Bibhav Acharya

Crossing the quality chasm in resource-limited settings.

Over the last decade, extensive scientific and policy innovations have begun to reduce the “quality chasm” - the gulf between best practices and actual implementation that exists in resource-rich medical settings. While limited data exist, this chasm is likely to be equally acute and deadly in resource-limited areas. While health systems have begun to be scaled up in impoverished areas, scale-up is just the foundation necessary to deliver effective healthcare to the poor. This perspective piece describes a vision for a global quality improvement movement in resource-limited areas. The following action items are a first step toward achieving this vision: 1) revise global health investment mechanisms to value quality; 2) enhance human resources for improving health systems quality; 3) scale up data capacity; 4) deepen community accountability and engagement initiatives; 5) implement evidence-based quality improvement programs; 6) develop an implementation science research agenda.

Partnerships in mental healthcare service delivery in low-resource settings: developing an innovative network in rural Nepal

BackgroundMental illnesses are the largest contributors to the global burden of non-communicable diseases. However, there is extremely limited access to high quality, culturally-sensitive, and contextually-appropriate mental healthcare services. This situation persists despite the availability of interventions with proven efficacy to improve patient outcomes. A partnerships network is necessary for successful program adaptation and implementation.Partnerships networkWe describe our partnerships network as a case example that addresses challenges in delivering mental healthcare and which can serve as a model for similar settings. Our perspectives are informed from integrating mental healthcare services within a rural public hospital in Nepal. Our approach includes training and supervising generalist health workers by off-site psychiatrists. This is made possible by complementing the strengths and weaknesses of the various groups involved: the public sector, a non-profit organization that provides general healthcare services and one that specializes in mental health, a community advisory board, academic centers in high- and low-income countries, and bicultural professionals from the diaspora community.ConclusionsWe propose a partnerships model to assist implementation of promising programs to expand access to mental healthcare in low- resource settings. We describe the success and limitations of our current partners in a mental health program in rural Nepal.

The Mental Health Education Gap among Primary Care Providers in Rural Nepal

ObjectiveIn low- and middle-income countries, the majority of individuals with mental illness go untreated largely because of a severe shortage of mental health professionals. Global initiatives to close the mental health treatment gap focus on primary care providers delivering this care. For this to be effective, primary care providers require the skills to assess, diagnose, and treat patients with mental illness.MethodsTo assess primary care providers’ training and experience in caring for mental health patients, the authors conducted five focus groups at three isolated district hospitals in rural Nepal where there was no access to mental health professionals.ResultsPrimary care providers reported limited training, lack of knowledge and skills, and discomfort in delivering mental health care.ConclusionTo address the mental health education gap, primary care providers in Nepal, and perhaps other low- and middle-income countries, require more training during both undergraduate and graduate medical education.

Global health delivery 2.0: using open-access technologies for transparency and operations research.

Duncan Maru and colleagues at Nyaya Health describe several simple Web 2.0 strategies they have implemented during the course of delivering medical and public health services in rural Nepal.

Collaborative Care for Mental Health in Low- and Middle-Income Countries: A WHO Health Systems Framework Assessment of Three Programs

The collaborative care model is an evidence-based intervention for behavioral and other chronic conditions that has the potential to address the large burden of mental illness globally. Using the World Health Organization Health Systems Framework, the authors present challenges in implementing this model in low- and middle-income countries (LMICs) and discuss strategies to address these challenges based on experiences with three large-scale programs: an implementation research study in a district-level government hospital in rural Nepal, one clinical trial in 50 primary health centers in rural India, and one study in four diabetes clinics in India. Several strategies can be utilized to address implementation challenges and enhance scalability in LMICs, including mobilizing community resources, engaging in advocacy, and strengthening the overall health care delivery system.

Developing a scalable training model in global mental health: pilot study of a video-assisted training Program for Generalist Clinicians in Rural Nepal

Background. In low- and middle-income countries, mental health training often includes sending few generalist clinicians to specialist-led programs for several weeks. Our objective is to develop and test a video-assisted training model addressing the shortcomings of traditional programs that affect scalability: failing to train all clinicians, disrupting clinical services, and depending on specialists. Methods. We implemented the program -video lectures and on-site skills training- for all clinicians at a rural Nepali hospital. We used Wilcoxon signed-rank tests to evaluate pre- and post-test change in knowledge (diagnostic criteria, differential diagnosis, and appropriate treatment). We used a series of ‘Yes’ or ‘No’ questions to assess attitudes about mental illness, and utilized exact McNemars test to analyze the proportions of participants who held a specific belief before and after the training. We assessed acceptability and feasibility through key informant interviews and structured feedback. Results. For each topic except depression, there was a statistically significant increase (Δ) in median scores on knowledge questionnaires: Acute Stress Reaction (Δ = 20, p = 0.03), Depression (Δ = 11, p = 0.12), Grief (Δ = 40, p < 0.01), Psychosis (Δ = 22, p = 0.01), and post-traumatic stress disorder (Δ = 20, p = 0.01). The training received high ratings; key informants shared examples and views about the trainings positive impact and complementary nature of the programs components. Conclusion. Video lectures and on-site skills training can address the limitations of a conventional training model while being acceptable, feasible, and impactful toward improving knowledge and attitudes of the participants.

