DRAFT mhGAP Situation Analysis Tool-Framework

Introduction

Mental Health Gap Action Programme (mhGAP)

Mental, neurological, and substance use (MNS) disorders[1] are prevalent in all regions of the world and are major contributors to morbidity and mortality, but treatment gap between the need for and availability of services for MNS disorders is enormous.

In order to reduce the gap and enhance the capacity of Member States to respond to the growing challenge, the World Health Organization (WHO) launched the Mental Health Gap Action Programme (mhGAP) in 2008. mhGAP provides health planners, policy-makers and donors with a set of clear and coherent activities and programmes for scaling up care for priority conditions (depression, psychosis, bipolar disorder, epilepsy, developmental disorders, behavioural disorders, dementia, alcohol use, drug use, suicide/self-harm.

Within mhGAP, evidence-based guidelines have been developed for the mental health priority conditions.

These guidelines form the basis of mhGAP-IG. The mhGAP-IG includes clinical protocols and algorithms for management of priority conditions by non-specialist health care providers.

A training package has been developed by WHO to train non-specialist healthcare providers. The training package focuses on imparting the skills and knowledge needed to provide assessment and management for people with mhGAP priority conditions.

mhGAP Support and Supervision Guide is one of the tools to assist implementation of the mhGAP programme. Other mhGAP normative related materials such as, “mhGAP Programme Guide”, “mhGAP situation analysis tool”, “mhGAP Monitoring and Evaluation Guide”, ”mhGAP-IG Training of the Trainer and Supervisors Guide”, are under development (see box).

The training of the supervisor will be covered in the ”mhGAP-IG Training of the Trainer and Supervisors Guide”.

mhGAP related materials

  • Mental Health Gap Action Programme (mhGAP)
  • An action plan to scale up services for MNS disorders for countries especially with low and lower middle incomes
  • mhGAP Intervention Guide (mhGAP-IG)
  • Clinical protocols and algorithms for management of priority conditions
  • mhGAP Manual for Programme Planners*
  • Guide providing practical support for planning, developing, managing and monitoring mhGAP
  • mhGAP Training Package*
  • Training materials based on mhGAP-IG; includes slides, facilitators guides, and participants guide
  • mhGAP Situation analysis tool*
  • Baseline situation analysis tool at country, region, district and facility level
  • mhGAP Adaptation Guide*
  • Guide to adapt mhGAP-IG and training materials to the local context
  • mhGAP Support and Supervision Guide*
  • Guide on supervisory visits with forms for use
  • mhGAP Training of the Trainers and Supervisors Guide (ToTS guide)*
  • Module to provide ToTS to future trainers and supervisors
  • mhGAP Monitoring and Evaluation Toolkit*
  • Toolkit with list of indicators and form to monitor and evaluate the progress of mhGAP

* Draft or field test version available upon request (contact email: ith the subject “Request for XXX (insert the document you request)”, with your name, affiliation and e-mail address).

mhGAP Situation Analysis Tool

Goal of the Situation Analysis: The goal of the situation analysis is to provide preliminary understanding of the capacity and needs at each of the implementation sites. This information is useful for project planning purposes and monitoring and evaluation (M&E).

Resources:Depending on the area in which you are running a situation analysis, it can be a large-scale and expensive task and therefore design and implementation of the situation analysis is subject to available resources. If resources are scarce, it may be necessary to consider raising or allocating resources specifically for this task.A situation analysis conducted with fewer resourcescan look very different than one conducted with extensive resources, however a brief and adequate analysis may still be attainable with proper planning and implementation.

How to Conduct a Situation Analysis

Followingare suggested general guidelines ofconducting a situation analysis for in-country project personnel.

