Primary Urban Health Care Unit and Community Movement
The mental health services in the country are far from developed, and not easily accessible. The minuscule mental health budget often concentrates on building of services in expensive psychiatric hospital set-ups rather than primary or community care, or close to where people live. These services often, only concentrate on the more severe mental health conditions, while common mental health conditions like panic attacks, anxiety, stress, and depression which are more likely to be experienced by anyone at any given point of time are largely
It is in this context that Iswar Sankalpa launched a pilot project – the Urban Mental Health Programme (UMHP) – Project Sambandhan – in partnership with the Kolkata Municipal Corporation (KMC) in wards 78 and 82.
This project aims to evolve a holistic care pathway for the socio-economically disadvantaged population in the slums in both these wards – by integrating mental health services with physical health care services in the primary health care setting. By reaching out to those having some mental health conditions – the project aspires to promote early detection and minimise stigma as well. Hence, UMHP focuses on the preventive aspects of mental illness and health – and thus leads to quicker intervention.
UMHP has a dualistic goal –
- To integrate mental health services with general health services offered at the ward health units of the two wards under the KMC and in the process train and create non-psychiatric workers in the field of mental health. This will help in establishing a faster identification, intervention and treatment process.
- To evolve a community movement towards positive mental health. This is an inclusive idea of mental well-being and not simply the absence of mental health conditions. This will help target the knowledge, attitude and practices of the community and bring change.
Our vision is that these wards will serve as models which the KMC can adapt in their other wards, heralding a new Calcutta – the city of joy where madness is no longer misunderstood, shunned and discarded off, but embraced and provided intervention, treatment and support.
The Urban Mental Health Programme (UMHP) works in two wards (78 and 82) of the Kolkata Municipal Corporation and is a clinic based intervention model. It is simultaneously working on creating a positive movement towards mental health care in the surrounding community. These wards have a concentrated slum population and the majority of the families belong to the low income or below-poverty line groups.
The Target Group:
The philosophy behind starting a programme like UMHP in such a low-income group community encompasses understanding the dynamics of living in an urban slum.
In a research paper released by the United Nations – Understanding Slums, Case studies for the Global Report on Human Settlements 2003, it was estimated that about one
third of the population of Kolkata lives in slums, of which over 40% of Kolkata’s slum residents have been slum dwellers for two generations or longer, and more than half originate from the Kolkata hinterland.
Space crunch, big families, and poor sanitation coupled with the majority being engaged in the informal sector with average monthly earnings between 500 and 1700 rupees; some three-quarters of the Kolkata slum population are below the poverty line. These pre-existing conditions contribute to the high illiteracy of this population which consequently leads to very limited options for raising the standard of living, and thus creating a vicious cycle of poverty, unemployment and illiteracy.
This scenario further intensifies the poor knowledge and information disseminated amongst these communities and leads to a low level of health awareness amongst our target population, regarding general health care, and an even lower awareness on mental health care.
Services in West Bengal:
The current scenario of mental health care being accessed in West Bengal can be understood through the Performance of Mental Hospitals 2002-03 to 2006-07;
|1)||OPD attendance of persons with mental health conditions (Mental Hospitals, Medical Colleges, District Hospitals, NGOs, Nursing Homes||632528||576874||496912||367005||381669|
|2)||Indoor admission of persons with mental health conditions (Mental Hospitals only)||1516||1245||1032||712||862|
According to World Health Organisation (WHO) estimates, the worldwide prevalence of mental health conditions is, approximately –
- 1% major mental illness,
- 4-5% minor mental illness,
- 3-5% substance dependence and
- 3% mental retardation,
This implies that about 10-12% of a given population at any given time has a mental health condition. Given that West Bengal’s population is about 80 million, the absolute number of persons with a mental health condition is 8 million but the number of persons accessing OPD care in 2006 was less than 7 lakhs. Further, an estimated 5% of persons with major mental health conditions need inpatient care and this number is estimated to be 32,000 – the admissions in the same year was less than 2000. The above estimates leave no room for doubt, the overwhelming need for extending mental health service delivery in the state.
The UMHP model of delivering mental health care facilities has been devised taking this background into account. These ward health units serve as the primary urban health care centres in Kolkata. They are both more localized and easy to get to, for the slum population, and are the first point of access to many who cannot afford private practitioners and long waiting periods at hospitals.
UMHP’s area of concern is increasing mental health services and integrating it with general health care and making these services more reachable to the common population. This is dually reinforced by all the awareness and sensitization activities undertaken under this model.
The Urban Mental Health Programme has an integrative care delivery model which can be represented as below –
The key activities under each component are as follows –
1. Ward Health Unit based Service Delivery –
- The clinics are located in the ward health units to integrate the service as well as minimize stigma and discrimination associated with mental illness and health.
