Home > Projects > Haiti Government -Full Presentation- Scaling up care

Mental health is central to health and social development

Design a system that lives up to these needs

This is very possible to do

Evidence and goals point to a needed systematic approach– using a community health-worker based “pyramid” of care

Leading innovation in community health:
Scaling up mental health care in
Gary S Belkin MD, PhD
New York University
Richard Douyon, MD
University of Miami
Key Messages
       Mental health is central to health and social development 
       Design a system that lives up to these needs 
       This is very possible to do 
       Evidence and goals point to a needed systematic approach– using a community health-worker based “pyramid” of care
       Such an approach is being modeled in Zanmi Lasante for potential scale-up
       Hospitals, conceived differently, have a critical role in this
       Any model– as this one- has to logically lead to clear benchmarks and planning tasks so thatGoH leads otherwise fragmented actors
       There are emerging networks eager to support this

The Vicious Cycle of Social Challenges and Mental


World Health Organization: World Mental Health Report, 2001: p. 30

Mental health–  Burden but also critical mediator Think innovatively about

structure: Deliver care in ways that follow the causal paths




Early childhood

A Systematic Planning Model

       Starting point is to describe the skillsets needed to provide a range of evidence-based care pathways, and thendescribe the kinds of workers across whom those skillsets are distributed, provided that:

–  As many of those skills as possible are arranged so they can be done by the least specialized worker, as close to the community as possible, with the right supports for them to be able to do so.

       This allows for as much overlap as possible within the roles and design of overall primary health care (which should also follow a health worker-based design).

       This allows a rapidly accessible career path entry opportunity and rapid workforce expansion

       This allows for adaptation along local practice and a basis for prevention and cross-sector work

       This specifies the tasks and expectations to align actors and develop benchmarks for GoH action


Adhere to 2 guiding tasks:

       Get the skill-sets right- Establish a core Pyramid of Care as a flexible foundation for multiple care pathways and to coordinate largescale implementation 

       Follow 4 Implementation Rules

Skill Set Packages


A few evidencesupported  skill sets can provide a foundation that carries a range of  care pathways to  span needed 

range of action








Effective and integrated mental health care, needs effective, rational design and staffing of primary health care



Hospitals as anchors


• National Centers of Excellence and Referral (rehabilitated, staffed, and re-defined missions for Mars & Kline and Beudet) and Department primary designated general hospitals with 5-10 inpatient psychiatric beds each will host key leadership functions of referral, quality review/ monitoring, and training/supervision for these pyramids.

Inside the Pyramid of Care

        Staffing and budgeting assumptions will vary depending on actual functional  unit of organization, parallel development of a primary care health worker (CHW) –based capability, and on inclusion of preventive functions and a broadened initial layer of pyramid-eg to teachers, etc as providers/partners

        The ZL pilot can provide valuable information along with select large NGO experiences to date in specifying the resources needed for this model- and expected ZL-MSPP workshops could be an opportunity to explore first-step spread of that model to other areas

        Assuming hospital-anchors at the Department level and mobile and other pyramid staff estimated through population ratios at arrondissement levels, and based on experience in skilled health worker use and population coverage, a minimum target of 1:200 skilled CHW:household ratio, and 1:10- 1:20 ratio of  mid-level mental health provider to CHW, and ~20-40 psychiatrists initially.

        Regionalization of small inpatient psychiatric beds/units within general hospitals and rehabilitation of Mars and Kline /Beudetand their staffing 

        This does not include human resource needs for: institutionalizing training capacity in current Haitian teaching faculties, enhancing Monitoring & Evaluation infrastructure, adoption of quality improvement and services management and program evaluation practices and roles.

Aligning change and leadership

        This framework of delivery provides a set of tasks and targets that can align the fragmented work of multiple stakeholders around mental health

        These functions and elements can be translated into national and local level benchmarks as appropriate (eg % target worker type/population ratio-met, % CHW-referred cases- treated, etc) to enforce accountability and focus actions and expectations towards systems-building across actors and geographies

Supports to Achieve a Pyramid Model

        Ministry office for mental health integration

        Capable Haitian university/training faculties especially for training mid-levels

        Huge pool for potential Haitian workforce expansion

        ZL pilot

        Specific NGOs with broad, well organized primary care structure and reach, and/or mental health capacity agreeing to shared model

        International organizations for adoption and use of quality improvement/M&E methods and tools

        Rebati Sante Mental

        Caribbean Hub for Community Mental Health

        Partners for use of cellular other innovative mhealth technologies


Model Scale-up Planning Scenario

Steering Group– Intergovernmental (key planning ministries, institutions)

 Aligns with budget and other-sector and national planning

 Addresses obstacles of Planning and Implementation group (P&I)  Oversees and gets reports from P&I   

P&I Group– MSPP, key providers of mental health and primary care,  training institutions and other-sector allied with model (egEducation)

Within this Model- identifies gap areas and recommends and then coordinates implementation of Workplan with:

 – Targets-timelines

 -Staging of implementation

 -Identifies proven health implementation and improvement methods for the 10  Department

Teams to use

Recommends benchmarks for success and implementation, quality, oversight

-Department MSPP, elected and community  leaders,

area health, etc

Department Teams

-Department MSPP,  elected and community   leaders, area health, etc

Department Teams

-Department MSPP, elected and community  leaders, area health, etc

      Department  Teams