  1. Appoint a Situation Analysis Working Group or focal point: This working group or focal point will be responsible for conducting the situation analysis and all related tasks including customizing the tool, collecting data, analyzing data, andgenerating report(s).
  1. Customize the Tool: Use the proposed tool template as a starting point to begin developing a tool specific to country or region. In some cases, the tool may need to be translated. Review each item keeping in mind the following characteristics:
  2. Relevance of Content: Is each item relevant to provide information about MNS disorders in your country?
  3. Feasibility: Can each item be collected feasibly in your country?
  4. Cultural Appropriateness: Is each item culturally appropriate in your country?
  5. Understanding: Did the respondent understand each item as presented by the surveyor without further instructions or clarification? Are supplemental instructions required?
  6. Simplicity: Is the tool formatted in a way that can be easily completed by the surveyor and respondent?
  7. Thoroughness: Does the tool, overall, capture the most important aspects of MNS disorders in your country? Did the tool miss anything important? Are there important levels of data that additionally need to be collected?
  8. Burden: Does the tool require too much effort to complete for the amount of information that is deemed valuable? A common mistake in situation analysis is to collect more data than are analyzed. Balance between thoroughness and burden is required.
  1. Coordinate with Monitoring and Evaluation indicators: The information collected in the situation analysis will provide baseline data formonitoring and evaluation of the programme. Items must be strategically selected to meet the objective of the monitoring and evaluation.
  1. Selection of Sites: Before data collection for situation analysis starts, make sure that the districts and faclities for mhGAP implementation have been selected.
  1. Implement Tool: Collect all possible sources of information to support comprehensive completion of the tool. (See below for description of sources of data)
  1. Data collection:Data can be collected from secondary or primary sources. First utilize existing data, whichhas already been collected. Only consider conducting new data collection when the data is not available from existing sources.
  2. Existing Data:
  3. Published literature: These can include international scientific journals or country-specific published journals. This should include both biomedical and social science journals.
  4. Unpublished gray literature: These publications can also come from international organizations (e.g., WHO, ILAE) or local NGO’s or government publications and reports. These sources can be hardcopy or online resources.
  5. WHO/UN/other sources of information: WHO/United Nations/World Bank has country profiles that provide information on general and health background. Any of these country profiles can be used. In addition, there often are country’s administrative or other records that can provide information about country, regions and districts. Some examples are: WHO country profiles; WHO-AIMS country profile; World Bank country profiles; WHO Statistical Information Systems. Appendix A provides a list of sources of secondary data that may be useful.
  6. Routinely collected data: These data can include information that is routinely collected as part of an on-going protocol such as clinical information, medical history, vital status, discharge status of patients cared for in a clinic. Some of the data may be collected and compiled through the country’s health information system, while other data may be found in files in clinics. Another example of routine collection is socio-demographic information collected in governmental census or surveys.
  7. Data collection methods to consider if the data is not available:
  8. Clinic or facility-based: These are best suited to understand the patterns and standards of treatment and care, clinical workflow and referral systems once people access the healthcare system. These data generally do not provide generalizable information about the underlying general population.
  9. Key informants or expert opinion(This is usually qualitative data): When possible, use key informants or experts to obtain referral to other more generalizable sources of data such as those described above. When above sources are not available, data can be collected by soliciting opinions from key informants or experts. It is important to explicitly note which data represent expert opinions since caution is especially needed during interpretation from such data.Data may be collected through narrative interviews or free listing.It is important to identify a range of key informants and experts. For example, this group should not include only specialists such as neurologists, but also people with MNS disorders and community leaders.
  10. Qualitative data: These data include individual or group interviews (e.g. focus groups) and are designed to understand a narrow topic with greater depth than can be obtained from a broad survey. Focus groups are well suited for understanding the cultural context of stigma, traditional beliefs or customs underlying health seeking behaviours, barriers to seeking treatment etc.
  11. Population-based: If resources allow, a comprehensive door-to-door survey will provide the most generalizable and representative data of the underlying population. Such designs are ideal to estimate prevalence of MNS disorders, treatment gaps in the community, knowledge, attitudes, practices of general population, attitudes of stigma, number of people not accessing or unable to access health systems for care, or other psychosocial aspects of MNS disorders.
  1. Priority of Data Sources:
  2. More recent data are preferred over older data. If there are data within the country that provide more recent information than other data sources (i.e., WHO/UN/World Bank), the more recent in-country statistics take precedence. In many cases, due to resource constraint, secondary data may be preferable compared to undertaking primary data collection. A balance between resources for situation analysis, feasibility and recency is required.
  3. Data that can be generalized or are representative take precedent over data from a convenience sample of a selected group (i.e., key informants, opinion leaders). Where possible, collect data from studies or sources that can provide the best generalizability or representativeness. In general, key informants should be the last resort for obtaining data.
  1. Analysis: Analysis of data obtained by the tool should use both quantitative and qualitative methods, where appropriate. Data across Facilities should be used to provide a representative understanding of the District (or the administrative unit one level higher). Data across Districts should be used to provide a representative understanding of the Region. Where possible, a general understanding of differences and similarities betweenDistricts and Facilities (e.g. geography, population it serves, specialty or type) will offer a more accurate representation of how comprehensive the overall health capacity is within the larger administrative unit. Specifically, analysis should be conducted with the aim of explainingthe current capacityin terms of geography, access, and equity:
  2. Are Facilities/Districts geographically dispersed throughout of the District/Region?
  3. Do Facilities/Districts provide health access equally throughout the District/Region?
  4. Is MNS disorders care and treatment available to all within a District/Region given data across Facilities/Districts?
  1. Feedback and Discussion: Preliminary results obtained by the situation analysis working group should be presented to the project coordination committee for feedback and discussion.
  1. Reporting: The final deliverable of a situation analysis is a thorough report that provides a general representative understanding of the socio-demographic, political, economic context of the country and the selected district as well as the general background of health and services issues pertaining to MNS disorders. Furthermore, it details the capacity of the healthcare infrastructure and human resources to treat MNS disorders using information obtained about facilities. A summary of community resources will offer an understanding of how people with MNS disorders can cope with their condition outside of the healthcare environment. The situation analysis report should contain the following sections:
  2. Contextual background
  3. Health background related to MNS disorders including prevalence and treatment gaps
  4. Current capacity in terms of health infrastructure and systems
  5. Current capacity in terms of human resources
  6. Community resources available to people living with MNS disorders
  7. Conclusion that synthesizes all information and identifies barriers to implementation of WHO Programme
  8. Recommendations that are listed in order of priority

