Chitwan: The district of one-horned rhinos and PRIME

By Mallika Chaulagain

Communication and Research Uptake officer

When I first joined TPO Nepal, I was equally excited and nervous to take on the position of research uptake officer. Having an immense interest in the field of mental health yet no experience whatsoever, I set out to explore the inner workings of this domain. And since learning takes place better in the actual field, I went to Chitwan district to understand the projects of TPO Nepal.

Despite being a public health professional, I had never given much importance to mental health, and always had a covert feeling of stigma towards people living with mental illness. But my Chitwan visit was an eye-opening experience and my perception towards them has been altered enormously as well as respect for mental health professionals has deepened.

The enormity of PRIME

Program for Improving Mental Health Care (PRIME) is a multi-national research project currently implemented in five countries (Ethiopia, India, Nepal, South Africa and Uganda). In Nepal, PRIME is being implemented in Chitwan district by TPO Nepal. It aims to generate world class research evidence on how mental health services can be provided through primary health care level. The most interesting thing about PRIME is that it implements and evaluates district mental health care plan (MHCPs) which is a comprehensive care package on how to integrate mental health services into existing health care system.

PRIME works on the concept of task sharing; since mental health experts are unavailable in the ground level, health workers (prescribers and non-prescribers) are given training to build their capacity in detection, diagnosis and management of priority mental health problems.

It started in 2011, initially piloted from two health facilities of Chitwan district. In 2014, it was implemented in 12 health facilities. It was then scaled up in 2016 to cover 33 more health facilities, thus covering all 45 health facilities of this district.During my week-long visit, I observed two health facilities where PRIME is being implemented- Jirauna Urban Health Clinic and Padampur Health Post.

Since the scale up phase one and a half years ago, Jirauna UHC has already managed 56 cases while Padampur has provided services to 36 cases. Cases are referred to the health facilities by trained FCHVs and other community workers through the Community Informant Detection Tool (CIDT). CIDT is a tool where stories and pictures describing the four priority mental disorders (depression, psychosis, epilepsy and alcohol use disorder) disorders have been included. If anyone in the community has similar story as mentioned in the tool they are referred to the health facility. Similarly, community sensitization programs conducted by the community workers also helps to identify the cases.

In the health facility, prescribers provide assessment, diagnosis, basic psychosocial support and psychotropic medicines whereas non-prescribers provide focused psychosocial counseling. Community based counselors also assist the health workers with counseling services. To decrease the dropout rate in follow up, FCHVs provide Home Based Care through regular home visit.

Mentoring and supervision of the trained health workers is carried out in three ways. Quarterly case conferences are carried out where health workers from different health facilities come together and discuss challenges faced during service delivery, which is facilitated by a mental health professional. Or, health workers can also reach out to specialists as part of tele-supervision to discuss challenges faced in diagnosis or case management. A specialist also visits health facilities from time to time for the supervision of health workers.

Durga Shrestha, Auxilliary Health Worker of Jirauna UHC said “This program has helped to bring out the cases from community, which would have remained hidden otherwise. It was difficult at first to get used to filling the mental health OPD register, but now it’s just like filling any other registers here. I like this program very much.”

At Padampur health post, Auxiliary Health Worker, Ramchandra KC shared “Service users are very happy as they have access to services in their own community now and are eager to spread the message after recovery. Stigma surrounding mental illness has also decreased remarkably in the community.” He also held the opinion that Ministry of Health should provide mental health services nationwide from primary level just like any other basic health services; immunization, family planning etc.

It was surprising to see that in spite of a number of challenges like lack of separate counseling room in the health facilities; frequent turnover of trained health workers; problem in regular supply of medicines; and stigma towards people living with mental illnesses in the community, health workers are enthusiastic to provide mental health services from the primary health care level.

Myth: People living with mental illness cannot be treated

There is a widespread belief that mental illness is untreatable and people living with mental illness are unable to enjoy their normal life. I myself believed in this myth, which was shattered when I participated in the service users’training where they share their side of story through the medium of pictures. After recovery, they had clicked wonderful photos related to their lives and were able to present it confidently in front of other service users and their caregivers. Service users who have recovered from mental illness are not only provided treatment, but also empowered and engaged in mental health system by mobilizing and involving them in health workers trainings and community sensitization programs.

At the end of my field visit, I was overwhelmed by the remarkable changes seen in the lives of these people which was possible only through the services provided by PRIME.