Barriers preventing the successful integration of mental health services into Primary Health Care in Nigeria : a mixed methods approach

RESUMO: A Nigéria tem uma população estimada em cerca de 170 milhões de pessoas. O número de profissionais de saúde mental é muito diminuto, contando apenas com 150 psiquiatras o que perfaz aproximadamente um rácio de psiquiatra: população de mais de 1:1 milhão de pessoas. O Plano Nacional de Saúde Mental de 1991 reconheceu esta insuficiência e recomendou a integração dos serviços de saúde mental nos cuidados de saúde primários (CSP). Depois de mais de duas décadas, essa política não foi ainda implementada. Este estudo teve como objetivos mapear a estrutura organizacional dos serviços de saúde mental da Nigéria, e explorar os desafios e barreiras que impedem a integração bem-sucedida dos serviços de saúde mental nos cuidados de saúde primários, isto segundo a perspectiva dos profissionais dos cuidados de saúde primários. Com este objetivo, desenvolveu-se um estudo exploratório sequencial e utilizou-se um modelo misto para a recolha de dados. A aplicação em simultâneo de abordagens qualitativas e quantitativas permitiram compreender os problemas relacionados com a integração dos serviços de saúde mental nos CSP na Nigéria. No estudo qualitativo inicial, foram realizadas entrevistas com listagens abertas a 30 profissionais dos CSP, seguidas de dois grupos focais com profissionais dos CSP de duas zonas governamentais do estado de Oyo de forma a obter uma visão global das perspectivas destes profissionais locais sobre os desafios e barreiras que impedem uma integração bem-sucedida dos serviços de saúde mental nos CSP. Subsequentemente, foram realizadas entrevistas com quatro pessoas-chave, especificamente coordenadores e especialistas em saúde mental. Os resultados do estudo qualitativo foram utilizados para desenvolver um questionário para análise quantitativa das opiniões de uma amostra maior e mais representativa dos profissionais dos CSP do Estado de Oyo, bem como de duas zonas governamentais locais do Estado de Osun. As barreiras mais comummente identificadas a partir deste estudo incluem o estigma e os preconceitos sobre a doença mental, a formação inadequada dos profissionais dos CPS sobre saúde mental, a perceção pela equipa dos CSP de baixa prioridade de ação do Governo, o medo da agressão e violência pela equipa dos CSP, bem como a falta de disponibilidade de fármacos. As recomendações para superar estes desafios incluem a melhoria sustentada dos esforços da advocacia à saúde mental que vise uma maior valorização e apoio governamental, a formação e treino organizados dos profissionais dos cuidados primários, a criação de redes de referência e de apoio com instituições terciárias adjacentes, e o engajamento da comunidade para melhorar o acesso aos serviços e à reabilitação, pelas pessoas com doença mental. Estes resultados fornecem indicações úteis sobre a perceção das barreiras para a integração bem sucedida dos serviços de saúde mental nos CSP, enquanto se recomenda uma abordagem holística e abrangente. Esta informação pode orientar as futuras tentativas de implementação da integração dos serviços de saúde mental nos cuidados primários na Nigéria.------------ABSTRACT: Nigeria has an estimated population of about 170 million people but the number of mental health professionals is very small, with about 150 psychiatrists. This roughly translates to a psychiatrist:population ratio of more than 1:1 million people. The National Mental Health Policy of 1991 recognized this deficiency and recommended the integration of mental health into primary health care (PHC) delivery system. After more than two decades, this policy has yet to be implemented. This study aimed to map out the organizational structure of the mental health systems in Nigeria, and to explore the challenges and barriers preventing the successful integration of mental health into primary health care, from the perspective of the primary health care workers. A mixed methods exploratory sequential study design was employed, which entails the use of sequential timing in the combined methods of data collection. A combination of qualitative and uantitative approaches in sequence, were utilized to understand the problems of mental health services integration into PHC in Nigeria. The initial qualitative phase utilized free listing interviews with 30 PHC workers, followed by two focus group discussions with primary care workers from two Local Government Areas (LGA) of Oyo State to gain useful insight into the local perspectives of PHC workers about the challenges and barriers preventing successful integration of mental health care services into PHC. Subsequently, 4 key informant interviews with PHC co-ordinators and mental health experts were carried out. The findings from the qualitative study were utilized to develop a quantitative study questionnaire to understand the opinions of a larger and more representative sample of PHC staff in two more LGAs of Oyo State, as well as 2 LGAs from Osun State. The common barriers identified from this study include stigma and misconceptions about mental illness, inadequate training of PHC staff about mental health, low government priority, fear of aggression and violence by the PHC staff, as well as non-availability of medications. Recommendations for overcoming these challenges include improved and sustained efforts at mental health advocacy to gain governmental attention and support, organized training and retraining for primary care staff, establishment of referral and supportive networks with neighbouring tertiary facilities and community engagement to improve service utilization and rehabilitation of mentally ill persons. These findings provide useful insight into the barriers to the successful integration of mental health into PHC, while recommending a holistic and comprehensive approach. This information can guide future attempts to implement the integration of mental health into primary care in Nigeria.

