Community-based Mental health and Psychosocial Integration in Nepal

Innovation summary

Mental health is one of the least prioritised areas of health and development in Nepal. Non-governmental organisations and civil society organisations are seen to provide mental health and psychosocial services to address an urgent unmet need for mental health support. There is an urgent need to integrate and streamline mental health services and improve the capacity and skills of health professionals to improve and strengthen access to mental health to affected populations in the country.

CMC-Nepal, a local NGO aims to address this need by implementing their Community Mental Health and Psychosocial support program through primary health care system. The goal of this innovation is to address mental health concerns of people in remote areas and communities through strengthening the capacity of health service providers, counsellors and teachers as they are part of local resources to address mental health and psychosocial needs at community.

The programme aims to achieve three primary outcomes as a result of their work:

Increase access to mental health psychosocial services at the local community level
Support people with mental health conditions and their families to be able to work in their communities
Networking with local government and DPOs to respect, protect and fulfil the rights of people with mental health conditions
With the support of the Government of Nepal, upscale the community-based mental health programme at the local, national and provincial level

Impact summary

In 2018, a total of 3972 patients accessed mental health treatment services from primary health care facilities through the programme
In 2018, a total of 2244 adults and 499 children registered as beneficiaries of psychosocial counseling services through the programme
24400 people from various communties engaged in mental health awareness activities
Capacity-building for mental health and psychosocial services was provided to 84 health service providers, 409 teachers and 88 counselors
Implemented 9 self-help-groups (SHG) for improving service seeking behaviour and support from families and communities

I always felt that I'm the one to take the responsibilities of household work so due to work stress my health was deteriorating. After participating in group counselling session, I learned I can ask my children to support me in household work. Now I can allocate some time to rest and eat.

- Participant from group counselling

Innovation details

Mental health conditions are prevalent in low-income- countries like Nepal. It is reported that about 20% of the population has a mental health condition. Mental ill-health brings with it social stigma in Nepal, with more than 85% of people¹ who are unable to access services for treatment, and experience increased risk of mental health problems in survivors of GBV, women, children and old aged people.

As per guided by the National Health Policy (2015), National Mental Health Policy (1997) and Act Relating to the Human Rights of Person with Disability (2017), CMC-Nepal works with the Social Welfare Council of the Government of Nepal to implement its community mental health and psychosocial programme. The aim of this programme is to enhance access to mental health and psychosocial services by integrating them into existing district hospitals, primary health centres and health posts. This programme will be implemented in 4 districts (Okhaldunga, Udayapur, Surkhet and Jajarkot) of Nepal.

CMC-Nepal is contributing to build the technical capacities of prescribers in mental health and non-prescribers in psychosocial support) through the training (basic and refresher), clinical supervision conducted at health facilities and from the distance coaching. In addition, the programme has the following components of work:

Trained health workers within health facilities provide mental health and psychosocial services at the usual health care delivery systems.
Trained health workers consult with CMC-Nepal's psychiatrist and supervisors if they experience challenges with the diagnosis and management of mental health problems.
Supervisions are carried out by the psychiatrists and CMC-Nepal’s psychologists for knowledge and skill enhancement in mental health and psychosocial support of trained health workers.
Running awareness campaigns through radio programmes, exhibitions, orientation to female community health volunteers, traditional healers, mothers' groups and community people
Empowering persons with mental and psychosocial disabilities, their families and other stakeholders for the protection of fundamental rights for people with psychosocial disabilities and reduction in social inclusion
Advocating at the central and provincial level for the integration of mental health services into the public health system
Supporting people with mental health problems to access treatment at higher facilities and gain economic empowerment for livelihood support

Key drivers

Collaboration with policy makers and other key actors

Mental health services were developed in collaboration with the health ministry at central and province and municipality. Authorities from all three tiers are involved in developing the service and municipality involved in monitoring and ensuring the supply of psychotropics into health facilities. Further collaboration is also maintained with local level NGOs to mobilize counsellors at the community level for additional support.

