INTEGRATING THE RESPONSE TO NCDS AND MENTAL HEALTH IN THE CONTEXT OF BUILDING RESILIENT HEALTH SYSTEMS IN AFRICA: WORKSHOP SUMMARY DISCUSSION PAPER JANUARY 2024 Francisca Ayodeji Akala Amparo Gordillo-Tobar Rialda Kovacevic Andre Medici Rachel Nugent INTEGRATING THE RESPONSE TO NCDs AND MENTAL HEALTH IN THE CONTEXT OF BUILDING RESILIENT HEALTH SYSTEMS IN AFRICA WORKSHOP SUMMARY Francisca Ayodeji Akala Florence Baingana Amparo Gordillo-Tobar Rialda Kovacevic Andre Medici Rachel Nugent January 2024 Health, Nutrition, and Population (HNP) Discussion Paper This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. 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Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank Group, 1818 H Street, NW, Washington, DC 20433, USA; fax: 202-522-2625; email: pubrights@worldbank.org. © 2024 The International Bank for Reconstruction and Development / The World Bank 1818 H Street, NW, Washington, DC 20433 All rights reserved. ii Health, Nutrition, and Population (HNP) Discussion Paper Integrating the Response to NCDs and Mental Health in the Context of Building Resilient Health Systems in Africa Workshop Summary Francisca Ayodeji Akala,a Florence Baingana,b Amparo Gordillo-Tobar,c Rialda Kovacevicd, Andre Medici,e and Rachel Nugentf a,c,d Health, Nutrition and Population, World Bank, Washington, DC, United States b Regional Mental Health, World Health Organization e,f Consultant, World Bank, Washington, DC, United States Document based on the workshop: Integrating the response to NCDs and Mental Health in the Context of Building Resilient Health Systems in Africa with the participation of government representatives from Eswatini, Ethiopia, Ghana, Kenya, Lesotho, Rwanda, Uganda, and Zimbabwe Abstract: From June 6 to 8, 2023, the Ministry of Health of Rwanda organized an event entitled “Integrating the Response to Noncommunicable Diseases (NCDs) and Mental Health (MH) in the Context of Building Resilient Health Systems in Africa” followed by a technical workshop, with the participation of representatives from the governments of Eswatini, Ethiopia, Ghana, Kenya, Lesotho, Rwanda, Uganda, and Zimbabwe. The event and the workshop were prepared by the World Bank Group (WBG), with support from the World Health Organization (WHO) and with collaboration from United Nations Children’s Fund (UNICEF), the African Centres for Disease Control and Prevention (Africa CDC), and other multilateral agencies and nonprofit organizations. The workshop was under funding provided by the Access Accelerated (AA) Trust Fund. The full program of the event is included at the end of this summary report. The rate of noncommunicable diseases (NCDs) in the African Region increased by 67 percent between 1990 and 2017. In 2019 NCDs were responsible for 37 percent of African deaths, and by the year 2030, they will be the main cause of the burden of disease in the Region. The incidence of mental health (MH) challenges increased by 13 percent in the Region since 2017. In addition, Africa is experiencing high rates of suicide and alcohol abuse, especially among young people. Yet, the average per capita expenditure on MH provision in African countries is US$0.46, with only 1.6 health professionals per 100,000 population working in this field. Primary health care and community-based services are essential strategies to support health systems and to avoid the consequences of early mortality and the social and economic losses brought on by the increased incidence of NCDs and MH. The challenges imposed by NCDs require a stronger collaboration among African countries to see how policies developed in different countries could be adaptative to other regional needs and contexts. iii Countries participating in the workshop shared some achievements and discussed the challenges ahead for the integration of the provision of mental health services and NCDs care at the first level of care. Keywords: Noncommunicable diseases, integrated provision, Africa Region, mental health, suicide, health systems. Disclaimer: The findings, interpretations, and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent. Correspondence Details: Amparo Gordillo-Tobar, 1818 H Street, NW, Washington, DC 20433 USA; telephone: (202) 473-1000; email: agordillotobar@worldbank.org; website: https://www.worldbank.org/. iv Table of Contents RIGHTS AND PERMISSIONS ...................................................................................... II PREFACE ........................................................................................................................ VI ACRONYMS ................................................................................................................... IX PART I – THE EVENT .................................................................................................. 10 PART II – THE WORKSHOP DAY ONE.................................................................... 14 PART III – WORKSHOP DAY TWO ........................................................................... 20 ORIGINAL WORKSHOP AGENDA........................................................................... 25 v PREFACE The rate of noncommunicable diseases (NCDs) in the African Region increased by 67 percent between 1990 and 2017. In 2019 NCDs were responsible for 37 percent of African deaths, and by the year 2030, they will be the main cause of the burden of disease in the Region. The incidence of mental health (MH) challenges increased by 13 percent in the Region since 2017. In addition, Africa is experiencing high rates of suicide and alcohol abuse, especially among young people. Yet, the average per capita expenditure on MH provision in African countries is US$0.46, with only 1.6 health professionals per 100,000 population working in this field. Challenges countries experience in terms of addressing NCDs include underestimating their health, social, and economic impact; vertical and therefore fragmented approach to treating chronic diseases; poor data and information systems; and lack of engagement and support of other sectors in addressing this challenge. Barriers related to the social perception of mental health across the region and beyond include limited access to institutions that provide services and the lack of collective understanding and knowledge to eliminate the mental health stigma toward people living with mental health conditions, which are preventing them from being accepted, integrated into society, or seeking care. In addition, a common challenge faced by people with mental health conditions in everyday life includes one own’s feelings of shame of having the mental health disease, further leading to social isolation (self- stigma). From a health systems perspective, challenges countries are facing include lack of suitable funding, strong governance, appropriate service delivery, and adequate data management. The emerging issues of the epidemiological transition and the double burden of disease in African countries require a greater focus on reducing the cost of tackling NCDs and mental health challenges to increase health benefits for the entire region. NCD and MH challenges are adding to the existing challenges of infectious diseases/maternal and child mortality, making clear the need for an integrated response instead of a siloed approach of competing priorities. There are considerable challenges to integrating NCDs at primary levels of care in Africa, and some of them are related to how to define appropriate strategies for health systems strengthening, improved governance and leadership, and policies aligned with human rights standards. In the area of health financing, it is necessary to identify and map future resource needs. There are five main actions that governments need to take in the fight against NCDs and mental health problems. The first is to increase knowledge about what to do, what to fund, and how to increase efficiency in service delivery. The second is to guarantee the quantity and quality of human resources trained to provide services; the third is to integrate all processes associated with the provision of services, breaking existing silos and working in integrated health teams at all levels of complexity. The fourth is to have sound policies that are backed by strong leadership and collaboration at the highest vi level. And finally, the fifth is strengthening the supply chains, ensuring adequate medicines and medical equipment in the region. Primary health care (PHC) and community-based services are essential strategies to support health systems and to avoid the consequences of early mortality and the social and economic losses brought on by the increased incidence of NCDs and MH. The challenges imposed by NCDs require a stronger collaboration among African countries to see how policies developed in different countries could be adaptative to other regional needs and contexts. Countries participating in the workshop shared some achievements and challenges they are experiencing in terms of addressing NCDs and MH. The Eswatini team concluded with four points: the recognition of the vulnerability of the population living with