Institutional legacies, employment and professional integration of non EU/EEA doctors in France

Internationally, policies for attracting highly-skilled migrants have become the guidelines mainly used by the Organisation for Economic Co-operation and Development (OECD) countries. Governments are implementing specific procedures to capture and facilitate their mobility. However, all professions are not equal when it comes to welcoming highly-skilled migrants. The medical profession, as a protective market, is one of these. Taking the case of non-EU/EEA doctors in France, this paper shows that the medical profession defined as the closed labour market, remains the most controversial in terms of professional integration of migrants, protectionist barriers to migrant competition and challenge of medical shortage. Based on the path-dependency approach, this paper argues that non-EU/EEA doctors' issues in France derive from a complex historical process of interaction between standards settled in the past, particularly the historical power of medical corporatism, the unexpected long-term effects of French hospital reforms of 1958, and budgetary pressures. Theoretically, this paper shows two significant findings. Firstly, the French medical system has undergone a series of transformations unthinkable in the strict sense of a path-dependence approach: an opening of the medical profession to foreign physicians in the context of the Europeanisation of public policy, acceptance of non-EU/EEA doctors in a context of medical shortage and budgetary pressures. Secondly, there is no change of the overall paradigm: significantly, the recruitment policies of non-EU/EEA doctors continue to highlight the imprint of the past and reveal a significant persistence of prejudices. Non-EU/EEA doctors are not considered legitimate doctors even if they have the qualifications of physicians which are legitimate in their country and which can be recognised in other receiving countries.

Academics as parents--parents as academics : a study of the integration of intellectual and child-care labours /

Discussions concerning the challenges of combining work and family are certainly not new, and still actively continue. There is, however, a silence in the related literature regarding a comprehensive description of integrating specifically university academic ~. work and family responsibilities. This silence is especially evident for men who are parents as well as academics. With the participation of 4 key informants, this qualitative research study gave voice to men and women who participate in the academic labour of a Canadian university as professors, and as graduate students, along with the parenting labour of at least 1 child under the age of7. Methodology was developed to reveal in-depth perspectives regarding the work practices employed by 4 key informants as they combined intellectual and child-care responsibilities. Multiple data collection methods included journal reflections, day time observation sessions, a focus group, and a final evaluation questionnaire. Using research findings, together with information extrapolated from Three Models of the Family (Eichler, 1997), this study also took steps toward developing a Proposed "Three Models of the University," to offer explanation for the work practices of the key informants as academics/parents, and also for future consideration in university policy formation.

Scales, networks and uncertainty : an examination of environmental policy-making in Ontario

Through a case-study analysis of Ontario's ethanol policy, this thesis addresses a number of themes that are consequential to policy and policy-making: spatiality, democracy and uncertainty. First, I address the 'spatial debate' in Geography pertaining to the relevance and affordances of a 'scalar' versus a 'flat' ontoepistemology. I argue that policy is guided by prior arrangements, but is by no means inevitable or predetermined. As such, scale and network are pragmatic geographical concepts that can effectively address the issue of the spatiality of policy and policy-making. Second, I discuss the democratic nature of policy-making in Ontario through an examination of the spaces of engagement that facilitate deliberative democracy. I analyze to what extent these spaces fit into Ontario's environmental policy-making process, and to what extent they were used by various stakeholders. Last, I take seriously the fact that uncertainty and unavoidable injustice are central to policy, and examine the ways in which this uncertainty shaped the specifics of Ontario's ethanol policy. Ultimately, this thesis is an exercise in understanding sub-national environmental policy-making in Canada, with an emphasis on how policy-makers tackle the issues they are faced with in the context of environmental change, political-economic integration, local priorities, individual goals, and irreducible uncertainty.

