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October 2010
Integration of mental health into primary care in Sri Lanka

Rachel Jenkins (1) , Jayan Mendis (2), Sherva Cooray (3) and Marius Cooray (4)

  1. Director of WHO Collaborating Centre, Institute of Psychiatry, kings College London
  2. Director of National Institute of Mental Health, Sri Lanka
  3. Consultant Psychiatrist , Central and North West London NHS Foundation Trust, The Kingswood Centre, London NW9 
  4. Consultant in Occupational Medicine, Consultant in Occupational Medicine and General Practitioner

Introduction
This report describes a WPA funded train the trainers programme to train trainers for primary care in Sri Lanka in 2010, in collaboration with the National Institute of Mental Health, Sri Lanka and in dialogue with the Sri Lanka Ministry of Health.

Mental health needs in Sri Lanka are as high if not higher than in other parts of world. Indeed the suicide rates are amongst the highest in the world, and 1994  figures are 49.6 per 100,000 males and 19 per 100,000 females per year (1).

There has not been a robust epidemiological study of mental disorder in Sri Lanka, but assuming rates are similar to other countries there will be at least approximately 10% CMD and 1% psychosis. After the Tsunami, one study of 89 people in one area found rates of 40% CMD. The long standing conflict has also probably exacerbated rates of illness (2).

The Sri Lankan health system is a government funded decentralised public health system, accompanied by a robust private sector. Table 1 shows the different health system levels, the cadres at each level. Sri Lanka has long emphasised prevention and public health, and this is reflected in the division of labour for different cadres, some of whom focus on public health and others focus on treatment of disorder, resulting in two parallel sets of health tiers, one for preventive work and the other for curative work. This emphasis on public health has probably contributed to Sri Lanka’s high immunisation rate and good life expectancy relative to some other middle income countries. 1.6 % of total health budget is spent on mental health.

Table1 - Health system structure in Sri Lanka

Health system level Population coverage Management structure

Public Health system
Cadre

Treatment system
Cadre
Private system

   Ministry of Health

   Special and teaching hospitals

   19 M    - Secretary of Health (Perm. Secretary)
   - Director General of Health Services
   - Deputy Director General Medical Services
   - Director of Mental Health
   Director of Mental Health is a public health doctor.    No psychiatrist in MOH  

   National Institute of Mental Health
   1013 beds

   19 M    Director Dr. Jayan
   Reports to Director of Mental Health
     8 Psychiatrists
   300 Psychiatric nurses
   0 Psychologists
   6 Occupational therapists
 
   9 Provincial Hospitals
   600 psych beds each
   2.1 M    Provincial health minister

   Provincial health council
     1 Psychiatrist
   12-15 Psychiatric nurses
   0 Psychologists
   1 Occupational therapist
   1 Social Worker
   Private psychiatrists
   25 District hospitals
   30 psych beds each
   0.76 M    District medical officer

   District health council

   (3 districts don’t have a psychiatrist).
   276 MOHs-deal with public health, maternal , child health, immunisation, prevention, teaching and training    1 Psychiatrist
   10 Psychiatric nurses
   0 Psychologists
   1 Occupational therapists
   110 Medical Officers of Mental Health MoMHs; intention is to have 276 in total
   276 district medical officer OPD
   392 district assistant medical officers
   144 consultant specialists, some Community Support

   Officers (ex midwives) in 3 districts as pilot. Report to mmoh.
 
   Sub district hospitals      Accountable to district medial officer    254 PHNs
   1697 PHIs,
   8937 midwives
   Medical officers OPD  
   Rural hospitals
   Not much used-going to transform to long term care
     Accountable to district medical officer      Registered Medical practitioners
   1-2 nurses
   1 midwife
 
   Dispensaries    10,000    Accountable to district medical officer      Registered medical practitioners (3 year training)    Private GPs not accountable to public system but do have own college


Human resource availability at the different levels in the health system

Sri Lanka has 19 million population and 48 psychiatrists.  There are no psychiatric nurses but 800 nurses attached to psychiatric units having the same experience in psychiatry, 3 psychologists only attached to the university units and 57 occupational therapists and 20 psychosocial workers (PSWs) and 60 assistant PSWs. This means that there is approximately 1 psychiatrist per 500,000 with these psychiatrists placed at the national, provincial and district levels in the health system.