NCDs to infectious diseases, including the human immunodeficiency virus (HIV); the potential efficiency of increased decentralization and integration of services with expansion of services and decreasing risk to clients; and the urgent need to solve problems in the supply and distribution of NCD medications. The Ethiopia team considered that, given their high social and economic impact, NCDs and mental health conditions ought to be the government’s priorities. However, integration of MH and NCDs in the health system requires reengagements and political will. The main weakness the country is facing is the regional- and district-level low budget allocations. The Ghana team expressed the need to invest in NCDs and MH. Considering the high social and economic return of these investments, the health care system that needs to tackle these health conditions ought to be more responsive. The main challenges the country is experiencing are associated with financing, fragmented health service delivery, and an overwhelmed workforce. The capitation payment pilot has been tested, revealing a potential opportunity to improve efficiency in resource allocation. The lack of accreditation of services at PHC has delayed reimbursement of some facilities debilitating the process of access and care integration. The Kenya group expressed that investing in NCDs is a priority and the country has the goodwill and a supportive policy to support this. However, the main weaknesses are the lack of data and poor use of the existing data; competition in the use of public funds with other programs and scarce resources to develop investment cases; the need for training of the workforce at the PHC) level; and the need for an improved referral process. The Lesotho team identified its priority to integrate NCD and MH into PHC. However, there is a need to invest in infrastructure, promote public health awareness, promote multisectoral coordination, and strengthen the surveillance system for NCDs and MH to achieve the objective. Rwanda shared about the burden of posttraumatic stress disorder in the country affecting MH of its population. Further, the country is facing an aging population, which is creating pressure to tackle NCDs. However, the country has already implemented some interventions to improve NCDs and MH. Weaknesses include the lack of funding, deficient supply chain, and poor staffing at the primary health care level. Opportunities vii include the possibility of public-private partnerships to improve PHC services and specialized care for NCDs and MH. The country is moving to have additional financing funds from the use of sin taxes (alcohol, tobacco, sugared beverages, etc.), and strengthening the corporate social responsibility fund, which is currently poorly coordinated. The Uganda team believes that investments in NCDs and MH will generate better opportunities for the country. It recognized the value digital tools appear to play in achieving this. The main bottlenecks for the country include a lack of institutional capacity, fragmentation of the data collection processes, and the need to utilize benchmarking of international experiences. Zimbabwe participants articulated a need for the country to prioritize investing in addressing NCDs due to the epidemiological transition the country is experiencing. The country's strengths to proceed in this direction include the current formulation of policies and strategies. The weaknesses include limited financial resources, poor data, lack of government prioritization, and a harsh economic environment. There are bottlenecks in integration, such as programming made by silos and a lack of harmonization of national priorities. viii ACRONYMS CDC Centres for Disease Control and Prevention COPD Chronic Obstructive Pulmonary Disease FFS Fee-for-Service HPV Human Papillomavirus MH Mental Health MOF Ministry of Finance MOH Ministry of Health NCD Noncommunicable Disease PHC Primary Health Care RBC Rwanda Biomedical Center SDG Sustainable Development Goal UNICEF United Nations Children's Fund UHC Universal Health Coverage VBHC Value-Based Health Care WBG World Bank Group WHO World Health Organization ix PART I – THE EVENT Dr. Francisca Ayodeji Akala, Practice Manager of Health, Nutrition, and Population at the World Bank Group (WBG) in Africa opened the event by highlighting that the emerging issues of the epidemiological transition and the double burden of disease in African countries require a greater focus on reducing the cost of tackling noncommunicable diseases (NCDs) and mental health (MH) challenges to increase health benefits for the entire region, emphasizing the role of primary health care (PHC) in this process. Box 1 shares Main Lessons Learned from the Event. Box 1: Main Lessons Learned from the Event • The burden of noncommunicable diseases (NCDs) and mental health (MH) conditions is rapidly increasing in African countries. The current response from governments, with the support of international partners, has been insufficient to meet the growing demand. Political commitment, strong leadership, and additional public funds are needed to address these issues. • Integrated health policy is key for addressing NCDs and MH in a dual way: integrating and aligning all levels of service delivery to coordinate the health response and integrate NCDs and MH into primary health care (PHC). However, most countries do not have a clear view about how integration should be done. • Countries need to build and/or upgrade NCD and MH reporting systems (such as electronic medical records, costing systems integrated with service delivery, and outcome evaluation registries) to increase coverage, improve outcomes, and provide sustainable funding. • PHC and community-based services are essential strategies to support health systems and to avoid the consequences of early mortality and the social and economic losses brought on by the increased incidence of NCDs and MH. • Supply chain issues are common. Stock-outs occur, prices are too high, and procurement is inefficient and fragmented. Costs of medicines are unaffordable both to government and households. • NCDs and MH strategies are underfunded and poorly managed in most countries, making the current system unsustainable in the long term. Sustainable and efficient financing to reduce the burden of NCDs and MH is urgent. • NCD challenges are adding to the existing challenges of infectious diseases/maternal and child mortality, making clear the need for an integrated response instead of a siloed approach of competing priorities. World Health Organization (WHO) Country Representative in Rwanda, Dr. Brian Chirombo, highlighted that NCDs are already responsible for 37 percent of African deaths in 2019 and, by the year 2030, will be the main cause of the burden of disease in the Region, with a strong impact in early mortality and poverty increasing the financial needs of the health systems. Dr. Chirombo emphasized the emergence of mental health challenges, whose incidence has increased by 13 percent in the Region since 2017, despite accounting for less than 2 percent of government health expenditure. This situation requires integrated and strategic investments in NCDs and MH promotion and prevention to avoid early mortality and morbidity associated with NCDs and the increased incidence of mental illnesses that drain opportunities for regional economic and social development. 10 Dr. Sabin Nsanzimana, Minister of Health in Rwanda, spoke on the emergence of NCDs and MH in Africa, which can be addressed by consistent policies on promotion, prevention, and community services, to avoid the increasing burden of morbidity and mortality, save lives, and increase efficiency of economic resources used in the health sector. Dr. Nsanzimana highlighted the path to achieve this by implementing a Four “S” Strategy to address NCDs and mental health in Africa. The first “S” stands for “Staff” (training and retention of personnel); the second is “Space” (infrastructure—building sound and long-lasting facilities, including health posts and well-equipped health centers); the third is “Systems” (creating technical and operational solutions to prevent and support care through sound policies and strategies); and the fourth is “Supplies” (providing all necessary inputs, such as medicines and equipment, preferably through local production). According to the minister, it is critical to change the regional culture and increase individual responsibility and action on “what we eat and how we move. If we want to fight NCDs, we must also set good examples in our communities,” he said. A telltale sign of whether the system is on the path to achieving universal health coverage is if those receiving services have truly benefited from implemented changes. Godfrey Kagaayi, a mental health advocate from Uganda, pointed out that there are internal and external barriers/challenges to be faced when dealing with mental health issues. The external barriers/challenges related to the social perception of mental health include limited access to institutions that provide services and the lack of collective understanding and knowledge to eliminate