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Proposal for DHQ & THQ HOSPITALS

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Overview of Presentation Introduction 

Objectives

Methodology

Situational Analysis

Gaps/Issues Identification

Recommendations

Mental Health Care Model

Way Forward

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Introduction

There is no health without mental health

WHO defines as:

“…A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity “

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To study the existing mental health facilities available in Punjab

To identify key local healing systems

Develop a learning curve through study of international best practices

Explore all possible avenues for creating community awareness

Effective public health interventions for prevention of mental disorders

Develop a comprehensive mental health care model at the THQ and DHQ level

OBJECTIVES

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Methodology

Situation Analysis•Literature review•Department visits

•Facility visits•Individual interviews

•Brain storming

ConsultationWorkshopFinal proposal

Draft Proposal

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SITUATION ANALYSIS

WHO envisaged mental health as an integral part of Health

It is estimated that by year 2020, Depressive illness would be the 2nd largest contributor to the economic burden of disease worldwide

Mental illnesses are major causes of disabilities contributing 28% of total disabilities

Amongst top 10 conditions causing disability,5 (Depression, Psychosis, Mental retardation, Epilepsy and Drug Abuse) are mental illnesses

As per an estimate 15-20% of world population is suffering in one or the other mental ailment/disorder

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•About 13% of total population in Pakistan is suffering from mildto moderate psychiatric illness and 1% has severe incapacitatingmental disorders

Area Total population sufferers

Pakistan 168million 21.849million

Punjab 86 million 11.18million

Projected by 2.69% GR population census 1998

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There are about 5million Drug addicts in Pakistan of whom 75,000 are needle users most would develop ‘psychosis’

More than 0.1million have severe mental retardation

Incidence of suicide among young has multiplied

Runaway children have become a growing problem

Juvenile delinquents tend to become hardened criminals

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Infrastructure

Number of Psychatricts/10,000

Number of Psych Nurses/10,000

Number of Neurologists/10,000

Number of Psychologists/10,000

Number of Social Workers/10,000

Professionals

Total Psychiatric beds/10,000

Psychiatric beds in mental hospitals/10,000

Psychiatric beds in general hospitals/10,000

Psychiatric beds in other setings/10,000

0.2

0.08

0.14

0.2

0.4

0.24

0.06

0.148

0.02

In Pakistan:

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PovertyIlliteracyUnemploymentLack Of Basic AmenitiesMarginalization Of WomenDomestic ViolenceChild AbuseWars/Internal ConflictsNatural CalamitiesTerrorism Sectarian/Political/EthnicCaste/Ethnic DiscriminationAttitudesLack of recreational facilities

Chronic IllnessesPost Trauma PathologiesPost-partum mental Illness Congenital AnomaliesSenile Dementia

SOCIO-ECONOMIC FACTORS HEALTH FACTORS

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Human Resource

AwarenessSystemic Weakness

Infrastructure

GAPS

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Key RecommendationsProvision of Mental Health Care for Punjab in

three step plan

Short Term (0-3 years)Medium Term (3-5 years)Long Term (5-10 years)

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Short Term (0-3 years)

Infrastructure

•Provision of space in OPD block

•Provision of semidetached indoor facility

•500 ft2 per bed as per MSDS

•Equipment: Diagnostic and Therapeutic

•HMIS

•Kitchen, Store, Vocational Therapy

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Gradual Development of Mental Health Units

• OPD to begin providing its services

• 5 and 10 beds ward to provide indoor at THQ and DHQ respectively within a year

• Progression into 10 and 20 beds facility within 1-3 years of roll-out

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Demonstration units at DHQ Hospitals

To begin with, DHQ units should be demonstrated in the following 14 Districts

AttockBahwalnagarD. G. KhanGujranwalaGujratJhangJhelum

KhanewalMianwaliMuzaffargarhR. Y. KhanSahiwalSargodha Sialkot

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Phased Implementation at DHQ

0-12 Months: 14 DHQ

demonstration units

Phased Phased ImplementationImplementation

1-3 years: Remaining

DHQ Hospitals

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Mental Health Care Units at THQ Hospitals

•District Officers advised to advertise vacancies

•Fill THQ posts randomly based upon the availability of human resource

•Bond for the post-graduate scholarship holder to serve in their town after the specialization

•Incentive/bonus/perks to work at THQ

•Longer and performance based contracts

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Integration into Primary Health Care

• At BHU and RHC; MOs to be given medical education

• To ‘screen and refer’

