Lady Health Visitor (LHV) based Community Mental Health Program in Chitral

Lady Health Visitor (LHV) based Community Mental Health Program in Chitral

Pakistan
Organization type: 
nonprofit/ngo/citizen sector
Project Stage:
Growth
Budget: 
$1,000 - $10,000
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

Aga Khan Health Service, Pakistan (AKHS, P) aspires to see a world with healthy population and without health inequity. It wants people to have access to affordable and functional health services during sickness. Mental illness is an underdiagnosed and undertreated health problem in poor countries and poor populations. The involvement of community health workers has the potential to address mental health problems in a feasible and appropriate manner, especially in disadvantaged and isolated communities.

About Project

Problem: What problem is this project trying to address?

Aga Khan Health Service, Pakistan (AKHS, P) aspires to see a world with healthy population and without health inequity. It wants people to have access to affordable and functional health services during sickness. Mental illness is an underdiagnosed and undertreated health problem in poor countries and poor populations. The involvement of community health workers has the potential to address mental health problems in a feasible and appropriate manner, especially in disadvantaged and isolated communities.

Solution: What is the proposed solution? Please be specific!

Diagnosis and management of mental illness is considered reliable if provided by mental health care specialists who are generally available only in the urban setting. Women and young girls in remote communities are more at risk of developing mental illness because of socio-environmental risk factors such as restricted mobility, patriarchal society and lack of women empowerment. However, stigma attached to the mental illness and high cost of care in urban centers poses major barriers in their timely seeking of care. Community believes in supernatural causes to these symptoms hence local healers are preferred providers for mental illnesses. These providers use harsh treatment such as burning body parts, thrashing the patient, restraining them in chains etc. AKHS, P Maternal and child health clinics are present in each of these areas and are accepted women friendly spaces. LHVs are respected and trusted care providers for MCH and primary care. Therefore, AKHS, P decided to broaden the role of LHVs in early diagnosis, follow up care and counseling of patients with mental illness. Visiting doctors and LHVs of AKHS, P was trained in AKHS, P designed protocols, identification, classification and management of mental illness. Diagnosis made by LHVs was then corroborated by trained visiting physicians. The innovation has opened doors for provision of care for mental illnesses in the rural areas which are otherwise hard to reach.
Impact: How does it Work

Example: Walk us through a specific example(s) of how this solution makes a difference; include its primary activities.

To provide access to mental health services particularly to women in the rural areas, the Aga Khan Health Service, Pakistan and a team of international collaborators piloted a model of basic mental health care delivery through LHVs who are the only certified health care providers in these areas. The pilot has two aims: 1) Train LHVs in diagnosis, basic mental health counseling and follow up care; 2) Launch mental health destigmatization campaign in selected regions. Diagnostic and depression management guidelines were developed in collaboration with the Aga Khan University, WHO and psychologists from Yale and Tehran University for use as a reference guide by the LHVs. The study was launched in the four remote valleys of Chitral district: Chuinj, Gharam Chashma, Herchine and Susoom. Training of LHVs and the destigmatization campaign were launched between April and September 2010 in different areas. After participating in destigmatization and awareness programs, community brought their family members to LHVs who used diagnostic criteria and protocol to confirm their diagnosis. Their diagnosis is corroborated by the visiting physician who visits the area once a month.
Sustainability

Marketplace: Who else is addressing the problem outlined here? How does the proposed project differ from these approaches?

Four areas selected for the project include Chuinj, Gharamhashma, Susoom and Herchine in Chitral district of Khyber-Pakhtoonkhwa, Pakistan with a total population of around 35000. The main source of income in these areas is considered to be subsistence agriculture with average land holding of less than one hectare; 90% of the population is engaged in farming. A household income and expenditure survey conducted by the Aga Khan Rural Support Programme (AKRSP) in Northern Areas and Chitral in 1991 revealed that 75% household income was being derived through off-farm sources in Chitral. The socioeconomic status of the majority of the population is very low in these areas as compared to other villages in the district. According to socio- economic survey conducted by AKRSP in 2005, 41% of the population of the district live below the poverty line and an additional 16% qualify as ‘vulnerable’ or in danger of falling under the poverty line. According to 1998 census report, the literacy rate of the district was 40%. The literacy ratio in female was 22% while male literacy rate was 58%. Though the ethnic region of Chitralis (inhabitants of Chitral) is associated with central Asia's cultures but being part of the Khyber Pakhtunkhwa province of Pakistan, the Chitrali society is highly influenced by the neighboring Pathan / Pushtun and Afghan customs and traditions, resulting in conservatively restricted participation and mobility of women folk in the mainstream activities of socio-economic development. In the recent decades, there has been an increasing trend of providing early age education to girls but in fact, higher education for females is still not being taken seriously, which results in lack of leadership among the local women in Chitral. As a tradition, women are considering to be responsible for household chores, taking care of children and livestock and participating in farming activities with their male counterparts.
About You
Organization:
Aga Khan Health Service, Pakistan
About You
First Name

Rozina

Last Name

Mistry

Twitter
Facebook Profile
About Your Organization
Organization Name

Aga Khan Health Service, Pakistan

Organization Phone

+9221-3536-1197

Organization Address

3 and 4, F-17/B, Block 7, KDA, Scheme 5, Clifton, Karachi, 75600

Organization Country
Country where this project is creating social impact

, N

How long has your organization been operating?

