When a mental health care programme promotes patient-centred care:
the integration of a vertical programme as an entry point to improve the quality of primary health care services in Guinea.

International colloquium
Integration and Disease Control
26-27-28 November 2002
Institute of Tropical Medicine, Antwerp.

Abstract:

Mental health care interventions in Africa, when conceived, designed and implemented as classical disease control programmes mainly focus on drug compliance. They often give, however, far less attention to social and rehabilitation components.

In 2000, the SaMOA project (SAnté Mentale en milieu Ouvert Africain) launched a mental health care pilot programme in a urban quarter of Conakry (Guinea). The project was implemented in a set of primary care health centres run by the Guinean NGO ‘FMG’ (Fraternité Médicale Guinée). This project led to useful insights in the magnitude and nature of mental health problems in an African town.  It provided relief to patients, families and communities. But, more importantly, this project had a significant impact on the general consultation process, far beyond mental health issues. Indeed, there are indications that it improved the quality of interpersonal care, one of the two pillars of quality of care as defined by Donabedian.

In this paper, we describe the specificity of the approach to mental health care problems used in this setting. The specific hypothesis tested in the SaMOA project is that the management of most mental problems, whatever their initial severity, can and should be addressed on an ambulatory basis and in a patient centred way. Hence the need to integrate medical and social approaches, so as to address the family and community dimensions of mental health problems.

We illustrate how this approach contributed to the unexpected change in the health workers attitudes and in their way to interact with patients in routine outpatient curative care services. Medical doctors became aware that their consultation time increased and they themselves attributed this to the wider scope they adopted in the clinical process, beyond diagnostic and prescription aspects.

We discuss the characteristics of the approach used in SaMOA that were instrumental in strengthening the quality of general health care services. We conclude that the strengthening of primary care services depend to a large extent on the coherence between the strategic options adopted by the disease-centred approach and the patient-centred model of care, a relevant model for primary care services.

Introduction

Following decades of vertical disease control programmes, it became fashionable to systematically integrate programmes in the package of activities offered in the primary care services network. For programme managers it is a mean to increase efficiency, cutting redundant costs sharing expenditures among multiple programmes and increasing the recruitment base. For primary care promoters it is a mean to enlarge the scope of activities, to increase the credibility of the services and to channel available resources to the health centres.  The price to pay for programme managers is to invest in the co-ordination of activities with multiple players. Primary care managers, in turn, struggle to balance the competition of interests among various programmes and to keep a hold on the priority setting. Both hope for a mutual reinforcement, a win-win strategy with the integration of disease control programme in basic primary care services. However this is now challenged in view of the collapse of the public primary care services in many countries given the shrink of resources and pilot disease control programmes want guarantees before handing over there activities to primary care services. The issue of integration is therefore back on the agenda.

We argue that a successful mutual strengthening does not merely depend on an adequate sharing of resources or a more effective hunt to recruit patients. It has to a large extent to do with extent to which the content, the design and the rationale basis of the intervention is consistent with the core business of primary care.

We present the results of an intervention, the SaMOA project (Santé Mentale en Milieu Ouvert Africain), which addresses mental health care in three urban suburbs of Conakry. Beyond the achievement of the programme objective, the project yielded an unexpected by-product affecting profoundly the host primary care general services. The purpose of our paper is to show how a project, focusing on a specific health problem, (mental health), did change the behaviour of health professionals in the course of their other routine curative activities and improved the quality of basic health care services. Health workers became aware that their relationships with their ordinary patients, changed towards a more patient-centred relationship. We argue that this unexpected by-product of the project occurred because the model of ambulatory mental health care, specific to the project, was coherent with the patient centred model most welcome to improve quality of care at first line health service level.

In our paper, we first present briefly the context of the intervention, the situation of primary health care and the development of mental health care in Guinea. We explain the rationale for the intervention and the hypothesis under test. We also describe the course of action. Together with the expected results, pertaining to the hypothesis under test, we then expose the unexpected by-product, which came out in the course of the project.  The discussion of our findings will mainly focus on the characteristics of the approach used in SaMOA that were instrumental in strengthening the quality of general health care services. We analyse more specifically the interpersonal relationships between providers and patients. We will then draw lessons from this experience for the debate on integration.

Context

nMental health in Guinea, a huge unmet need.