Low income countries like Sri Lanka; success story(a)trained in recognition(b)early management

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Development of IT-Based Referral System

• Timely, swift and seamlessly integrated referral system

• Storage, sharing, transport of crucial information in data-base

• Computerized ‘Wellness card’ for follow-up and referral advice

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Motivate patients to ‘keep in touch’

Facilitate access to data-base

One doctor ascribed to a patient

Codified information

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Human Resource

(i) Creation/Sanction of New Posts

Specialists in Psychiatry and Neurology

•Posts in BS-18 as ‘District Specialists’ for each DHQ Hospital

•Posts in BS-18 as ‘Tehsil Specialists’ for each THQ Hospital

•Should be given a career path up to BS-20

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Clinical Psychologist B.Sc (Hons), Advanced Diploma, MS

Two posts in BS-18 for ‘District Psychologist', male and female for each DHQ One post in BS-18 for ‘Tehsil Psychologist', either male or female for each THQ

Psychiatric NursePost-graduate Diploma

4-6 Psychiatric Nurses for each DHQ2-4 Psychiatric Nurses for each THQ

Medical Officers At least two MOs to work as post-graduate trainees

Provision of posts to Para-medics and ward-staff

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•Sufficient remuneration to attract doctors not only from Periphery but from tertiary care centers

•Desired placements in their home town

•Provision of housing

•Recreation leave (out of leave account)

•Transport

•Job security (pensionable and longer contract)

•Offering continuity in service

•Incentive of stipend during their training

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Short Term (0-3 years)

(ii) Training•College of Physicians and Surgeons must recognize PIMH as a teaching facility and leverage from its resources

•Psychiatry to be strengthened at graduate level for nurses

•Number of seats at PGCN should be increased for post-graduate nursing

•Para medics; course outline for MHA

•Training of technicians for diagnostic and therapeutic facilities

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(iii) Enhancement of facilities at Post-graduate institutes

•Enhancement of Diploma seats at various Post-graduate Institutes

•Post-graduate scholarships for DPM,DCPS,DCN for aspiring specialists in public and private sector

•Pre-requisite for qualification of DPM and FCPS could be his work experience in the proposed mental health units at DHQ/THQ hospital

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Collaboration with Tertiary Care

•Head of department assigned to mentorship, referrals, community awareness programmes, satellite clinics

•Once a month, Tertiary care staff could give cover to the assigned DHQ/THQ hospitals

•One day in the week at the Tertiary Care OPD exclusively for referrals

•MOs to be posted at DHQ/THQ to be trained at Tertiary Care

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Model Drug Abuse CentreIn

DHQ Hospitals

AIM

To establish independent Drug Detoxification & Rehabilitation Centers at each newly developed Psychiatric unit

Indoor capacity of 10 beds at DHQ

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Understanding the local Mind-sets

•A large number of neurotic/psychotic patients visit faith healers

• Perform damm (prayers), give taweez (amulets), blow religious verses on drinking water, exorcise ‘evil spirits’ by physical abuse

•Most ‘aamils’ give a blind diagnosis of ‘voodoo’ to all seeking help

•Blind faith of locals in their remedies

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Medium-term (3-5 years)

•Establishment of MH units in the remaining THQs

•Well established nursing training institute at all DHQs

•Well equipped diagnostic center (CT Scan, Psychometry, EEG,EMG) with High-Tech laboratory at DHQs and THQs

•Therapeutic ECT at DHQs

•Surveillance cameras

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•Non-institutionalized rehabilitation

•Vocational Therapy

•Inter- sectoral collaboration

•Outreach programme

•Social mobilization

•Rescue service/ 24 hour help-line

•Multidisciplinary Approach

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Long-term (5-10 years)

•Establishment of Child Psychiatry unit

•Geriatric ward

•Psychiatric village may be developed for patients requiring seclusion

•Layered Mental Health Care System

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MSDS,SOPs,JDs &

Referral System

Com

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Short Term

Long Term

Medium Term

3 years

5 years

10 years

Mental Health Care Model (Illustration)

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•Identify Effective Initiatives•Employ Possible Practical Strategies

•Ensure Cultural , Religious And Social Acceptance

•Assess Needs and Determinants•Document process and out come•Engage key stakeholders in the

process

•Assess Needs and Determinants•Document process and out come•Engage key stakeholders in the

process

Implementation

Way Forward

Workable Mental Health Care Model

Systemic Assessment