PRIME CEO inspired by visit to Chitwan district in Nepal
By Prof Crick Lund
On the morning of 15 September I flew from Kathmandu to Chitwan, the PRIME district implementation site in Nepal. I was accompanied by Nagendra Luitel, the PRIME Nepal Project Coordinator. Our plan was to visit health facilities where the PRIME district mental healthcare plan had been implemented, as well as facilities that have been involved in the scale up phase. We also wished to visit the PRIME research team, based at the TPO Nepal offices in Chitwan.
After initial meetings with the local PRIME district coordinator Anup Adhikari, field research coordinator Manoj Dhakal, and clinical supervisor/trainer Parbati Pandey, we met with the local district psychiatrist Dr Sunil Kumar Shah, who has been involved in training and supervising prescribers in the district and is based at the Bharatpur hospital Chitwan. He spoke enthusiastically about his support for the PRIME mental healthcare plan implementation, and the model of training and supporting primary care workers to deliver mental healthcare using the mhGAP intervention guide.
We then visited Gitanagar Health Post, where we were warmly received by the head of the facility (Mr Chitra Bahadur Sunar) and the staff. I asked Mr Sunar about typical cases of depression that they see, and he said that they frequently see women who present with medically unexplained physical aches and pains, poor sleep, flattened affect and social withdrawal “they like to be alone”, often brought about by chronic personal, social or economic adversity. I then asked how he explains the diagnosis to the patients. He said “I tell them there is nothing physically wrong with them, and that they have a problem of the heart/mind. And I refer them to the counselors we now have trained at our facility. Sometimes if their condition is severe I also prescribe an antidepressant, fluoxetine. And in most cases they respond very well.” He and other staff also described similar successes with treating psychosis and epilepsy, provided medication is available (which has been a challenge for the Ministry of Health). They also showed their record-keeping system, demonstrating how mental health indicators have been integrated into routine health management information systems in the facility. During the visit to Gitanagar Health Post, I also had an opportunity to speak to a service user who had previously suffered from depression, was now fully recovered, and was actively participating in a stigma-reduction programme to educate primary care staff about her experience of living with mental illness.
The next day we visited one of the scale-up facilities (Bachhauli Health Post), where the PRIME training and materials have recently been introduced. We were given a colourful and generous reception, presented with garlands of flowers, and once again had an opportunity to discuss the PRIME implementation with Mr Shiva Ghimire, the in-charge of the facility, and staff, including prescribers, non-prescribers and female community health volunteers. In addition to discussing their own work, staff in the facility were interested in PRIME’s work in other countries – how similar was it to the work in Nepal, what were the challenges in other countries, and how were these being addressed. We had a stimulating discussion on these issues, and the many challenges of integrating mental health into primary care in low resource settings.
We also had an opportunity to meet with a group of 15-20 female community health volunteers, who have been using the Community Informant Detection Tool (CIDT), developed by the PRIME Nepal team, to identify people with psychosis, epilepsy, depression and alcohol use disorders living in the community. They were a remarkable group of dedicated women, who have committed themselves to improving access to care, and reducing mortality among people living with mental illness in Chitwan.
During our visit to Bachhauli we were able to speak to another young woman who had struggled with depression for some time, but was on the road to recovery. Later we spoke to a young man who had suffered with alcohol dependency for several years, and was now recovered and also participating in the stigma-reduction education programme for primary care workers.
In both facilities I was struck by the primary healthcare workers’ enthusiastic support for the addition of a mental health component to the packages of care available in the primary care facilities. In many low and middle-income countries I have had policy makers, service managers and primary care providers inform me that we cannot add mental health to primary care services because the services are already over-burdened. Yet in Chitwan I was being told that it was possible – in fact that the mental health tools like the mhGAP, the PRIME counseling manuals, the indicators developed by the Emerald project, and the CIDT, developed by PI Mark Jordans and the PRIME Nepal team were all empowering the primary care and community workers. The mental health skills and instruments were providing health workers with tools to address the needs of their patients, when previously they had no such tools.
This was reaffirmed during our afternoon visit to the chief of District Public Health Office Mr. Madhusudan Koirala , who has also given his support for the implementation of the PRIME mental healthcare plan in the district. This has included improving the supply of generic essential psychotropic medication, which has been a major challenge for the Ministry of Health in the past.
In the afternoon of the second day we visited the TPO Nepal offices where I was given a warm welcome by the local PRIME research staff, administrators and counselors. I was impressed by the high level of commitment, the excellent teamwork and the rigour of the fieldwork, including the attention to detail in data collection and management systems.
I came away from Chitwan inspired. There was clear evidence that the PRIME mental healthcare plans that we have worked so hard to develop, implement and evaluate over the last 5 years were showing a real impact in the lives of people living in Chitwan. Congratulations to Mark Jordans, Nagendra Luitel, Suraj Koirala and everyone involved in the PRIME work in Nepal.