In Guinea, despite a remarkable effort to build a comprehensive health care system over the past fifteen years, mental health is largely ignored by the health system, as is the case in many developing countries. In 1987, with the support of WHO and UNICEF, Guinea launched a vast countrywide rehabilitation programme for primary care services: the PEV-SSP-ME programme[1]. This programme involved nearly all health centres of the country within a few years, and later also district hospitals. The primary care network of Conakry, the capital city, was later developed along the same principles. The focus was on increasing the accessibility to an essential package of primary care services. Given the countrywide scale of the project, the challenge was to avoid losing control over the rapid development of health services. The activities were thus closely circumscribed, standardised and monitored. They focused on a few activities deemed essential in primary care: curative consultation to channel essential drugs for common medical conditions, Expanded Immunisation Programme (EPI) and Antenatal Care (ANC) to cover mother and child health needs. Leprosy and tuberculosis control activities were also integrated at a second stage. But primary care health centres are not equipped to deal with mental health problems. With exception for diazepam as an anti-epileptic drug, the list of essential drugs available in health centres does not include psychiatric drugs. There are no guidelines designed to address psychiatric conditions while ‘ordinogrammes’, (algorithms for the diagnosis and the treatment used in Guinea) cover most other common conditions. Though district hospitals are supposed to be able to deal with mental health problems, there is only one specialised psychiatric service for the whole country, based in the national teaching hospital (CHU). This service is staffed with the only 3 psychiatrists available for the whole country. They designed a national programme to put mental health care on the agenda, but it is still under discussion.

nSaMOA: a Guinea-Belgian collaboration for an integrated mental health project.

In a urban neighbourhood of Conakry, SaMOA, a primary care based mental health project runs for four years, in the health centres run by ‘Fraternité Médicale Guinée’ (FMG). The project is a joint venture, which brings together three organisations: FMG, La Gerbe and Medicus Mundi Belgium. Fraternité Médicale Guinée (FMG) is a socially committed health care organisation. This local Non Governmental Organisation (NGO) was created about 6 years ago by a group of young medical practitioners to offer comprehensive primary care. FMG runs three health centres in three deprived urban neighbourhoods of Conakry as part of the first line services official network. The strengths of FMG are the community orientation of their services, their institutional integration in the official network of health centres, and their widely recognised achievements in the field of primary care. La Gerbe is a Belgian mental care institution from Brussels, Belgium. For years, ‘La Gerbe’ has been promoting an ambulatory approach to mental health care and claims that no matter their severity or their specific feature, mental health care problems can and should be dealt with in their context as ambulatory cases. Institutional hospital care should thus remain the exception. Medicus Mundi Belgium (MMB) is a medical development aid NGO from Belgium. MMB supports long term health development projects for years in all continents.

Intervention: the hypothesis under test and its implementation.

The project hypothesis under test: Is ambulatory care a relevant option for mental health in African health care settings?

Basically, the hypothesis tested by the SAMOA project is to confirm that, in Africa, as well as in Europe, the offer of mental health care on an ambulatory basis and within the frame of the first line basic health services, staffed by non specialist general practitioners, is feasible and effective.

This hypothesis tests the relevance, in the African context, of two key assumptions. The first assumption embedded in the project philosophy strongly claims[2].  that ‘there is no universal feature for mental health problems. They can only be understood and addressed in a given social and cultural context” “Out of context, the strange words of madness become strangers’ words. Mental illness needs to be heard and expressed where it arises, where it unfolds, in day to day life. Mental illness in itself never justifies hospitalisation, only dangerous behaviour or extreme isolation does”. Therefore mental health care is best organised as ambulatory care. The second assumption claims that general practitioners, if adequately trained and backed up, can and should deal with most mental health problems. This second assumption only came in the forefront at partnership identification stage. Indeed, the initial project promoters approached FMG and its primary care services because the shift towards ambulatory care seemed too challenging for the university psychiatric services. The integration of mental health care in first line services was then a consequence of the choice of primary care centres as partners. But during the project design and implementation, the comprehensive and ambulatory nature of primary care arose as an asset to test the relevance of the first assumption. From there on, the capacity building of the first line health services staff to take up mental health care and the integration of mental health care in their package of services became a core element of the project and was embedded in the project hypothesis.

Project implementation.

