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Monthly Archives: November 2012

Q&A with Shekhar Saxena(WHO-Mental Health)

Excerpts from the interactive session that  Residents and Faculty @ Dept of Psychiatry had with Dr Shekhar Sexena (Director Dept of Mental Health-WHO).

1. Sir, What is your advice to psychiatrists who want to make a career in community-psychiatry?

2. You said in the initial 20yrs(of your professional life)you actually did clinical work and then changed to became a public health person-why and how?

3. What are the rewards that one gets as a public health professional?

Ah.. good question. If there were no rewards I suppose I would not be very happy and would come back to clinical practice. .so there are rewards…

I think the whole thinking process which goes into policy making is something very rewarding ….Also the kind of problems I was challenging you with -on the public health logic vs the clinical logic…this puts a lot of challenges into the thinking and many times the learned solutions have to be challenged and changed. A lot of learning occurs from other people..it is good to work with people from different backgrounds. .When we talk  to mental health professionals or health professional one tends to get one kind of messages, but it changes with others like health economists, public health people, health advisors, ministers…

Just like today we were discussing the barriers of integrating mental health into primary care in Karnataka state -about how difficult it really is..these barriers (global and local) challenges me..getting to hear people from different backgrounds.. one start enjoying that kind of learning after a while.. how to overcome barriers, how to find solutions, where to cut, where to groove… it is just like in clinical practice where we think what are the barriers for this patient to recover..

Problems are the same every where whether it is Karnataka or some where else.only the circumstances change. and solutions vary. so how to fix it..that is the challenge..

4. If one were to assume a hypothesis that mental health is not possible through primary care what are the other options to deliver care?

5. What are your views on the hidden primary care -when a specialist does primary care (knowingly or unknowingly)it is called so. How is this a barrier in integrating mental health into primary care? In NIMHANS which is a tertiary centre the specialists are actually involved in spending large amount of their time in delivering primary care! How does one tease that out?

This is a matter of demand and supply. NIMHANS is an excellent institute and everybody knows that if they come here they will get good care and so obviously people will come here and you are victim of your own success!..the better you do more people will come and it will becomes a defacto  “primary care” for people with mental illness.It is not to confuse with the primary health care which is the place where a person goes when he  has health problems…whereas in this case a person is identified as having a problem of mental health or neurology or neurosurgery and comes directly here -it is a matter of demand and supply.

I don’t think we can shut the doors and make things better. .people will find a side door, a back door…and people will come here.I think the solution is -for an institution like NIMHANS to really increase capacity elsewhere and show a lot is happening elsewhere so that people don’t feel that they have to go to NIMHANS- and that they can find care elsewhere which is almost as good for their problems. That is capacity building. It is not easy. I am not at all suggesting that NIMHANS should decrease its stature but it should spend energies in creating capacity outside NIMHANS- that  is only solution,but health systems are very complex so these are easy to say but not very simple to do, and so there is no real solution there…

Another solution that might come in the somewhat distant future is the payment mechanisms…many countries have that. India is a country where health care is supposed to be free. Infact it is not free because when people come for care they spend money on transport, buying some drugs, they spend money on staying here..so it is expensive.Remember that people came here because they have no choice even though it is expensive.. therefore one of the things to do is to have a kind of payment system which would take care to provide incentives for care which is more cost effective vs care which is less cost-effective and at NIMHANS care is less cost-effective because you have the experts providing care.

So the idea is to really create a system in such a way that the person can find something which is less expensive for him and for the system as-well and which is available somewhere nearby in his community …the pyramid of care that I was talking about..we have to create capacity for self care in the community, capacity of carers before the person  thinks of coming here.

6. Is it a good idea to target mental health in toto or to target specific areas of mental health from a community perspective?

It depends on what purpose.If it is service delivery, specially in hands of primary or secondary care providers, one has to prioritise ..one has to target. ICD has 300 codes for mental disorders. so obviously cannot target all, one has to target some ..WHO intervention guide targets eight conditions..only 8 from among Mental, Neurological and substance use disorders. It includes depression of-course..  then severe psychotic illness which includes schizophrenia, then ..child and adolescent disorders, suicide, epilepsy, dementia, alcohol and drug use problems..so just 8 conditions.  so from a public health perspective the system needs to take care of these 8 problems which are most disabling and burdensome and each one of them have cost effective solutions  and when people are trained in dealing with these 8 problems they will develop ability to see other conditions too. and to look at it from an  advocacy perspective I personally think..(rest of audio is lost in the recording device)

7. Finally how do we conceptualise long term health care with specific reference to mental disorders?

Also adding an interview of Sekhar Sexena available @youtube.

On convergence of community-based rehabilitation and MNREGS

The Mahatma Gandhi Rural Employment Guarantee  Act/Scheme (MNREGA)  aims at enhancing the livelihood security of people in rural areas by guaranteeing hundred days of wage-employment in a financial year to a rural household whose adult members volunteer to do unskilled manual work.Very recently convergence of community-based rehabilitation of people with disability (both mental and physical) with this scheme is being attempted and facilitated by various agencies. Although not as an exhaustive list presenting here below a few such detail which have been collated from the web.

1. Experiential account as told to Dr Kishorekumar by a beneficiary of MNREGS -from one of our extension clinics for mental health. (audio in Kannada language. consent for upload taken)

2. Experiential account from another beneficiary (source The Banyan)

I have enjoyed working in the MGNREGS scheme. We all work together as a group.  If one of us is feeling weak, the rest of us help and finish the work. It has brought us all closer together. We also get paid regularly and with the extra money,we are able to buy food and other provisions by ourselves.”

3.  Excerpts from a study on performance of NREGA in Kerala (source Rural development Department of Kerala).

4.  DMHP Thiruvananthapuram facilitating convergence of community based rehab with MNREGS (source The Hindu)

…Another important aim of the project was to encourage panchayat representatives to include those undergoing treatment for mental illnesses in some rehabilitation projects such as the Mahatma Gandhi National Rural Employment Guarantee Scheme as group work can have therapeutic effect on them.

In the past two or three years, DMHP Thiruvananthapuram has helped register many of its patients under MNREGS as it was found that the work is well suited to them as it is done in groups and under supervision. Once registered they can rejoin the work even if there is relapse or hospital admission, thus providing a constant source of income.

5. Community based Rehabilitation initiative of Voluntary Health Association of Tripura  is facilitating employment opportunities for people with disability in the MNREGS.

Therefore from above details it can be understood that the MNREGS can  provide immense opportunity for extending community-based rehabilitation  to  people with disabilities.

20.08.2014…………There has been widespread reports of MNREGA becoming financially inefficient because of corruption in implementation. There has been no clarity of its aim, lack of non creation of tangible assets has been a drawback. In terms of efficiency of the program via a vis its aims of creation of tangible assets, it could be questioned if including disabled people into MNREGA will dilute its aim of creating tangible assets in a time bound manner. With a change in orientation of the program from just giving jobs with assured work days and wages to one where such work translates into outcomes of measurable assets, the continued inclusion of disabled people in the scheme can become difficult in future.