Abstract
This paper seeks to review the available evidence to determine whether a systems approach is employed in the implementation and evaluation of task shifting for mental health using lay providers in low- and middle-income countries, and to highlight system-wide effects of task-shifting strategies in order to better inform efforts to strength community mental health systems. Pubmed, CINAHL, and Cochrane Library databases were searched. Articles were screened by two independent reviewers with a third reviewer resolving discrepancies. Two stages of screens were done to ensure sensitivity. Studies were analysed using the World Health Organization's building blocks framework with the addition of a community building block, and systems thinking characteristics to determine the extent to which system-wide effects had been considered. Thirty studies were included. Almost all studies displayed positive findings on mental health using task shifting. One study showed no effect. No studies explicitly employed systems thinking tools, but some demonstrated systems thinking characteristics, such as exploring various stakeholder perspectives, capturing unintended consequences, and looking across sectors for system-wide impact. Twenty-five of the 30 studies captured elements other than the most directly relevant building blocks of service delivery and health workforce. There is a lack of systematic approaches to exploring complexity in the evaluation of task-shifting interventions. Systems thinking tools should support evidence-informed decision making for a more complete understanding of community-based systems strengthening interventions for mental health.
Highlights
Mental health accounts for a large and growing burden of disease (Whiteford et al 2013)
This is especially true of mental health in low- and middleincome countries (LMICs), where availability of services is not matched to population needs (Weinmann & Koesters, 2016)
The search strategy consisted of three concepts: (1) lay providers, including community health workers, health aides, local references to community health workers such as accredited social health activists, non-physician health workers, community-based practitioners, and other associated terms; (2) mental health, including the standard set of disorders under the definition of common mental disorders (CMDs) such as anxiety, depression, dementia, schizophrenia, and substance abuse, as well as strategies for treatment such as supportive counselling, cognitive behavioural therapy, and others; and (3) LMIC setting, as this study is focused on alternatives for delivery of mental health services in resource-poor settings
Summary
Mental health accounts for a large and growing burden of disease (Whiteford et al 2013). According to the Global Burden of Disease Study, between 2005 and 2013, disability-adjusted lifeyears attributed to mental and neurological disorders increased by 9.7% and 16.1%, respectively (Murray et al 2015a). Despite this burden, a study across 17 countries demonstrated that only 20% of persons with common mental disorders (CMDs) received treatment in the year prior to the survey, with only 10% receiving minimally adequate treatment Availability and scale-up of essential health services to achieve health system goals is often impeded by health workforce shortages (WHO, 2006) This is especially true of mental health in low- and middleincome countries (LMICs), where availability of services is not matched to population needs (Weinmann & Koesters, 2016). The World Health Organization (WHO) estimates that there is a need for 1.18 million mental health workers to move towards closing the mental health treatment gap (Fulton et al 2011)
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