The project was facing two main difficulties to start with. First, the primary care services were usually almost never attended for mental health problems. Still it has long been proven that psychiatric problems are spread all over the world. There was thus no doubt that the problems existed but there was uncertainty about the workload and the featuring of problems, which would surface. Second, the medical staff of the health centred were ill prepared and lacked experience in handling this type of patients. The project was designed to address these two issues. It started with the identification and treatment of patients during consultations and home visits as a first exploration of the matter and as an induction of the medical staff.

Two important features of the strategy were indeed joint consultations and home visits. The principle of joint consultations was to gather the general practitioner of the local health centre together with a visiting psychiatry specialist from Belgium, whether during consultations or home visits.  This features typically a vocational type of training. The training process involved swiftly the whole health centre teams, beyond the sole MD in charge. This training approach was further elaborated with exchange visits of professionals from and to Belgium. Health professionals of FMG, 3 medical doctors and 4 social health workers or nurses, travelled to Belgium for attachments[3] in mental health care institutions deemed relevant to the project’s approach. The joint clinical work was reinforced with fruitful case discussions by e-mail in between international visits. Right from the beginning it was asserted that the whole process was to be a bi-directional learning process where practitioners from both institutions, specialists or generalists, learn as much from the patients themselves as from their peers in a very open mind.

The principle of home visits was to move out of health centre’s walls and meet the patients and their relative in their living environment. It rests on the assumption that the heart of mental health problem management is in the interaction between the patient and his close living environment. Home visits were an opportunity for the staff to have insights in the daily life of the population they serve. It was also an occasion to witness how mental health patients were being considered and cared for at their home and to have an understanding of the difficulties a family has to deal with the social disturbance a mental health problem creates.

End of 2001, two years after activities started, the health centres felt confident enough to launch three initiatives, one in each health centre. A therapeutic garden in the premise of one centre, a graphic workshop for epileptic children in another centre, and a discussion support group for psychiatric patients on treatment in the third centre, were set up.

Results. Beyond the confirmation of research hypothesis, provider’s behaviour changed towards patient centredness.

The intervention was monitored throughout and we briefly present the result pertaining to the hypothesis under test. But the impact of the project went beyond its expectations. We also present unexpected results, which enrich the debate on integration and generate hypothesis for the improvement of interpersonal relationships in first line health services.

Ambulatory mental health care integrated in primary care services: Feasible & effective.

From January 2000 to December 2002, 830 psychiatric patients have been registered with 364 patient registered during the first year of the project only (Table 1). Almost all cases have been dealt with using only 4 common generic drugs. Many schizophrenic patients even with very severe long lasting stupor came out of lethargy and started to envisage a social life. Chronic epilepsy could be controlled, allowing rehabilitation for severely handicapped children. Not only the local practitioners but also the expatriate specialists were amazed by the high effectiveness of simple standard treatment on very severe and very long lasting untreated schizophrenia. Ambulatory care with the full participation of patients, families and relatives was fairly easily adopted and none of the patients had to be referred for hospitalisation, no matter how severe the disease was.

Table 1: SaMOA project statistics 2000-2002

The proportion of mental health consultation among all consultations rose from 3% to 5% between 2001 and 2002. (If we exclude the months of February and August 2000, as it corresponds to expatriate visits, it was only 2% in 2000). The proportion of new patients coming from the area of responsibility of the health centres was 53 % in 2000, 20% were from other suburbs of Conakry, and 27% were from rural areas or even neighbouring countries. In 2001, these figures changed with 12% from the area of responsibility, 68% from other suburbs of the town and 20% from outside the capital city. This trend shows that the FMG health centres increasingly attract psychiatric patients from outside their area of responsibility. Moreover, the number of mental health consultations increases faster than the number of new ‘SaMOA’ patients. The number of follow up visits rose from an average of 2 visit per year to an average of 5 visits per year. It is consistent with the chronic feature of most mental diseases. It reflects the long-term relationships, which builds over time with patients coming for follow up visits.

The effect of the presence of expatriate visiting consultants was marked at the beginning of the project but vanished thereafter, demonstrating the take-over by the health centre’s staff. During the visit of February 2000 and August 2000 there was indeed a marked increase of the number of new patients. It was far less pronounced during the visits of February, August and November 2001. The visits of the FMG teams in Belgium in October, in November, and in December 2000 and in May, in June, and in July 2001 abate the number of consultations. But in general, the number of consultations for mental health care increases over time and shows a positive trend as from November 2001 (Figure 1). The take off follows the second training visit of a FMG team in Belgium, and the launch, at the end of the year, of three specific activities in the three health centres: the therapeutic garden, the graphic workshop for epileptic children and the discussion support group.