There is a national mental hospital with 1013 inpatient beds (Angoda) staffed by 8 psychiatrists, 300 psychiatric nurses, and 8 occupational therapists but with no psychologists.  There are 9 provincial psychiatric inpatient units with around 600 beds  altogether  , and each staffed by 1 Psychiatrist, 12-15 Psychiatric nurses, 0 Psychologists,  1 Occupational therapist and 1 Social Worker.  

There are 25 district hospitals. The district hospitals deploy staff for public health tasks, general curative services and for mental health. 276 Medical Officers of Health across the country deal with public health, maternal, child health, immunisation, prevention, teaching and training at the district level. The general curative services at district level are delivered by 276 district medical officers assisted by district assistant medical officers, and consultant specialists. The mental health services at district level are generally staffed by 1 Psychiatrist, 10 Psychiatric nurses, 0 Psychologists, and 1 Occupational Therapist. Three district hospitals have no psychiatrists. The district medical officer of health (generally each responsible for a catchment population of approximately 70,000 who takes referrals of people with mental disorder.  The psychiatric nurses are general nurses who have been given 1 month of training and then regular refresher courses, and are largely employed in the psychiatric wards at national, regional and district levels.

At the sub district hospital level there are both public health staff and general treatment staff.  The public health staff comprise public health nursing sisters  (PHNS), public health inspectors (PHIs) and midwives who  do immunisations, (254 PHNs , 1697 PHIs, 8937 midwives distributed across the 276 subdistricts who address monitoring of pregnancies, environmental health (mosquitoes, public health and hygiene), maternal health, and child health primary prevention.  The general treatment staff are Registered Medical Practitioners (with 3 year general training) who treat general patients of all kinds.  There are also 110 medical officers of mental health (MOMHs) in the country. This cadre is a relatively recent development in Sri Lanka, developed to assist in the decentralisation of mental health services. MoMHs are qualified doctors who have been selected either for a one month course in psychiatry or a twelve month diploma in psychiatry, leading to a certificate from College of Psychiatrists, leading to the title of medical officer of mental health (MMOH). The intention is to have 1 MoMH in each of the 276 subdistricts in which case there will eventually be 1 MoMH per 70,000 population; at present there are 110 MoMHs, resulting in an actual ratio of 1 per 173,000 population.

The rural hospitals are staffed by registered medical practitioners, 1-2 nurses and 1 midwife.  They are not much used, being often leapfrogged by patients who go straight to the subdistrict or district level, and the Ministry of Health is therefore considering plans to transform them into rehabilitative long term care facilities for people with complex and severe mental and neurological disorders.

The dispensaries are each responsible for around 10,000 population and are staffed by Registered Medical Practitioners (who have a 3 year medical training) and general nurses. There are also numerous private GPs who have their own professional college and standards but are not accountable within the public system. However, they are crucial to consider here as they see a significant proportion of the general population and are a major source of referral of people with mental illness.

Thus, the mental health programme has until now been staffed as a vertical programme from national to sub-district level. Neither the current nor the planned availability of MoMHs is adequate for MoMHs to be the front line health workers for mental health, and to see, assess and manage all people with mental disorder. Rather it makes logistical sense that they should be viewed as the first level of specialist care, taking referrals from primary care, with more complex referrals being passed to district psychiatrists. Whether the prevalence rates of mental illness are similar to those in the rest of the world or higher than elsewhere, nonetheless, if the general population of Sri Lanka is to have equitable access to mental health care, it is essential to integrate mental health into primary care (the lower levels of the health system including the general health workers and public health workers in subdistricts, rural hospitals and dispensaries). Certainly a staff –population ratio of either 1 per 173,000 (current situation) or of 1 per 70,000 (planned situation) is completely inadequate to form the front line of mental health care.

