THE JOINED-UP YBU INFLOW/OUTFLOW STRATEGY

In Uganda, and many other sub-Saharan African countries, mental hospitals remain overcrowded and institutionalised because of two system dynamics:

1. Outflow blockages: People who are ready to be discharged from hospital remain ‘trapped’ due to family poverty, stigma, family distress, and lack of community based mental health
2. Uncontrolled inflow: Families in need of support, and the police managing disorder in the community, use the mental hospital as the default destination in times of crisis because mental health services and medicines are scarce in the community, but available at the national mental hospital.

Without addressing both flows simultaneously, institutionalisation will persist.

The YouBelongHOME program. OUTFLOW

YouBelong Uganda began its work in 2017, to strengthen the public (mental) health system, and to energise the movement towards deinstitutionalisation, using a health systems approach. YBU developed and implemented the YouBelongHOME program, that involves structured and evidence based pre and post discharge planning, family preparation, and supported reintegration.

The YBH outflow strategy has evolved and demonstrated excellent potential for effectiveness.

Working with the Ministry of Health and Butabika National Referral Mental Hospital, (currently with over 1200 patients in a 550 beds hospital), the current YouBelongHOME, 40+ per month discharge model re integrates a minimum of 40 (and often up to 60) persons a month. This has minimized return to hospital care within 12 months of discharge to only 30%, with most relapses managed by families, using mainly phone support. YBU is attempting to display the impact of this program, and to encourage its incorporation into the hospital’s own discharge planning procedure.

The YouBelong Uganda deinstitutionalisation strategy is in keeping with WHO policy and is designed to be replicable and scalable, across sub-Saharan Africa.

Expanding to INFLOW reduction.

YBU knows that outflow is not enough. For an institutionalised system to change, inflow reduction is essential, and to do this, YBU must adopt a whole of country approach that will need the significant involvement of regional referral hospitals, and their mental health units, that are a major source of referrals to the national mental hospital. The inflow reduction strategy will involve:

• Partnership with the Ministry of Health, in leading a 2026 East African roundtable of stakeholders to prepare a national deinstitutionalization blueprint.
• Capacity building of key geographically located primary health centres to provide early diagnosis and treatment of mental health conditions through onsite training of non-specialist health workers at health centres II, III and IV (Appendix 1).
• Dialogue with national and local government officials to support the training and supervision of mental health staff and to ensure that they are maintained at strategic primary health centres.
• Strengthening supply chains of essential mental health medicines in Uganda, to ensure medicines are available at key primary health centres, and that continuity of medicines supply becomes normative in health systems management.
• Training of police in alternatives to crisis containment through default to the national mental hospital.
• Dialogue with the range of government and non-government psychosocial and community support services, to move beyond silo’d responses, to providing services in a coordinated and collaborative approach, that speaks to the overall goal of deinstitutionalisation and strengthening community mental health services.

Regional Referral Hospital Strategy.

Regional Referral hospitals (RRHs) are critical pressure points in the mental health system.

They generate referrals to the national mental hospital and experience revolving door admissions due to a non-responsive primary health care system.

The YBH approach will involve strengthening pre discharge assessment and preparation practices in-facility, building capacity of the referral health system, training of non-specialist health workers in mental health care, and the management of essential mental health medicine supplies at primary health facilities in the catchment area of the RRH, to manage both the outflow and inflow dynamic.

YBU proposes working with 3 RRHs over an initial three-year period to develop the intervention, build capacity of the facilities at RRH and strengthen referral systems.

Thereafter, progressively scale to the remaining 10 RRHs country wide over a 5-year period.

This work with also significantly reduce the number of persons referred from the regional hospitals to the national mental hospital.

IMPACT GOALS OVER 3-5 YEAR PERIOD.

1. The national mental hospital to reach an inflow/outflow tipping point that would allow the hospital to move from constant crisis mode to tertiary hospital short term acute care not long term ‘institutional care.’
2. Non specialist health workers at targeted primary health centres trained to have the requisite competencies to provide evidence-based health care without needing to refer other than those with most acute needs to hospital care.
3. The primary health centres together with the district leadership will have streamlined the management of the medicines supply chain, to ensure non interrupted availability of essential mental health medicine stock, targeted to the demand of health centres.
4. Police collaborate with the health system appropriately regarding persons abandoned in community, and those in crisis.