Promoting Mental Health Treatment in Traditional Bhutanese Society

Competition Finalist

This entry has been selected as a finalist in the
Rethinking Mental Health: Improving Community Wellbeing competition.

 When Bhutan launched a national mental health system in 1997, it introduced modern mental health practices into communities who until then had relied solely on traditional forms of treatment. In Bhutan, these two oftentimes competing methodologies were linked successfully by stressing advocacy, education, training, and treatment.

 

About You

Organization: Department of Psychiatry, JDW National Referral Hospital, Thimphu Visit websitemore ↓↑ hide↑ hide

Section 1: About You

First Name

Chencho

Last Name

Dorji

Country

Bhutan

Section 2: About Your Organization

Organization Name

Department of Psychiatry, JDW National Referral Hospital, Thimphu

Organization Website

Organization Phone

+975 2 322496/7 extn. 341/308/415

Organization Address

Department of Psychiatry, JDW National Referral Hospital, Thimphu Bhutan

Organization Country

Bhutan

Is your organization a

Government

Your idea

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Name Your Project

Promoting Mental Health Treatment in Traditional Bhutanese Society

Country your work focuses on

Bhutan

Describe Your Idea

 When Bhutan launched a national mental health system in 1997, it introduced modern mental health practices into communities who until then had relied solely on traditional forms of treatment. In Bhutan, these two oftentimes competing methodologies were linked successfully by stressing advocacy, education, training, and treatment.
 

Innovation

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What makes your idea unique?

Acceptance of modern medicine, particularly psychiatric treatment is a huge challenge in a traditional society like Bhutan, where most people prefer traditional forms of treatment. However, traditional treatment is not effective in treating severe mental disorders such as schizophrenia.

To address this problem, an innovative pilot project to introduce modern psychiatry to Bhutan was launched in 2002. As a first step, focus group discussions with community leaders, traditional healers, and health providers modeled on international best practices (including case identification according to ICD 10 diagnostic criteria) helped identify persons with mental illness in the community. This represented the first time that community leaders and traditional healers were involved in case identification. Local health workers followed up on these cases by providing a diagnosis and offering treatment under the supervision of trained psychiatrists. This pilot project was conducted in three distinct geographical regions in Bhutan.

The experiences and knowledge gained during the pilot is presently being expanded to the remaining 17 districts in Bhutan. The successful collaboration between modern health workers and traditional healers will help expand mental health services to the rest of Bhutan in a cost effective way, achieving multiple objectives at the same time:

1. Introduce modern mental health practices in traditional Bhutanese society
2. Mobilize community support to identify and treat severely mentally ill persons
3. Provide a platform for traditional healers and modern health workers to work together
4. Train primary health workers to diagnose and treat mental disorders in the community

Do you have a patent for this idea?

Impact

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What impact have you had?

The pilot project succeeded in achieving the following objectives:

We created sustained awareness and advocacy among community leaders and traditional healers about the prevalence of mental illness in the community and the unmet needs of patients. Community leaders and traditional healers in particular have started referring severely ill mental patients to modern doctors for treatment.

This resulted in traditional and modern health workers working together successfully and understanding each other better. The pilot project has brought the practitioners of the two systems together, appreciating each other strengths and weaknesses and collaborating and consulting each other for a common cause - to provide the best treatment and avoid duplication and confusion among patients.

Together we identified, diagnosed, and initiated treatment on more than 300 severely mentally ill patients in the community who would otherwise not have received treatment. The primary health workers had this wonderful opportunity to learn from real patients and get hands-on training to diagnose and provide treatment to these patients in their own homes and communities.

Through this process of advocacy and by generating data on mental illness, the political leaders and government bureaucrats were sensitized about the mental health needs of the population and that mobilizing resources to address those needs can have a sustainable impact.

Problem

A major challenge is the lack of awareness about mental health disorders among the Bhutanese. Our strategy of creating mental health awareness among the general population includes creating partnerships, collaborations, and engaging the community in the education process, rather than relying solely on mass media.

A second problem is the difficulty in identifying mentally ill patients due to the social stigma in seeking psychiatric care, and discrimination of mentally ill patients. Surveys to identify cases are very time consuming, resource draining, and not cost effective. This novel method of collaborating with the community leaders and traditional healers in identifying mentally ill persons in the community is a cost-effective alternative.

The third challenge is the lack of knowledge and skills among the primary health care workers in diagnosing and managing mental disorders. This project involves hands-on practical teaching of health workers on case identification and managing patients in the community.

Actions

Irrespective of whether a health worker participates in the project or not, all primary health workers will be given regular training on basic psychiatric skills and management.

