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Table 3 Synthesized CMOCs for a sample included study

From: Promoting good policy for leadership and governance of health related rehabilitation: a realist synthesis

Reference: 01 Title: Araya R, Alvarado R, Sepulveda R, Rojas G. Lessons from scaling up a depression treatment program in primary care in Chile. Rev Panam Salud Pública. 2012;32(3):234-240.
Key words Setting Design Population Intervention System-wide or project-specific Sectoral or inter-sectoral Cadre Quality (MMAT)
Community mental health services; Depression; Healthcare delivery; Mental health; Chile. Chile: Programa Nacional de Diagnóstico y Tratamiento de la Depresión) National Depression Detection and Treatment Program (PNDTD). Retrospective qualitative study; In-depth semi-structured interviews with six key informants. Depression treatment programme users. PNDTD, Chile. This research reports on a summary of elements that led to scaling up and sustainability of the PNDTD programme, Chile, 2008. Strategic alliances were created across sectors with strategic partners, between the Mental Health Unit and the Primary Care Division (PCD), and with the Ministry of Women. Senior Officers at the Ministry of Health (MoH). 3 quality score –Qualitative.
Contexts Mechanisms Outcomes CMOCs
1. Scientific Evidence
 i) A national disease-burden study was conducted.
 ii) Two large psychiatric morbidity surveys were conducted.
 iii) Other studies showed that depression was also very common among primary care patients.
 iv) A trial was conducted of cost-effectiveness of an improved treatment of depression through primary care in Chile.
 v) A randomized controlled trial of a programme to improve the management of depressed women in the primary care setting showed positive results.
 vi) The MoH hired an academic institution to undertake a small scale evaluation of the effectiveness of the programme.
1. i) The psychiatric morbidity surveys were used to advocate for more resources for the PNDTD.
ii) The studies were based on local data.
iii) The Mental Health Unit at the MoH leveraged available evidence effectively.
iv) A workable action plan was presented to policymakers.
v) There was ongoing communication between the research team and those designing the programme.
1. The MoH decided that depression would become the country’s third highest health priority for 2002. 1. Scientific evidence:
When scientific evidence on a disease burden is collected, and used to advocate for more resources; based on local data; and effectively leveraged and presented to policymakers with a workable action plan, a specific health issue can be established as a national health priority – even in a context of socioeconomic challenges such as in a low- or middle-income country.
2. Teamwork and Leadership
 i) There was an informal team of leaders acting in parallel at different levels and with a shared vision.
2. Leaders shared common features: “politically friendly” and trustworthy; good at forming alliances; able to apply technical information; and good communicators. 2. Effective teamwork and leadership facilitated the creation of powerful strategic alliances, which facilitated institutionalizing the programme within the ministerial framework. 2. Teamwork and Leadership:
Effective teamwork and leadership – by a group of respected and “politically friendly” professionals acting as leaders in a team effort; who are capable of communicating effectively with decision-makers; with the capacity to detect emerging opportunities and react accordingly; who are capable of negotiating political agreements at all levels; who have at least basic technical knowledge, and can prepare a solid proposal; and who are trustworthy individuals capable of forming alliances with strategic partners – can create powerful strategic alliances, which can facilitate institutionalizing a programme within a ministerial framework.
3. Strategic Alliances
 i) There was a strategic alliance between the Mental Health Unit and the PCD.
 ii) Other strategic alliances were formed outside of the MoH, with the Ministry of Women and some universities.
3. i) A strong alliance was created – the Mental Health Unit had technical capacity while the PCD had resources.
ii) Academics provided information, which provided support for introducing the programme.
3. The PCD accepted ownership and management of the programme. 3. Strategic alliances:
Strategic alliances – with key individuals who have positions of political power in a MoH; across sectors with strategic partners; that can persist over time; and with other units by which a programme may be co-owned – can result in a PCD accepting ownership and management of a programme.
4. Programme Institutionalization
 i) A gradual process occurred of “institutionalization” of the programme.
4. i) The programme was aligned with well-known models of care, similar to those of other ministerial programmes.
ii) The programme was introduced as another ministerial programme, complying with regulations and ring-fenced funding.
iii) New and ring-fenced funding was secured.
iv) A critical-mass of human resources was used.
v) The programme had itemized resource allocation, e.g. resource allocation for psychologists, medication, etc.
vi) The programme was highly structured in technical and financial terms.
4. The programme was highly sustainable. 4. Programme institutionalization:
Institutionalizing a programme – by using well recognized models of healthcare delivery within the MoH; placing the programme among other well established PCD programmes; introducing personnel that are widely available and at an affordable cost with the potential to lead the programme locally; and fence-ringing any new and essential financial resources – can result in strong programme sustainability.
5. Task-shifting:
 i) Responsibility for most patient care was transferred to the PCD, away from specialized psychiatric services.
 ii) Transfer of responsibilities from psychiatrists to psychologists was conducted, who were widely available at an affordable price.
 iii) Psychologists were hired as key players.
5. Task-shifting may increase the availability of human resources, allowing more patients to receive treatment. 5. When the PNDTD was scaled up, psychologists were hired in all primary care centres and became the programme’s cornerstone. 5. Task shifting:
In contexts of a shortage of specialized health workers, task-shifting to less specialized health workers may increase the availability of human resources for health so that more patients can access healthcare.