the mental health stigma toward people living with mental health conditions that prevent them from being accepted, integrated into society, or seeking care. A common challenge faced by people with mental health conditions in everyday life includes one own’s feelings of shame of having the mental health disease further leading to social isolation (self-stigma). To face these internal and external barriers, social behavioral changes are needed. Increasing openness to listening to young people seeking care and sharing their stories is key to finding resilience and hope for people living with mental health conditions. It is also important to support systems and empower people with information about mental health conditions. Mental health policies must be human-centered and need to ensure that people with lived experience are at the center of the problem to be solved. At the political level, people's lived experiences must be included in the political framework. The topic of Economic Savings and Perspectives to Finance an Integrated Response to NCDs and Mental Health in the Context of National Health Policies towards Resilient Health Systems in Africa was addressed in more detail by representatives of three countries: Ethiopia (Dr. Hiwot Taffese Solomon), Ghana (Dr. Daniel Nuer Atwere), and Lesotho (Dr. Maneo Molliehi Ntene). Dr. Solomon expressed that MH-NCDs are a top priority for the government of Ethiopia. Ethiopia’s share of NCDs in the health budget increased from 11 percent to 25 percent between 2017 and 2020. At the same time, the government adopted an integrated health service delivery strategy, avoiding the creation of silos in the implementation of disease treatment policies and focusing on improving cost- effectiveness and better service user outcomes. The remaining challenges in NCDs and MH are the lack of human resources to address risk factors and the lack of coordination of case management. In Ethiopia, health strategies and policies are people-centered. There are associations representing different groups of diseases, and their voices and challenges are represented in biannual review meetings, where these associations are invited to express their claims and demands. 11 Dr. Atwere, (Ghana's Ministry of Economy), explained that sources of funding and revenue for health are provided by the national budget (10 percent of tax revenues) and donors/partners (20 percent of the health budget). Resources are complemented by private insurance schemes and out-of-pocket expenses. On the revenue side, some earmarking mechanisms help to generate additional resources to finance government spending. For example, excise taxes (2.5 percent) are earmarked for health. Health taxes have been levied on tobacco, alcohol, and sugary drinks to improve health behaviors. This has generated additional revenue, but not essentially for the health sector. On the expenditure side, investments in health infrastructure were exempt from taxation. However, the positive impact of removing value-added taxes on medicines was offset by the increase in the cost of pharmaceuticals. The Ministry of Finance (MoF) oversees Ministry of Health (MoH) funds to ensure they are used efficiently by participating in various MoH committees, including those associated with NCDs and mental health spending. About 50 percent of government health funds go toward paying salaries and wages in the sector. Dr. Ntene, from Lesotho, highlighted the elevated prevalence of MH issues in the country (20.8 percent of the population) associated with high levels of poverty and stunting in comparison to other countries in the region. NCDs and MH conditions are emerging problems in the country, and the government is introducing mechanisms to prevent NCDs by increasing the tax burden on tobacco, alcohol, sweetened beverages, and other, so-called sin taxes. Community health workers at the district level have been critical for care provision for NCDs and MH for the poor. Lesotho is improving infrastructure for NCDs, such as constructing a cancer treatment center and working to ensure the availability of health care workers and medicines in the poorest communities and rural underserved areas. Following this panel, a discussion about the Region’s vision of future collaboration and partner support in combating chronic conditions and addressing mental well-being in Africa included the participation of Dr. Florence Baingana, (Africa Regional Adviser for Mental Health and Substance Abuse, WHO); Dr. Adelard Kakunze, (Head of the Division for Disease Control and Prevention of the Africa Centres for Disease Control and Prevention, CDC); Dr. Juliet Nakku (Executive Director of the Butabika Hospital, Uganda); and Dr. Mary Flaviane Nyngasi (Head of National Cancer Control of Kenya). Dr. Baingana highlighted that there are three main actions that governments need to take in the fight against NCDs and mental health problems. The first is to increase knowledge about what to do, what to fund, and how to increase efficiency in service delivery. The second is to guarantee the quantity and quality of human resources trained to provide services; and the third is to integrate all processes associated with the provision of services, breaking existing silos and working in integrated health teams at all levels of complexity. To implement these key actions, WHO has developed supporting material for learning and guidance for countries in this process. In addition, WHO is supporting countries to integrate NCDs and mental health, facilitating access to existing global funds for health financing, as well as developing small projects for this purpose in five African countries. Dr. Kakunze presented the role of Africa CDC on NCD and MH issues detailing its institutional strategy, which includes six key priorities: (i) Prepare African countries to develop and integrate strategies for NCD, mental health conditions, and injuries; (ii) Strengthen commitments and countries’ capabilities to resource allocation for these 12 purposes; (iii) Promote multisectorial coordination between health and other sectors toward the proposed integration of NCD, MH issues and injuries; (iv) Promote stable and trained health workforce, starting at community levels and developing models for task sharing and task shifting in these areas; (v) Promote sustainable funding and coordinate with donors to ensure that there are shared funds for NCDs and MH; and (vi) Promote access to vital technologies, medicines, and diagnostics to reduce dependency on outside sources. In the past two years, Africa CDC has organized two capacity-building workshops to increase the implementation capacities of member states. Dr. Nakku discussed what can be done to support NCD and MH policies in Uganda, prioritizing the need to implement strategies to increase knowledge about risk factors and adequate behaviors at a community level. Dr. Nakku explained that self-awareness of the population is crucial to reducing risks at an individual level. In the health system level, it is vital to increase the leverage of resources at the primary health care level, strengthening the role of PHC workers in promotion and prevention, and increasing their ability to deliver patient care. There is a huge lack of personnel and PHC workers who need to be contracted and appropriately trained to be able to manage their tasks under the umbrella of an integrated NCD health care model. Monitoring and evaluation are essential functions to ensure proper planning and to translate data into actionable health delivery. It is necessary to define and develop indicators that could be obtained through digitalization and electronic medical records. PHC policies need to be better designed and costed and the engagement of the Ministry of Finance is essential to assure the sustainability of all these needs. Dr. Nyangasi discussed the agenda that is underway in Kenya. It is focused on developing legal frameworks to address the risk factors and long-term vision of NCD and mental health in the country, highlighting the key points of a transformative agenda that leads to NCDs care, discussing how the country can develop a governance mechanism that will ensure a multisectorial and countrywide approach to NCDs. This includes (i) integration of NCD research into other population surveys; (ii) implementation of research focusing on best practices to inform proper planning and policy development; (iii) support to build national teams to deliver on their mandate in terms of laws regarding NCDs; and (iv) the health system approach, focused on how to strength leadership, service delivery, and health information systems related to NCDs. Closing remarks for this discussion, by Professor Claude Mambo Muvunyi (from Rwanda Biomedical Center, RBC), highlighted that the challenges imposed by NCDs require a stronger collaboration among African countries to see how policies developed in different countries could be adapted to other regional needs and contexts. He also highlighted the need to discuss new strategies to convince policy makers to prioritize investing in NCDs and mental health issues. This day concluded with a visit to the Kigali Genocide Memorial. It is the final resting place for 250,000 victims of the tragic events in the 1990s. The memorial stands witness to Rwanda's extraordinary journey toward healing and reconciliation after the genocide and provides a clear insight into the scale of mental health issues related to collective violence, stigma, and discrimination, as well as the Rwandan government's way of reversing this dramatic situation along the years after the tragedy. 