Integrating Mental Healthcare into General Healthcare in Aceh

Innovation summary

Prior to the tsunami, one mental health hospital existed in the province which had one part-time and two full-time psychiatrists and occupancy rate usually over 100%. Primary and secondary health centres did not have the capacity to deliver mental health services and patients were expected to pay for services out of pocket.

This innovation seeks to foster efficient and sustainable community based mental health services by developing leadership, integrating mental health services into the primary health care system and restructuring programmes and institutions to address the lack of mental health services after 30 years of conflict and the aftermath of the 2004 tsunami.

Impact summary

All districts in Aceh have at least some capacity to deliver mental health services at the primary care level
At least five districts had allocated funds specifically for mental health programmes, one year after the reform. Before the tsunami, none of the districts had specific mental health budgets.

“Disaster can lead to the opportunity to scale up mental health services.”

– Dr Andrew Mohanraj, Psychiatrist & Mental Health Development Advisor, CBM South East Asia and Pacific Regional Office

Photo Credit: CBM Indonesia

Innovation details

Following the tsunami in 2004, more than 100 Indonesian and international organizations came together to offer a wide range of mental health and psychosocial support services e.g. support to tsunami survivors, and awareness and demand for services. After most of these agencies left Aceh, Indonesia’s Ministry of Health and the World Health Organization provided leadership to develop sustainable community based mental health services, based on WHO’s Recommendations for Mental Health in Aceh (2005). The main objective was to integrate mental health into the province’s PHC system. The following activities, alongside additional parallel efforts by international organizations, occurred to ensure this objective was achieved:

Mental health programme planning workshop was organised to build consensus on developing mental health services in PHC and commitment from major stakeholders.
A training module was developed with the University of Indonesia’s Faculty of Nursing for community mental health nurses on mental health care delivery as the programme would rely on community mental health nurses to deliver the care. Three training levels – basic, intermediate, and advanced – were developed to teach nurses to provide care of people with severe mental health problems and to prevent mental disorders and promote mental health.
Medical Officers, the Ministry of Health and the Department of Psychiatry’s Faculty of Medicine developed a short refresher course on primary care psychiatry.
Training and supervision were implemented in 11 of the most affected districts of Aceh. In each district, 10 primary care centres were selected. A total of 110 PHC centres and 220 nurses participated. The nurses were responsible for providing mental health services in their communities.
Reform executed at the Banda Aceh Mental Hospital by international organisations advocating for open wards instead of locked wards, developing training programmes for doctors and nurses, and establishing a fully equipped epilepsy clinic.
First psychiatric intensive care unit established in Jantho General Hospital in Aceh Besar, now serving as the model for providing acute inpatient mental health care in a general hospital.
Two inpatient units established within general hospitals covering patients along the west coast and the central region of Aceh.

Key drivers

Immediate Coordination of Relief Efforts

The coordination of relief efforts in the immediate aftermath of the emergency to ensure best distribution of resources and the minimisation of service gaps, both indirect contributing factors to sustainability.

Challenges

Fund and Resources used for Short-Term Relief

Initially, the influx of funds and resources by more than one hundred international and national NGOs after the emergency were primarily used for short-term relief and support rather than allocating a portion of funds for strengthening and developing the existing mental health system. Should the latter have been factored into the plan, secondary care mental health services could have thrived at a higher level. However, after one year post tsunami, only a few remaining agencies formed an informal coalition to pursue long term sustainable scale up.

Continuation

There are plans to replicate this innovation in other parts of the country and also in neighbouring countries like Timor Leste. The challenge is to demonstrate to host governments that investment in mental community mental health pays off ultimately especially when people with chronic mental illness also can function as full citizens of society in all the characteristic components of a democratic society. Community mental health service innovations also likely to be sustainable only if it is integrated into the existing system of community health care rather than existing as a separate parallel service.

Partners

Indonesia's Ministry of Health
CBM
Norwegian Red Cross
United States Agency for International Development (USAID)
WHO

Funders

Asian Development Bank (ADB)
CBM
Norwegian Red Cross
United States Agency for International Development (USAID)
WHO

Evaluation methods

An evaluation of the entire mental health integration program has not been conducted, however individual organizations have conducted evaluations for their respective parallel projects. For example CBM conducted an evaluation to gather results and outcome-oriented information from all stakeholders. The sample selection included patients, their families, community health workers, trained mental health nurses, doctors and health office focal persons. The five criteria that were addressed were:

Quality of project design
Efficiency of the implementation
Outcomes (change)
Potential sustainability
Potential to scale up the project and replicate in other areas

Impact details

All districts in the province have at least some capacity to deliver mental health services at the primary care level. Three district general hospitals are providing short-term hospitalization and outpatient services, however three additional units are still needed to cover the remaining areas of Aceh. At the tertiary level, the existing Banda Aceh Mental Hospital has improved its quality of care. Further, district health officials have increased their commitment to mental health by allocating a budget specifically for mental health programmes which was non-existent prior to the tsunami.

A total of 110 primary health care centres and 220 nurses were trained in 11 of the most affected districts of Aceh (supported by WHO). In addition, training for community based mental health services was conducted in 5 districts of Aceh, allowing for over 4,000 clients’ recovery out of 15,852 clients served, as of 2013 (supported by CBM).

Research

Multimedia

Menuju Kebebasan - Aceh Psychosocial Rehabilitation Programme

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Country

Indonesia

Affiliated organizations

CBM

World Health Organization