Leapfrogging of the dispensaries, rural hospitals and even the subdistrict hospitals is common. If someone is ill, they often go straight to the district hospital and see a medical officer in the OPD, or go to a private doctor, or request a home visit from a private doctor.  

Sri Lanka has already experimented with extending the vertical system of mental health specialists to the lower tiers of the health service. Thus, three districts have piloted the use of community support officers who are former midwives who have been given a one month training, but it is not at all clear that the government will produce and sustain the remaining CSOs to give Sri Lanka a ratio of 1 CSO per 10,000 population. In addition, there has   been an alternative plan to replace CSOs with Sanitary Labourers which already exist as a cadre, and who would like to be trained, and this has now been piloted, but found to be unsuitable for mental health work.

Therefore, given the scarcity of psychiatrists, psychiatric nurses and medical officers for mental health, and given the difficulty in production and sustainability of CSOs or sanitary labourers as mental health personnel, it is therefore crucial, as indeed it is in all other countries (3-15), to include mental health in the basic training, post basic training and CPD of all health cadres at subdistrict, rural hospital and dispensary levels in both curative and preventive services. This will include the medical officers working in outpatient departments, for OPD, the Medical Officers of Health, the PHNs and PHIs.  In Colombo, the National Institute of Mental Health has already run some training courses for registered medical practitioners and Family Health Workers on mental health.

The WPA therefore aims to collaborate with the Sri Lanka Ministry of Health and the National Institute of Mental Health to integrate mental health into the work of the lower tiers of the health service, both curative and preventive. It will also attempt to integrate mental health into the work of general practitioners in the private sector who are a key source of referrals to the medical officers of mental health.

 

 

 

 

Methods

Coordination
The coordinating team consist of Professor Rachel Jenkins, Director of the WHO Collaborating Centre, Institute of Psychiatry London, Dr. Jayan Mendiz, Director of National Institute of Mental Health, Sri Lanka and Drs Sherva and Marius Cooray, in dialogue with Professor Mario Maj, President of the WPA. Detailed discussions with Sri Lankan partners and stakeholders was undertaken through 2009 in order to enable the selection of the appropriate cadre to deliver efficient training to front line general health workers,  training sites, and adaptation of the training materials for Sri Lanka (see below).

Funding
The WPA allocated funding to train 155 trainers (45 psychiatrists, 110 medical officers of mental health) and 95 specially selected others (RMPs, DMOs ) in order to equip the trainers to roll out the training on a continuous basis funded by local district health funds.

Training methods and materials
Curriculum and teaching materials were originally developed by the WHOCC for a Nuffield foundation funded programme to train primary care staff in Kenya, in collaboration with Kenya partners (colleagues in primary care, the Ministry of Health, University of Nairobi, professional and regulatory bodies for nurses and clinical officers), and based on the Kenya adaptation of the WHO primary care guidelines (11, 12). These materials have subsequently been adapted for use in Malawi (16), Nigeria (17), Pakistan (18), Iraq (19), and Oman (20). They were adapted by Sri Lankan colleagues for Sri Lanka in 2009. A cluster randomized controlled trial of the training course has been conducted in Malawi (16), and a second in Kenya is underway (21) , and both will report in due course. A multicomponent evaluation is also being carried out in Iraq, and will report shortly (19).

The training programme for primary care is a five day course, and consists of five modules, the first covering core concepts (mental health and mental disorders, and their contribution to physical health, economic and social outcomes); the second covering core skills (communication skills, assessment, mental state examination, diagnosis, management, managing difficult cases, management of violence, breaking bad news);  the third covering common neurological disorders (epilepsy, Parkinson’s disease, headache, dementia, toxic confusional states), the fourth covering psychiatric disorders (content based on the WHO primary care guidelines for mental health, Sri Lanka adaptation) and the fifth covering health and other sector system issues of policy; legislation; links between mental health and child health, reproductive health, HIV and malaria; roles and responsibilities; health management information systems; working with community health workers and with traditional healers; and integration of mental health into annual operational plans.