13 PART II – THE WORKSHOP DAY ONE Mr. Claude Mambo Muvunyi, Director General, Rwanda Biomedical Center, and Dr. Francisca Ayodeji Akala, Practice Manager of Health, Nutrition, and Population at the WBG in Africa, set the stage for the two workshop days highlighting the need to look at other allies beyond the health sector, and the need to discuss the NCD and MH agenda for each country to show what can be learned and adapted for each country’s context. Box 2 shares Main Lessons Learned from the Event. Box 2: Main Lessons Learned from the Workshop (Day 1) • Integration of noncommunicable diseases (NCDs) and mental health (MH) services into primary health care (PHC) can be enabled by mapping current health system loopholes, accessing existing infrastructure, receiving technical support for tailored solutions, and coordinating with international partners for support in knowledge-sharing and technical assistance. • Gaps in governance, funding, service delivery, medicines, technology, trained workforce, surveillance systems, and research for management solutions are some of the top regional priorities that need to be addressed. • The average per capita expenditure on MH provision in African countries is US$0.46, with only 1.6 health professionals per 100,000 population working in this field. There is insufficient coverage, quality services, and lack of data systems for monitoring and evaluation. Most countries offer insufficient pharmacological and psychological interventions compared to growing needs. • The region is experiencing high rates of suicide and alcohol abuse, especially among young people. The low investment in MH has entailed high indirect economic costs for families, representing significant losses and challenges for economic growth. • To respond to the challenges in MH service provision, some countries are formulating strategies to integrate NCD and MH services, preparing investment cases centered on integration mechanisms, involving governance and leadership, financing, human resources, and information technology. International partners such as the World Bank Group (WBG) and the World Health Organization (WHO) have provided financial and technical support for investment cases. • The WBG is supporting in-depth analysis and discussion on NCDs and MH, funding framework policies and implementation guidelines to integrate NCDs and MH into PHC using funds for reforms of existing programs. It is also supporting referral and counterreferral systems, as well as identifying resource needs and strategic actions. The World Bank also plans to increase this support by combining its financing with the governments’ own resources and coordinating with international partners. • Integrating NCDs and MH improves health outcomes, increases service efficiency, and generates higher-quality interventions at lower cost. Given the fragmented structure of health services in Africa, some countries are implementing efficient integrated interventions to improve service user satisfaction and increase access to services and quality of care. Rwanda Health Insurance, for example, is building an integrated framework for mental health and NCDs in primary health care facilities (419 of the 508 health centers run by nongovernmental organizations [NGOs] and community health services). • Selecting proper payment mechanisms for NCD and MH improves efficiency and sustainably. Transforming simple itemized budgets or fee-for-service (FSS) schemes into global schemes or bundled payments linked to performance, results, or value incentives are targeted solutions to achieve better results. 14 Dr. Amparo Gordillo Tobar, Senior Economist of the WBG complemented the introduction by explaining the dynamics of the working group activities and the expected outcomes for the next two days, consisting of a country assessment of the integration of MH and NCDs, and a discussion of plans at short, medium, and long term, to implement them. The next panel presented the Public Health and Development Challenge of NCDs and MH in Africa. The panel discussed the NCDs and MH burden of disease in the countries and their connection to the Social Development Goals (SDGs), setting the stage in identifying key gaps in health systems. This session's participants were Adelard Kakunze (from Africa CDC), Muhamed Ould Sidi (from WHO in Africa), and Florence Baingana (from WHO in Africa). Dr. Kakunze presented the Africa CDC as a regional technical specialized institution acting as an autonomous agency of the African Union. He emphasized the six African CDC strategic priorities (mentioned the day before) and addressed the increasing awareness about NCDs, injuries, and mental health in the continent. He also noted that the Africa CDC published a specific study about NCDs in the continent focusing on the need to integrate NCDs at primary health care levels. Dr. Sidi presented the role of WHO in the Africa Region and its five priorities concentrated on addressing (i) cardiovascular diseases, (ii) cancer, (iii) chronic respiratory disease, (iv) diabetes, and (v) mental health. He also highlighted that low- income countries in the region are experiencing the highest burden in these five conditions. From a health systems perspective, challenges are mainly seen in funding, governance, service delivery, and data management. Jointly with the support of Africa CDC, they are developing indicators to achieve better focus on government priorities in areas such as NDCs and MH conditions. Dr. Baingana highlighted the existence of frequent humanitarian crises that further impact the mental well-being of the population. Suicide rates in Africa are the highest globally and are the sixth-leading cause of mortality in the continent. Several challenges affect young people’s MH status, such as the frequent use of alcohol among children between 13 and 15 years of age. MH conditions severely affect work performance among young adults. Governments are frequently challenged when trying to implement measures to improve the situation. Conflicts with the alcohol industry weaken governments’ positions to increase taxes for alcohol, for example. To face these challenges, WHO is supporting African countries in developing policies, preparing investment cases, and supporting special initiatives to improve MH programs and promote their integration with health services. However, the big challenge is how to increase the number of MH specialists. The third panel focused on How NCDs and MH Conditions Could Be Included under the Umbrella of Universal Health Care Coverage (UHC). The panel discussed the needs of NCD and MH services regarding health system strengthening and service delivery. Dan Chisholm (health economist, from WHO), and Noel Chisaka (health specialist from the WBG) presented in this panel. Dr. Chisholm, from WHO, defined the roots of the increasing need to strengthen health services and the accompanying challenges. Considering that the rate of NCDs in the Africa Region increased by 67 percent between 1990 and 2017, many challenges 15 started to come up, such as the need to (i) consider a different approach to health promotion, disease prevention, and treatment, suited to chronic conditions; (ii) avoid fragmented approaches and increase integration among health care delivery levels; (iii) address inadequate funding and information constraints to access better health care; (iv) reduce the inequity in access to and regional and social distribution to health services; and (v) improve coordination and collaboration within and beyond the health sector. Global and regional frameworks of action to address NCDs, MH conditions, and their underlying risk factors are available to guide local action, including addressing PHC and universal health care (UHC). There are considerable challenges to integrating NCDs at PHC levels in Africa, and some of them are related to how to define appropriate strategies for health system strengthening, improved governance and leadership, and policies aligned with human rights standards. In the area of health financing, it is necessary to identify and map future resource needs. In terms of human resources, the challenge is in how to promote evidence- and competency-based training of nonspecialists. Dr. Chisaka, from the WBG, discussed health system strengthening, highlighting the need to link health policies with economic development policies. For well-performing PHC, strengthening all levels of care is required, speeding up health care provision by breaking institutional and facilities’ barriers to access. After these two panels, a round of discussions took place with questions to all presenters. Most of the questions were focused on the following aspects: