Community Psychiatry in India

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On Integration of vertical health programs in India (public health discussion)

An excerpted tweet-summary from Health Systems Asia Conference 2013 on theme of vertical health program integration in India. Click here

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Primary care integration project for mental health: Kerala situation

The following are some random interactions (during open discussion) between delegates at the state level workshop on DMHP (Nov 6, 2013, Ernakulum) on the issue of primary care integration of mental health care.

1. While talking about the many projects (Santhwanam, Snehasparsham and Prateksha (pain and palliative program- it was called the “Malapuram model” when mental health component gets integrated into it)) which he is stewarding, Dr Krishnakumar (Director, IMHANS, Kozhikode)  shared his views on the  grander project of “mental health integration into primary care” as follows…

…now what are the problems in achieving primary care integration?… as a former health secretary has said (candidly) “what you are doing (in the name of integration) may be harmful, because previously in Malapuram, the PHC doctor was at least seeing a few mentally ill patients, now that you are going there, they are no longer seeing any! So you are actually not integrating care (mental health) in primary care but taking care away from the mentally ill”, and that is a fact,…Kiran was successful (integrated mental health care)..we don’t know how he has achieved it ..we have tried our best in Waynad, Malapuram and Kasargode to give training for PHC doctors (for mental health integration) but we failed.

2. Earlier in his presentation, Dr Raju, Secretary, Mental health Authority, while talking about the future directions for DMHP said

…about full integration of mental health care into primary care…Dr Kiran (Nodal officer) has said that Trivandrum has achieved this goal!

3. After his presentation on the Trivandrum DMHP, Dr Kiran answered the following questions that were put to him.

(A selected few as transcribed below from audio recording)

Did you provide any incentives for the doctors (at PHC)? (by Dr Gururaj, Public health expert and resource person, NIMHANS, Bangalore)

No incentives were given for doctors, ..but for  a project undertaken under Cherupur Grama panchayat, ASHA workers were remunerated for home visits during a household survey (Rs 100 per day during project period).

So Dr Kiran you say you have trained all medical officers in PHC and CHC in Trivandrum district? (By Dr Ramkumar, Field Psychiatrist, Kottayam)

Almost all, except some 10-15 doctors who did not come after repeated calls.

Okay, it is a tremendous achievement, I want to know, among all the trained medical officers, did all of them take up mental health care? (Dr Ramkumar)

…(having) interest is a big factor in it, some of them however viewed this new responsibility (even the various other general health care routine responsibilities) as additional work burden. There fore we got an order passed by the district medical officer (DMO) that they have to run a separate clinic for mental health on every Thursday from 11AM to 1 PM and a monthly report has to be sent to the DMO, and a copy of the same has to be sent to the DHS.

So do you think if a similar order is issued by DMOs in other districts the same could happen there? (Dr Ramkumar)

It is possible. There has to be some pressure at the initial level before it takes off on its own. The NMHP guidelines say mental health care has to be part of the routine OP work of the PHC doctor, however the MOs said that screening for mental illness is not possible during their routine OP hours because of time and logistic constrains. Another reason was that due to stigma patients did not prefer treatment during general OP hours. In fact the MOs themselves had suggested the separate OP for the mentally ill as it will also be easier to maintain a register if OP is separate like that in the NCD clinics.

Dr Prabhachandran (Health Dept.) added that the training was also sometimes on a one-to-one basis in a liaison-attachment pattern and many of the trained medical officers who developed interest in the subject has also opted for post graduate training later.

(Dr Ramkumar) It might be a good idea to compare the attributes of the trained MOs who later take up mental health care as part of their work and those who do not. This might inform other DMHPs to decide on whom to train based on such profile instead of training everybody.

Dr Kiran concluded by saying that the most important determinant which could predict if the learned psychiatric skills  gets applied in the OPD by a trained MO was his/her personal interest in delivering psychiatric care. For the others who do not get motivated, a small nudge from the DMO in the form of an official order to run separate OPD for the mentally ill was found to work in Thiruvananthapuram DMHP.