The course is conducted through multi-method teaching of theory, discussion, role plays and WPA videos on depression, psychosis and somatisation.  There is a major emphasis through the course on acquisition of practical skills and competencies for assessment, diagnosis and management. Each participant has to complete over 25 supervised role plays on different topics in the course of the week, and to observe and comment on 25 role-plays conducted by colleagues. The role plays, videos, discussions and theoretical slides are accompanied by the Sri Lanka WHO primary care guidelines.  Each participant is given both a hard copy print out and a CD of the guidelines, all the teaching slides, role plays and teacher’s guide.

Pilot study
In November 2009, we have trained 25 MoMHs and 5 psychiatrists in a pilot run, funded by the Cooray Family Trust, and have further revised the training materials in the light of this experience to suit Sri Lanka.  

Training sites
In 2010, we are training  the remaining  MoMHs and all the MOHs, using 5 training weeks, based respectively in Colombo (capital city on west coast), Kandy (centre of Sri Lanka), Jaffna (north coast), Batticola (east coast) and Galle (south coast) (see Figure 1).

Evaluation
The Phase 1 testing of the training intervention so far has included: a) Iterative improvement of the course, based on feedback from teachers and students on the early courses; b) detailed collated written feedback from participants, regularly scrutinized by teachers; c) pre- and post-test evaluation of the participants. We also plan examination of routine data collected before and after training in two districts; and supervision observations of clinical practice in 15 health facilities across three districts, in collaboration with the Ministry of Health, in order to appraise how efficient and effective was the working of the level 2 and 3 service providers in mental health management following their participation in the training course.

Progress to date
Continuing dialogue has been held with the Sri Lanka Minister of Health, WHO country office, College of Psychiatrists, and leading professionals of various cadres including GPs.

Training courses have so far been held in Colombo and Kandy, with 26 and 25 participants respectively. Pre-assessment scores were good, indicating a relatively high quality of the post-basic training received by the medical officers of mental health, but nonetheless the training course was able to achieve improvements of Colombo training pretest 66.4% and posttest 81.94%; Kandy pre test 74%, post test 90%).

The trainers found they initially had to work hard to achieve vigorous participation by the trainees, who are more used to didactic teaching and a powerful educational hierarchy, but the use of multiple discussion sessions and role plays facilitated active learning and practice of core competencies, including and especially assessment of suicidal risk, and explanation of side effects of medications to assist adherence.  

Opening workgroups on the problems faced by MoMHs graphically described the pressures they have to deal with, resulting from the lack of integration of mental health in primary care (see Box 1).

Box 1 - Problems faced by medical officers of mental health

Problems faced by medical officers of mental health
  • Excessive work load-too many patients to be seen by the doctor in the clinic
  • Very little time available for each patient e.g. 1200 patients have to be seen by 20 doctors in 6 hours in a clinic, which is 60 patients per doctor which is 10 patients an hour, or 6 minutes each patient
  • Lack of time to take a history or to educate the patient about their illness and medicine compliance
  • Lack of adequate knowledge about mental health in doctors (stemming from too little exposure to psychiatry in basic training , and in continuing professional development)
  • Shortage of essential medicines in clinics and inpatient units
  • Shortage of dedicated beds for psychiatry, so that sometimes agitated patients have to be cared for  on a general medical ward which creates difficulties
  • The need to transfer some patients to distant inpatient units creates problems for families, resulting in a greater financial  burden to the family, especially for poor people. Sometimes very aggressive patients have to be transferred to Angoda for a few days and are then transferred back before recovery.
  • Lack of community based psychiatric treatment settings. Patients are discharged home after acute treatment, but then with lack of adequate follow up there are frequent relapses
  • Too few staff, with no social workers or occupational therapists available
  • Lack of laboratory facilities
  • Declining family support to patients
  • Language problems, especially with Tamil populations
  • Cultural stigma towards psychiatric staff and patients
  • Shortage of medical officers even at tertiary care units, leading to multiple management problems
  • Lack of compliance by patients 
  • Most helpful and will improve the training skills of the participants

