BACKGROUND: Although effective treatment modalities for mental health problems currently exist in Nigeria, they remain irrelevant to the 70% of Nigeria's 120 million people who have no access to modern mental health care services. The nation's Health Ministry has adopted mental health as the 9th component of Primary Health Care (PHC) but ten years later, very little has been done to put this policy into practice. Mental Health is part of the training curriculum of PHC workers, but this appears to be money down the drain. AIMS OF THE STUDY: To review the weaknesses and problems with existing mode of mental health training for PHC workers with a view to developing a cost-effective model for integration. METHODS: A review and analysis of current training methods and their impact on the provision of mental health services in PHC in a rural and an urban local government area in Nigeria were done. An analysis of tested approaches for integrating mental health into PHC was carried out and a cost-effective model for the Nigerian situation based on these approaches and the local circumstances was derived. RESULTS: Virtually no mental health services are being provided at the PHC levels in the two local government areas studied. Current training is not effective and virtually none of what was learnt appears to be used by PHC workers in the field. Two models for integrating mental health into PHC emerged from the literature. Enhancement, which refers to the training of PHC personnel to carry out mental health care independently is not effective on its own and needs to be accompanied by supervision of PHC staff. Linkage, which occurs when mental health professionals leave their hospital bases to provide mental health care in PHC settings, requires a large number of skilled staff who are unavailable in Nigeria. In view of past experiences in Nigeria and other countries, a mixed enhancement-linkage model for mental health in PHC appears to be the most cost-effective approach for these Nigerian communities. DISCUSSION: Nigeria is currently experiencing a 'double epidemic', and with high infant and maternal mortality rates, the burden of mental health problems is still invisible to policy makers. Meagre resources allocated to mental health need to be utilised maximally with cost-effective interventions. This mixed enhancement-linkage model draws on the strengths of both models, while taking into account their limitations. Concrete conclusions cannot be drawn until the model developed is fully tested. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: This model has the potential of making mental health services available, accessible and acceptable in these communities. This should reduce the burden of suffering for the mentally ill by providing treatment and restorative care, promoting mental health and preventing mental illness in the populace. IMPLICATIONS FOR HEALTH POLICY FORMULATION: The current mental health policy for Nigeria focuses on enhancement as the mode in which mental health can be successfully integrated into PHC and so far this has not been successful. Results emerging from this model can be presented to policy makers thereby supporting replication in other parts of the country. This could ultimately lead to a change in the mental health policy on training for mental health at the PHC level. IMPLICATIONS FOR FURTHER RESEARCH: Mental health services and mental health economics research are still at the stage of infancy in Nigeria. This study provides baseline information and should stimulate further research in these two vital areas.

A Cost-Effective Model for Increasing Access to Mental Health Care at the Primary Care Level in Nigeria.

Short-term training for health workers at all levels has been an important strategy for introducing new family planning health and nutrition interventions or for improving ongoing program activities for many years. This paper reports on development and implementation of in-country training as an outgrowth of a US-based program at the Center for Population and Family Health of Columbia University (CPFH). There is a consensus about the design process for this training which includes a needs and resources assessment formulation of a training design including goals objectives content and the evaluation strategy elaboration of training content and development of a training implementation plan. Training assessment processes the methods and approaches used to judge progress consist generally of pre-assessment (for example a survey of trainee expectations) ongoing or process assessment (for example rapid feedback) and post-assessment which often refers back to the other 2. An example is given in this report of implementation of a training program in primary health care and rural hospital management for medical officers assigned to rural hospitals. CPFH sent training personnel to the Sudan to implement a training program consisting of an interview a visit to a nearby village for information-gathering and a final unit in which participants returned to the field for a management audit and were encouraged to write a subsequent work proposal. Based on the findings of this test project a set of pre-assessment process assessment and follow-up assessment approaches have been developed. A field assessment reported 5/9 of the program participants had shifted from 100% curative to 30%-70% preventive care emphasis in the administration of programs.

Design and assessment processes in short term training programs for family planning primary health care and nutrition program management.

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Design and assessment processes in short term training programs for family planning primary health care and nutrition program management.