Levels of Data Collection

The situation analysis contains items that assess current capacity and needs at the national-, regional- district-, and facility-level. (See the table below for exhaustive lists of items at each data level.)Each level has its own individual form - see the attached files.

  1. National-level: This level is intended to give a general health and system assessment of the country and specific activities associated with MNS disorders. Items of the tool at this level assess political and administrative structure, economic indicators, demographic characteristics, political structure, budget and financing, general health indicators, and indicators relevant to MNS disorders.
  2. Regional-level: Region is defined as the first formal administrative subdivision of the country. In some instances, this is equivalent to “state” or “province”. Regional-level data provide a more specific understanding of the region that contains selected sites for the situation analysis. The items on this level assess similar aspects as those at the national-level, but are specific to the selected region. Furthermore, additional items assess treatment guidelines for MNS disorders, availability of diagnostic equipment, psycho-social aspects of MNS disorders, and community resources from the presence of any informal health care for MNS disorders.
  3. District-level: A District is defined as a division within the administrative division for the country below the regional level. The goal of the section is to provide details that cover the district and factors that impact general health and MNS disordersin the region. In addition to demographical information about the specific district, items on this level asks specifically about MNS disorders information systems,MNS disordersmedication and treatment, psychosocial aspects of MNS disorders, educational resources, human resources, health service structure, pathway of care, and community resources.
  4. Facility-level: The facility-level items assess information about MNS disorderscare at the level of health facility. Items at this level include questions on health services, MNS disordersreferrals, human resources, MNS disorderscare and training, information systems, and community linkages with the specific facility.

Content - Items

Specific items exist within each level of data. The following table provides overview of large categories of items for each level of data. The items are designed to address four components: (1) national policy and strategy development; (2) training of health care providers; (3) delivery of MNS disorders care within the primary health care setting; and (4) reviews community-based health promotion aimed at increasing awareness of MNS disorders. The table below provides a summary of items mapped to the national-, regional-, district-, and facility-level data.

Level of Data / Categories of items
National and Regional /
  • Socio-demographic and Economic Factors
  • Health Service Structure
  • MNS Disorders Service Delivery System
  • MNS DisordersPublic Education and Promotion Programs
  • Health Workforce
  • Organizations for people with MNS disorders and their families
  • Budget and Financing (National Level only)
  • Policy and Legislation for Mental Health (National Level only)
  • Health Information Systems (National Level only)
  • Diagnostic Equipment (Regional Level only)
  • Psycho-social Aspects of MNS disorders (Regional Level only)
  • Informal Care for people with MNS disorders and their families (Regional Level only)

District / In addition to many of the items above being taken at District level, the district level of the tool also includes:
  • Services and Medication Financing
  • MNS DisordersCare Training
  • Pathway of Care
  • Overview of Health Facilities in the district

Facility / In addition to several of the items above being taken at the Facility level, the facility level of the tool also includes:
  • Administration and Services of particular clinic
  • Type of facility, patient services, number of people covered, number of people served per month in general and for MNS disorders, staff types and MNS disorders care training
  • MNS Disorders Services, Referrals and Supervision
  • Health Care Financing
  • Community Involvement with MNS disorders care

The different level forms (National, Regional, District and Facility level) include the categories listed in the table above. The categories include several items which are numbered to collection of relevant information. While some are self-explanatory (e.g. 'literacy rate'), others have a small description helping users to understand what kind of information is required for the item.

At the end of each form, there is a space to fill in the name and information of all of the relevant stakeholders for that level. There is also a table for recording the data sources that were used to collect the information. This is important because it will provide all stakeholders and project workers with an idea of the accuracy of the data. Some data will be readily available from trustworthy secondary resources, but you may have to be creative in obtaining some data. Primary data collection methods such as surveys, expert informants and focus groups may be necessary but can be resource and time intensive to conduct.

Writing the mhGAP situation analysis report

The situation analysis report is an important document for the planning and implementation of mhGAP and will inform the next stage of this process. It is a means of presenting the collected data in a useful and meaningful manner.