o Practical solutions and next steps for improving the implementation of NCDs and MH provision to be implemented in complex health systems focused on service delivery, data systems, outcome indicators, and human resources. o How PHC could be funded and managed? PHC tends to be understaffed, reducing the opportunities for providing quality services. Leveraging community health workers is essential as PHC strategies need to focus on the community level of care. o NCD and MH issues increase the pressure for additional investment at PHC levels, as well as reorient this level to be organized to attend to acute and chronic cases, as has been done in South Africa. o Integration between different levels of care requires rethinking health functions, patient flows, and processes. o To avoid delays and inefficiencies it is better to focus on simple solutions that can be implemented in the shortest time, and could be scalable. o Part of the governance on implementation requires a meaningful engagement of patients, communities, and families with lived experience of NCDs and MH problems. The experience of the Global Fund is a good example of how these experiences could be implemented with different stakeholders. In this process, community health committees can play a critical role. 16 The workshop further looked at addressing Economic and Health Benefits Arguments for the Integrated Provision of Care. The panel was moderated by Dr. Noel Chisaka, from the WBG; and with the participation of Dr. Regis Hitimana, chief benefits officer, Rwanda Social Security Board; and Dr. Rachel Nugent, WBG consultant and associate professor of the Department of Global Health of the University of Washington State (USA). Dr. Hitimana, from the Rwanda Social Security Board, discussed the challenges of Health System sustainability, such as fast technological changes and aging populations leading to costly health care; increasing social inequities; changing expectations of the population about what the care delivery should be; and growing costs of inputs in health care delivery, such as for medicines, equipment, and human resources (not only training but also remuneration). Countries such as Rwanda face problems related to the exodus of health workers to developed countries. The issue to address is how to avoid the drainage of health investments in human resources. Further, fragmented insurance systems are inefficient. Research findings support the reorientation of health care systems toward integrated care to meet increased demand with tight budgets. There are positive results of integrated care in MH and NCDs, generating improved economic and health outcomes, such as lower costs for treated cases and reduction of mortality. Health care integration leads to more efficient services and more cost-effective interventions. Health Insurance Systems are interested in the most efficient and cost- effective interventions to achieve patient satisfaction, and increase access to services and quality of care. Dr Nugent, from the University of Washington State (USA), discussed the preparation process and methodology for investment cases in NCDs and Mental Health. The economic impact of inaction in health care underscores that the world cannot afford to stand by and watch NCDs destroy families and individuals. Developing an investment case for NCDs and MH conditions can be a powerful tool to draw attention to their burden. Nonetheless, a proper process and methodology ought to be used. The purpose of the investment cases is to provide supporting evidence to fight against this disease burden and to create feasibility of actions, by identifying the effective and locally relevant interventions, and offering policies and planning guidance. Some key questions to have in mind as an investment case is being built include What are the right tools to address the needs? What does the investment case tell us that we do not already know? Who needs to be involved? Where is the money for implementation coming from? Some countries such as Kenya have achieved success thanks to the well-conducted investment case that brought visibility to health goals, accelerated progress on the implementation of UHC, and accelerated investments and resource mobilization. As set out by Dr Nasri Omar, (MoH Kenya), the investment case covered large NCDs, such as cancer, cardiovascular diseases, chronic obstructive pulmonary disease (COPD), and mental health, mapping their burden of disability, needed clinical interventions and human resources, and policy measures; and estimating the financial costs of the interventions and measuring social losses associated with these diseases, such as loss of social benefits to families and communities. The Kenya investment case showed that prevention of cervical cancer (early diagnosis and human papillomavirus [HPV] vaccine delivery), for example, has high cost-benefit ratios, saving 359,000 lives with costs lower than 6 percent of the government’s health expenditure. However, the implementation of investment cases needs political commitment, early engagement of stakeholders, affordability of the planning process, and institutional capacity of both the Ministries of 17 Health and Finance. Nonetheless, it is equally relevant to identify constraints of the system regarding technical assistance and monitoring and evaluation in each stage of the process to demonstrate the effectiveness of the use of the resources. The fifth panel of the second day addressed the questions of Financing and Payment Mechanisms for MH: A Proposal for a Regional View of the Expenditure in Mental Health in Africa. The panel was moderated by Dr. Rogers Ayiko (World Bank) and consisted of a joint presentation by Dr. Amparo Gordillo-Tobar (senior health economist of the World Bank) and Dr. Andre Medici (senior health economist retired from the World Bank and consultant of the same institution). Dr. Gordillo-Tobar presented the meaning and relevance of provider-payment mechanisms, detailing what services and mechanisms are currently available for NCDs and mental health services. She showed a rational framework for understanding the existing payment mechanisms and how these mechanisms should support the process of integrating health care provision. Having a framework and understanding how these mechanisms support the process of integrating health care provision of services is the first step in utilizing this health system lever correctly. NCDs are associated with aging processes, and multimorbidity demands the use of more technology for treatment and usually costs more. All of this requires specific payment systems linked with integrated care. She also presented the results of a survey on mental health financing and payment systems in Latin America and the Caribbean Region, and shed some more light on how countries are struggling to pay for mental health services with traditional payment systems. Dr. Medici discussed mental health spending according to the countries’ income profile, emphasizing that no one solution fits all countries. Nonetheless, to achieve integration of the provision of health services at the first level of care, reforming primary care payment systems is critical. Fee-for-service (FFS) payment systems could be used in situations where services’ provision is scarce to attend to needs, but it is important to remember that the FFS could induce duplications and waste of resources when services are provided beyond the needs. The international experience recommends payment systems for NCDs linked to outcomes. However, results-based payment systems need powerful data and structured information systems to measure outcomes and health service costs as requirements to be implemented. Payment systems need to optimize resource allocation. Value-based health care (VBHC) payments, linked with results, are associated with better care for patients, and better health for the population because they create the basis to promote healthy behaviors and to implement prevention measures. Promoting policies for healthier populations also contributes to lower costs associated with better health outcomes. During the discussion, the participants highlighted questions associated with the long way ahead to implement VBHC in African countries, the difficulties associated with purchasing and costing health care in NCDs and mental health due to their complexity, the lack of a culture of monitoring and evaluation, and other related issues. Dr. Amparo Gordillo Tobar introduced the subjects for work in small groups to wrap up the questions discussed in the last days focusing on the reality of each one of the eight countries participating in the workshop. The first round of discussions was based on two questions: (i) Why does investing in NCDs and MH matter in the broader health system context of your country? and (ii) What are the current payment mechanisms existing for 18 NCDs and Mental Health in your country or which do you think will be feasible to implement? The sixth panel of the second day presented the following subject: Protecting the well- being of vulnerable populations: Children and Adolescents; Gender and Violence, and