Figure 1: Trend in the mental health care consultations from January 2000 to March 2002

 A by-product: The integration of ambulatory mental health care in primary care affects positively patient-health worker relationships.

Observation of the processes at work in the project suggests a behaviour change of health staff in their relationships with their patients, well beyond psychiatric patients. Indeed, discussions with the doctors and the other health workers involved in the project and working in the health centres openly acknowledged a gradual but profound change in their behaviour.  Opening the black box, it became apparent that the project had an unplanned though probably foreseeable impact on their clinical practices. It is the content of this black box that constitutes the substance of this paper.

Indeed, as a result of the project, overall attitudes of staff towards patients improved. First they noticed an extension of the length of their general curative consultations. The staff realised that the opening hours of their services gradually increased. They found out that it was not explained by an increase in the number of patients and that many clinical encounters were taking increasingly more time. It was not an isolated phenomenon but concerned several staff. Second, they discovered that many symptoms, usually diagnosed and managed according to standard protocols, were actually cues offered by the patient. The exploration of these cues unveiled much more complex underlying problems than the protocols considered. They were often related to their families or to a wider social context and requested a specific approach beyond a merely biomedical answer. The staff also realised that they were addressing these problems with the psychosocial approach they adopted for psychiatric patients though they did not systematically diagnose them as mental disorders. Third, there was a shift of initiative from the ‘health facility dragging population to utilise services’ to ‘patients and family pushing health workers to respond to their emerging needs’. Indeed, the treatment of many psychiatric patients, especially very severe schizophrenia, responded remarkably well to the treatment. Coming out of a state of stupor, emerging from their lethargy, they started to express their needs to the staff who helped them so efficiently. These demands went beyond medical treatment, requesting social support. Families started to ask the health centre to envisage the future of the education of children left out of school because of their condition. Some patients were asking how far they could be reassured, thanks to their treatment to consider working, loving or build a family. They even asked the health centre social staff for support to get jobs or to intervene in families. They also positively contributed to the influence of the project. For instance, the patients themselves, and also their families while their condition improved, could ‘diagnose’ other patients and bring them to the health centre or support other families. A community network is gradually extending. Fourth, precisely because of the experience so gained, health workers started to be able to connect the biomedical with the family and the social domains during their ordinary consultations. This holistic approach is an important characteristic of family medicine. This is nothing new indeed to professionals trained within the paradigm of family medicine. But so far in developing countries, the emphasis on community work was not much related to the clinical activities but rather to the community mobilisation for preventive programmes. Eventually they realised that it required the involvement of different type of health workers and an array of competencies, hence the need to strengthen multidisciplinary teamwork. The holistic clinical management of patients, more than the rationalisation of work processes, bound the relationships between social staff, reception staff, nurses, and medical doctors.

Discussion

These results warrant three levels of discussion.  First the confirmation of the hypothesis of the project and its consequence on the design of mental health care programmes. Second, the meaning of the unexpected impact of the project approach on the general consultation and its potential to improve the quality of primary care services. Third the contribution of these results to the debate on integration of disease control programmes in first line health services.

Ambulatory mental health care integrated in primary health care, an alternative to trickle down standardised psychiatric protocols.

These results confirm the hypothesis of the project. Although this is not the main purpose of our paper, these results can be summarised as follows. First, health centre’s teams, led by a general practitioner, supported by adequate specialised supervision, can handle mental health care. Second it is relevant and effective to address mental health problems as ambulatory cases, with the full participation of the patients and their carers and relatives. The transfers of capacity to the FMG teams seem to be acknowledged by the communities, given the trend of SaMOA services’ utilisation rates (Figure 1). These findings should influence the design of mental health care programmes. They also raise further research questions specially related to mental illness management, which are presently addressed on the basis of available qualitative and quantitative information. For instance, the comparison of the case mix with international figures would be interesting. An in depth analysis of the results, to confirm the potential, but also to show the limits of the treatment strategies implemented, and of the tools developed by the project, such as the therapeutic garden, the discussion group or the graphic workshop would be worthy. An evaluation of the effectiveness of the training method (bi-directional exchange visits & attachments) would be useful. An in-depth qualitative analysis of the e-mail exchanges would explore the potential of new technology for training.