- The clinics offer information to persons on how to access government-run and other health services and facilitate a referral service
- The clinics offer intervention by the medical officer/psychiatrist and dispense medicine.
- The clinics in cooperation with the case manager, social worker, counsellor and health worker provide an on-going counselling and home based follow-up service
- The clinic space is utilised to organise vocational training sessions and recreational group activities for the clients
2. Empowerment of Persons with Mental Health Conditions
The focus will be on the client’s vocational participation and engagement in avenues of supportive employment. The team will focus on exploring these avenues in and around both the wards and advocating placement. The feasibility of self help groups in the wards will be explored.
3. Community Stakeholders address Human Rights Issues
The project model entails creation of a Community Mental Health Committee to be formed of the Borough Chairperson, Municipal Councilors, Religious and Opinion leaders of the community or any person of importance in the government and community. Such a body will ensure the protection of human rights of the persons with mental health conditions.
The health workers involvement in identification, follow up and home visits targets not only the client but the families as well hence focusing on reducing stigma and upholding the person’s needs and rights.
4. Sensitization of the Government, Community, Police, Media, and Judiciary
This project seeks the recognition of the persons with mental health conditions as human beings with rights to live a life of dignity as the foremost change, accompanied by a community movement towards mental health awareness. This will in turn address the gap in mental health care service delivery and lead to advocating state responsibility in minimising this gap by securing infrastructure and services for this target population. There is also a need to advocate change in the treatment meted out to a citizen with a mental health condition by the police, judiciary, media and the hospitals.
This model focuses on treatment and empowerment of persons with mental health conditions and providing a sustainable care system along with checks and balances against human rights abuse and issues. The overall progress of this care delivery system will be complemented through awareness, sensitization and advocacy measures.
Key Achievements in 2012-2014 :
The clinic at ward health unit 78 started in September 2012 and the clinic at ward health unit 82 started in June 2013. Given below is a glimpse of the reach and accomplishments of the project from April 2012 to September 2014-
- Signing of the Memorandum of Understanding (MOU) with Kolkata Municipal Corporation, thereby legally affiliating Iswar Sankalpa’s work with that of the KMC, providing the crucial impetus required to initiate sustainable change.
- Training of Medical Doctors and Health Workers of ward 78 and 82 to strengthen their knowledge, attitudes, and practices regarding mental health.
- Consolidation and efficient functioning of the clinic in the health unit of wards 78 and 82
- Distribution of psychotropic medication supplied by the KMC from the health unit itself at no cost
- Awareness and advocacy campaigning in both wards 78 and 82, leading to increasing knowledge on mental health and changing attitudes and practices towards mental illness in the communities
Number of people who have visited the clinic for mental health related services
Number of people registered as clients under the programme in the clinic (receiving medical and counseling services):
Number of awareness events done in the community
Number of people in the community covered through awareness events
Number of KMC doctors (under borough IX) who attended mental health related trainings
Number of KMC health workers (under borough IX) who attended mental health related trainings
Much Madness is Divinest Sense
By Emily Dickinson
Much Madness is divinest Sense –
To a discerning Eye –
Much Sense – the starkest Madness –
’Tis the Majority
In this, as all, prevail –
Assent – and you are sane –
Demur – you’re straightway dangerous –
And handled with a Chain –
This poem by Emily Dickinson rightly captures the alienation of mental health conditions in common parlance and the majority of the population.
Working in the area of mental health then, the biggest challenge is to counter the misconceptions and culturally ingrained understanding surrounding ‘madness’ and mental illness. It is our constant endeavour to not have the ward health unit labelled as a ‘mad person’s clinic’ and to work towards building a community which focuses on positive mental health. Our awareness events and sensitization work with the local community tries to respond to the different stigma ideas about mental health conditions and the people affected by it.
As the UMHP is working in partnership with the Kolkata Municipal Corporation, and offering clinic services from a ward health based unit, it implies increased role of the health unit staff. Iswar Sankalpa has conducted a few trainings for the Medical Officer and Health Workers on identifying and treatment options for persons having a mental health condition, along with focusing on counselling, family education and continuous follow up care. This being a relatively unknown area for the health unit staff, it is a challenge to ensure their interest in understanding mental health and being sensitized towards persons coming to seek intervention at the clinic. Through this process, the project also has to eke out the staff’s own misconstrued notions around mental health and work on their capacity building.
UMHP attempts to incorporate mental health care with physical health care at a primary urban health care centre which encompasses a whole range of challenges including handling bureaucracy, setting up new systems within existing government health care facilities, keeping the team and health worker staff motivated, engaging the community in accessing these services by working on increasing their knowledge about mental health and targeting their attitudes and practices, and understanding the community we work in, in order to be able to understand the environment contributing to their mental health issues.
By approaching this multitude of inter-linked challenges through possible solutions, negotiations and partnering, they can be looked into with greater depth and attempts at resolutions may lead to a degree of success.