Poverty Groups. The panel was moderated by Dr. Tengile Tsabedze, from the World Bank, and included Dr. Juliana Lindsley (country representative of UNICEF in Rwanda) and Dr. Richard Johnson from the Healthy Brains Global Initiative (HBGI). Mental health interventions require flexibility, adaptability, and focus on performance. Focusing on social outcomes and shifting analytical approaches to practical implementation and program delivery seems one of the tested approaches in achieving results. Dr. Lindsley concentrated her presentation on the need to focus on social protection and childhood behaviors to protect children from future mental health problems. NCDs are largely neglected among children, and it is necessary to move toward a multisectoral approach to prevent and avoid complications of NCDs in children. In Africa, one in seven adolescents aged 10–19 years have mental health challenges and need psychosocial support, especially in the early years. Therefore, early detection of mental health issues is crucial. UNICEF has focused its efforts on health management information systems and community engagement of children and young people. However, Improving the mental health of children requires the assurance of the caregiver’s mental health, and unfortunately that is not always the case. UNICEF, for example, focuses its efforts on health management information systems and community engagement of children and young people. Dr. Johnson focused on the need for social outcomes, which are critical for programming, shifting the analytical approach to practical implementation and program delivery. Mental health interventions require flexibility, adaptability, and focus on performance. 19 PART III – WORKSHOP DAY TWO After a short recap of the second day, conducted by the World Bank team, the first panel of the last day was about the Integration of NCDs and MH at the Primary Level of Care in Africa, presenting the experience of three countries about the Integration of Disease Management in the Provision of the First Level of Care, as well as actions that can be taken in this direction across different sectors. Box 3 shares Main Lessons Learned from the Event. Box 3: Main Lessons Learned from Day 3 The third day was dedicated to address the gaps of integration of noncommunicable disease (NCD) and mental health (MH) service delivery, discussing how this integration works at the primary or first level of care, as well as pointing out the critical elements for achieving effective reforms of health systems that include NCDs and MH. Uganda gaps include inadequate capacity at primary health care (PHC) due to issues of training and information gaps because of underreporting. Kenya is using digital platforms to improve data quality and availability. Quality improvement initiatives are being utilized in several ways for NCDs and MH. However, the need for additional training for health workers was also mentioned. Rwanda is working on investigating home deaths and strengthening cause of death registrations. It started implementing community health worker programs to address NCDs and MH screening and referral. Ghana is developing a mapping exercise to identify nongovernmental organizations (NGOs) that can collaborate and integrate Ministry of Health (MoH) priorities on these areas. Lesotho is fighting to increase the limited resources applied to MH services, and Ethiopia is enabling district information systems to better map the needs of MH and NCD financing. General gaps found in all countries are associated with capacity-building, data management, availability of medicines at the PHC level, and inadequate funding. There is no magic bullet for integrating NCDs into PHC, and it is necessary to build a costing matrix for integration. Most countries have integrated NCDs and MH in their documents and strategies, without practical solutions for real integration at the services level. There are some lessons about working with other sectors and improving information systems. Uganda has integrated NCD/MH with disaster preparedness. Issues of financing and payment mechanisms were highlighted as critical elements in designing essential health reforms to improve NCDs and public health service delivery. It is necessary to promote organized discussions at the country level to address how to design program partnerships and specify possible interventions. The panel was composed of Dr. Kenneth Kalani Okware, from the Ministry of Health of Uganda; Dr. Francois Uwinkindi, manager of the NCDs, Division, Ministry of Health of Rwanda; and Dr. Steven Mutiso, lead of the Renal Program and NCDs of the Ministry 20 of Health of Kenya. The panel was moderated by Dr. Rialda Kovacevic, a Health Specialist at the World Bank. Dr. Okware presented the state of NCDs and mental health in Uganda discussing the policies developed and implemented and the system’s responses during emergencies. In addition, in the country other sectors have contributed to supporting MH policies. However, the country is facing a challenge of limited funding and lack of management capacity to provide services and supplies, and low priority of NCDs due to the nation’s limited awareness of the strain they put on the country’s overall well-being. Dr. Uwinkindi presented the status of NCD control in Rwanda, mentioning that while deaths are reported, the causes of death are poorly reported. However, the country is improving its reporting system of causes of death. Data from the health facilities show that NCDs are the cause of death for 39 percent of the Rwandan population, and 70 percent of these deaths occur at home. Verbal autopsy programs have been implemented at a community level to capture this data. Rwanda is also investing in training human resources for NCDs at primary care levels. Dr. Mutiso discussed the status of NCDs in Kenya, showing pilots to facilitate the identification of NCD acute episodes at home and improve the transportation system by ambulances to reduce the gap in NCDs being addressed. Following this panel, the World Bank team introduced a new subject for the country teams to work in small groups, focusing on two questions: (1) What are the bottlenecks limiting integration in your country? and (2) What will it take to address them? The second panel of the last day was about What Do NCDs, and MH Mean for Africa? This panel proposed the discussion about what countries are doing to respond to contemporary NCDs and MH challenges, addressing what are the critical elements to achieve effective health system reforms that include NCDs and MH. The panel was moderated by Dr. Patrice Mwitende (World Bank), with the participation of the country teams of Ghana, Lesotho, and Ethiopia. The team from Ghana presented the status of NCDs and MH in the country, focusing on preventive health care and the work of wellness clinics. This work includes the provision of health talks in schools where teachers are trained to screen for mental health among the kids. The government is developing a mapping exercise to identify all possible NGO partners in NCDs and MH to link their actions with Ministry of Health priorities. An NCD multisectoral committee was formed to define country priorities and to encourage NGOs to work in the geographic areas deprived of services. Ghana developed an investment case to add MH services to the benefits package of the National Health Insurance. The challenge is that MH services are provided free of cost to the population, according to the country’s Mental Health Act. The team from Lesotho presented the status of mental health status in the country, pointing out that one in five persons suffer from mental health illness (20.8 percent). The team also presented the structure of mental health delivery services in the country, identifying some of the gaps, such as staff, space, supplies, information, and support systems. Resource allocation for mental health is limited to 1.8 percent of the government's national health budget. Several actions need to be in place to improve MH services, including advocacy for the integration of MH in health facilities, updates on the 21 mental health law and guidelines, and improved awareness in the community about MH issues. The team from Ethiopia presented the status of NCDs and MH in the country, discussing how the district information systems are starting to include data on mental health expenditures and current payment mechanisms used to remunerate services. The third panel of the last day discussed the question of NCDs and Mental health Prevention, Promotion, and Protection. The panel focused on Integrated Action to Reverse NCD-Related Public Health and Development Threats in Africa. The panel was moderated by Dr. Rachel Nugent (University of Washington State – USA) and presented by Dr. Manuel Sibhatu (Director, Resolve to Save Lives in Ethiopia) and Dr. Adelard Kakunze (Africa CDC). Dr. Sibhatu’s presentation showed the work of the Resolve group on increasing clients’ access to NCD medicines in Ethiopia, tackling questions related to procurement, supply chains and the effort to use generic drugs, and the issues on regulation and sustainability, among