Primary care centred mental health care programme, an option to introduce patient-centred care in Africa.

The main focus of this paper is the by-product of the project pertaining to the behavioural change of health personnel. Before starting the discussion on its meaning, it is useful to recall the issue of quality of care in health services in Africa, more specifically regarding interpersonal relationships.

Despite a significant increase in the offer of health services over the past 10 years they remain largely under-utilised. This under-utilisation of basic curative services in the public sector is a source of concern. Indeed, it undermines the uptake of many programmes, which have been integrated in the package of primary care services. Various hypotheses are explored to explain this situation. The impact of fees on financial accessibility, the impact of recurrent shortage of drugs, the level of competence or of qualification of the staff, the competition of alternative offer, the turn-over of the staff are raised as factors impeding an adequate use of services.

Beyond all these managerial or logistical problems, the under-utilisation is increasingly related to a lack of confidence of the population with their services. Recent anthropological studies confirm that this has to do with the health workers attitudes. These attitudes go from the worst with violence towards patients, delivering mothers for instance, or with racketeering of patients, to the least with the application of a strictly standardised clinical management which leaves nearly no space for negotiation and thus interaction between staff and patients. Most of the time the relationship is very bureaucratic and impersonal. Of course there are many places where very empathic relationships are preserved. But the magnitude of the problem is a source of concern. The introduction of the concept of responsiveness in the World Health Report 2000 insisting on respect for privacy and for dignity confirm that it is taken seriously and on a large scale. If we refuse to assume that all the people behaving rudely are simply ‘bad’ people, then we must accept that it has probably to do with the way the health system builds a normative behaviour, which leave aside the caring dimension of health care. Initiatives are taken to promote behavioural change and instil sense of caring in health services. On the one hand, the introduction of competition, of incentives to be more clients oriented is often promoted as a possible answer to the problem. On the other hand, training trough cascade training of trainers and workshops are proposed to enhance communication skills.

What happened in this project is very different: the holistic relationships promoted by the mental health project permeated the routine consultations. The relationships of the staff with regular patients in primary care consultation evolved, along with the building of therapeutic relationships with psychiatric patients. We consider this unexpected result as a by-product in the sense that it was not anticipated as a potential result of the project. Indeed, it was not obtained through testing a hypothesis. It was thus not being explored or monitored before the project started, nor during the process, nor is it done systematically yet. Though it had not been systematically documented, we still believe that this unexpected result is worth to report and discuss as it yields promising area for further research.

To put it in a nutshell, the clinical practices in the basic curative consultation shifted gradually towards a patient-centred approach, a characteristic of good family medicine. And this happened precisely because the attitudes and practices, which were developed in the frame of the mental health care ‘Samoa’ project, PERMEATED the routine curative health care. We argue that this was possible because the disease control programme was integrated in the primary care services. This integration was not reduced to the delegation of programme activities to health centre. Actually, the project invented and implemented a locally adopted and adapted concept for ambulatory mental health care. And this was done from the beginning within first line services.

How did it happen? This permeation was possible because of the convergence and the coherence between the interpretative model followed by the mental health care project and the patient-centred model desirable for primary care.

There is a tension between two approaches, in the world of psychiatry (Figure 2). On the one hand, the explanatory model considers the patient as having an altered perception of the reality, leading to an irrational behaviour, which needs to be corrected. On the other hand, the interpretative model considers the patient as only having a different perception of the reality, which lead to perfectly rational behaviour according to that reality. What counts is to make sense of this seemingly irrational behaviour. The Samoa project attempts a synthesis of these two models: First being responsive to the suffering of the patient and also their family but also trying to make sense of behavioural problems so as to help patient and relative to better deal with the issue.

Figure 2: the psychiatric domain paradigms

There is also a tension between two approaches, in general medical practice (Figure 3). On the one hand, the biomedical model considers the search for a causal agent or a dysfunctional organ to explain the disease as its core task. On the other hand, alternative medicine in Europe, traditional medicine in Africa attempt to understand what you did wrong to become ill or who is doing you harms. The patient-centred model reconciles the two approaches, putting health problems in a bio-psycho-social perspective. This is done through the articulation of the patient’s experience of illness unveiled through facilitation, with the clinical reasoning of the practitioner so as to propose a common assessment and negotiated treatment. This model emerged in the field of family medicine. Family medicine, indeed, considers patient-centredness as a core concept for primary health care.