Power, potential, and pitfalls in global health academic partnerships: review and reflections on an approach in Nepal

ABSTRACT Background: Global health academic partnerships are centered around a core tension: they often mirror or reproduce the very cross-national inequities they seek to alleviate. On the one hand, they risk worsening power dynamics that perpetuate health disparities; on the other, they form an essential response to the need for healthcare resources to reach marginalized populations across the globe. Objectives: This study characterizes the broader landscape of global health academic partnerships, including challenges to developing ethical, equitable, and sustainable models. It then lays out guiding principles of the specific partnership approach, and considers how lessons learned might be applied in other resource-limited settings. Methods: The experience of a partnership between the Ministry of Health in Nepal, the non-profit healthcare provider Possible, and the Health Equity Action and Leadership Initiative at the University of California, San Francisco School of Medicine was reviewed. The quality and effectiveness of the partnership was assessed using the Tropical Health and Education Trust Principles of Partnership framework. Results: Various strategies can be taken by partnerships to better align the perspectives of patients and public sector providers with those of expatriate physicians. Actions can also be taken to bring greater equity to the wealth and power gaps inherent within global health academic partnerships. Conclusions: This study provides recommendations gleaned from the analysis, with an aim towards both future refinement of the partnership and broader applications of its lessons and principles. It specifically highlights the importance of targeted engagements with academic medical centers and the need for efficient organizational work-flow practices. It considers how to both prioritize national and host institution goals, and meet the career development needs of global health clinicians.

Including International Medical Graduates in Global Mental Health Training.

To the Editor: As academic departments continue to develop programs in global mental health (GMH), we want to describe our experiences in University of California San Francisco (UCSF) and Nepal to highlight the importance of collaborating with international medical graduates (IMGs). The training and practice of GMH requires an understanding of local languages and cultures. Trainees and junior faculty in high-income countries (HICs) interested in GMH may not speak the local language and may not be familiar with the cultural nuances at the sites in lowand middle-income countries (LMICs). This can lead to challenges ranging from trainees feeling frustrated or worried about their overall impact to some trainees avoiding GMH experiences altogether. Training programs have traditionally responded to this by creating coursework in cultural competency and asking the local site to provide translators and bilingual mentors. This response has substantial shortcomings. First, cultural “competency” cannot be mastered via didactics but needs to be constantly revisited with humility and ongoing guidance. Second, relying on local resources for translation and cross-cultural navigation burdens the host site where bilingual personnel are often busy clinicians. A largely overlooked partnership to address these shortcomings is engaging IMGs and physicians who are in training or practice in high-income countries after having completed medical school abroad. A GMH program at UCSF Department of Psychiatry involves studying the effectiveness of non-specialist health professionals in providing mental health care in Nepal. This requires expertise in developing, implementing, and assessing a curriculum for the health workers. In each step, cultural, linguistic, and systems-level understanding of the learners (Nepali health professionals) is critical. Our partner IMGs from Shared Minds, a non-profit organization, play a critical role in the success of our GMH program by adapting training for Nepal-based learners and by acting as consultants for USbased trainees interested in working in Nepal. IMGs often straddle the two worlds of LMICs and HICs, are bilingual, and understand the host site’s culture in a way that allows them to provide ongoing mentorship for trainees. Combining this with their expertise in clinical knowledge, IMGs from Shared Minds have helped create culturally appropriate training materials for the GMH program by incorporating typical patient presentations, local idioms of distress, culturally appropriate criteria to describe “impaired function,” and contextually credible standardized patient cases [1]. The training materials include Nepali translations of protocols from the World Health Organization and lecture videos narrated in Nepali. IMGs’ awareness of the pressing needs of the site has helped define priorities for the program. They have a deep understanding of the medical system in Nepal and have allowed our department to navigate sensitive issues like professional and institutional rivalries, and identify reliable sites to maintain a lasting partnership. The materials developed by this program are now being incorporated into mental health training for hundreds of health workers in the earthquake-affected regions in Nepal. Additionally, IMGs from Shared Minds * Bibhav Acharya bibhav.acharya@ucsf.edu

Developing and deploying a community healthcare worker-driven, digitally- enabled integrated care system for municipalities in rural Nepal

Integrating care at the home and facility level is a critical yet neglected function of healthcare delivery systems. There are few examples in practice or in the academic literature of affordable, digitally-enabled integrated care approaches embedded within healthcare delivery systems in low- and middle-income countries. Simultaneous advances in affordable digital technologies and community healthcare workers offer an opportunity to address this challenge. We describe the development of an integrated care system involving community healthcare worker networks that utilize a home-to-facility electronic health record platform for rural municipalities in Nepal. Key aspects of our approach of relevance to a global audience include: community healthcare workers continuously engaging with populations through household visits every three months; community healthcare workers using digital tools during the routine course of clinical care; individual and population-level data generated routinely being utilized for program improvement; and being responsive to privacy, security, and human rights concerns. We discuss implementation, lessons learned, challenges, and opportunities for future directions in integrated care delivery systems.

Translating mental health diagnostic and symptom terminology to train health workers and engage patients in cross-cultural, non-English speaking populations

Although there are guidelines for transcultural adaptation and validation of psychometric tools, similar resources do not exist for translation of diagnostic and symptom terminology used by health professionals to communicate with one another, their patients, and the public. The issue of translation is particularly salient when working with underserved, non-English speaking populations in high-income countries and low- and middle-income countries. As clinicians, researchers, and educators working in cross-cultural settings, we present four recommendations to avoid common pitfalls in these settings. We demonstrate the need for: (1) harmonization of terminology among clinicians, educators of health professionals, and health policymakers; (2) distinction in terminology used among health professionals and that used for communication with patients, families, and the lay public; (3) linkage of symptom assessment with functional assessment; and (4) establishment of a culture of evaluating communication and terminology for continued improvement.