Mental health problems in low- and middle-income countries, such as Uganda, form a significant proportion of the global burden of disease ^{Reference Mathers and Loncar1} and there is a need to find strategies to tackle them. In many of these countries there is a shortage of mental health professionals, which can be partly explained by recruitment of staff to the UK and other wealthy nations. ^2,3 This has led to demands for high-income countries to support the development of mental health capacity in low- and middle-income countries. ^{Reference Patel, Saraceno and Kleinman4} Although some commendable individual efforts have been made, ^{Reference Patel, Boardman, Prince and Bhugra5} more formal partnerships, or links, between UK institutions (such as National Health Service (NHS) trusts and universities) and health institutions in low- and middle-income countries are required that would provide a more long-term and sustainable impact on healthcare development. ^{Reference Leather, Ismail, Ali, Abdi, Abby and Gulaid6,Reference Crisp7}

There is already a momentum of commitment to support the development of international partnerships to increase national mental health capacity, ^3,8-10 which was strengthened by the recent Crisp Report, ^{Reference Crisp7} where ‘ways in which UK experience and expertise in health can contribute practically and strategically to health in developing countries’ were discussed. Here we describe the experiences of a link that has developed since 2004.

Formation of the link

The aim was to establish an educational partnership between then East London Foundation Trust (ELFT) and Butabika Hospital, the main psychiatric teaching and referral hospital in Uganda, which would be founded upon targeted, short-term exchange visits by staff. The link was to be collaborative and mutually beneficial, to involve all professional disciplines and to be guided by an agreed set of goals to support the development of:

1. • alcohol and drug services;

2. • child and adolescent services;

3. • post-traumatic stress disorder (PTSD) services;

4. • community mental health services;

5. • acute in-patient services;

6. • particular professional groups - psychiatric clinical officers, occupational therapists, psychologists and social workers.

In setting these goals we aimed to harness the specific experience and expertise that existed in ELFT to support and strengthen professional initiatives already instigated at Butabika.

The link was set up with the help of the Tropical Health and Education Trust (THET), a voluntary agency that aims to strengthen the training of frontline health workers in less developed countries by establishing links for their hospitals/training schools with their counterparts in the UK, had already supported the work at Butabika Hospital since the mid-1990s. In 2004, THET approached ELFT to develop links with Butabika. Over the next year, staff from ELFT and Butabika made exchange visits to assess the viability of joint working and a link was formalised by the boards of both institutions. Link committees were set up, and included the chair of the East London Foundation Trust, who has been a strong advocate for the link within the Trust. The development of the link was supported by a consultant psychiatrist from another trust, who had previous experience of Ugandan mental health services, and a programme coordinator from THET, who knew Butabika well.

Activities within the link

During the first 3 years, nine staff from ELFT and nine staff from Butabika have made exchange visits (targeted training visits). Each visit is tightly defined to meet specific objectives, agreed before the visit by both institutions. Exchange visitors from both institutions are recruited through internal advertisement and appointed according to the needs of the link. Visits have been undertaken by a variety of disciplines (including nursing staff, occupational therapists, psychiatrists and a psychiatric clinical officer) specialised in those areas that were agreed in the initial objectives. Visits from Butabika have ranged from 4 weeks to 6 months, whereas visits to Butabika have been for 2 weeks. Funding for the link has been secured by a variety of methods, including seedcorn funding from the Health Foundation to support the development of the link, Commonwealth fellowship funding for specific exchange visits to ELFT, payroll giving, and fundraising events in London. Articles in local newspapers, professional journals and Trust publications, as well as themed seminars, have raised awareness of both the link and of global inequalities in mental health. The link has also been involved in liasing with other NHS links, both through organised events and informal networking. ¹⁴

Achievements of the link

Although the link has been operational for little over 3 years, we have established a strong partnership. This initial work has closely followed the priorities defined in the agreement between the two institutions, and some concrete outcomes can already be seen (Table 1).

Table 1. Outcomes at Butabika from East London and City Mental Health Trust (ELCMHT)–Butabika link programme

