Integration of mental health services into primary health care setting in Chitwan: Observations from senior government officials

On 27 April 2017, a team of senior officials from the Ministry of Health (MoH), Department of Health Services (DoH) (including Management division, PHC-RD, and the Leprosy control division), Social Welfare Council (SWC), Mental Hospital and Women Commission visited different health facilities of Chitwan district where the Programme for Improving Mental Health Care (PRIME) has been implemented. TPO Nepal, in collaboration with District Public Health Office (DPHO) has been implementing PRIME in the entire Chitwan district where all primary health care workers and Female Community Health Volunteers (FCHVs) are trained on mental health care. Mental health services available in the primary health care clinics included screening and diagnosis of priority mental disorders, basic psychosocial support, advanced psychosocial counseling, psychotropic treatment and continued care. In the community, FCHVs are trained in detection and referral of people with mental health problems and home base care. The team visited four health facilities in both implementation and scale up sites. The team was divided into two groups; the first group visited Gitanagar and Jagatpur health posts while the second group visited Jutpani PHC and Jirauna Urban Health Unit (UHC).

On visiting health facilities, the team interacted with health post in-charges, other trained health workers, and Female Community Health Volunteers (FCHVs). They also interacted with people receiving mental health services from these health facilities. The health facility in-charges from all four health facilities presented an overall status of mental health services, types of mental health services available, and challenges and difficulties. The team also observed mental health reporting systems,availability of psychotropic medicine, treatment protocols and guidelines in the health facilities.

The FCHVs briefly shared how they detect people with mental health problems in the community by using the Community Informant Detection Tool (CIDT). The senior level officials also asked FCHVs about the challenges and difficulties they are facing while referring people for treatment and providing Home Base Care (HBC).

The group also interacted with people receiving mental health services from the respective health facilities. The major issues raised by the service users were regular supply of medicines and frequent transfer of the trained health workers. In the meeting, the service users and their caregivers highlighted the importance of psychosocial support for treatment of mental health and psychosocial problems.

On 28th April, the team participated in a half-day workshop organized jointly by World Health Organization (WHO), Primary Health Care Re-vitalization Division (PHC-RD) and TPO Alliance/TPO Nepal. In the workshop, the Project Coordinator (PC) of PRIME Nepal presented an overview of the PRIME project, its objectives and coverage.The PC also briefly presented the activities conducted in Chitwan districts, and preliminary results of the studies conducted in PRIME. The preliminary results show that the mental health service provided by trained primary health care workers was effective in reducing mental health symptoms and disability. Similarly, it shows that the detection of priority mental disorders increases after introduction of mental health gap action program (mhGAP) training. PRIME also helped in increasing treatment coverage for depression and alcohol use disorders in the community.

There was also an open discussion in the workshop for sustainability of mental health services in Chitwan after the PRIME project has been phased out. The major challenges for continuation of the mental health services came up in the discussion were regular supply of medicines, supervision of trained health workers and FCHVs and continuation of community counselors. The senior officials from MoH and DoH ensured that MoH will allocate sufficient budget for sustainability of the program in Chitwan from the next fiscal year. They also highlighted that PRIME has generated evidence for integration of mental health services into the PHC,so MoH will expand this program in other part of the country because the burden of mental health problems is very high in the country. The MoH officials also discussed about the policy level work that MoH has done in the past few months. Recently MoH has included six psychotropic medicines in the essential drugs list, developed a Standard Treatment Protocol (STP) for primary health care workers and revision of mental health policy.

In conclusion, the senior level MoH officials appreciated the amount of work that TPO Nepal has been doing in Chitwan to generate evidences on integration of mental health services into PHC. They also provided few important suggestions for effective implementation of the program. Formulation of the self-help groups, engagement of community stakeholders in the program, and active involvement of DPHO were key suggestions provided by the team.

The World Health Organization (WHO) Nepal provided financial and technical support for the program. The mental health focal person from WHO Nepal discussed the importance of integration of mental health services into primary health care system. He also shared that the new mental health policy emphasized community mental health; therefore, the evidence generated by PRIME is crucial for improving mental health services in Nepal.