The World Health Organization's Mental Health Gap Action Programme (mhGAP) has been developed with the aims of training and capacity building in order to deliver services for people with mental, neurological and substance use disorders for countries especially with low and middle income. According to the WHO “Mental, neurological and substance use disorders are common in all regions of the world, affecting every community and age groups across all income countries. While 14% of the global burden of disease is attributed to these disorders, most of the people affected -75% in many low-income countries- do not have access to the treatment they need”.
Kashmir has been going through conflict since 1947 and in the last 25 years there has been armed conflict which has led to many fold increase in mental disorders. Conflict is ongoing and people continue to suffer, with limited access to mental health services. There is only one psychiatric hospital based in capital Srinagar with 25 to 30 psychiatrists for the whole population of Kashmir valley (approximately 800,000 people). Given the system is very centralized, there are not any psychiatric services at the primary care level and there is very limited access to psychiatrists at the district level.
District Mental Health Program
The District Mental Health Program, part of the National Mental Health Program, is the flagship program for mental health intervention in India. It is the first initiative to move away from institutionalization to community care by collaborative arrangement with strong community participation, linkages with voluntary sector and civil society initiatives,with academic institutions from inter disciplinary backgrounds and use of private sector knowledge and skill base with adequate safeguards against commercial interests prevailing over public interests.
The overall objectives are:
- To deliver a standardized mhGAP training to prescribers and non-prescribers working in primary care settings in Kashmir
- To increase participants’ confidence and skills in the assessment, diagnosis and management of the priority conditions prioritized by mhGAP
- To increase participants’ skills in a range of training techniques, facilitators and supervision skills, identifying a pool of local mhGAP champions
- To raise the profile of mental healthcare among primary care workers
The innovation works alongside the District Mental Health Program to use a decentralized community based approach to the problem by:
- Training the mental health team at the identified nodal institutes within the state
- Increasing awareness about mental health problems and effective health seeking patterns
- Providing adequate services to promote early detection and treatment of mental illness in the community itself with both outpatient and indoor treatment and appropriate follow up measures
- Collecting data and experience for future planning, research and improving service provision
Further it seeks to take the mhGAP training program one step further by evaluating the training. This element is an innovative feature, one that other mhGAP programs do not usually include.
3 Phases of Training in Kashmir
To date there have been 3 phases of training in Kashmir as part of this innovation, supported by the Director of Health Kashmir:
Preliminary Primary Care Training (September 2013)
A two-week preliminary primary care training was conducted for 120 health professionals from all over Kashmir in September 2013. The training was delivered by a team of UK, Kashmiri and Dutch psychiatrists and psychologists who were recruited from the Royal College of Psychiatrists Volunteering and International Psychiatry Special Interest Group.
Secondary Care Training (August 2014)
The second phase was coordinated by the secondary care level to link primary and secondary levels of care effectively. This phase included new participants from secondary care and from the private sector. The training specifically focused on the child development modules of the mhGAP.
Pilot Program in Ganderbal District (August 2014)
Following a series of meetings over 2013-2014, a steering group was formed for development and implementation of the pilot project in the Ganderbal district. This steering group was essential in preparing an extensive background sketch for the implementation of the pilot.
Training was repeated in August 2014 and focused on primary care physicians in Ganderbal district. The meeting was held with the Chief Medical Officer, the Block Medical Officer and medical officers of the Ganderbal district to establish a robust supervision, monitoring and evaluation system over the following year as per supervision and monitoring framework. The BMO and MO were identified as supervisors.
The objectives of the pilot training program were:
- To train all GPs in the Ganderbal district of Kashmir (India) in mhGAP implementation guide tool
- To implement the mhGAP based integrated mental health primary care service in Ganderbal
- To implement a supervision framework for 1 year for GPs in Ganderbal