SAINT TONIS COLLEGE, INC.

United Church of Christ in the Philippines

Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING

MENTAL HEALTH GAP ACTION PROGRAM

(mhGAP)
“What mental health needs is more sunlight, more candor, and more unashamed
conversation.”
– Glenn Close.
SCALINGUP CARE FOR MENTAL, NEUROLOGICAL AND SUBSTANCE USE
DISORDERS

Health:
Health is a state of complete physical, mental and social well-being and not merely
the absence of disease or infirmity. – WHO
-the state of being free from illness or injury. OXFORD DICTIONARY
The WHO, health is important in mental health

Mental Health:
“Mental health is a state of well-being in which an individual realizes his or her own
abilities, can cope with the normal stresses of life, can work productively, and is
able to make a contribution to his or her community.” - WHO
Mental health refers to cognitive, behavioral, and emotional well-being. It is all
about how people think, feel, and behave. People sometimes use the term “mental
health” to mean the absence of a mental disorder. – MEDICAL NEWS TODAY
Crucial to the overall well-being and related to the development countries.

Mental, neurological, and substance use disorders are common in all regions of the world,
affecting every community and age group across all income countries. While 14% of the global
burden of disease is attributed to these disorders, most of the people affected - 75% in many low-
income countries - do not have access to the treatment they need.

The MENTAL HEALTH GAP ACTION PROGRAM

 The WHO Mental Health Gap Action Program (mhGAP) aims at scaling up services
for mental, neurological and substance use disorders for countries especially with
low- and middle-income. The program asserts that with proper care, psychosocial
assistance and medication, tens of millions could be treated for depression,
schizophrenia, and epilepsy, prevented from suicide and begin to lead normal lives–
even where resources are scarce.
 Mental, neurological and substance use (MNS) disorders are highly prevalent,
accounting for a substantial burden disease and disability globally. In order to bridge
the gap between available resources and the significant need, the World Health

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

1
TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
Organization launched Mental Health Gap Action Programme(mhGAP). The
objectibe of mhGAP is to scale-up care and services using evidence-based
interventions for prevention and management of priority MNS conditions.
 In 2008, WHO launched the mental health gap action programme (mhGAP) in
response to the wide gap between the resources available and the resources urgently
needed to address the large burden of mental, neurological, and substance use
disorders globally.
 The prgogramme was endorsed in 2002 by the 55th World Health Assembly
 Through the MhGap, WHO aims to provide health planners, policy makers, and
donors with a set of clear and coherent activities and programmes for scaling up
care.
 Why is mhGAP important?
 Purpose of mhGAP-IG adaptation
 To clarify referral pathways.
 To make materials consistent with relevant national treatment
guidelines and policies, as appropriate.
 To provide a basis for the development of appropriate training
programmes and tools
 Who can use mhGAP?
 It is for use by doctors, nurses, other health workers as well as health
planners and managers. The Intervention Guide presents the integrated
management of priority MNS conditions using algorithms for clinical
decision making.

OBJECTIVES OF MHGAP:
The development of the mental health action programme (mhGAP) reflects WHO’s commitment
to closing this gap by scaling up care for mental health and substance use disorders. The key
objectives of the action programme are:
 To reinforce the commitment of governments, international organizations, and other
stakeholders to increase the allocation of financial and human resources for care of
mental health substance use disorders.
 To achieve much higher coverage with key interventions in the countries with low
and lower middle incomes that have a large proportion of the global burden of
mental health and substance use disorders.

 Through these objectives, MHGAP provides evidenced-based guidance and tools to

advance toward achieving the targets of the mental health action plan 2013-2020.

 Its vision is to provide effective and humane care for all people with mental, neurological
and substance use disorders with the particular focus on the poor and the vulnerable one’s
in low and middle-income countries by providing service delivery, reducing the treatment
gap and increasing financial and human resources for mental health care.

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

2
TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
STRATEGIES

This programme is grounded on the best available scientific and epidemiological evidence on
priority conditions. It attempts to deliver an integrated package of interventions, and takes into
account existing and possible barriers to scaling up care.

