Can eLearning boost the Mental Health capacity in low income countries?

More then 239.000 extra mental health workers are needed in the South and only 54,5% of the low income countries have psychiatric training facilities! How to fill this gap?
In this article possible eLearning applications in 4 mental health capacity areas in low income countries are investigated. With figures, examples and links the current state of art will be presented. A conclusion will be given (‘Yes, it can’) as well as recommendations for the future.
Discussions, comments and additions are very welcome!

Introduction:
According to the World Health Organization (WHO) in the Lancet Global Mental Health Series, mental disorders contribute to 12% of the global burden of disease and make up 5 out of 10 leading causes of health disability. In the meantime 75-85% of people with mental illnesses have no access to mental health treatment in low income countries, the so called mental health treatment gap. Mentioned reasons for this treatment gap are: the lack of funding and resources, the stigma surrounding mental diseases, lack of understanding and knowledge in the population, in policy makers and in health workers, and a lack of mental health capacity building.

Most low income countries have a huge shortage of well trained mental health workers. Countries like Eritrea, Liberia and Chad for example have only one psychiatrist for the whole population. According to the WHO the median number of psychiatrists per 100 000 population in the world is estimated at 1.2 with the median number within low income countries being as low as 0.05/100 000 population. And since most well trained professionals work and live in the cities, the remote rural areas are extra underserved.
Calculations of the WHO indicate further that low and middle income countries worldwide need an extra 239 000 fulltime equivalent staff (psychiatrists, nurses and psycho-social care providers) to fill the treatment gap of 8 mental, neurological and substance abuse related problems. These estimations for Ethiopia are for example; 659 more psychiatrists (now 18), 6113 more specialized nurses (now 236) and 5275 more psychosocial care providers (now 800).

In efforts to built more mental health capacity in low income countries, one must consider the following: Most mental health workers, students and institutes face a constant lack of finance. The budgets for mental health are often far below WHO standards and many developing countries spend just one per cent of their overburdened health budgets on mental health. The consequence is that mental health care institutes often lack resources for adequate treatment and basic care of their patients, let alone money for additional education of their staff or new students.
Health or mental health education facilities are rarely present or generally inadequate in low income countries. According to Julio Frenk a.o. in the Lancet for instance 26 sub-Saharan countries have no or only one medical school and according to the WHO only 54,5% of all low income countries have a specific psychiatric education program. And the content, quality and duration of the few existing programs are still very diverse. On top of that is the brain drain; many mental health specialists migrate to higher income countries, or stay oversea, after finishing their education. And since most people in low income coutries can’t afford to travel and stay overseas, in order to get their preferred education, one must look for cheaper and feasible solutions to fill this immense capacity gap.

What can eLearning contribute here? What is already in place and what needs further exploration and development?
Here we go:
1: The academic courses and degrees:
There are a lot of institutes or companies in the world who offer degrees and certificates online, but the level, costs and international recognition varies a lot. It seems that only programs with international funding or involvement of NGOs are affordable for the average student in low income countries. For example the Queen Mary University of London full time MCs Mental Health Distance Learning program costs 8.000 UK pounds (GBP) or 13.000 USDollar for one year……
Examples of counseling, psychology and social work online courses are Quantum Units Continuing Education based in USA (costs 3 USD for each hour/CEU), UK Open Learning (costs for most courses 330 GBP or 540 USD), and ACS Distance Education based in Australia and UK (costs for instance 1.099 GBP or 1.800 USD for a 600 hour certificate course in counselling).
Specialized online courses for becoming a psychiatrist are rare or even not there. I could not find them. But the World Psychiatric Association, WPA offers specific educational programs about e.g. schizophrenia, depressive disorders and personality disorders. They also developed Core Curriculums in Psychiatry for medical students, where they subscribe ‘what every doctor in the world should know about psychiatry’. For more information about ideas and future education projects of the WPA you can read the article of Allan Tasman of the WPA Secretary for Education.
Other promising projects in the South like the African Virtual University, AVU and Agence Universitaire de la Francophomy, AUF among others, have some health programs, but not (yet) online mental health courses or degrees.

2: Additional training of mental health staff, policy makers and human resource managers:
Most low income countries have no specific mental health policy. Others countries are trying to reorganize their mental health care in more affordable and feasible models. Special courses and training are needed to facilitate this building and/or shift in policies and design. A few organizations offer this kind of competence-leadership education, sometimes 100% and sometimes partially online, most of them addressing the general/public health field, like the USAID funded Leadership, Management and Sustainability Program, educating in 140 countries through distance learning, and the Virtual Leadership-Development Program (VLDP), which is available in 6 languages and has been delivered to more then 1.700 participants in the health sector. A few international programs address specific mental heath staff and policy makers like the International online Mental health Leadership Program of the Melbourne School of Population Health, the International Diploma on Mental Health Law and Human Rights of the ILS Law College in India, and the Mental Health and Policy and Service International Master in Portugal.
Additional online education about ICT techniques and applications are also essential, since these topics are hardly ever addressed in academic medical or psychiatric courses and even anno 2011 there is no guarantee that policy makers and international funders are already internet savvy. Examples in this area are the UN-APCICT Virtual Academy of ICT Essentials for Government Leaders Program, and the Commonwealth Leadership Training on eHealth and ICT.

