Lady Health Visitor (LHV) based Community Mental Health Program in Chitral
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Rozina
Mistry
Aga Khan Health Service, Pakistan
+9221-3536-1197
3 and 4, F-17/B, Block 7, KDA, Scheme 5, Clifton, Karachi, 75600
, N
More than 5 years
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Operating for 1‐5 years
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.
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.
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.
More than 10,000
More than 10,000
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
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.
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
Induction of one therapeutic counselor to provide services to the cases identified from the four centers
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
1. Re-enforce destigmatization messages three times a year;
2. Introduce life skill program for youths
3. Prepare community based marital counseling program
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.
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.
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.
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.
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.
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.
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.
Please select up to three in order of relevancy to your project.
PRIMARY
Limited diagnosis/detection of diseases
Lack of physical access to care/lack of facilities
Lack of affordable care
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.
Please select up to three potential pathways in order of relevancy to you.
PRIMARY
Enhanced existing impact through addition of complementary services
Leveraged technology
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.
Technology providers, Academia/universities.
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.