Neurological, Psychiatric, and Developmental Disorders Meeting the Challenge in the Developing World (2001) / Chapter Skim
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3 Integrating Care of Brain Disorders into Health Care Systems
3 Integrating Care of Brain Disorders into Health Care Systems
Pages 57-96
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From page 57... ...
The 1978 international Conference on Primary Health Care produced the Alma-Alta Declaration a strategy promoting health for all that has been broadly accepted by both developing and developed countries. Under this strategy, primary health care is defined as essential health care based on practical, scientifically sound, and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination.
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From page 58... ...
Other programs organized at both the national and local levels have been developed in India, Colombia, China, Iran, Malaysia, Tanzania, and Brazil.tl9-24] Additional features of primary health care systems contribute to their potential for reducing the impact of neurological, psychiatric, and developmental disorders.
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From page 59... ...
INTEGRA TING CARE OF BRAIN DISORDERS 59 :: BOX 3-1 intea~ration-:-of :Menta~l Health: Services-:-: i ~ ~ ~ - I i -I ~ ~ ~~ i-: ~ ..
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From page 60... ...
. I.Then~ -~-primary.~health- care staff~were trained.
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From page 61... ...
In some communities, community health workers provide primary care services. These workers need a minimum of some high school education; basic training in health care; and additional training in the diagnosis and treatment of brain disorders, the dispensing and monitoring of medication, support for community rehabilitation, prevention of disorders, and means of reducing stigma and discrimination.
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From page 62... ...
Key features of the WHO model guiding primary mental health care may be adapted to address the broader range of brain disorders and may include the following objectivest56~: Formulation of a national policy on brain health and establishment of a national or regional brain health department; Financial provision for the employment and training of personnel; An adequate supply of essential medicines; · A network of facilities linked by appropriate transportation; · Data collection to support planning of programs, monitoring of outcomes, and epidemiological research; Integration of care for brain disorders with general health services and collaboration with relevant nonmedical agencies; Use of workers without specialization in brain disorders, including primary health care workers, nurses, medical assistants, and physicians, for basic care; and Training of brain health professionals who train and support nonspecialized health workers.
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From page 63... ...
risk factors'~for stroke)
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From page 64... ...
Secondary care centers could also provide technical and administrative support for primary care clinics in their district or region. Continuing education, which has been shown to improve the performance of community health workers, should include instruction on the symptoms of major brain disorders and ways to help patients maintain proper treatment.~24,64,65]
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From page 65... ...
and Tanzania,[55] community health workers need to receive both basic training and regular continuing education in basic diagnostic skills and basic treatment and rehabilitation protocols.
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From page 66... ...
Nurses. Primary health care in low-income countries has always relied heavily on nurses, but they could play an even larger role in the system of care envisioned here (see Box 3-3~.
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From page 67... ...
Physicians who supervise or train other primary care providers also need instruction in effective communication skills in order to develop the skills of community health care workers. The supervising physician should regularly work alongside health workers and receive case referrals from them.
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From page 68... ...
Comprehensive operational research to establish appropriate training requirements, costeffective interventions, and future research needs will be most useful when the services provided by private physicians are considered jointly with public health system measures.~92,93] Schools and Educators When developmental and other brain disorders occur in children, educators may be the first to recognize them.
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From page 70... ...
Although a scientific basis and empirical evidence of their effectiveness may be lacking, there is little doubt that some aspects of traditional healing benefit patients.~103] Most community health workers and other care providers in developing countries come in regular contact with traditional healers and are aware of their practices.~89, 104, 105]
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From page 71... ...
Operational research on such collaborative efforts may identify opportunities in other countries seeking to facilitate constructive cooperation with traditional healers. Where resources for primary health care are extremely limited, traditional healers, who vastly outnumber community health workers, can be recruited and trained to provide primary care.~96,1 16-1 18]
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From page 72... ...
New information should be collected in local studies that include comparisons of financing, costs, and service utilization, as well as rigorous assessments of costeffectiveness.Ll 23] Once neurological and psychiatric care have been incorporated into a system of health care, maintaining a cost-effective program will require monitoring, evaluation, and comparison with new alternatives.
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From page 73... ...
