Epidemiology and Mental Health Policy, WHO Collaborating Centre (Mental Health), Institute of Psychiatry, King's College London, London, UK.
BMC Health Serv Res. 2013 Sep 30;13:368. doi: 10.1186/1472-6963-13-368.
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.
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).
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.
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 ISRCTN 53515024.
非洲的卫生系统存在诸多弱点，这严重制约了其在降低传染性和非传染性疾病负担方面的进展（《非洲卫生监测》特刊，2011 年，第 14-24 页），领导层、治理、卫生人力、医药产品、疫苗和技术、信息、财政和服务提供等方面的主要挑战也已得到充分描述（《国际医学档案》，2008 年，第 1 期：27）。本文采用焦点小组方法，探讨了卫生工作者对普遍存在的卫生系统薄弱环节对将精神卫生纳入初级保健带来的挑战的看法。
在肯尼亚贫困的农业区纳安萨省进行了两次 90 分钟的焦点小组讨论，参与者是从评估初级保健精神卫生培训方案影响的随机对照试验中抽取的 20 名卫生工作者，10 名来自接受培训的干预组诊所，10 名来自未接受培训的对照组诊所。
这些焦点小组讨论表明，肯尼亚存在一些普遍的卫生系统薄弱环节，影响了卫生工作者照顾有精神卫生问题的患者的能力，也影响了他们实施精神卫生继续教育方案中学到的新技能。这些薄弱环节包括药品供应、卫生管理信息系统、对初级保健诊所的区一级监督、国家卫生部门目标中对精神卫生的重视程度较低，特别是在区一级目标中缺失，导致精神卫生被排除在现有区一级监督之外，以及区管理团队对精神卫生的认识不足。卫生工作者还表示，在艾滋病毒培训课程中没有涵盖精神卫生内容，这一点也很突出，在区一级监督中过于注重艾滋病毒，而忽视了其他卫生问题。
肯尼亚普遍存在的卫生系统薄弱环节影响了将精神卫生横向纳入常规初级保健实践的努力，使卫生工作者的努力受到极大挫折。改善药品供应、信息系统、明确将精神卫生纳入区一级目标、管理和监督初级保健，很可能会极大地提高初级保健工作者的效率，并使新获得的技能在实际中得到更好的应用。将精神卫生纳入卫生系统的一个主要手段是将精神卫生纳入社区、初级保健和区各级的国家卫生部门改革战略，而不仅仅是在省和国家更高一级，从而使区一级对初级保健的支持性监督成为常规做法，而不是非常稀缺的活动。
试验注册号 ISRCTN53515024。
