This post contains audio and written excerpts from the workshop on Community Care: Prospects and Challenges during the IPS-South Zone conference, Oct 2013 at Kumarakom, Kottayam, Kerala. The expert panelists were (1)Dr Ramasubramanian, (2) Dr Praveen Lal and (3) Dr D Raju. The Session was chaired by Dr N S Jinen.
1. Audio excerpt from talk by Dr Ramasubramanian (M.S Chellamuthu Trust & Research Foundation, Madurai, Tamilnadu) on the Madhurai-DMHP experience of community based rehabilitation.
2. Excerpts from talk by Dr Praveen Lal (Dean, Kerala University of HealthSciences)
Grass root health workers are a demoralised group as their work is not recognised as the health system bypasses them, said Dr Praveen Lal in his talk, which mainly touched on the conceptual framework, policy aspects and deficiencies in mental health training and services programs and the efforts for improvement.
More people take care from private sector than from the government sector. Therefore it remains to be seen as to how to include private sector in community based services.
Continuity of care between hospital and community is a lacunae. He asked whether we could have hospitals without outpatient care so that outpatient care could be entirely outsourced to Community mental health teams.
Outreach services by specialists as it exists now, disincentive the GP from initiating mental health services directly as case detection is immediately clubbed with referral. Lack of political will, is one reason for NMHP/DMHP being a non starter as appraised by official authorities. Professional elitism is another reason. Bringing in democratization and demystifying professional demeanour without jeopardizing the professional standing should be the sure way of moving ahead.
3. Audio excerpt from talk by Dr D Raju (State Nodal Officer and Secretary, Mental Health Authority, Kerala State) on Kerala- DMHP scenario.
4. And finally excerpts from the interactive session.
- A suggestion for thinking about innovations in community pharmacy, roping in qualified pharmacists on pro rata basis to ensure better dispensing of psychotropic medications was put forward.
Blog comment: Current practice of nursing staff disbursing psychotropics in DMHP outreach clinics have come under criticism. Role of pharmacists need to be roped in as suggested, not only for efficient dispensing of medications but also for optimal role utilization of mental health skills of nursing staff.
- A fundamental question about whether it was time to move away from the primary care integration of mental health services model was raised. Reasons being that -times have changed, psychiatrists are more in number (Kerala produces about 40-50 psychiatrists in a year) and patients can travel easily as better and quicker facilities for travel have come into being at least in the southern parts of the country. It could be argued that having three psychiatric centers in each district will solve the problem of accessibility as people in a district will not need to travel more than 50 kms for mental health care. With good turn over of psychiatrists, within five years time all vacancies for psychiatrists could be filled including those in the DMHP which have been difficult to fill as young professionals are attracted by better pay packages in the private sector and overseas. The counter point raised was whether the psychiatrists were indeed applying themselves to the true role of a consultant and seeing patients referred to them rather than being the doctor of first contact for people with mental health needs. The intention of primary care integration is to ensure that basic mental health services are available to all and not to negate specialist care. The psychiatric specialists need not feel professionally threatened nor should they consider the trained primary care doctor as a competitor in delivering mental health services.
- It was also mentioned that no psychiatrist who has passed his DPM or MD will find the job designation of the DMHP psychiatrist (traveling 20 days a week to different part of district) as a good career choice.
Blog comment: Regarding the issue of job profile of the DMHP psychiatrist, the issue of traveling 20 days a week is probably only secondary in the mind of the young professional who is contemplating about it as a career choice; what is primary is the pay and service package and how it compares with the alternatives. Whether incentives are inbuilt in, to cover the drudgery of travel would be the consideration as one could observe that specialists in the private sector are not particularly bothered about the travel they have to make to multiple centers to earn their pay. The fact being that services are actually turning mobile internationally, makes it imperative that the inertia of the current incentive structures which implicitly favors the static, are actively reversed.
- Tamilnadu model of assessment and certification and bringing mentally ill to receive benefits of the PWD Act was lauded. The fact that it is not happening in Kerala was noted and it was commented that the reason was because of absence of awareness among mental health processionals themselves and the existing cumbersome processes involved in securing these benefits. In Kerala, the disability certification camps conducted by social welfare department did not make much headway compared to those conducted for other disabilities because of lack of coordinated activities between health and social welfare dept.
Blog comment: Poor rates of disability certification is only partly because of lack of awareness. The already aware doctors shy away from certification because other counterproductive awareness! These is fear of the legal overlay and bureaucratic overlay. Undue fear of excessive demands from patient family side for frivolous certification, fear of certification misuse by relatives for property dispute issues and the doctor being drawn to court are present. Recent issue of Learning disability certifications being rejected because of frivolous inclusion has brought a bad name to certifications of all kinds, rendering doctors not enthused about certification in general. The issues of simplifying the procedure has been contemplated two years ago by the social welfare dept however it has not been given sanction yet. The bureaucratic tyranny of the medical boards continue to rule. Lack of awareness about allowance for carers of mentally ill and the mentally retarded is palpable among mental health professionals.