Having identified youth (which constitutes over 50% of the total population) as a vulnerable group, life skills and counseling training are provided to school teachers and counselors. School based parent education programmes on issues such as drug abuse, teen pregnancy, and school dropout etc. are included in the school calendar.

Continuing the cooperation between traditional healers and modern health workers is key in sustaining the identification of patients and reducing the social stigma attached to seeking mental health treatment.

Securing resources remains a challenge and the fundraising plan includes developing tools to keep donors informed, involved, and motivated. In order to keep our budgetary needs low, we plan to roll out the project in only one or two districts at a time.

Results

The pilot project took about a month to complete in each district. The first few days were spent on training local health workers. The next stage involved extended focus-group discussions to identify potential cases in their community. The third phase was the visit to households to confirm diagnosis and initiate treatment. More than 300 severe mentally ill patients were identified and put on medication. More than 60 health workers were trained on mental health throught this project. More than 500 community leaders, traditional healers and government civil servants were oriented to mental health concepts through this method.

As a result of these efforts, awareness of mental health, mental disorders and help seeking behaviour have increased among the Bhutanese population. In the three pilot districts, treatment and social support to patients has increased significantly. Health workers have become more open and receptive and government funding to mental health programs has increased.

What will it take for your project to be successful over the next three years? Please address each year separately, if possible.

The success of the pilot project will help introduction in the remaining districts, without disrupting regular health services. We plan to continue the process of advocacy, education, training of health care workers, identification of cases, and treatment in one or two additional districts each year. The availability of funding, government support, and human resources are critical for successful continuation.

The population density and geographical terrain vary significantly in size and accessibility in Bhutan. In the coming year, the project will target a relatively accessible district (e.g. Haa with a population of 15,000). In the following year, an accessible but more densely populated district (e.g. the capital Thimphu with a population of 70,000) will be targeted. Additional districts (e.g. Punakha with a population of 25,000) are planned for next.

A collaborative research initiative is being formulated so that modern mental health practitioners and traditional healers can compare the cost effectiveness of different methods of therapy in chronic diseases such as somatoform disorders.

Mental health is gradually becoming an important issue on the national health agenda at both the local and national levels of planning and operation in Bhutan.

What would prevent your project from being a success?

Lack of adequate funding will be the biggest challenge for this project. Mobilization of community support and motivation of health workers is also key to the success of this project. A fast developing country like Bhutan faces the double burden. On the one hand, the country is still facing high rates of infectious and communicable diseases like diarrhea, acute respiratory infections and malnutrition. While on the other, it is beginning to face problems that are non communicable disorders such as diabetes, hypertension, alcoholism, and mental disorders. At the same time, unforeseen natural catastrophes such as flash floods, storm winds, and earthquakes that afflicted the country this year can divert scarce resources away from this project. Therefore, adequate resource allocation in the face of competing demands from the limited pool of resources will be a major constraint.

This project involves gathering community leaders, traditional healers, religious and spiritual leaders, officials, health workers, and other significant players at one meeting place. Next, extended focus group discussions with these actors need to be conducted, followed by hands-on training for health workers, and case identification of mentally ill patients. All these require financial and logistical support with an important role for the Government of Bhutan, which is both a direct source of funding as well as a conduit for external donor funding.

How many people will your project serve annually?

More than 10,000

What is the average monthly household income in your target community, in US Dollars?

$50 - 100

Does your project seek to have an impact on public policy?

Yes

Sustainability

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What stage is your project in?

Operating for 1‐5 years

In what country?

Bhutan

Is your initiative connected to an established organization?

Yes

If yes, provide organization name.

Department of Psychiatry, JDW National Referral Hospital, Thimphu, Bhutan

How long has this organization been operating?

More than 5 years

Does your organization have a Board of Directors or an Advisory Board?

Does your organization have any non-monetary partnerships with NGOs?

Yes

Does your organization have any non-monetary partnerships with businesses?

Yes

Does your organization have any non-monetary partnerships with government?

Yes

Please tell us more about how these partnerships are critical to the success of your innovation.

The Psychiatry Department is part of the Jigme Dorji Wangchuck National Referral Hospital, which is a public organization under the Ministry of Health, Royal Government of Bhutan. This Department serves as the technical advisor to the National Mental Health Programme, Department of Public Health as well as the National Referral and Treatment Centre for severe psychiatric patients in the country. The bulk of the funding comes from the government. WHO and other international organizations like DANIDA provide funds occasionally. It is important that the government consider this project as a long term cost-effective measure to decrease the burden of mental disorders in the country.

What are the three most important actions needed to grow your initiative or organization?

The government should recognize that promoting mental health, preventing mental disorders, and treating them effectively, is an important public health strategy to reduce the burdens associated with disease and disabilities due to mental disorders.