Domestic policy responses to the food price crisis: The case of Bolivia

In face of the global food crisis of 2007-2008, severe concerns arose about how developing countries would be affected by the extreme short-term fluctuations in international commodity prices. We examine the effects of the crisis on Bolivia, one of the poorest countries of the Americas. We focus on the effectiveness of the domestic policy interventions in preventing spillovers of the development of international food prices to domestic markets. Using a cointegration model, we study price interdependencies of wheat flour, sunflower oil and poultry. The analysis suggests that the policy measures taken had little effect on food security during the food crisis. Throughout the entire period, perfect price transmission between the Bolivian poultry and sunflower oil markets and the respective international reference markets existed. Bolivian prices were determined by international prices and the policy interventions in the markets of these two commodities were not found to have had an effect. The government's large-scale wheat flour imports did not shield Bolivian consumers from the shocks of international prices.

How do domestic policies affect the integration of Ethiopian fertiliser markets with world markets?

Frequent shifts in policy on fertiliser markets have occurred in Ethiopia with the aim of facilitating both physical and economic access of farmers to fertiliser. The last shift was the introduction of a monopoly on each stage of the supply chain in 2008. Furthermore, government control of prices and margins as well as stockholding programmes are also present on the markets. This paper evaluates the effect of these policies on the integration of domestic with world markets of fertiliser, using cointegration methods. Time series data of diammonium phosphate (DAP) and urea prices on world, import and retail markets between 1971 and 2012 are used. The findings show high transmission of price signals from world markets to import prices for both DAP and urea. However, between import and retail prices there is no evidence of cointegration for urea, while for DAP full price transmission is concluded. In the retail market, domestic transaction costs associated with storing large volumes of fertiliser act as a buffer between import and retail prices, especially for urea. Therefore, economic benefits could be achieved by reducing the size of stocks and revising the demand estimation process.

The challenges of Europe's fourfold union. Bruegel Policy Contribution 2012/13, 16 August 2012

Five years after the first tremors in Europe’s banking system, what makes the crisis unique is the absence of a democratically accountable decision-making framework; there is an 'executive deficit' that compounds Europe’s democratic deficit. The author argues that the only way to resolve the crisis successfully is a sustained effort to achieve a 'fourfold union' agenda: banking union, fiscal union, competitiveness union and political union. Progress must be made in parallel on each of the four components. In particular, successful progress towards banking union requires a combination of short term action, including the establishment of a temporary resolution authority to identify undercapitalised banks and to restructure them, and longer-term measures, including the creation of permanent authorities for supervision, resolution and deposit insurance.

The Gulf Cooperation Council as a New Regional Power: Time for the EU to Propose a Strategic Partnership. Bruges Regional Integration & Global Governance Papers 3/2012, November 2012

The Gulf Cooperation Council (GCC) is a de facto regional power in the Arab world. Its role has been crucial in some of the outcomes of the Arab Spring. The GCC countries have been very pragmatic in dealing with the uprisings, avoiding any revolutionary spill-over throughout the Gulf region. This paper examines to what extent the policies of the European Union (EU) in the Gulf have changed since the beginning of the Arab Spring. It argues that despite the calls by the European Parliament and by the High Representative Baroness Ashton to improve the relationship, the EU’s support for a new policy in the Gulf after the Arab Spring is stalling, and little new or concrete has been achieved. The paper concludes that the Union needs a reinforced partnership that merges the various EU policies in the region into a single strategic partnership with the Arab countries.

