Developing models of balanced mental health care: the case of Pakistan

The development of mental health systems which provide a balanced spectrum of services needs to address conceptual, structural, functional and financial issues. This task is further complicated by the fact that mental health system development is an ascending spiral where a higher level is likely to come forth once a basic level is traversed. It is precisely for this reason we feel that the paper by Thornicroft and Tansella is a bold attempt to tackle the conceptual issues of planning and delivering a balanced spectrum of services, thus shifting the focus away from the sterile debate of community versus hospital based care.

Balanced care needs to cater for promotion of mental health and prevention of mental illnesses, as there is a common misconception that mental health care is 'limited' to recognition, treatment and rehabilitation of mental illnesses. Widening of the conceptual boundaries of mental health beyond management of mental illnesses, though potentially fraught with danger, is nevertheless the first step in translating the bio-psychosocial approach, inherent in the definition of health and the essence of balanced care, into practice. This is exemplified by the concept of mental health promotion defined as "an action and advocacy to address the full range of determinants related to mental health and enhancing the value placed on mental health by individuals, families and societies" (1). Promotion of mental health thus involves action in the spheres of policy, legislation, housing, education, employment and mental health literacy (2).

Difficulties arise both at conceptual and execution levels. At the conceptual level, primary prevention is often considered to overlap with promotion, particularly in case of universal prevention. At the execution level, mental health promotion involves a multi-disciplinary approach, whose individual components are not operationalized and for which mental health professionals are not trained. Moreover, structural, functional and financial issues need to be tackled if balanced care is to become a reality.

Developing a mental health delivery system capable of providing a balanced range of services would involve a redefinition of roles, which have to be explicit, and training to provide the necessary skills to take up new roles and responsibilities by the professionals from mental health and related disciplines. This would undoubtedly bring about issues of power and control to forefront. Political and administrative commitments would be necessary to provide legislative reforms and finances. Planning must be inbuilt within the system to provide the necessary flexibility to adapt to the local realities.

Pakistan has developed in a phased manner, over the last seventeen years, a community-based programme of mental health care delivery, aimed at providing a balanced model of care for countries having limited resources and faced with the double burden of communicable and non-communicable illnesses. During the first phase, a preliminary evaluation was made of the needs and demands for mental health services in the community, to gauge the knowledge, attitude and practices and to educate the community using mosques and social congregations at the faith healers. This was followed by the preparation of training and teaching materials for primary health care personnel and education material for the community. The next phase involved activities in the realm of intersectoral collaboration for promotion of mental health and prevention of mental illnesses. Education administrators were sensitized to the need for incorporating mental health principles in improving the quality of education. This activity has now been completed at the national level. The next stage involved the development of a training package for school teachers, which was carried out in a decentralized manner. The response of school teachers and children is overwhelming, with the formation of the All Pakistan Teachers' Movement for mental health being one example. The faith healers were also provided with colored case identification cards, similar to those being used by multipurpose health workers and they are serving as an important source of referral to health care facilities.

Research and evaluation activities are being carried out side by side with the above-mentioned activities, particularly in the field of promotion of mental health and prevention of mental illness.

The next stage involved the development of indicators for evaluating the community mental health programme. The study was carried out in two areas, one with and the other without the mental health component in primary health care. It showed that in the index area there was a significant increase in detection of psychiatric cases (62.4%) as compared to the control area (12.7%). In addition to the enhanced detection rates, there was a significant increase in uptake of all services provided at primary care level. There were reduced infant mortality and maternal mortality rates, as a result of increased utilization of the antenatal care facility and increased rates of immunization, showing that integration of the mental health component in existing primary health care systems can result in improvement in indicators of general health care (3).

To evaluate the school mental health programme, a prospective casecontrol study was carried out. This study showed that school children and teachers are effective agents of social change, and that school mental health programmes can help change the perception of the community about mental health problems (4).