More than 5 years

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Innovation
What stage is your project in?

Operating for 1‐5 years

Tell us about the community that you engage? eg. economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts.

Four areas selected for the project include Chuinj, Gharamhashma, Susoom and Herchine in Chitral district of Khyber-Pakhtoonkhwa, Pakistan with a total population of around 35000. The main source of income in these areas is considered to be subsistence agriculture with average land holding of less than one hectare; 90% of the population is engaged in farming. A household income and expenditure survey conducted by the Aga Khan Rural Support Programme (AKRSP) in Northern Areas and Chitral in 1991 revealed that 75% household income was being derived through off-farm sources in Chitral. The socioeconomic status of the majority of the population is very low in these areas as compared to other villages in the district. According to socio- economic survey conducted by AKRSP in 2005, 41% of the population of the district live below the poverty line and an additional 16% qualify as ‘vulnerable’ or in danger of falling under the poverty line. According to 1998 census report, the literacy rate of the district was 40%. The literacy ratio in female was 22% while male literacy rate was 58%. Though the ethnic region of Chitralis (inhabitants of Chitral) is associated with central Asia's cultures but being part of the Khyber Pakhtunkhwa province of Pakistan, the Chitrali society is highly influenced by the neighboring Pathan / Pushtun and Afghan customs and traditions, resulting in conservatively restricted participation and mobility of women folk in the mainstream activities of socio-economic development. In the recent decades, there has been an increasing trend of providing early age education to girls but in fact, higher education for females is still not being taken seriously, which results in lack of leadership among the local women in Chitral. As a tradition, women are considering to be responsible for household chores, taking care of children and livestock and participating in farming activities with their male counterparts.

Share the story of the founder and what inspired the founder to start this project

Founder of this initiative is Aga Khan Health Service Pakistan (AKHS, P)- a subsidiary of Aga Khan Development Network (AKDN). AKDN has a long history and tradition of serving the humanity and those living in the most difficult situation across the developing world through pioneering evidence-based interventions. Aga Khan Development Network-is a conglomerate of multisectoral institution. AKHS, P is recognized as one of the leading non-governmental organization in health in Pakistan. It operates a large network of more than 100 primary and secondary care facilities across the country. AKHS, P believes in the philosophy of “Care is Cure." In the area of women and child health, AKHS, P has already demonstrated noteworthy models and achievements. Increasing report of suicide, particularly among girls and women from Chitral and Gilgit Baltistan during the last few years drew AKHS, P’s attention towards exploring the underlying causes of mental illness. The socio-environmental situation and vulnerability of women to mental illnesses, prompted AKHS, P to develop this idea of "LHV based mental health program." This is the first research proposal selected by recently launched “Yale World Fellow Program research grant” in which researchers from Pakistan, Iran and US worked together to develop this model.

Social Impact
Please describe how your project has been successful and how that success is measured

Findings of the project indicate that from October 2010 to April 2011, 77 cases of depression were diagnosed by LHVs from patients who self-referred mostly after participating in the de-stigmatization campaign; 100% of the diagnoses made by LHVs/nurse were corroborated by the visiting physician; 92% of the cases diagnosed were women, 30% of the women were in the age group of 35-45 years and 29% were in the age group of 25-35 years, 74% of the women were married and 18% were single. 50% of the cases with depression were referred for comprehensive management; 77% of the diagnosed cases showed improvement in their symptoms after diagnosis and counseling by LHV. Data monitoring is ongoing at this time and may provide insight into the actual incidence of mental illness in rural areas. It is worth noting that none of the registered case of severe depression committed suicide during this entire surveillance period.

How many people have been impacted by your project?

More than 10,000

How many people could be impacted by your project in the next three years?

More than 10,000

Winning entries present a strong plan for how they will achieve growth. Identify your six-month milestone for growing your impact

Task 1: Establishment of “controlled drug pharmacy”
Task 2: Development of open Medical record system;
Task 3: Induction of one therapeutic counselor to provide care to the cases

Task 1

Establish an LHV managed “controlled drug pharmacy” with m-health prescription by the off-site physician. Currently there is no pharmacy available in these areas to provide continuity of care.