The European Union in the Arctic: A Pole Position? Bruges Regional Integration & Global Governance Papers 4/2012, December 2012

With temperatures in the Arctic rising at twice the pace of anywhere else in the world, the European Union (EU) decided in 2008 to begin formulating an overall Arctic policy tackling maritime, environmental, energy and transport challenges. This attempt to draft a comprehensive policy on a topic that the EU had rarely touched upon unavoidably ran up against other existing strategies from Arctic and non-Arctic states. Against this background, this paper examines whether the EU’s current Arctic policy is conducive to framing a strategy that is both correctly targeted and flexible enough to represent Europe’s interests. It shows that the EU’s approach can serve as an effective foreign policy tool to establish the Union’s legitimacy as an Arctic player. However, the EU’s Arctic policy is still underestimating its potential to find common grounds with the strategic partners Russia and China. A properly targeted Arctic policy could help influence Russia over the EU’s interests in the Northern Sea Route and strengthen cooperation with China in an endeavour to gain recognition as relevant Arctic players.

Ideational change in the WTO and its impacts on EU agricultural policy institutions and the CAP

This paper argues that the Uruguay Round Agreement on Agriculture (URAA) introduced the market liberal paradigm as the ideational underpinning of the new farm trade regime. Though the immediate consequences in terms of limitations on agricultural support and protection were very modest, the Agreement did impact on the way in which domestic farm policy evolves. It forced EU agricultural policy makers to consider the agricultural negotiations when reforming the Common Agricultural Policy (CAP). The new paradigm in global farm trade resulted in a process of institutional layering in which concerns raised in the World Trade Organization (WTO) were gradually incorporated in EU agricultural institutions. This has resulted in gradual reform of the CAP in which policy instruments have been changed in order to make the CAP more WTO compatible. The underlying paradigm, the state-assisted paradigm, has been sustained though it has been rephrased by introducing the concept of multifunctionality.

Think local, act local? Issues of co-ordination and integration in Local Agenda 21

The political response to the complex package of environmental problems which threaten the future of our planet has been to introduce a new agenda of environmental action based on the principles of sustainability and subsidiarity. This has been crystallised in world agreements signed at the Earth Summit in Rio. One of these, Agenda 21, calls for the governments and communities of the world to prepare action plans for their areas which can build consensus between the various stakeholder groups and feed the principles of sustainable development back into their policies and day-to-day practices. This paper explores the experience of Local Agenda 21 type processes at three levels in the South East of England: the regional, county (sub-regional) and local level. In particular it undertakes a critical appraisal of the success of these participatory and consensus-building exercises in developing an integrated and co-ordinated approach to environmental action planning. It concludes that, although much useful work has been done in raising awareness and modifying policy and practice, there are significant cultural and institutional barriers which are hindering progress.

Discerning policy and drivers for sustainable facilities management practice

Due to the changing nature of the facilities management (FM) profession, facilities managers are increasingly engaged with the evolving sustainability agenda in the UK and the development or uptake of sustainability policies within their organisations. This study investigates how facilities managers are engaging with the sustainability agenda and the drivers, policy issues and information they use to improve their sustainability performance management. A web based self-administered questionnaire survey of facilities managers in the UK was conducted to identify drivers and issues that influence and support good sustainable practices. A total of 268 facilities managers responded. The results indicate that legislation is the most important driver for the implementation of sustainable practices. Corporate image and Organisational ethos are also recognised. However demand for efficient monitoring, management and reporting on environmental impact is not highly rated even though the top three issues of sustainability managed by facilities managers are energy management, waste and recycling management and carbon footprint. In addition, facilities managers are expected to take ownership of activities assigned to the reduction of carbon emission. Government industries and organisation with high turnover are more likely to have a sustainability policy. Financial constraints are the main barriers while legislations are the main driver for implementing sustainability. For non-profit organisations and the charitable sector, financial constraints are no hindrance to implementing a sustainability policy. The conclusion drawn is that sustainability agendas continue to be influenced by regulated environmental issues rather than a balanced approach which takes into consideration the wider social and economic aspects of sustainability. While this scenario is far from ideal, the expectation is that the organisation will trust FM to take a vital role in delivering a comprehensive sustainability policy due to the rising tide of legislation, public scrutiny, as well as the needed business case for genuinely embracing sustainability. However, as the integration of sustainability with core business strategies is continuously evolving the emphasis on different drivers will vary from organisation to organisation as well as the responsibilities of facilities managers.