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Ramkumar

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New Draft Health Policy Of India: Comments by two public-health experts from Kerala.

Excerpts (total ~6 min audio in malayalam) of comments by Dr Ramankutty, Achutamenon Centre for Health Science Studies (~4min) and by Dr B Iqbal, public health activist and academic (latter 2 min) on the new draft health policy of India. The audio is extracted from a seminar on the challenges of public health care in India, organised as part of the state conference of the Communist Party of India (CPI) at Kottayam on 27th February 2015.

Mental health financing in Kerala State: an overview

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The under-funding of Community Mental Health services in Kerala State gets media attention as District Mental Health Programs (DMHP) in certain districts are folding back because of lack of funds. Seen above are excerpts from a media report - article in Ente Vartha, Malayala Manorama on Friday 19 December 2014. (see PDF version here).

Another report (see pdf here) which highlight  ‘central fund crunch in NRHM allocation’, says

The programmes of Institute of Mental Health and Neuro Sciences (IMHANS) Kozhikode, including community mental health programme, child development disability programme and  child development services, which catered to thousands of patients in Kozhikode, Wayanad, Malappuram and Kasargod districts, are  in trouble due to the fund crisis.

What is pertinent to note about such reports is that, matters relating to financing of mental health services, which are customarily relegated to the inaccessible policy spaces, are now becoming public debate. The report literally quotes figures like – What is needed is 1.6 crores, but what is provided is 50 lakhs. Such instability of funding is undoubtedly unsustainable for community mental health services in the state.

These facts are reflected in some technical reports as well -for example the WHO/WONCA report on primary care integration of mental health, dwells in detail on the inception (1999) and financing aspects of DMHP, Thiruvananthapuram. It says

Without an initial start-up grant from the national government, the programme would not have been implemented.

Following approval…by the national government, funds were allocated for an initial period of five years… At the end of the initial funding period, the state government was not able to earmark funds to continue the programme, although this was planned and expected by the central government. The programme continued by using some of the original funds that were not yet spent, and with financial support from the mental health centre …Now state funding for the programme has been secured for 2008 and 2009.

So, how much indeed, are the funds available for mental health services in the state? How is it being spent now? Where is it being spent?  Are Community Mental Health services getting adequate funding? Or are most of the available funding going to institutional facilities? Lets explore…..

One way to get an overview about the “financing” aspects of mental health care delivery in the state would be to extract data from the annual plan (and the budget thereof) of Kerala State, which is available in the public domain. That is what, this write up will primarily do.

But before doing that lets us have a brief look at the fundamentals of mental health financing. This shall be in Page 2 (see icon below, can be skipped to proceed to main matter). It includes some basic definitions, about why to look at financing at all, and what are the key questions in financing which are relevant when we are thinking about the development of community mental health services.

We shall then zoom into the Kerala context and examine the current resource allocation pattern and look at the key questions that are relevant for the development and expansion of community mental health care in the state.This shall be in Page 3(click on page icon below). However you can grab a quick summary of the findings below.

Summary of findings on financing of mental health in Kerala 
Finding 1 In the absence of a strategic plan logically derived from the policy, the short term annual operational plans or the budget allocations themselves have become the defacto policy in Kerala. Such occurrence has been forewarned and recommended to be avoided in the WHO service package document on mental health financing(see Page2). 
Finding 2  Of every 100 Rupees of the health budget ear marked via line items for mental health care, only 12 Rupees of it is allotted for community mental health services in Kerala now. 
Finding 3 Persistent 'Contractualization' of staff in Community mental health services may relegate this service into an inferior cadre in comparison to staff in institutional facilities.

Advance Directive in end-of-life care.

Dr Babu Paul (IAS Retd.) was the chief guest at the Palliative Day observance at Caritas Hospital, Kottayam last week.He talked about palliative care with respect to the ethical aspects involved. He disclosed an advance directive which he had made for himself. See video excerpt below (~ 2min, Video courtesy Dr Manu John, Palliative care Dept, Caritas Cancer Institute, Kottayam).

Transcript:

I am 72, going on 73.I am happy in my current situation but ready to be called home by my creator any time now. I therefore make the following wish list.

I may not be kept alive by artificial life support systems except as a purely temporary measure up to 6 hours and for unavoidable medical reasons.

I should not be resuscitated…..

In Summary the doctors are allowed to undertake comfort measures. I would prefer not to be shifted to any hospital….No artificial or IV feeding at all. May my body go in peace and my soul rest in peace.

As advance directive in mental health care is being introduced in India by the new act, it needs to be remembered that we are only at a stage of advance directives slowly evolving even in end-of -life care in our country.

2014 in review

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog was viewed about 850 times in 2014. If it were a cable car, it would take about 14 trips to carry that many people.

Click here to see the complete report.

School Psychiatry: Charting the landscape of mental health interventions in schools.

Schoolpsychiatry

My presentation at Central Tranvancore Psychiatric Society (CTPS) monthly meet at Kottayam yesterday, was on the topic of mental health interventions in schools. Prof Varghese Punnose, HOD, Dept of Psychiatry, Gov Medical college, Kottayam was the chairperson.

