service delivery models

Since decades the ‘better prognosis hypothesis’ keeps looming in international research and debates. It’s the assumption, or conclusion, from international research, that outcomes for schizophrenia are better in developing countries compared with developed countries.

Suppose there is a difference in the course of schizophrenia between rich and poor countries (and sometimes it seems there is), what could we learn from this? Could this give us answers on how to treat people with (and after) a psychosis? Could it give us clues for more effective models of care, new protocols, new ideas and inspiration for the difficult roads to recovery? And what is the role of medication? Must we stick to the current biomedical model of treatment?

In this blog post research and literature about this issue is reviewed, with links and citations. Special attention is given to 'culture' and 'medication' as possible causes of a possible 'better prognosis' in developing countries.

Recent studies (Harrow, Wunderink) on the long term (negative) effect of antipsychotics is included as well.

The conclusions are:

1. It seems plausible that generally people living with schizophrenia in poor countries are better off regarding there overall functioning and recovery. But, due to limitations and inaccuracies in the studies so far, this is still more an interesting hypothesis then a strong fact.
2. Although limited in scale and generalizability the Harrow and Wunderink studies give some evidence in the direction of negative long term effects of anti-psychotic drugs.
3. So, whether it is true or not that people with schizophrenia in poor countries have a better prognosis, it seems obvious that the possible (long term) negative effects of anti-psychotic medication is bigger then assumed in the last decades.
4. It’s possible that not/never receiving or discontinuation of anti-psychotic medication, is one of the main determinants in the ‘better prognosis hypothesis’, and underestimated thus far.
5. In order to get a full picture of the onset, nature and long term outcome of schizophrenia in individuals, or in countries, or even between countries, one must take medication as one of the possible variables in the study.
6. There is a strong urge to develop and study alternatives in the treatment of psychosis and schizophrenia. Maybe, in this regard, we can learn a lot from poor countries!
7. The call for new standards of care for people living with schizophrenia is heard here and there, but, given the hypotheses and evidences mentioned above, I think not hard enough yet.

Today nearly 75% of the 450 million people worldwide with mental illness and epilepsy live in the developing world, and 85% of these people have no access to treatment. The size of the problem is vast, with depression projected to be the leading global burden of disease by 2030.

It's a complex picture. Mental illness and epilepsy have long been the 'poor relation' of global health and development agendas, taking a back seat to more prominent issues; often being underfunded, misunderstood and considered taboo. Those living with mental illness and epilepsy often live in poverty, experience daily acts of cruelty and denial of their basic rights, are prevented from exercising choice, pursuing opportunities or planning for the future.

The experiences of these most marginalised are often 'hidden in plain sight' as Kevin Isack, a young person from Tanzania explains: "I had to drop out of school because of my failure ...I led a quiet, buried life".

With almost no treatment available, people often use traditional healers which are expensive and trap them in a vicious cycle of poverty: "We used to move here and there searching for traditional healers' treatments. We sold our livestock, crops and sometimes I used to work in the others farms so as to get money to pay traditional healers. It cost me a lot."

13 years ago, BasicNeeds was established as an international development organisation to respond to this humanitarian emergency, and has now worked with hundreds of national and international partners across 12 countries, helping more than half a million people with mental illness and epilepsy, and their family members.

But we need to do more. With the support of the Skoll Foundation and our many other partners, we are now scaling up our operations to reach at least 1 million more people who are living with mental illness and epilepsy in low and middle income countries in the next five years. We will do this by accelerating the implementation of our Model for Mental Health and Development, which combines health, socio-economic and community orientated solutions with changes in policy, practice and resource allocation to make real change in the lives of people we work with.

A key part of this scale up plan is the development of social franchises. Social franchising is about the replication of a tried and tested model, in our case this is the BasicNeeds Model for Mental Health and Development.

Like a business based franchise approach, our social franchise system will support independent organisations operating in low or middle income countries (such as international non-government organisations, in-country NGOs or country governments) to take on the delivery of the Model in their territory, increasing the impact of their work and most importantly, the quality of life for people with mental illness, epilepsy and their families.

We aim to compliment and strengthen local interest and leadership in mental health, epilepsy and development, working with partners who know their territory well and want to do more.

We know our Model works and are excited to offer potential franchisee partners a comprehensive package which will support them to implement the Model and link into our wide peer practitioner, research and policy networks.

By supporting BasicNeeds through the CrowdRise challenge we can reach out to more people with mental illness and epilepsy who are in need of help. If you are interested in our social franchise plans and want to find out more, we would be pleased to hear from you. Please contact us via our website.

- Jess McQuail, BasicNeeds Franchise Manager


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Integrated Innovations to Improve Treatments and Expand Access to Care

Mental disorders are prevalent in all regions of the world, in every community and across every income level. An estimated 13% of the global burden of disease is attributable to mental disorders, with almost three quarters of this burden affecting people in low- and middle-income countries.

Grand Challenges Canada is seeking to improve treatments and expand access to care. We are committing up to $10 million CAD for the most promising bold ideas with big impact. Our focus is on low- and middle-income countries. We expect to fund proposals through two funding streams: seed grants (up to $250,000 CAD over 2 years) and transition-to-scale grants (up to $2,000,000 CAD over 3 years). Proposals must provide innovative solutions to address one (or more) of the following challenges in low-resource settings:

  • Integrate screening and core packages of services into routine primary health care
  • Reduce the cost and improve the supply of effective medications
  • Provide effective and affordable community-based care and rehabilitation
  • Improve children’s access to evidence-based care by trained health providers
  • Develop effective treatments for use by non-specialists, including lay health workers with minimal training
  • Incorporate functional impairment and disability into assessment
  • Develop mobile and IT technologies (such as telemedicine) to increase access to evidence-based care

Grand Challenges Canada is looking for solutions that demonstrate a clear path to scale and sustainability, have measurable outcomes of increased access to care and improved treatment, and can ultimately serve as models that can be replicated or scaled in other low-resource settings, or have lessons for other settings. Grand Challenges Canada does not fund capacity-building initiatives alone. We are seeking evidence-based, affordable treatments or innovative service delivery models that can be scaled in a sustainable manner.