor, and monitor the training that is essential and indispensable for the successful and sustained integration of basic mental healthcare into the primary healthcare delivery system.

Currently, the country’s scenario is characterized by the existence of elegant intervention models that have not been widely adopted. The reasons for this are discussed in some articles of the supplement. Our goal is to make interventions generalizable, sustainable, and applicable at grassroots levels. Hence, our partners in capacity-building projects have always been state actors, rather than dedicated project staff. To the best of our knowledge, this program is one of the first of its kind to address multiple states in India simultaneously. Also, the existing public healthcare workforce was trained to deliver services.

Critics may argue about the rigor and purity of the research methods used to conduct the implementation research, thereby questioning the conclusions drawn. From a purely research perspective, this may also be true. However, one issue stands as the strong point of the research initiative. The real-world settings and contexts in which the research occurred make the results more generalizable and practically grounded. Another aspect is the involvement of the public health workforce itself as research participants. Involving dedicated project staff is one of the key factors driving the spectacular successes of many previous intervention models. Still, it also contributes to the failure of those results to become generalizable. Another issue that is close to reality was that mental health work was added to their ongoing responsibilities and not taken up as a dedicated task. We concede, however, that there is no end to the quest toward perfection, and as such, the same must continue. We are open to constructive criticism and are aware that peer acceptance is the way forward and the path for health systems to implement the findings across the length and breadth of our vast country.

Our gratitude is due to several individuals and institutions, in addition to the funding agency. Dr. Satish Chandra Girimaji (Director, NIMHANS during the start of this project) entrusted the responsibility to our team. Dr. Pratima Murthy (Dr. Girimaji’s successor), for her constant guidance and support, and for her help in navigating all the complexities involved in executing a project of this magnitude and scope. The project and accounts sections of NIMHANS, which were responsible for project management, were both headed by the Registrar, NIMHANS. The legal section of NIMHANS assisted us in clearing and approving all the MOUs by ensuring they conformed to the prescribed formalities. Gratitude is also due to administrators at the state-level and district-level health administrators who steered the initiative. District-level health administrators are the immediate administrative supervisors of primary care workers, and the integration of mental healthcare into general healthcare in primary settings will never be a reality without this sustained local leadership. Indeed, in our considered opinion, local leadership is one of the most pressing needs for the Indian Mental Health Scene to leapfrog into the next level. Next, all cadres of primary healthcare workers, including doctors, Community Health Officers, and field-level workers (ASHAs), will be involved as trainees. It is worth noting that these ground-level professionals are often overburdened with multiple responsibilities and deserve our commendation for undertaking this mental health training task without any additional incentive. Though the overall participation was far from ideal, as indicated in multiple places in the supplement, this eventuality is multifactorial and requires serious attention from several stakeholders. We also owe a great deal to the project staff, who were specifically hired to implement the program. They demonstrated immense commitment, a strong sense of team spirit, and exceptional focus on completing tasks on time. Apart from training (which was their primary responsibility), they did several other things, including coordinating with the project section and account section, liaising with the funding agency every week, updating them about the project progress and clarifying their doubts, preparing timely reports by carefully documenting the progress on a day-to-day basis, collecting data for research, and analyzing them. Without the team effort, this work would not have been possible.

Conclusions

This article provides valuable insights into the experiences and lessons learnt from implementing a multi-state mental health capacity-building program for primary healthcare providers in India. It outlines the program's journey, from its initial conception through the planning phase to execution. It also highlights the research opportunities generated from the accrued data. It ends by discussing the broader implications of such capacity-building programs for public mental health care in India.