Figure 3: The family medicine paradigms

But why did the Samoa model spontaneously let the patient centred model permeate in the curative consultation? We identify two reasons.

First, The permeation of practices from one activity to the other has to do with the specific nature of mental health: mental health is characterised by a continuum between the normal and the abnormal. We all have neurotic behaviours! When does it become abnormal? Because the border is blurred, the health workers adopted spontaneously with ordinary patients the attitude they had learnt when dealing with psychiatric patients. The continuum between ‘normal’ and ‘abnormal’ and between psyche and body builds bridges between mental health care and basic primary care.

Second, the specific approach followed by the SaMOA project is fully consistent with the patient centred clinical method. The interpretative model for mental health care recognises behavioural norms as a social collective construct. Under this paradigm, a mental ‘disorder’ reflects a ‘different’, rather than a distorted, perception of the environment. The clinical approach builds on the recognition of this perception and attempts to reduce the gap with other’s perception. It entails a participatory process, involving the patient and his social environment unveiling through facilitation the perception gap to build a therapeutic alliance. The mental health care approach followed by the SaMOA project recognised the importance of the illness experience, and adopted a participatory approach considering the patients and their relatives as a source of interpretation of what happens to them and not only as a source of information for medical decision making. This is precisely what the patient-centred clinical method promoted by family medicine does. The dialogue with the clinician is not reduced to a mere data collection of signs and symptoms to inform the clinical reasoning. Beyond symptoms, the illness experience is elicited, and articulated with the clinical reasoning and therapeutic planning. In addition, the consideration for the interaction between the disease and the social environment, which was key in the Samoa project is also consistent with the primary care paradigm.

Contribution to the integration debate.

Whether expected results or unexpected by-products, our findings suggest that this integrated mental health programme actually strengthened the basic health services.

Our analysis permits to draw lessons for the integration of disease control programme in patient centred services. Coherence and consistency of methods and approaches is key to successful win-win integration. The integration of disease-control approaches reinforces basic health care when the management of a specific disease rests on approaches that are also relevant and appropriate to other routine health services. But it can go much further and strengthen more specifically basic services when the strategic options adopted by the disease-centred approach are consistent with the patient-centred character, which is required for primary care services.

These findings are particularly relevant in the present context of the HIV/AIDS epidemic and of the rise of degenerative chronic diseases with the epidemiological transition. We believe that it is one of the characteristics of a primary care centre to be socially oriented. We believe that one of the functions of primary care is to enable impaired patients to live a worthy life. We also believe that patient centredness is the cornerstone of first line services. Therefore, like our mental health care programme, disease programmes centred on diseases like diabetes, cardiovascular diseases or Aids are particularly good candidates for integration in primary care services. These diseases have indeed a social integration dimension. Rather than cure, their management focuses on enablement and rehabilitation with as objective to cope with the disease and live a worthy life. They require a long lasting relationship and commitment for which a patient centred clinical method is definitely appropriate.

Still, such integration would strengthen the community and patient-centred dimension of the care, only if the prime objective of the programme, hence its design, focuses primarily on patient’s individual and social enablement rather than merely on metabolic or clinical parameters control.

In other word, our findings call for a fundamental shift of focus in the integration debate. The contribution of our paper is indeed to propose a shift of the focus of the debate about the ‘integration of disease control programmes in basic health services’ -a managerial discussion- towards a discussion of the ‘integration of disease-centred programmes in patient-centred services’.

P.S. :

L’article est cosigné par :

Dr Pierre BLAISE (département de santé publique de l’Institut de Médecine Tropicale, Anvers)

Dr Abdoulaye SOW (directeur des programmes de « Fraternité Médicale Guinée », Conakry)

Dr Michel DEWEZ (neuropsychiatre, psychanalyste, coordinateur Sa.M.O.A.)

Et proposé pour publication dans « tropical medicine and international health ».

[1] Programme Elargi de Vaccination – Soins de Santé Primaires – Médicaments Essentiels

[2] Translated from Dewez, M. Sa.M.O.A. – Santé Mentale en milieu Ouvert Africain. Chronique d’un projet. Bruxelles 2001, October 21^st .P 4 & 8

[3] October-December 2000; May-July 2001; May July 2002