Accordingly, adequate resources need to be invested, whether it is in developing human resources or
infrastructure. Multilateral organizations like the WHO, and other donors, should continue to advocate and support the country financially and technically to develop its mental health programme.

Local NGOs can play a crucial role in advocacy and creating awareness on mental health. Health workers play a dominant role in the implementation of the project activities. Hence, it is important to keep them motivated and interested in the subject by conducting periodic and regular refresher training courses and awarding them incentives for exemplary service.

The Story

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What was the defining moment that led you to this innovation?

“...As the brother of two siblings with schizophrenia I was determined to study psychiatry and find ways to address their health needs in tradition-bound Bhutan...”

Bhutan, an isolated country in the Himalayas, only in the 1960s introduced a modernized education and health care system. Still, change comes slowly and most Bhutanese seek health treatment from religious and traditional medicine, seeing a doctor only when traditional practices have failed. Modern medicine has not grown significantly over the past decades, due to staffing and funding constraints. The first generation of doctors and health workers lack basic skills in managing psychiatric cases and modern mental health care was introduced in the country only in 1997. Since then, a core group of two psychiatrists and five psychiatric nurses were trained abroad.

Extending psychiatric services to the wider population is hampered by limited training of primary health care workers and limited demand from the population. The strategy is to integrate mental health care through the well developed network of primary health care services. This entails training and exposing primary health workers, doctors, and nurses on basic psychiatric skills and management.

There is also a need to create public demand for such services by way of health education campaigns. The scope of the campaigns has to spread beyond influential leaders to religious healers, shamans, astrologers, and herbal doctors, who can influence patient decisions. Stigma and discrimination of the mentally ill still exists, and this pilot also aims to address that.

The defining moment that lead to the development of this unique project was the realization that we could address these challenges at the same time. The success of the pilot project has inspired us to set bigger goals, extending this success to the rest of Bhutan and acting as a ‘best practice’ to other countries.

Tell us about the social innovator behind this idea.

"...My name is Chencho Dorji, and I am the first trained psychiatrist in the Kingdom of Bhutan..."

I became a psychiatrist after two of my siblings became ill with schizophrenia, with no treatment options available. Now with treatment, both my siblings are doing well and leading productive lives.

After completion of my psychiatry residency training in Sri Lanka and Australia in 1999, I began building a comprehensive mental health care program in Bhutan, facing many challenges!

An initial challenge was from within the health system. First, I had difficulty finding cases to treat. Only a handful of patients with suspected psychiatric disorders were referred to me and none came at their own initiative. Bhutanese knew little about psychiatry and those that did refused to see me because of the stigma attached. People believed that treatment was only for the “mad or insane” and those consulting me were labeled as having “madness”. Even the hospital administration doubted there would be any work for a psychiatrist, let alone a need for a separate ward, and I initially worked emergency department shifts instead. Slowly my outpatient numbers grew, more and more people came to see me as they witnessed patients improve with treatment.

Initially psychiatric patients were kept in the general ward, and doctors and nursing staff were ambivalent as they had little prior experience in managing these cases. However, in 2004 for the first time in Bhutanese history, a separate psychiatry ward with eight beds was established in Thimphu, with two psychiatric nurses that were trained abroad.

Since that difficult start, we have treated more than 500 inpatients and 3000 outpatients, and trained more than 300 health workers.

In 2007, I was awarded the Hubert Humphrey Fellowship to study Addiction Psychiatry at the Bloomberg School of Public Health, Johns Hopkins University, USA.

How did you first hear about Changemakers?

Through another organization or company

If through another, please provide the name of the organization or company

Erik Detiger at Philantropia www.philantropia.org

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226 weeks ago Norbu Wangchuk said: This is a very good article Sir, and your plans for the future seems nobel and will be successful. I have come across 5 people who are ... about this Competition Entry. - read more >
226 weeks ago Promoting Mental Health Treatment in Traditional Bhutanese Society has been chosen as a winner in Rethinking Mental Health: Improving Community Wellbeing.
227 weeks ago Naveen Shakir said: On November 20, 2009 the judges reviewed the entries for the Changemakers Rethinking Mental Health: Improving Community Wellbeing ... about this Competition Entry. - read more >
229 weeks ago Promoting Mental Health Treatment in Traditional Bhutanese Society has been chosen as a finalist in Rethinking Mental Health: Improving Community Wellbeing.
235 weeks ago Chencho Dorji updated this Competition Entry.
235 weeks ago Tyler Ahn updated this Competition Entry.
235 weeks ago Chencho Dorji updated this Competition Entry.
235 weeks ago Chencho Dorji updated this Competition Entry.
236 weeks ago Chencho Dorji updated this Competition Entry.
236 weeks ago Chencho Dorji submitted this idea.