PRIORITY CONDITIONS
 A disease area can be considered a priority if it represents a large burden (in terms of
mortality, morbidity or disability), has high economic costs, or is associated with
violations of human rights.
 The area of mental, neurological and substance use consists of a large number of
conditions. The priority conditions identified by the above criteria for mhGAP are
depression, schizophrenia and other psychotic disorders, suicide, epilepsy, dementia,
disorders due to use of alcohol, disorders due to use of illicit drugs, and mental disorders
in children. These disorders are common in all countries where their prevalence has been
examined, and they substantially interfere with the abilities of children to learn and with
the abilities of adults to function in their families, at work, and in broader society.
Because they are highly prevalent and persistent, and cause impairment, they make a
major contribution to the total burden of disease. Disability is responsible for most of the
burden attributable to these disorders; however, premature mortality – especially from
suicide – is also substantial. The economic burden imposed by these disorders, includes
loss of gainful employment, with the attendant loss of family income; the requirement for
caregiving, with further potential loss of wages; the cost of medicines; and the need for
other medical and social services. These costs are particularly devastating for poor
populations. Annex 1 summarizes the burden created by these disorders and the links
with other diseases and sectors. Moreover, MNS disorders are stigmatized in many
countries and cultures.
 Stigmatization has resulted in disparities in the availability of care, discrimination and in
abuses of the human rights of people with these disorders.

INTERVENTION PACKAGE
 Considerable information about the cost effectiveness of various interventions for
reduction of the burden of MNS disorders is now available. Although it is useful to
determine which interventions are cost effective for a particular set of disorders, this is
not the end of the process. Other criteria need to be considered in decisions about which
interventions to deliver, such as the severity of different disorders (in terms of suffering
and disability), the potential for reduction of poverty in people with different disorders,
and the protection of the human rights of those with severe MNS disorders.

 The package consists of interventions for prevention and management for each of the
priority conditions, on the basis of evidence about the effectiveness and feasibility of
scaling up these interventions. In this context, an intervention is defined as an agent or
action (biological, psychological, or social) that is intended to reduce morbidity or

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

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TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
mortality. The interventions could be directed at individuals or populations, and were
identified on the basis of their efficacy and effectiveness, cost effectiveness, equity,
ethical considerations including human rights, feasibility or deliverability, and
acceptability.

 Interventions cannot be provided as freestanding activities, but should instead be

delivered in a variety of packages and through different levels of a health system.
Delivery of interventions as packages has many advantages, and is the most cost-
effective option in terms of training, implementation, and supervision. Many
interventions go naturally together because they can be delivered by the same person at
the same time – e.g. antipsychotics, and family and community interventions for
treatment of schizophrenia.

Table 1Evidence-based interventions to address the priority conditions

Condition Evidence-based Examples of interventions to be
interventions included in the package
Depression Treatment with Treatment with older or newer
antidepressant medicines antidepressants by trained primary health-
Psychosocial interventions care professionals.
Psychosocial interventions such as
cognitive behaviour therapy or problem
solving.
Referral and supervisory support by
specialists.
Schizophrenia Treatment with antipsychotic Treatment with older antipsychotics by
and other medicines trained primary health-care professional
psychotic Family or community within community setting.
disorders psychosocial interventions Community-based rehabilitation.
Referral and supervisory support by
specialists.
Suicide Restriction of access to Multisectoral measures that relate to
common methods of suicide public health, such as restriction of
Prevention and treatment of availability of most toxic pesticides, and
depression, and alcohol and storage of supplies in secure facilities.
drug dependence See examples of interventions for
depression, disorders due to use of

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

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TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
alcohol, and disorders due to use of illicit
drugs.
Epilepsy Identification and treatment Treatment with first-line antiepileptic
with antiepileptic medicines medicines by trained primary health-care
professionals.
Referral and supervisory support by
specialists.
Dementia Interventions directed Basic education about dementia and
towards caregivers specific training on management of
problem behaviours by trained primary
health-care professionals.
Disorders due to Comprehensive policy Policy and legislative interventions
use of alcohol measures aimed at reduction including regulation of availability of
of harmful use of alcohol alcohol, enactment of appropriate drink-
Interventions for hazardous driving policies, and reduction of the
drinking and treatment of demand for alcohol through taxation and
alcohol use disorders with pricing mechanisms.
pharmacological and Screening and brief interventions by
psychosocial interventions trained primary health-care professionals.
Early identification and treatment of
alcohol use disorders in primary health
care.
Referral and supervisory support by
specialists.
Disorders due to Pharmacological and Psychosocially assisted pharmacotherapy
illicit drug use psychosocial interventions, of opioid dependence using opioid
including agonist agonists such as methadone or
maintenance treatment for buprenorphine.
opioid dependence Early identification and provision of
prevention and treatment interventions for
drug use disorders by trained primary
health-care professionals.
Referral and supervisory support by
specialists.
Mental Prevention of developmental Measures within health sector such as
disorders in disorders provision of skilled care at birth, effective
children Pharmacological and community-based services for maternal
psychosocial interventions and child health care, prenatal screening
for Down’s syndrome, and prevention of
alcohol abuse by mothers.
Multisectoral measures that relate to
public health such as fortification of food
with iodine and folic acid, and