See above a matrix of existing mental-health provisions in schools of Kerala and see slides of my presentation below.

Panel discussion: rehabilitative, community-participatory and social security aspects of Schizophrenia-care.

See above some brief sound excerpts (~7 minutes) from a panel discussion organised at Gov. Medical college, Kottayam (MCK) as part of World Mental Health Day 2014. (audio was captured by me using mobilephone microphone:-)

The panelists were as below. Dr Lakshmi Gupthan (MCK) was the moderator.

1. Adv. G Jayashankar, Kottayam District Legal Service Cell (focused on mental health act, Reception order, Rehabilitation services)

2. Fr. Micheal Joseph, Kottayam Social Service Society. (focused on team based and participatory approach, community based rehabilitation through home based care)

3. Dr. V K Usha, Prof. Psychiatric Nursing Dept. (focused on family based interventions, emphasized need for including family members into the multidisciplinary care team)

4. Dr. Ipe Varghese, HOD Social work Dept, BCM College Kottayam. (focused on the need for advocacy for building social security nets in this era of diminishing carers in families and generating evidence for local interventions)

Photo courtesy: Dr Rajeev K M (MCK),  From L to R Dr Usha, Dr Ipe, Fr Micheal, Adv. Jayashankar, Dr Varghese Punnose, Dr Laksmni.

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A prototype dementia-care approach through DMHP.

My presentation at SIPSCON 2014 (Indian Psychiatry Society(IPS), Kerala State  Branch, Annual conference) focused on the emerging idea of integrating mental health care through community nurses in the palliative care program. A model for integrating home-based care for late-stage dementia was presented.  See slides below. Also see newspaper reports on same: The Hindu Report; MalayalaManorama Report. [Incidentally it is two years since this blog was stated in October 2012. It is matter of great happiness that the blog got a mention in the address of the IPS State President at the annual meeting at Kochi. See text of the presidential address here. [added on 22.01.2015, the same published as article in Kerala Journal of Pstchiatry see here ]

Does Kerala still have a deficit for psychiatrists?

If the data from The National Survey of Mental Health Resources carried out by the Directorate General of Health Services, Ministry of Health and Family Welfare which was done in 2002 (appendix 1, page 10 of this parliamentary document has data from it) is appraised now (12 years have passed), it might be safe to assume that as far as Kerala is concerned there might be no deficit for psychiatrists!

The survey pegs the ideal basic requirement for professionals as under

i. Psychiatrists : 1.0 per 1,00,000 population
ii. Clinical Psychologist : 1.5 per 1,00,000 population
iii. Psychiatric Social Workers : 2.0 per 1,00,000 population
iv. Psychiatric Nurses : 1.0 per 10 psychiatric beds.

Based on this ratio, places that were already having excess psychiatrists were Chandigarh (+22), Delhi (+18), Goa (+12), Pondicherry (+5).

States with most number of psychiatrists were Maharashtra (486), Tamilnadu (262), Kerala (238), Karnataka (198), Andhra Pradesh (180).

Kerala had a deficit of only 80 psychiatrists at that time (12yrs back) from a requirement of 318, calculated based on 1 psychiatrist/1 lakh population, for a population of 318 lakhs (census 2001). Since then population of Kerala has increased by another 15 lakhs to 333 lakhs as per 2011 census.

But with the recent annual turn over of 40 postgraduate seats for psychiatry in the state (which has greatly increased because of the beginning of postgraduate training in the private medical colleges) it might be safe to believe that the deficit for psychiatrists in the state may have been cleared!

Implication of this aspect with respect to mental health policy of the state need to  be considered. Certain aspects which need assessment are

  1. Ascertaining the geographical distribution of psychiatrists in the state and redeployment in Thaluk (sub-district) level and under represented areas,
  2. Continued deficit of allied professionals (see table below),
  3. Abandoning the hitherto doctrine of increasing mental health service-personnel by training primary care physicians.

Table 1 (created based on data from 2002 survey)

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Some health-policy trends worth emulating for DMHP-Kerala.

The following are recent trends in the health sector of Kerala. These are directions which are worth emulating for DMHP.

  • The DMHP is understaffed. It comprises of a 4-5 member team for a district -while programs like the palliative program for each district has anywhere from 100 -200 staff. The Kottayam district palliative program that I am aware of (see training program @Kottayam) has more than hundred community nurses supported by about 7 doctors from the health dept. One feature of the staff remuneration is that only the doctors are permanent staff of the government while all the community nurses are employed on contract – which essentially means less salary, no perks and other benefits and no permanency of tenure. It is know that such an arrangement leads to poor staff motivation, translates to poor quality of care and high staff attrition. The community nurses of the palliative program have organised themselves and constantly lobbies for change. The government has also taken cognizance of it. There is a possibility of regularizing this cadre.