Target areas	Activity	Outcomes at Butabika
Support to PCOs	2 psychiatrists – 2 training workshops, 2004 and 2006.	Development of Ugandan national PCO association.
	PCO projects.	21 PCO projects to develop community outreach, alcohol education and treatment of epilepsy in 11 regions around Uganda.
	1 PCO – 4-week training placement to learn about community psychiatry at ELCMHT.	Print of PCO newsletter.
Support to OTs	2 OTs – on-the-job training in Uganda, 2005, and 6-month placement at Butabika.	Setting up a special craft project for female in-patients.
	1 OT – 4-week training placement at ELCMHT.
Drug and alcohol services	1 nurse and 1 OT – 2-week training visit to Butabika: workshops on motivational interviewing; teaching around assessment, diagnosis and management.	Targeted training of lead nurse.
	1 nurse – 3-month placement at ELCMHT.	New alcohol and drug unit opened in July 2006: 65 new patients seen since June 2007, average 105 follow-up patients seen each month.
		6 specialist and 80 general staff trained.
Child and adolescent services	1 psychiatrist and 1 nurse – 2-week training visit to Butabika: teaching sessions on history taking, emotional disorders and treatment, developmental disorders, child abuse and neglect, conduct disorders and PTSD.	Targeted training of lead nurse.
	1 nurse – 3-month placement at ELCMHT.	Children moved to children-only ward.
		New child and adolescent unit opened in November 2006. Average 30 patients attend each month since December 2007.
		Day programme for children and adolescents established.
		Register of children admissions begun.
Psychotrauma	1 psychologist and 1 psychiatrist – 2-week training visit to Butabika, 2007.	Targeted training of lead nurse.
	1 nurse – 6-month placement at ELCMHT to gain experience in trauma-focused CBT.	New psychotrauma unit opened in March 2007: 30 new patients seen since July 2007, average 26 follow-up patients each month.
	Ongoing supervision from ELCMHT by email and telephone.
Community	1 psychiatrist and 1 OT – 2-week training visit to Butabika, 2007.
	1 nurse – 3-month placement at ELCMHT.
	Targeted training of specialist nurse in community.
	Strengthening of community services.

Benefits of the link have been experienced both in London and in Uganda. The psychiatric clinical officer annual workshops have stimulated an ethos of postgraduate education and interdisciplinary liaison. Visitors have lectured, led workshops and small teaching groups, and co-facilitated workshops, which have been a catalyst for the development of a Ugandan national psychiatric clinical officer association, and an associated newsletter. Psychiatric clinical officer projects have strengthened community outreach services and developed alcohol education and epilepsy services. Following targeted training at Butabika, the lead nurse from the new alcohol and drug unit at Butabika subsequently spent 3 months at East London and City Mental Health Trust (ELCMHT) and was not only seconded to the three specialist addiction units, but also experienced a variety of community and non-statutory drug and alcohol services in East London. She returned to Uganda to head the new service and to disseminate her training both to specialist nurses on the new unit and to general nursing staff. This targeted training of middle-grade health workers has allowed the benefits of her new skills to bring additional benefits to Ugandan patients.

UK staff involved in exchange visits and in hosting have greatly enhanced their cultural awareness, important for ELFT, which serves a diverse population. The opportunity to work overseas has improved staff morale and motivation to work in the Trust and this contributes to NHS staff retention. A Ugandan nurse who spent 6 months in the PTSD centre in East London is now in charge of the PTSD unit at Butabika; and while in London she was able to support the management of patients from Uganda by educating staff in London about Ugandan culture and translating disorder-specific rating scales into Luganda.

Evaluation of the link

The link has been evaluated in the following ways: audit of changes in service provision at Butabika following link activity; reports by exchange staff from both institutions with details of activities undertaken; specifically developed questionnaires eliciting perceived benefits; focus groups with exchange staff, which have been transcribed and analysed; and case studies written by exchange staff describing outcomes of their work.

The benefits of the link are evident at individual, institutional and national levels (Table 2) in London and in Uganda and are often felt at all three levels. Examples of these are given in the section above.

Table 2. Benefits derived by both the UK and Uganda from East London and City Mental Health Trust (ELCMHT)–Butabika link programme