- Rehabilitation should be at PHC level and community based and it was warned that if district headquarter rehab centres are built (as is being planned in Kerala) it can degenerate to institutionalization.
Blog comment: Collaborating with community based rehab programs like those already being organised by the palliative programs which are running well in Kerala is definitely one way of going ahead. Day care centers are a need of the hour in Kerala as most homeless people in long stay home (almost all in the private sector) are people with family members who are unable to take care of them. Having a day-care home could be one way of sharing care of these people between the state and the family members.
- It was said that the pattern of the specialist-run outreach DMHP clinics has to change if fidelity to Bellary model is to be achieved. Specialist in outreach clinic has to do IEC and training rather than see patients which is what is happening now. It was added that psychiatrists as a group did not work for DMHP, it was always some individuals who had contributed. The DMHP in a nutshell had just worked as prescribes of psychotropic medications in a decentralized manner. This has to change.
Blog comment: (warning-long read :)) Inability for fidelity with the Bellary model need not be considered as a limitation because…….. The story (as told by the late Prof. R L Kapur in Chapter 8, Mental Health Indian Perspective 1946-2003, Edited by S. P Agarwal, DGHS) is that the ICMR-DST study of severe mental morbidity (1987 Report) which was done before the NMHP and DMHP days had evaluated prospectively, the ability of doctors and health workers to recognise and manage psychotics and epileptics at the PHC level in four different centres ( Bangalore, Vadodara, Patiala and Kolkata). The findings were not very encouraging at that time itself. The report reads so..
It was discovered that while the knowledge gained after training for both doctors and MPWs was extremely good, their actual performance over the year was not. Only 20% of the actual cases were picked up by a few MPWs who were motivated; there were many who did not refer even a single case to the PHC doctors. Hardly any patient detected was followed up by the MPWs in the community. Most of those who went to the PHC doctor for follow-up treatment, came on their own. Many patients preferred to consult the specialist staff in the research teams. When asked why the job was poorly done, many excuses were given. Some complained about family planning targets they had to meet, which prevented them from doing this work. Others feared that if they did a good job, this would also become a national programme with targets to be met. Some also wanted to be paid for their extra efforts. There were also some MPWs who said that they knew of more cases, but could not persuade the patient’s relatives to take them to the PHCs. In general, the influence of the PHC personnel in the community was very poor. Neither the doctor nor the health workers were able to organise any programme to impart mental health education, which was one of the objectives of the research project. Record keeping was extremely poor in all the four centres. In short, there was a lack of motivation and leadership. It is intriguing why this particular study has never been referred to by the enthusiasts of the PHC-based mental health programmes.
Without taking into account the findings of this study, first, the NMHP and then the DMHP was launched. Dr R L Kapur goes on to say that the NMHP at its inception was more a wish list than a serious exercise and about the Bellary DMHP-model he says
NIMHANS launched a pilot model programme in the Bellary district to implement the NMHP, at a district level. In some ways,this was a more rational exercise compared to the ambitious aims of the NMHP, as the scope was limited to just one district. Here also, the personnel of the PHCs in the district were trained to recognise and manage mental patients in the community. A specially trained programme officer was appointed to conduct a regular mental health clinic and also to monitor the progress in PHCs all over the district. Good results were described, but on close-examination, the picture did not appear to be as rosy as claimed. In a paper read at the 23rd Annual Conference of IPS-South Zone on 14 October 1990, the programme officer in charge of the Bellary model, talked of the difficulties in correct diagnosis, the choice of appropriate medication, as well as dosage and difficulty in handling side effects of medicines. He also talked of administrative problems like the transfer of personnel who became acquainted with the programme, poor motivation on the part of personnel and the erratic supply of drugs. Being an optimistic person, he gave suggestions regarding measures which could be taken to make the model programme more effective, but was transferred himself, before he could carry out these measures, An informal enquiry by the author to people working in the Bellary district revealed that the model actually fizzled away in the very district where it was first tried out. Unfortunately, the documents from NIMHANS or the Karnataka Health Ministry continue to paint a glowing picture of the Bellary model. Perhaps, if the programme had been evaluated by a research team, whose members were not involved in administering the programme, one would have learnt many things which would have been useful for future programmes
Incidentally the problems with the Bellary model was read out as a paper in the 23rd annual conference of the IPS- South Zone in Oct 1990 (marked as red in the excerpt above) and it is heartening that we are discussing the same issues in a workshop in the 46th version of the annual IPS-south Zone conference today in Oct 2013, 23 years later!
Acknowledgement : I thank Prof V Sathesh, Dr Bobby Thomas and Dr CR Radhakrishnan for the warm hospitality offered at Kumarakom.