others. Dr. Kakunze highlighted the work of the CDC with the African governments to pass preventive regulations for banning trans-fat products (31 governments in Africa had already done so), to include essential NCD medicines in the national lists of essential drugs, and to improve the accuracy of health diagnosis by using electronic records. Following this panel, the World Bank team proposed group work addressing the following questions: (1) How to design programs and build partnerships across sectors? and (2) How to monitor potential interventions? The fourth panel of the last day launched the discussion of NCDs and Mental Health Service Development and Reforms. Rwanda, Eswatini, and Zimbabwe shared an overview of key elements of balanced and comprehensive NCDs and mental health services and their major challenges. The panel was moderated by Dr. Florence Baingana. The Rwanda team shared the country’s progress in the reduction of cervical cancer, where the country was able to diagnose 55 percent of cases and cover 97 percent of the target population for HPV vaccination. The Eswatini team also described their efforts on scale-up service delivery and integration of NCDs and MH. The Zimbabwe presentation was focused on improvements related to cervical cancer services delivery and in the establishment of MH policy boards. The county also completed a MH investment case, showing the benefits and results of better investments in this policy. The last activity was the presentation and discussion of the working groups’ responses to the questions formulated and discussed during the workshop. This section was moderated by Dr. Amparo Gordillo-Tobar (World Bank) and presented the country’s future alignments with NCDs and MH priorities and the constraints in the short and medium terms. Box 4 presents the questions discussed in the working group during the workshop. 22 Box 4: Questions Discussed among the Country´s Working Groups 1. (a) Why does investing in noncommunicable diseases (NCDs) and mental health (MH) matter in the broader health system context of your country? (b) What are the current payment mechanisms existing for NCDs and MH in your country, or which do you think will be feasible to implement? 2. (a) What are the bottlenecks limiting integration in your country? (b) What will it take to address them? 3. (a) How to design programs and build partnerships across sectors? (b) How to monitor potential interventions? 4. What will it take to scale up NCDs and mental health services and move toward UHC? The Eswatini team concluded with four points: recognition of the vulnerability of the population living with NCDs to infectious diseases, including HIV; the potential efficiency of increased decentralization and integration of services with expansion of services and decreasing the risk to clients; and the urgent need to solve the problems in the supply and distribution of NCD medications. The Ethiopia team considered that, given their high social and economic impact, NCDs and mental health conditions ought to be the government’s priorities. However, integration of MH and NCDs in the health system requires reengagements and political will. The main weakness the country is facing is the regional- and district-level low budget allocations. The Ghana team expressed the need to invest in NCDs and MH. Considering the high social and economic return of these investments, the health care system that needs to tackle these health conditions ought to be more responsive. The main challenges are associated with financing, fragmented health service delivery, and an overwhelmed workforce. The capitation payment pilot has been tested, revealing a potential opportunity to improve efficiency in resource allocation. The lack of accreditation of services at PHC has delayed reimbursement of some facilities debilitating the process of access and care integration. The Kenya group expressed that investing in NCDs is a priority, and the country has a goodwill and supportive policy to support this. However, the main weaknesses are the lack of data and poor use of the existing data; competition in the use of public funds with other programs and scarce resources to develop investment cases; the need for training of the workforce at the PHC level; and the need for an improved referral process. The Lesotho team identified its priority to integrate NCD and MH into PHC. However, there is a need to invest in infrastructure, promote public health awareness, promote multisectoral coordination, and strengthen the surveillance system for NCDs and MH to achieve the objective. The Rwanda team shared the huge burden of posttraumatic stress disorder in the country affecting the MH of its population. Further, the country is facing an aging 23 population, which is creating pressure to tackle NCDs. However, the country has already implemented some interventions to improve NCDs and MH. Weaknesses include the lack of funding, deficient supply chain, and poor staffing at the primary health care level. Opportunities include the possibility of public-private partnerships to improve PHC services and specialized care for NCDs and MH. The country is moving to increase financing funds from the use of sin taxes (alcohol, tobacco, sugared beverages, etc.), and strengthen the corporate social responsibility fund, which is currently poorly coordinated. The Uganda team believe that investments in NCDs and MH will generate better opportunities for the country. They recognized the value digital tools appear to play in achieving this. The main bottlenecks for the country include a lack of institutional capacity, fragmentation of the data collection processes, and the need to utilize benchmarking of international experiences. Zimbabwe’s participants articulated a need for the country to prioritize investing in addressing NCDs due to the epidemiological transition the country is experiencing. The country's strengths to proceed in this direction include the current formulation of policies and strategies. The weaknesses include limited financial resources, poor data, lack of government prioritization, and a harsh economic environment. There are bottlenecks in integration, such as programming made by silos and a lack of harmonization of national priorities. Summary of Countries' Challenges and Perspectives on Noncommunicable Diseases and Mental Health Common challenges Needs for successful integration 1. Understaffed at PHC level 1. Multisectoral coordination 2. Supply chain challenges 2. Strong data systems designed and used 3. Implementation of sin taxes for 3. Scaling up integration at PHC NCDs/MH 4. Training primary health care workers 4. Sectoral competition for resources 5. Financial resource mobilization 5. Lack of country data on costs of NCDs/MH Cross-cutting issues Priority areas to work 1. Ensure sustainable financing for 1. Focus on addiction and substance abuse NCDs/MH 2. Reorganization to address budget issues 2. Out-of-the-box thinking to raise 3. Integration: move from disease to a funding person-centered service 3. Addiction is a rising concern in 4. Increasing health staff number at the PHC Africa 5. Stabilized and innovative supply chain 6. Capacity-building on integration 7. Delivery of health care at the community level 8. Coordination of the interventions Notes: PHC = Primary health care; NCDs = Noncommunicable diseases; MH = Mental health. 24 ORIGINAL WORKSHOP AGENDA Day 1. June 6 – Health systems strengthening and the integrated provision of NCDs – Mental health in Africa Time Topic/Session Description Format Speakers Dr. Thaina Ndizeye (MoH): Setting the stage, welcoming guest of honor, international delegates, and participants: - Remarks by Dr. Francisca Ayodeji Akala, Practice 9:00– Welcome Short speech Introductions and remarks Manager, World Bank 9:30 remarks - Remarks by Dr. Brian Chirombo, World Health Organization, Rwanda Country Representative - Opening remarks by the guest of honor, Hon. Dr. Sabin Nsanzimana, Minister of Health, Rwanda Experience of living with Short speech - Mr. Godfrey Kagaayi, Mental Health Advocate, NCDs, focusing on mental Uganda health conditions Discussion among high- - Hiwot Solomon, Disease Prevention and Control, level officials about the Resilient Federal Ministry of Health, Ethiopia Economic Savings and health - Mr. Daniel Nuer Atwere, Head of Tax Policies, Ghana Perspectives to Finance an Panel systems, - Ms. Maneo Molliehi Ntene, Principal Secretary, 9:30– Integrated Response to NCDs, and Kingdom of Lesotho 10:30 NCDs and Mental Health mental health in the Context of National in Africa Moderator: Francisca Ayodeji Akala, Practice Manager, Health Policies towards World Bank Resilient Health Systems in Africa 10:30 – Coffee break 11:00 - Florence Baingana, Africa Regional Adviser Mental Health and Substance Abuse, WHO Discussion on the Region’s - Adelard Kakunze, NCDs and MH Lead, Africa CDC Partnering for vision of future Panel 11:00 - Dr. Daniel Kyabayinze, Director of Public Health, NCDs and collaboration and partner – Uganda mental health support in combating 12:00 - Dr. Mary Flaviane Nyangasi, Head National Cancer in Africa chronic conditions