Level of benefit	Benefits to UK	Benefits to Uganda
At an individual level (staff who have undertaken exchange visits, hosted visitors plus impact on service users)	Cross-cultural awareness – opportunity to work overseas and gain experience of diversity and practising in a different culture; fresh perspective of our service and culture when hosting visitors; translating this into more culturally sensitive practice; advocacy for international mental health.	Knowledge – increased knowledge around assessment/management/medication/care planning; exposure to alternative strategies for managing patients; support in developing new protocols/guidelines around care; increased opportunities to specialise.
	General – improved adaptability, flexibility and communication.	Skills – increased skills in areas of defined need.
	Education skills – increased confidence in education, teaching and training in novel settings.	Patient centredness – awareness of the importance of spending more time talking to patients; increased understanding of patients’ needs and experience; greater range of services catering to patients’ needs are now being developed.
	Management skills – improved leadership and management skills; working with limited resources; knowledge of service development; improved teamwork and liaison skills with other professional groups; stimulus to develop specific innovative practices.	Friendships.
	Motivation – improved relationships with colleagues and Trust management upon return; sense of pride in the Trust for its international social responsibility.	Cultural awareness.
		Motivation.
At an institutional level (ELCMHT/Butabika)	Workforce development – development of workforce (skills and knowledge base, cultural awareness, teaching and training skills, management and organisational skills; responsibility and adaptability).	Training – provision of quality training of different disciplines (nurses, OTs, PCOs) and in specialist areas; access to mental health providers in a high-income country leading to opportunities to gain knowledge, skills, etc; improved care to patients – less use of seclusion, specialist services, benefit from boost to staff morale.
	Staff retention – retain staff interested in international health and benefit from their return to work with renewed vigour and enthusiasm.	Support – dissemination of specialist skills by specialist leads; support in the planning and development of specialist services (specifically drug and alcohol unit, psychotrauma unit, child and adolescent unit, and community services) and their evaluation.
	Globally responsible – contributing to international development through addressing global inequalities in health, thus demonstrating international social responsibility.	Enhanced critical atmosphere – where staff now hungry for knowledge; eager to show they have learnt something new; ready to critically evaluate current practice; management now prepared to develop governance and to recruit.
		Funding of specific projects – to build piggery for occupational rehabilitation, PCO projects to strengthen community services.
At a national level (NHS/Ugandan mental health services)	Improved functioning – increased cultural awareness, allowing the NHS to be more responsive to the diverse communities it serves; stimulus to social cohesion; expansion of role in teaching and development.	Enhanced mental health services nationally – role of teaching hospital in providing excellence in care and modelling attitudes towards the mentally ill to all Ugandan health workers who are trained at Butabika.
	Opportunity to address global health inequalities – repay the debt it owes to low- and middle-income countries, given its role in the brain drain.	Raising profile of the mentally ill – advocacy for vulnerable groups (mentally ill, learning difficulties, child and adolescents): sensitisation and raising awareness through publicity that mental illness can be treated.
	Opportunity to learn from other healthcare systems.	Reinforcement of principles of patient and carer involvement.

As the link has achieved so much, the ELFT Board have acknowledged its success and value by funding a dedicated administrator for 1 year who will apply for grants for larger projects and will coordinate the expanding number of individuals involved. The link has also been consulted by the Department of Health as it clarifies the practical and financial implications of the Crisp Report.

The future of the link

In 3 years, the foundations of the link have been laid, but it aims to be a long-term relationship. As new services are being developed, and new skills exploited, Butabika and ELFT staff are assessing what needs to be done and are creating plans as to how this can be achieved. The period of external funding is drawing to a close and the link needs more regular and predictable funding to ensure sustainability. Innovative ways of joint working such as e-learning, teletraining or distance supervision can be built on top a foundation of exchange visits. So far, evaluation has focused on recording the numbers of staff involved in exchanges and training and numbers of patients seen by the new units in Uganda, but in future it will assess the impact of the associated link activity on patient clinical outcomes.

A variety of factors have helped to make the link successful. Butabika had previous experience of being in a link and so embarked with realistic expectations. The goals were set by Butabika Hospital, within the policy of the Ugandan government: ideas were not imposed upon the overseas partner but existing systems were strengthened. The programme began with requests from Uganda for support of training of psychiatric staff and will continue with local funding in Uganda and funds raised in the UK. The link had the support of the ELFT Board and Chair from the outset which ensured it was promoted in the Trust. The link would not have succeeded without financial support at the outset nor without the enthusiasm and commitment of the staff involved, who have done much work in their private time and have been willing to give up study leave to go on exchanges. As a result of THET's experience through initiating and managing other links, clear goals focused the early work of the link and evaluation by various means has given a wide perspective on what has been achieved. One of the main weaknesses has been difficulties with communication between the two partners in the link, exacerbated by problems with access to email in Uganda, intermittent exchange visits and an excessive reliance on communication through the two link coordinators. It is still early days for the link; it will get stronger as it gains greater financial stability that will allow more individuals to get involved and our work together to be further refined and developed.

The ELFT-Butabika link has followed the recommendations for establishing a successful link ^{15,Reference Wright, Silverman and Sloan16} and illustrates the principles set out in the Crisp Report. ^{Reference Crisp7} We have shown that an NHS trust can have a distinctive role to play in international development, and that a link can achieve significant results in a relatively short period. Our link offers a framework that supports NHS staff who wish to get involved in overseas work and share their skills, and our Trust has shown that it recognises the value of these experiences for their work within the NHS. The relationship between link partners is mutually beneficial: it not only fulfils the obligation of the UK to repay a little of what it owes to low- and middle-income countries, but also helps the UK public health system by developing its staff to be more flexible, motivated, engaged and culturally aware in an NHS that is, for its part, culturally enhanced and more globally aware. The link improves knowledge and skills of middle-grade health workers in low- and middle-income countries who deliver the services to the people who need it the most. In this way, international links can make a significant impact on the mental health of some of the poorest people in the world.

Declaration of interest

E.P. is a trustee and immediate past Chairman of THET and M.G. works for THET. D.B., J.B., T.O. and C.H. have all been involved in exchange visits funded by Health Foundation grants secured with the support of THET.