Discussion
The training programme for trainers is going well and participants find it helpful (see Box 2). The remaining training of trainers will happen in late 2010 and early 2011. These trainers are enthusiastic about running training courses for the various cadres working in subdistrict hospitals, rural hospitals and dispensaries, and can see that such training will greatly enhance the ability of these lower levels in the health system (see Table 1) to reduce the numbers of clients who need to be referred to the medical officers of mental health, and hence will enable more time to spent by the MoMHs as well on each patient, leading to better assessments and follow up, and also freeing up time in the working day for more intersectoral collaboration. The Ministry of Health is also enthusiastic about the training and is considering ways of providing funding for the roll out to primary care. Continuing dialogue and technical support over the coming years will be helpful in facilitating this process.

Box 2 - Qualitative feedback from participants about the training course

What do you think of the course?
  • Very practical
  • Useful; good overview; excellent etaching material; could be done faster, especially if everyone attending has some basic training in psychiatry
  • Good
  • Really good and very interesting-learnt a lot that helped me a lot.
  • Teaches us to delegate responsibility so more time can be allocated per client.
  • Very beneficial
  • Very good, very refreshing and practicable ways in practicing psychiatry
  • Up to date training for us for our work that will help patients and families achieve good mental health
  • Good-it reminds of our duties to the society
  • I learned to think from this course
  • Excellent
  • Very useful
  • Indeed helpful. Fruitful.
  • Extremely good.
  • Very useful and informative
  • Most helpful and will improve the training skills of the participants
  • Excellent; benefit a lot
  • Very informative and educative; presented in a very interesting way
Do you think it may help others and if so how?
  • To help others
  • Ideas for teaching, training and coordination. Meeting others involved in the same area of work. Teaching material of good standard is available so I can conduct teaching sessions without worries. Eye opener about patients’ rights
  • Yes-a biopsychosocial approach to patient care.
  • Yes, when dealing with patients and with University students and also in general practice.
  • To reduce workload, provide better care for patient, to organise and review work and to improve knowledge
  • Yes. I will spend more time with patients
  • Definitely. As a general practitioner, motivation to learn more about psychiatry and counselling
  • Will help with biopsychosocial interventions, and especially with Breaking Bad News
  • Yes! To be more vigilant while taking history to probe  for underlying mental illness which is not immediately presented to the doctor
  • Yes
  • Yes-to do better mental health service at primary care level
  • To practice at workplace
  • Yes: mainly to train others and also managing patients.
  • Yes. Got a more comprehensive view about mental illnesses. How to manage patients.
  • Yes –it will help me a lot
  • Improve the communication/teaching skills; change the thinking patterns; gained motivation towards community health
  • Yes, of course.
  • Yes. Helpful in identifying the mentally ill patients at outpatient level.
Do you have any suggestions for improvement of the course?
  • Role plays in Sinhalese would be more practical. Some repetition and overlap in slides which could be reduced.
  • Lengthen time allocated to role plays
  • Can include some more counselling sessions
  • More detail on community work in villages and rural areas
  • Get more trainers
  • Put up a summary slide at the end of a topic
  • The course duration should be longer.
  • Make it more interactive
  • Create more group work
  • Same course, expand to 1 week
Any other comments?
  • This course is exhausting for the lecturers!
  • Refreshments are very good; both lecturers very cooperative.
  • Thank you very much
  • Train all medical staff to recognise and respect  mental illness
  • Consider OPD and GP set up as the primary care level
  • Good work! 
  • Please hold similar programmes to other cadres including Medical Officers, psychiatrists , other specialty doctors and general staff.
  • Details of course should be informed prior; we came to know the contents once we came to the lecture hall.

Participants suggested that it would be very useful to establish a formal system of intersectoral collaboration for mental health, which could usefully follow the model of the National Authority on Tobacco and Alcohol (NATA). This national authority has oversight of district committees which contain representation from the Department of Police, the Excise Department, Education and NGOs, receive regular funding and meet at least once a year. The equivalent district mental health fora could contain representation from the Regional Directors of Health, a Medial officer of mental health, Social services, NGOs and relevant other stakeholders, and should meet quarterly to strengthen community based psychiatric service.