and Control Program, Ministry of Health, Kenya addressing mental well- being in Africa Moderator: Dan Chisholm, WHO 12:00 Closing remarks: Setting - Prof. Claude Mambo Muvunyi, Director General, – the stage for the next two - Rwanda Biomedical Center 12:30 days - Adelard Kakunze, NCDs and MH Lead, Africa CDC 12:30 – Networking 13:00 Welcoming reception and 13:00 lunch Visit the Kigali Remembrance and Genocide learning tour to Memorial understand the history of - Guided tour - KGM staff 15:00 (Optional the 1994 Genocide and - Q&A - All participants visit) explore the linkages to the mental health agenda Day 2. June 7, 2023 – The Integration agenda at the primary level of care and the case for investment Topic/Session Description Format Presenters/Discussants Time duration Welcoming remarks and - Short - Prof. Claude Mambo Muvunyi, Director introductions speeches and Opening General RBC Rwanda, Overview of module scope dynamic of the 9:00–9:30 - Francisca Ayodeji Akala and purpose workshop 25 Practice Manager WB - Amparo Gordillo Tobar, Senior Economist WBG NCDs and MH burden of - Adelard Kakunze, Africa CDC Public health and disease, connection to the - - Muhamed Ould Sidi, Africa WHO development challenge SDGs to set the stage in 9:30– Presentations - Florence Baingana, Africa WHO of NCDs and mental identifying key gaps in 10:30 - Q&A Moderator: Rialda Kovacevic health in Africa health systems to address this burden 10:30– Coffee break 11:00 NCDs and mental Health system - Presentations - Noel Chisaka, WB health, UHC, and strengthening, and service 11:00– - Dan Chisholm, WHO health system needs in relation to NCDs - Q&A 12:00 Moderator: Muhamed Ould Sidi, WHO strengthening and mental health services - Regis Hitimana, Chief Benefits Officer, Economic and Health - Presentation Rwanda Social Security Board Benefits Argument for the 12:00– - Q&A - Rachel Nugent Integrated Provision of 13:00 Care Moderator: Noel Chisaka 13:00– Lunch break 14:00 Financing and Payment Mechanisms for MH: A - Presentations - Amparo Gordillo-Tobar, and Andre Proposal for a Regional Medici, WBG 14:00– View of the Expenditure in - Q&A 15:00 Mental Health in Africa. Moderator: Rogers Ayiko Financial protection In focus: Introduction of small groups activities and their objective. Q1: Why does investing in NCDs and MH matter in the broader - Introduction health system context of - Amparo Gordillo Tobar followed by 15:00– your country? What are - Country teams and partners as small groups 15:45 the current payment facilitators of group work discussion mechanisms existing for NCDs and Mental Health in your country, or which do you think will be feasible to implement? 15:45– Coffee break - 16:00 Protecting the well-being of vulnerable populations: - Richard Johnson, HBGI, UNICEF, and 16:00– (a) Children and - Presentations Inbuto Foundation 17:00 adolescents; (b) Gender Moderator: Tengetile Tsabedze and violence; (c) Poverty, others - Short Group presentations 17:00– Groups sharing the of their speeches Day wrap-up Moderator: Andre Medici 18:00 discussions Q&A Networking Dinner 18:30 Day 3. June 8, 2023 – Integration of NCD and MH provision of services Topic/Session Description Format Contributors Duration Opening Welcome back and review day 2 Short recap - WBG leads 9:00–9:10 - Rwanda Integration of Disease Management in Integration of NCDs and - Presentations - Uganda - Dr. Kalani 9:10– the Provision of First Level of Care; and MH at the primary level Q&A Kenneth, Senior 10:10 actions that can be taken across different of care in Africa Medical Officer, sectors Mental Health 26 - Kenya- Moderator: Roman Tesfaye - Group facilitators Q2: What are the bottlenecks limiting Participants 10:10– Small group integration in your country? What will it 10:40 activity take to address them? 10:40– Coffee break 11:00 Responding to contemporary NCDs and - Ghana, mental health challenges: What are - Presentations - Leshoto 11:00– What do NCDs and MH critical elements to achieve effective Q&A - Ethiopia, 12:00 mean for Africa health system reform that includes NCDs Moderator: Patrice and MH? Mwitende - Manuel Sibhatu, An integrated action to reverse NCD- - Presentations Director, Resolve to 12:00– NCDs and mental related public health and development Q&A Save Lives 12:45 threat in Africa and beyond Moderator: Rachel health prevention, promotion, and Nugent protection Q3: How to design programs and build 12:45– - Group moderators partnerships across sectors? How to Small groups 13:30 - Participants monitor potential interventions? Lunch break 13:30– 14:30 - Rwanda Overview of key elements of a balanced - Eswatini and comprehensive NCD and mental - Zimbawe health service; presentation of major gaps 14:30– and challenges. Examples of country 15:30 efforts in NCDs (i.e., cervical cancer, Moderator: Florence diabetes). Integration efforts in different Baingana countries. Break 15:30– 15:45 NCD and mental health Q4: Final presentation prep of each - Group moderators 15:45– service development group: Connecting the dots of the Small groups 16:30 and reform workshop and adapting to country context for the next steps. A Representative per country: What will it take to scale up NCD and Uganda – Dr. Hafsa, mental health services and move toward Group Assistant 16:30– UHC? Identifying priorities for each presentations Commissioner 17:45 country. Presentation based on the Mental Health questions posted. Moderator: Amparo Elena Gordillo-Tobar Open discussion; main conclusions; - WBG and WHO subregional milestones, further learning 17:45– Closure Short speeches leads opportunities; next steps, thanks, and 18:00 - Participants goodbyes Notes: NCDs = Noncommunicable diseases; UHC = Universal health care; MH = Mental health; SDGs = Sustainable Development Goals; MoH = Ministry of Health; WHO = World Health Organization; CDC = Centres for Disease Control and Prevention; KGM = Kigali Genocide Memorial; WBG = World Bank Group; UNICEF = United Nations Children’s Fund; HBGI = Healthy Brains Global Initiative. 27 From June 6 to 8, 2023, the Ministry of Health of Rwanda organized an event entitled “Integrating the Response to Noncommunicable Diseases (NCDs) and Mental Health (MH) in the Context of Building Resilient Health Systems in Africa” followed by a technical workshop, with the participation of representatives from the governments of Eswatini, Ethiopia, Ghana, Kenya, Lesotho, Rwanda, Uganda, and Zimbabwe. The event and the workshop were prepared by the World Bank Group (WBG), with support from the World Health Organization (WHO) and with collaboration from United Nations Children’s Fund (UNICEF), the African Centres for Disease Control and Prevention (Africa CDC), and other multilateral agencies and nonprofit organizations. The workshop was under funding provided by the Access Accelerated (AA) Trust Fund. The full program of the event is included at the end of this summary report. The rate of noncommunicable diseases (NCDs) in the African Region increased by 67 percent between 1990 and 2017. In 2019 NCDs were responsible for 37 percent of African deaths, and by the year 2030, they will be the main cause of the burden of disease in the Region. The incidence of mental health (MH) challenges increased by 13 percent in the Region since 2017. In addition, Africa is experiencing high rates of suicide and alcohol abuse, especially among young people. Yet, the average per capita expenditure on MH provision in African countries is US$0.46, with only 1.6 health professionals per 100,000 population working in this field. Primary health care and community-based services are essential strategies to support health systems and to avoid the consequences of early mortality and the social and economic losses brought on by the increased incidence of NCDs and MH. The challenges imposed by NCDs require a stronger collaboration among African countries to see how policies developed in different countries could be adaptative to other regional needs and contexts. Countries participating in the workshop shared some achievements and discussed the challenges ahead for the integration of the provision of mental health services and NCDs care at the first level of care. ABOUT THIS SERIES: This series is produced by the Health, Nutrition, and Population Global Practice of the World Bank. The papers in this series aim to provide a vehicle for publishing preliminary results on HNP topics to encourage discussion and debate. The findings, interpretations, and conclusions expressed in this paper are entirely those of the author(s) and should not be attributed in any manner to the World Bank, to its affiliated organizations or to members of its Board of Executive Directors or the countries they represent. Citation and the use of material presented in this series should take into account this provisional character. For free copies of papers in this series please contact the individual author/s whose name appears on the paper. Enquiries about the series and submissions should be made directly to the Editor Jung-Hwan Choi (jchoi@worldbank.org) or HNP Advisory Service (askhnp@worldbank.org). 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