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

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TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
interventions to reduce child abuse.
Identification and initial care in primary
health-care settings.
Referral and supervisory support by
specialists.
 This template will need to be adapted for countries or regions on the basis of the
prevalence and burden of each of the priority conditions; evidence about efficacy,
feasibility, cost, and acceptability of the interventions in specific contexts; health system
requirements for implementation (including financial and human resource implications);
and cultural choices, beliefs, and health-seeking behaviours in specific communities. The
priorities and the methods used will inevitably vary between settings. Thus the
intervention packages and the delivery of the packages might differ between countries,
and even between different areas in the same country. For example, in many low-income
countries, more than three quarters of the population live in rural areas. Few services,
including human resources, reach such areas. The shortage of human resources thus
demands pragmatic solutions. Community workers – after specific training and with
necessary back-up, e.g. phone consultations with general practitioners – can deliver some
of the priority interventions

IDENTIFICATION OF COUNTRIES FOR INTENSIFIED SUPPORT

 Most of the global burden of mental, neurological, and substance use disorders occurs in
countries with low and lower middle incomes.
 These countries not only have the highest need to tackle this burden but also the fewest
resources available to do so.
 The conceptual principle of mhGAP is that since a small number of low-income and
lower middle-income countries contribute most to the global burden, and have
comparatively few human and financial resources, a strategy that focuses on mental
health care in these countries has the potential for maximum impact. mhGAP thus aims to
provide criteria to identify the countries with low and lower middle incomes which have
the largest burdens of MNS disorders and the highest resource gap, and to provide them
with intensified support. It should be noted, however, that the framework mhGAP
provides for country action is adaptable and can be used in any country where the
possibility for technical support exists. Therefore, this process does not mean denial of
support to other countries.
 Selection of countries for intensified support could use many criteria. One criterion could
be the burden of MNS disorders. The approach used in the Global Burden of Disease
project was to use DALYs as a summary measure of population health across disease and
risk categories. For example, total DALYs can be used as a measure of disease burden to
identify the countries with low and lower middle incomes which have the highest burdens
of priority conditions. DALYs per 100 000 populations can also be used to measure
disease burden. This criterion is useful to ensure that countries with small populations but

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

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TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
high rates of MNS burdens are included. Another criterion could be gross national
income (GNI) per capita, which is indicative of the relative poverty of countries.
 Another criterion could be the country’s readiness for scaling up. Although “hard”
indicators to measure a country’s readiness do not exist, “soft” indicators could include
any request for support from the country for scaling up activities in the area of MNS
disorders; any previous or ongoing collaboration between WHO and the country; or any
donor interest.

SCALLING UP
 Scaling up is defined as a deliberate effort to increase the impact of health-service
interventions that have been successfully tested in pilot projects so that they will benefit
more people, and to foster sustainable development of policies and programmes.
 However, pilot or experimental projects are of little value until they are scaled up to
generate a larger policy and programme impact. Until now, practical guidance about how
to proceed with scaling up has been inadequate.
 mhGAP aims to identify general approaches and specific recommendations for the
process of scaling up.

 Scaling up involves the following tasks:

o identification of a set of interventions and strategies for health-service delivery, and

planning of a sequence for adoption of these actions and of the pace at which
interventions can be implemented and services expanded;
o consideration of obstacles that hinder the widespread implementation of the selected
interventions, and the options that are available to deal with these obstacles; and
o assessment of the total costs of scaling up and sustaining interventions in a range of
generalizable scenarios.
These tasks require a clear understanding of the type and depth of constraints that affect a
country’s health system. Such constraints could operate at different levels, such as
community and household, health-service delivery, health-sector policy and strategic
management, cross-sectoral public policies, and environment and context.

BARRIERS TO DEVELOPMENT OF MENTAL HEALTH SERVICES

 The greatest barrier to development of mental health services has been the absence of
mental health from the public health priority agenda. This has serious implications for
financing mental health care, since governments have allocated meagre amounts for
mental health within their health budgets, and donor interest has been lacking.

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

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TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
 Another barrier identified was organization of services. Mental health resources are
centralized in and near big cities and in large institutions. Such institutions frequently use
a large proportion of scarce mental health resources; isolate people from vital family and
community support systems; cost more than care in the community; and are associated
with undignified life conditions, violations of human rights, and stigma. However, both
downsizing mental hospitals and making care available in the community will entail
challenges.
 The third barrier to development of mental health services, which relates to organization
of services, is the complexity of integrating mental health care effectively with primary
care services. The systems that provide primary health care are overburdened; they have
multiple tasks and high patient loads, little supervision and few functional referral
systems, and a discontinuous supply of essential medicines. Limitations in human
resources also contribute to this barrier, because low numbers and types of health
professionals have been trained and supervised in mental health care.
 Finally, a major barrier is likely to be the lack of effective public health leadership for
mental health in most countries.