Acknowledgements
The authors are extremely grateful for the financial support received from the WPA for the 5 training weeks in 2010 and 11, and from the Cooray Family Trust  for the pilot work in 2009, and  their continuing interest in the success of the programme. We are also grateful for the assistance of Sri Lankan colleagues in each of the training centres who have given considerable assistance with planning and coordination of the training weeks.

References

  1. World Health Organisation. Suicide Rates (per 100,000), by country, year, and gender
    http://www.who.int/mental_health/prevention/suicide/suiciderates/en    
    World Health Organisation; 2003 [updated May 2003; cited 2010].
  2. Hollifield M, Hewage C, Gunawardena C, Kodituwakku P, Bopagoda K, Weerarathnege K. Symptoms and coping in Sri Lanka 20-21 months after the 2004 tsunami. The British Journal of Psychiatry2008;192:39-44.
  3. World Health Organisation. Report of the International Conference on primary health care Alma Ata, USSR. Geneva: World Health Organisation 1979.
  4. Burns B, Regier D, Goldberg I, Kessler L. Future directions in primary care/mental health care research. International Journal of Mental Health1979;8:130-40.
  5. Shepherd M. Mental Health as an integrant of primary medical care. Journal of the Royal College of General Practitioners 1980;30:657-64.
  6. Jenkins R. World Health Organisation Guide to Mental and Neurological Health in Primary Care. London, UK: Royal Society of Medicine Press; 2004.
  7. Kiima D, Jenkins R. Mental health policy developments in Kenya 1999 - 2009. In preparation. 2009.
  8. Lambo T. Socioeconomic change, population explosion and the changing phases of mental health programs in developing countries. American Journal of Orthopsychiatry1996;26:77-83.
  9. Jenkins R, McCulloch A, Friedli L, Parker C. Developing Mental Health Policy. Taylor and Francis, editor: Psychology Press; 2002.
  10. World Health Organisation. Integrating mental health into primary care - a global perspective http://www.who.int/mental_health/policy/Integratingmhintoprimarycare2008_lastversion.pdf.  Geneva: World Health Organisation; 2008.
  11. Jenkins R, Kiima D, Njenga F, Okonji M, Kingora J, Kathuku D, et al. Integration of mental health into primary care in Kenya. World Psychiatry, In Press 2010.
  12. Jenkins R, Kiima D, Okonji M, Njenga F, Kingora J, Lock S. Integration of mental health in primary care and community health workers in Kenya - context, rationale, coverage and sustainability. Mental Health in Family Medicine, in press 2010.
  13. Mbatia J, Jenkins R. Mental Health Policy in Tanzania. Psychiatric Services, in press 2010.
  14. Kiima D, Jenkins R. Mental health policy in Kenya-an integrated approach to scaling up equitable care for poor populations. International Journal of Mental Health Systems2010;4(1):19.
  15. Jenkins R, Heshmat A, Loza N, Siekkinen I, Sorour E. Mental health policy and development in Egypt -integrating mental health into health sector reforms 2001-9. International Journal of Mental Health Systems, in press 2010.
  16. Kauye F, et al. Adaptation of the WHO primary care guidelines for use in Malawi, in preparation 2011.
  17. Gureje O, Hollins S, Botbol M, Javed A, Jorge M. Report on the WPA Task Force on Brain Drain. World Psychiatry2009;8:115-8.
  18. Taj R, Jenkins R. Adaptation of the WHO primary care guidelines for use in Pakistan, in preparation.
  19. Sadiq S, Jenkins R, et al. Adaptation of the WHO primary care guidelines for use in Iraq, in preparation.
  20. Jenkins R, et al. Adaptation of the WHO primary care guidelines for use in Oman, in preparation.
  21. Jenkins R. Adaptation of the WHO primary care guidelines for use in Kenya, in preparation.

Fig 1 - Sri Lanka

The map of Sri Lanka

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