Identifying the health systems changes necessary to sustain and scale up the integration of mental health services into primary care in Lagos, Nigeria

STATEMENT OF THE PROBLEM:
Despite the huge burden of mental health problems, about 85% of people with severe mental illness in sub-Saharan Africa (SSA) do not receive any form of treatment. Integrating mental health services into primary health care (PHC) has been advocated as the most viable means of closing this treatment gap. The linear model of intervention development, efficacy testing and implementation led to problems with sustainability over time and in real world setting. As there are policy and ethical implications of developing effective heath programmes without sustainability and scale-up, an understanding of the factors and processes that influences sustainability and scale up of an evidence-based intervention is needed for proactive planning

OVERALL AIM: This feasibility study aims to identify the strategies to facilitate the health system changes necessary to sustain and scale up mental health services in primary care in Lagos, Nigeria.
SPECIFIC QUESTIONS TO BE ADRESSED BY THE PROJECT
1) what is the state of implementation of the MeHPriC Project and what are the factors that are currently underlying its implementation?;
2) What are the dynamic interactions between the different components of the programme as regards contexts (inner and outer), implementation processes, implementation actors and intervention outputs and outcomes?;
3) How do these components influence the sustainability of the programme; and
4) What strategies may be required to facilitate the changes necessary for sustainability and scale-up

METHODOLOGY
There are 5 phases of the study.
1. In Phase 1, We will review policy documents and conduct in-depth interviews with selected policy makers to develop hypotheses, assess whether the target indicators for the project are met, identify how they are met, identify the key contextual facilitators and constraints and the way they affect the outcome.
2. In Phase 2, we will conduct a quantitative survey amongst the stakeholders including policy makers and administrators, programme managers, PHC health workers and recipients of care. They will complete scales to assess organisational readiness to change, sustainability and perceived intervention acceptability and feasibility
3. In Phase 3, we will conduct a brief evaluation of the implementation and through in-depth interviews, we will examine the stakeholders' perception about the health systems constraints to delivering, scaling up and sustaining the intervention. We will also observe selected PHC facilities to enable us to understand the factors that act as facilitators or barriers to sustenance of the intervention delivery.
4. In Phase 4, we will conduct a Theory of Change (ToC) workshop that will draw mainly on the results from the analysis of the earlier phases in combination with scientific knowledge and programme experience to identify health system changes that will improve sustainability in the delivery of the intervention.
5. In Phase 5, we will analysis and present the project report to the funders and the stakeholders

RESEARCH IMPACT:
1. The individual care recipients will benefit from sustained level of evidence-based interventions leading to better outcomes and improved quality of life.
2. This study will enhance the health workers knowledge, motivation and attitude in providing effective mental health interventions in a sustainable way.
3. The programme implementers will be able to identify and include sustainability components to their design and implementation of complex interventions.
4. Evidence generated in this study will be shared with the WHO team to inform potential strategies for a sustainability and scalability of mental health interventions in LMICs.
5. The project will inform Policy makers on methods of sustaining beneficial interventions thereby maximizing the judicious use of funds

STATEMENT OF THE PROBLEM:
There are policy and ethical implications of developing effective heath programmes without sustainability and scale-up. This feasibility study aims to identify the strategies to facilitate the health system changes necessary to sustain and scale up mental health services in primary care in Lagos, Nigeria.
SPECIFIC QUESTIONS TO BE ADRESSED BY THE PROJECT
1) what is the state of implementation of the MeHPriC Project and what are the factors that are currently underlying its implementation?;
2) What are the dynamic interactions between the different components of the programme as regards contexts (inner and outer), implementation processes, implementation actors and intervention outputs and outcomes?;
3) How do these components influence the sustainability of the programme; and
4) What strategies may be required to facilitate the changes necessary for sustainability and scale-up
METHODOLOGY
There are 5 phases of the study.
1. In Phase 1, Through review of policy documents and in-depth interviews we will develop specific hypothetical pathways that link the programme inputs to processes, outputs and outcomes within the health system
2. In Phase 2, we will conduct a quantitative survey amongst the stakeholders to assess readiness to change, sustainability, feasibility and acceptability
3. In Phase 3, we will conduct a brief process and outcome evaluation of the implementation, and through in-depth interviews, and institutional ethnographies, we will examine the stakeholders' perception about the health systems constraints to delivering, scaling up and sustaining the intervention.
4. In Phase 4, we will conduct a Theory of Change (ToC) workshop to identify health system changes that will improve sustainability in the delivery of the intervention.
5. In Phase 5, we will analysis and present the project report to the funders and the stakeholders

POSSIBLE IMPACT
The project offers a potential for significant impact both in terms of generating new evidence and influencing policy and practice in Nigeria and other LMICs. At the individual level, care recipients will benefit from expanded scope, increased reach and sustained level of evidence based mental health interventions leading lead to better outcomes and improved quality of life.
1. For health workers, this study will enhance their knowledge, motivation and attitude in providing effective mental health interventions in a sustainable way.
2. The programme implementers will be able to identify and include sustainability components to their design and implementation of complex interventions. This will reduce the heavy reliance on the quality assurance team to prevent "programme drift", which some of the time inadvertently hamper sustainability and optimization of interventions.
3. For the MeHPriC project team the results of this feasibility study will also inform the design of the proposal for a much larger study.
4. For the researchers, evidence generated in this study will be shared with the WHO team to inform potential strategies for a sustainability and scalability of mental health interventions in LMICs. The findings will also contribute new knowledge to international health policy and systems research debates on why, when and how to strengthen the health systems to support and sustain effective interventions.
5. The study will also help build health system research capacity in Nigeria. Junior researchers recruited to work on the project will receive a range of training and mentoring in methodological and conceptual development.
6. The project will inform Policy makers on methods of sustaining beneficial interventions thereby .

Our study will also have an impact on a wider level, as it will provide insights that are relevant for other LMICs that are scaling up their mental health services.

We will communicate our findings and engage the identified stakeholders? Our engagement methods will include dissemination of policy briefs to international and national policymakers, creating a website and use of social media platforms for MeHPriC project information dissemination, presentation at state and national meetings and conferences, regular review of the project with key decision makers, newsletters, press releases and media in