Framework for country action

 mhGAP aims to provide a framework for scaling up interventions.
 The framework takes into account the various constraints existing in different countries.
 It is only intended as a guide for action, and should be flexible and adaptable enough to
be implemented according to the different situation

Political commitment
 first and foremost.
 acquisition of the necessary human and financial resources
 establish a core group of key stakeholders expertise to guide the process.
 Key stakeholders
o policy-makers,
o programme managers from relevant areas (such as essential medicines and
human resources),
o communication experts,
o and experts from community development
o and health systems.
o
Assessment of needs and resources
 A situation analysis -understanding of the needs and effective prioritization and phasing
of interventions and strengthening their implementation
 Tasks
o Describe the status of the burden of MNS ,resource requirements
o Examine the coverage and quality of essential interventions, reasons for low or
ineffective coverage;

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

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TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
o Synthesize the information to highlight important gaps that must be addressed for
scaling up care
o SWOT analysis
Development of a policy and legislative infrastructure
 Define a vision for the future health of the population, and specify the framework to
manage and prevent these disorders
 The Mental Health Policy and Service Guidance Package Resource Book on Mental
Health, Human Rights and Legislation
 Practical, interrelated modules, designed to address issues related to the reform of mental
health systems.
This Guidance Package - framework to assist & create policies and plans, to put them into
practice.

Actions required:
 Draft or revise policy to set out its vision, values, and principles, its objectives, and key
areas for action;
 Incorporate existing knowledge about improvement of treatment and care and prevention
of these disorders;
 Involve all relevant stakeholders;
 Develop means for implementation of the policy

Delivery of the intervention package

 Critical to ensure maximum impact, high quality, and equitable coverage of the
interventions.
 This depends on the capacity of services & available resources
 Key considerations for delivery of services include:
• Design for implementing interventions at different levels of the health system;
• Integration into existing services; strengthening of health system
• Implementation strategies to achieve high coverage strategies to reach populations with
special needs &special situations, such as emergencies

Integration at primary health care.

1. enable the largest number of people to get easier and faster access to services
2. gives better care;
3. it also cuts wastage.
 Health systems will need additional support to deliver the interventions. (The drugs,
equipment, and supplies) & their sustained supply.
 Appropriate referral pathways and feedback mechanisms between all levels of service
delivery will need to be strengthened

Strengthening of human resources

 Adequate and appropriate training

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

9
TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
 These conditions relies heavily on health personnel rather than on technology or
equipment
 The goal– to get the right workers with the right skills in the right place doing the right
things

 Key actions include:

o Appropriate training of different cadres of health professionals
o Improvement of access to information and knowledge
o Development of simpler diagnostic and treatment tools

Mobilization of financial resources

 Most countries do not assign adequate financial resources for care of MNS disorders ;no
specific budget
 Health budgets need to be increased and re allocated
 External funding
 Institutionally based models of care need to be replaced by community-based care
 More evidence-based interventions need to be introduced.

Monitoring and evaluation

  The scope of monitoring and evaluation reflects the scope of the implementation plan
 Each country will need to decide which indicators to measure and for what purpose;
when and where to measure them; how to measure them; and which data sources to use
FRAME WORK FOR MEASUREMENT OF HEALTH INFORMATION

Building partnerships

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

10
TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE
 SAINT TONIS COLLEGE, INC.
United Church of Christ in the Philippines
Purok 4, Bulanao Centro, Tabuk City, Kalinga
Philippines 3800
Tel. No. (074) 627-5930, Email Address: sainttoniscollege@[Link]
COLLEGE OF NURSING
 Fundamental to mhGAP is the establishment of productive partnerships – i.e. to reinforce
existing partners, attract and energize new partners, accelerate efforts, and increase
investments to reduce the burden of these disorders.
 WHO - lead technical agency
 guidelines were developed by 27 agencies and have been endorsed by the IASC(inter
agency standing committee) along with UN agencies, intergovernmental organizations,
Red Cross and Red Crescent agencies, and large consortia of NGOs
 UN agencies – e.g. UNICEF
 Government ministries The pacific island mental health network  NGOs and other
collaborating agencies
 ILAE,IBE – Global campaign against epilepsy
 Civil society
 Eg : Global forum for community health

MENTAL HEALTH GAP ACTION PROGRAM (mhGAP)

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TEAM SOYOSOY DI DAGEM
BACHELOR OF SCIENCE IN NURSING II-B
COMMUNITY HEALTH NURSING LECTURE