Report 1 (Indian express Aug 11th, 2014, Kerala), click here for full report

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The lesson to be learned for DMHP is that the DMHP could also aspire for such permanent cadre. As of now only permanent personal in DMHP are health service doctors who join program on deputation-all other staff are on contract including doctors in CHMP (NRHM version of DMHP)

  • Creating a permanent cadre is a tough ask for the government because of the financial implications. Kerala has had moratoriums on fresh recruitment of staff and it is known that financial ministry is averse to creation of new posts. There is high chance that the chief minister’s assurance to the nurses will remain on paper as just a promise. One potential way it can be achieved in a smaller scale is by re-designation and redeployment of existing and vacant or redundant posts. See this happening in the context of creating new departments in medical colleges.

Report 2 (The Hindu Aug 17th, 2014, Kerala) Click here for full report.

mch

Lesson for the DMHP is that it can easily aspire for permanent cadre by doing away with the deputation system while designating existing vacant posts  as special cadre for out-of-hospital care. Redeployment of mental health professionals who are concentrated in  mental health centers should be explored as a policy option. Such transition should be made attractive to the early adopters via incentives drawn from innovative  financing using DMHP money. 

  • Strengthening District hospital cancer care units in mission mode is a recent development. This is happening in addition to well developed cancer care institutes, medical college oncology departments and a successful community cancer care program in the form of well staffed palliative care program.

Report 3 (Mathrubhoomi, Aug 17, 2014, Kerala) See full report here.

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Lesson for DMHP is that most District hospital Psychiatric units are not functioning optimally. This is despite the fact that we have a fairly good functioning institutional care in MHCs, medical college psychiatry departments and emerging community programs (DMHP/CMHP) in all districts. I am aware of at least 3-4 district hospitals which do not have a psychiatrist.  Other district hospitals which have only one psychiatrist provides just nominal OP care with hardly any IP care. With innovative funding from the DMHP coffers, district hospital Psychiatric units could be invigorated like the  Sukhuratham- Project for cancer care in district hospitals.

(More trends will be added in future)

Added on 22-09-2014

Less than 2 months after the chief-minister had promised the palliative care contract staff that their services could be regularised, the state has puunged into a financial resource crunch. The finance minister has said that there are 30,000 extra employees working with the gov and their would be gradual removal of personell and no new creation of post in this fiscal year!

See here. An excerpt -

Kerala government adopts austerity measure; rules out creation of new jobs, 7.5 thousand jobs to be scrapped

DC CORRESPONDENT | September 23, 2014, 05.09 am ISTIST

Thiruvananthapuram: As part of the intense belt-tightening measures, the state government has decided not to create any new posts, institutions or agencies during this fiscal year, till March 31, 2015.

The finance department will also abolish 7,500 or 25 per cent of the total surplus staff of 30,000 before the end of this fiscal.

What’s more, no expenditure proposals for this fiscal will be entertained after November 15. Special workshops will be held during October for the clearance of files and departments have been asked to get sanction for their expenditure proposals during these workshops.

“Where post creation is unavoidable, it will be done only after examination by two committees,” additional chief secretary (finance) K.M. Abraham said. First the proposal will be put to a committee headed by the expenditure secretary, a representative of the General Administration department and the head of the concerned department. If the proposal is cleared by this committee it will be sent to the consideration of another committee led by the additional chief secretary (finance).

Facilitated self-referral as a case finding tool in outreach clinics.

Detecting common mental problems in primary-care via promoting self-referral: A CMHP experiment of influencing pathways to care by solicitation with a symptom list.

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One out of every five people who attend a primary health centre has one or the other mental health problem. The fact that it does not come to  the clinician's attention is unfortunate. Many reasons can explain this -at the clinician's level (skill acquity), the setting (differentiation of symptomatology), the patient (presentational clarity) and so on.
How health-care services can become accessible or inaccessible is one question which public health researchers are particularly concerned about. Pathways to care with its associated filters at the various interfaces of the health-care system is one useful framework to understand how care reaches or eludes the needy. Such understanding can help inform, influence and improve the accessibly of our services.
Pathways to care analysis at Community Mental Health Program (CMHP, Kottayam district) informed us that 11.7% of patients (see chart) were self-referred to the clinic. It means they found out about the schedule of the monthly clinics by themselves. They got the  information  by  reading  -the notice board at each Community Health Center(CHC), the newspaper announcement about the clinics, the notice board at the nodal centre (near ward 4, Medical college hospital) about the clinics.
We thought of augmenting the self-referred pathway by directly influencing the treatment seeking of people who come to the OPD. A small slip (see picture) which listed common mental health problems  was given to every patient at the OP registration counter at CHCs with a request to meet us at the "counseling room" (https://communitypsyindia.wordpress.com/2014/02/15/). We did it at CHCs where the CMHP had less than 20 patients for followup.
We found encouraging results as many patients came forward to meet us at the clinic after reading the slip. Sleeplessness and excessive worry were the common presenting symptom in people who came via this pathway.
It is therefore concluded that handing out a slip with symptom list of common mental health problems, at primary care OP is one way to improve detection of minor mental disorders and provide early intervention. Services and access to care can be improved by this simple approach.One barrier that was noted was - many of the older people found it difficult to read the fine print in the slip.
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