Background and context
Implementation challenges in PRIME
Need to design context-specific implementation approach
Design focused implementation: an overview
Results
Applying design focused implementation to PRIME: a case study
Design focused implementation phase | Outputs |
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Design | Theory of change |
Mental Health Care Plan | |
Service delivery process maps | |
Implementation | Capacity building package |
Implementation support tools | |
PRIME model customized to local context | |
Improvement | Reduction in PRIME model performance gaps |
Design phase: creating a District Mental Health Care Plan
Implementation phase: developing delivery capacity and support systems
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Iteration 1: This iteration involved developing the first version of the tools (checklists, job aids and operating procedures based on the process maps provided to case managers and medical officers) for screening patients, provision of pharmacological and psycho-social interventions, follow-up of patients, procurement and supply chain management of drugs and establishing an information system to monitor progress of various program components. A 2 days training program was offered to medical officers using WHO training materials and a separate 2 days program focusing on both innovation specific capacity (detection of mental health disorders in the community) and general capacity (overview of mental health and stigma reduction) was provided to front-line workers (community health workers) and nurses. Technical assistance was provided through weekly face-to-face meetings with both medical officers and front-line staff with the PRIME project team and quality assurance was performed using a monitoring system that tracked the number of patients detected, treated and referred.
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Iteration 2: Eight weeks after implementation, monitoring data found poor performance on key indicators, unavailability of psychotropic drugs and lack of reporting of mental health indicators in the HMIS system. Based on this data and on interviews with the staff, it became apparent that the linkage between the community and the facility could not be sustained without intense facilitation by PRIME staff. This brought about some improvements, but this model lacked fidelity to the process design because the health system functions were now taken over by program staff. In achieving the balance between fidelity and fit of implementation of an intervention, Castro [32] emphasizes the need for invariance in the core components of a program, and this iteration violated the core design.
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Iteration 3: The implementation strategy for this was based on the learning from iteration 2 but tested a solution that was being promoted by the government in the new District Mental Health Program [33] and for which government resources were potentially available, but which had never been implemented. This involved the recruitment of a new resource called a “Case Manager” who provided screening functions and basic counseling services but also coordinated care within the medical officers. Case managers were also provided with tools and training and weekly support meetings, and this iteration resulted in a significant increase in detection and treatment. More details about the implementation of PRIME are provided elsewhere [30]. Figures 4 and 5 show the progress in detection and treatment of patients with depression and alcohol use disorders across the multiple iterations of the model.××
Improvement phase: optimizing performance
Evaluation phase: using learning to improve implementation
Learning evaluation principles | Ways to assess principle | PRIME evaluation activity |
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Principle 1 Gather data to describe types of changes made by healthcare organizations, how changes are implemented, and the evolution of the change process | Interview with healthcare organizations to establish detailed understanding of the plan for implementing change at baseline by engaging organizational leaders | Theory of change workshops to gain inputs and consensus about how the PRIME model will be implemented |
Use mixed methods to monitor how this plan evolves | Use of monitoring, observational and focus group data to track Mental Health Care Plan execution strategy | |
Principle 2 Collect process and outcome data that are relevant to healthcare organizations and to the research team | Track performance on selected measures at regular time intervals throughout implementation | Monitoring system to track patients diagnosed, treated and referred throughout the implementation |
Principle 3 Assess multi-level contextual factors that affect implementation, process, outcome, and transportability | Collect qualitative and quantitative contextual data in real time | Situational analysis to understand the local service delivery context and barriers in Sehore district |
Conduct rigorous analysis to identify key contextual factors affecting outcomes | Case study to understand how the contextual factors affected the quality of implementation | |
Principle 4 Assist healthcare organizations in applying data to monitor the change process and make further improvements | Assist organizations in learning from their own data to refine their innovations with a focus on continuous learning | Data used for iterative improvements to the PRIME model and for process improvement |
Principle 5 Operationalize common measurement and assessment strategies with the aim of generating transportable results | To conduct internally valid cross-organization mixed methods analyses | Common outcome indicators across the five countries of the PRIME consortium enabling cross-country comparison of outcomes and implementation strategies |