Task 2

Development of open Medical record system atleast from one site for allowing physicians to access the patient record at his/her end in case of an emergency

Task 3

Induction of one therapeutic counselor to provide services to the cases identified from the four centers

Identify your 12-month impact milestone

1. Reduction in the incidence of suicides
2: More than 90% cases will be reporting in the early stages of depression
3: 95% Patients will become productive members of the society

Task 1

1. Re-enforce destigmatization messages three times a year;
2. Introduce life skill program for youths
3. Prepare community based marital counseling program

Task 2

1. Patient's relatives will be counseled about ensuring continuity of care;
2. Establish a community based appointment recall system.
3. Ensure access to essential medicines at the pharmacy.

Task 3

1. Community well being group will be established to address underlying social determinants of mental ill health;
2. Community counselors will be trained to counsel couples with marital problems.

How will your project evolve over the next three years?

1.The project will turn into a program and will be rolled out from all the 127 health care sites;
2.A cluster of primary care facilities will be connected to the secondary care referral facility for e-health consultation to improve the quality of follow up care of mental illnesses;
3.Life skill health promotion will be offered from school to enhance coping skills of the youths;
4.Antenatal and postpartum health education program focused on building new parent’s capacity in healthy parenting to help them deal with the changes in life more effectively;
5.Findings will be shared with multiple sectors to develop a supportive environment for improving mental health.

Sustainability
What barriers might hinder the success of your project and how do you plan to overcome them?

There are four elements of operational cost that will be managed in the following way:
1.Counselor cost: To be funded through individual philanthropy for two years. Fee for service, coverage to more centers by one counselor and incorporating counselor travel cost with the existing mobile field team will help contain the cost;
2.LHV cost: By integrating the model into existing program model, the cost will be kept to a minimum. A nominal charge will be introduced for consultation and treatment to ensure downstream sustainability of the model.
3.Medicine cost: Formulary will be kept to bare minimum and group purchase approach will be used to keep the working capital under control. Income will be generated by selling the medicine at market retail price with 10% discount to poor.
4.V-sat for tele-consultation: V-Sat will be an expensive undertaking and therefore donor support will be sought. It is expected that within three years, dial up network will be available in this geographical area reducing the high operational cost of the V-Sat.

Tell us about your partnerships

The project has following partners:
1. Aga Khan University Hospital, Yale University and Tehran University departments of psychiatry facilitated in the development of the diagnostic and management protocols for nurses;
2. Yale University provided initial seed grant of US$ 10,000.
3. WHO's technical assistance in training of the LHVs and doctors;
4. Aga Khan Health Service supported the cost of the staff salary and travel for monitoring and clinical care.

Explain your selections

Research grant of USD 10,000 supported AKHS, P in curriculum and protocol development, training and visit to Iran for learning from their model of community based mental health care program and consulting the designers of the Iran model.

How do you plan to strengthen your project in the next three years?

AKHS, P aspires that the project should expand in its scope and rigor. It is hoped that investment in E- consultation and Electronic medical record system will strengthen the project along with additional therapeutic counselors inducted to expand the scope of counseling care.

Challenges
Which barriers to health and well-being does your innovation address?
Please select up to three in order of relevancy to your project.

PRIMARY

Limited diagnosis/detection of diseases

SECONDARY

Lack of physical access to care/lack of facilities

TERTIARY

Lack of affordable care

Please describe how your innovation specifically tackles the barriers listed above.

1. In the absence of mental health specialist, community had no choice but to seek care from the local healers. By training LHVs in this model, community particularly women have access to quality detection and care of mental care;
2. The model will provide geographical access to mental health services through providing access to trained LHVs for follow up care. Visiting therapeutic counselor and e-consultation with physician will improve the quality of care for these patients, availability of essential medicines even in severe weather will help enhance quality of care in distant areas.
3. This innovation along with other support system will prevent clients and patients from incurring high cost of travel to cities to seek care for this condition which is a chronic disease.

How are you growing the impact of your organization or initiative?
Please select up to three potential pathways in order of relevancy to you.

PRIMARY

Enhanced existing impact through addition of complementary services

SECONDARY

TERTIARY

Leveraged technology

Please describe which of your growth activities are current or planned for the immediate future.

In the immediate future leveraging the e-technology has been planned so that the access is enhanced. Winter season is fast approaching and then it will be difficult for physician to access these areas. The risk of interruption in the follow up care will increase. We intend to approach technology providers, telecom companies and other donors to help us enhance the access to e-health.

Do you collaborate with any of the following: (Check all that apply)

Technology providers, Academia/universities.

If yes, how have these collaborations helped your innovation to succeed?

Protocols that we developed needed expert inputs of Academia and University but without the financial supports from "Yale University", this project would not have materialised. Similarly without the support of WHO in training, this project would not have achieved such recognition. Posibility of using Vset and e-technology and Open MRS through Internet provider will be instrumental in converting the vision of continuity of care for mental illness into a reality.