3: Ongoing supervision and on the job training:
In a lot of low income countries the current/new mental health policy is a community based mental health care, where high educated, often urban professionals, manage and support low educated, often rural/local community health workers or nurses. For this ‘remote control’ management, education and support ICT offers ample opportunities and eLearning is one of them.
There are fruitful examples of this distance support in the general/public health sector, like in Africa the (AMREF) African Medical and Research Foundation’s program for community health workers and nurses, the Malawi Labyrinth Virtual Patient project and the Uganda Communication and training for Health care workers, using PDAs in HIV-AIDS care and treatment.
One of the rare mental health examples is the pilot project of Telepsychiatry in South Brazil; a multidisciplinary service with the participation of psychiatrists, general practitioners, social assistants, nurses, psychologists and undergraduate students. Another the Mental Health First Aid Course of the University of Melbourne, Australia. Now still as a 12 hour course available on CDrom, but an online version is expected mid 2012. The course is designed for all employed in human services, such as teachers and any emergency service personnel, but seems applicable for primary care workers as well.

4: Informal learning and Open Source Ware:
Thanks to the new technologies and internet access one can organize ones own knowledge gathering and stay updated on the spot. Particularly the OCWs (Open Source Ware) are successful, like the OSW Consortium with member universities from 45 countries and more then 5000 courses freely online. Topics about mental health are rare in OCWs, but available. The John Hopkins Bloomberg School of Public Health offers for instance 60 graduates OCW courses online and a few about mental health. Some less organized and more grassroots communities are e.g. Connexions and Open Education Resources Commons; here everyone can upload and download material. A kind of Communities Of best Practice (COP’s) are The Movement for Global Mental Health, this site offers packages and programs of care and other upload possibilities and articles, and the Mental Health and Psycho Social Support Network which has more then 1000 files are uploaded. There are international journals who offer free downloads of their articles, like the International Journal of Mental Health Systems. There is a Mental Health wiki and a Wiki Textbook of Psychiatry, and there are many blogs, social media updates and hits in search engines.
Although one can stumble on thousands of mental health hits on this sites and learn a lot, there are no certificates or degrees connected to them, and there is a chance that one get lost in the overload of information and opinions.

Conclusions:
The results of this inquiry are quite disappointing with a slight glance of hope. Can elearning boost the mental health capacity in low income countries? Yes, and there seems no other more feasible solution either. But, the field seems still fragmented and immature. The fees for mental health distance education, for instance, are spinning out of control and what is affordable is mostly not certificated or formally recognized. There are promising developments in the general or public health capacity building sector, but mental health seems often disregarded or forgotten? Like missing the boat.
Although one must avoid too much cyber utopianism, there is so much to win here for the workers in this field and last but not least, for all the people with mental health disorders who are in need of professional and up to date treatment.

Recommendations for the future:
First of all a lot of advocating and lobbying must be done in order to get (online) mental health education on the agenda’s of institutes and policy makers. Although local and national situations must be taken into account, international collaboration seems to be imperative, as well as multi sector and multi layer tuning (academic institutes, international organizations, NGOs, donors, private sector, ICT sector, ministries of health etc.).
Central planning and alignment of accreditation by an international leading body (WPA, WHO, the World Federation for Medical Education?, the Movement for Global Mental Health?) can help avoiding more fragmentation.
Innovative and creative funding (public-private alliances, funding foundations, North-South bilateral initiatives) can help short-circuiting the already lean national budgets and the red tape procedures attached to them.
Or, in order to reduce costs, the high education institutes in low income countries must directly leap from a 1.0 education to a 3.0 education (Derek Keats and J.Philipp Schmidt), where ‘rich, cross-institutional, cross-cultural educational opportunities within which the learners themselves play a key role as creators of knowledge artifacts that are shared, and where social networking and social benefits outside the immediate scope of activity play a strong role’. Jumping into the mental health capacity area 4: Informal learning and Open Source Ware.
But whatever program design one chooses, one must consider the more general needs and circumstances of (rural) students in low income countries, like their financial (dis-)abilities, the often unreliable electricity delivery, the rough environments for the electronic devices, a possible preference for mobile learning and services, and personal or vocational reasons for (temporarily) disruption of education. Other recommendations that are mentioned in a distance learning for health report are the use of mix media and personalized support (face-to-face or via mail/chat) and ‘make sure the logistics work’.
One of the core competencies for mental health workers is effective communication with clients and family members, like structured interviewing, empathic listening, psycho-education, motivational techniques, to mention a few of them. Opportunities to practice with role play and/or get direct feedback on communication skills need to be incorporated. Only ‘learning a theory’ will not be enough. A blend of distance learning and self study with face to face on the job training seems most appropriate in mental health education.
Since mental health seems not a popular or even infamous? work field in low income countries, extra incentives can be put in place like education-job combination contracts, career possibilities, international recognized certificates, sense of ownership and participation, international networking and exchanges (or in the beautiful term ‘collaborative connectivity’), and last but not least propaganda, and a broad acknowledgement, for the fact that working in the mental health sector is great and an honor! isn’t it?
And since educating and supervising others is a time consuming activity, extra incentives must be put in place for professionals in the mental health sector who have the competencies and interest to teach others. Or maybe, as Julio Frenk a.o. in their Health Professionals for a New Century report state: ‘The options that deserve exploration is the short-term placement of graduates from rich countries seeking opportunities to contribute in other countries that are severely deficient in faculty’.
A last point of consideration are the community heath workers or other lay mental health practitioners. In most low income countries they are still the ‘spine of mental health care’ and they will continue to play a crucial role in the future mental health care designs. Targeting them in education programs, taking into account their levels of literacy and lack of formal education, can give the mental health care in low income countries the boost that seems to be so urgent.

Thus, yes it can!
Roos Korste, psychologist and trainer, founder of in2mentalhealth

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