Self-help group formation and mobilization

Once registered in primary health care facilities for mental health treatment, patients are organized into self-help groups, facilitated by mental health social workers. The SHGs support members in advocating for their treatment rights and reducing discrimination. The groups are actively mobilized for awareness campaigns on mental ill-health and stigma.

Collaboration with policy makers and other key actors

Mental health services were developed in collaboration with the health ministry at central and province and municipality. Authorities from all three tiers are involved in developing the service and municipality involved in monitoring and ensuring the supply of psychotropics into health facilities.
Further collaboration is also maintained with local level NGOs to mobilize counsellors at the community level for additional support.

Self-help group formation and mobilization

Once registered in primary health care facilities for mental health treatment, patients are organized into self-help groups, facilitated by mental health social workers. The SHGs support members in advocating for their treatment rights and reducing discrimination. The groups are actively mobilized for awareness campaigns on mental ill-health and stigma.

Mental health social workers

Social workers are invaluable to the programme as they use their recognition and registration within specific rural municipalities to carry out mental health work effectively. They are involved in a number of different components including empowerment, advocacy and rights-based work through the self-help groups and awareness raising at the family and community level about treatment adherence, availability of counselling services and family support for better recovery.

Challenges

Stigma

There is huge stigma against mental ill-health in Nepal and people with mental health conditions experience discrimination at both the family and community level. Stigma negatively affects treatment seeking for people with mental health conditions as well as social participation.

Policy and priority

Mental health is a low priority in Nepal and the existing mental health policy is dated (23 years old) and warrants a revision to have a clear strategy for the integration of mental health and psychosocial services at primary health care facilities.

Continuation

Municipality (local government) and state government have shown keen interest to develop mental health services into the primary health care system. There has been an increased service demand from the community and promising results show that the innovation has developed better coordination among municipality, state and federal government which helps in planning of services to upscale mental health service access in many parts of the country.

Partners

Funders

Tear Australia, Felm

Evaluation methods

The programme conducted an internal evaluation using the Result-based matrix (RBM) methodology developed and followed during implementation.

Project reports are prepared half-yearly and annually. Results-based matrix measures outcome level changes due to program interventions with indicators on case stories, SHG members reflections, stakeholders reflection during social audit and monitoring reports. Both Results-based matrix and project evaluation results showed program activity significantly contributed in increasing mental health and psychosocial service accesses in many remote parts of the country.

Social workers of the project make frequent family visits and use scales ranging from 0-10 scores for detection. A score of 0 means no improvement at all in psychosocial and mental health functioning, whilst a score of 10 indicates a complete improvement in symptomology and functioning which is the basis for measuring changes.

Mental health awareness is assessed from health facility registered through the programme e.g. reporting on service demand through number of cases registered, reflections from self-help groups during group interaction activities with mental health social workers.

Cost of implementation

Per person treatment cost for the provision of mental health and psychosocial support through community and primary health care is approximately NR 2533 (USD 23) per year.

Impact details

Mental health treatment service utilization from primary health care facilities received by 3972 in 2018
- 73% recovered, 27% are in stable mental condition as reported by the mental health assessment tool used
Psychosocial counselling service beneficiaries were 2244 adult and 499 children in 2018
- 84% of adults and 92% of children registered recovered from significant symptoms of distress, 16% of adults and 8% of children are continuing to receive services with improved levels of functioning.
Mental health awareness reached to 24400
- Increased service seeking behaviour, families and community are showing supportive behaviour to person with mental health problems
Capacity building in MHPS to 84 health service providers, 409 teachers-,88 counsellors.
- Trained resources engaged in service delivery.
Capacitated 9 self-help-groups (SHG)
- 75 SHG members received training about fundraising and mobilisation, networking, basic mental health and psychosocial support and effective advocacy
- 7 people with mental health conditions received livelihood support
Successful lobbying and advocacy
- 75% of municipalities supported improved budget for the supply of psychotropic medicines within the country

References

Luitel NP, Jordans MJ, Kohrt BA, Rathod SD, Komproe IH. Treatment gap and barriers for mental health care: a cross-sectional community survey in Nepal. PloS one. 2017;12(8).

Associates

Pashupati Mahat

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Country

Nepal