Such a program could also promote the development of an inten~ational cadre of neurological and psychiatric professionals focused on these issues in developing countries. A successful model for such a research program, the WHO Special Programme for Research and Training in Tropical Diseases, could be adapted for this purpose (see Box 3-6~.
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From page 74... ...
Participants in collaborative efforts to build the capacity for health care delivery and operational research can also contribute to the improvement of.national and local policies and programs. Support from the Camegie Corporation fi~nded health and behavior research training in East Africa out of the University of Nairobi and University of Dar es Salaam from 1990 to 1999.
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From page 75... ...
The program and suggested mechanisms for its role in research for brain disorders are described in Box 3-7. POLICY IMPLICATIONS Policies designed to support the expansion of health care services to address neurological, psychiatric, and developmental disorders in developing countries will need to be advanced at every level of governement, from local communities to international bodies.
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From page 76... ...
In Iran, for example, a program of childhood immunization that began as a vertical, stand-alone project achieved greater success when integrated into the existing system of primary health care.tl00] Such programs of integrated care could, with appropriate expertise and oversight, be augmented to include the prevention, identification, treatment, rehabilitation, and surveillance of brain disorders.
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From page 77... ...
Two basic approaches to preventing brain disorders require the support of national policy: public education and reduction of known risk factors.~58] Although education occurs at the community level, national policy should support the training of community health workers in educating their clients about the nature and causes of brain disorders.
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From page 78... ...
Community involvement in the development of health services tends to promote self-reliance and has been shown to increase demand for health care services.~24] Because district medical officers and their staffs play a vital role in determining local priorities and implementing plans, brain disorders should have a regular place on the agendas of these officials.
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From page 79... ...
Building such capacity in developing countries, as well as attaining the more specific goal of reducing the disease burden due to neurological and psychiatric disorders, will require international contributions of expertise and resources.~911 Two areas in which international support could be especially effective are described below.
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From page 80... ...
80 NEUROLOGICAL, PSYCHIA TR1C, AND DEVELOPMENTAL DISOBEY The Role of Professional Societies and International Organizations The international community of health care professionals can make significant contributions by assisting in the formulation of relevant health care policies that can benefit from their specialized knowledge concerning effective and costeff~cient methods of control, treatment, and rehabilitation of brain disorders. Policy makers are often pessimistic about the likelihood that disorders such as schizophrenia and epilepsy can be treated successfully.tl01]
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From page 81... ...
In recent years the World Psychiatric Association, the World Federation of Mental Health, and WHO's Nations for Mental Health of Underserved Populations Action Program (see Box 3-9) have battled against the stigma associated with most psychotic disorders.
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From page 82... ...
By supporting the Global Burden of Disease Study, the World Bank fostered new insights into the worldwide social and economic impacts of neurological and psychiatric disorders. The World Bank and other development banks
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From page 83... ...
Every country needs to have in place an effective screening/approval mechanism for new drugs, a cost-effective purchasing mechanism, an efficient distribution system, and local health care providers capable of getting drugs to the people who need them. To this end, model programs and international purchasing cooperatives should be encouraged.[l43,144]
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From page 84... ...
84 o see a: ._ Ct o so Cal ._ o so .
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From page 85... ...
Centers for such coordinated efforts have been established in a limited number of developing countries.9 Evidence for the successful development of research and intervention programs resulting from these initiatives indicates that similar centers could be adapted by other countries consistent with their national priorities and resources. The development of similar national centers for training and research is proposed for the provision of a range of services for brain disorders currently under way at existing centers: Organization of protocols and procedures for the care of brain disorders in primary, secondary, and tertiary care; Initial and continuing training of instructors, who in turn train community health care workers in basic care for brain disorders; Operational research to evaluate the effectiveness of treatments and delivery systems; Surveillance and monitoring of brain disorders and their risk factors; Data collection and analysis to support health planning and policy development at the community, primary care, specialist, and national levels; and Demonstration projects for evaluating the quality of care provided for brain disorders and its cost-effectiveness in various settings.
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From page 86... ...
CONCLUSION Integrating care for neurological, psychiatric, and developmental disorders into primary care-based health systems stands as the central challenge in reducing the impact of these disorders in developing countries. Given the existing constraints on resources, building comprehensive health care systems capable of addressing increasingly prevalent brain disorders must proceed gradually in most settings.
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From page 87... ...
Knowledge and attitude concerning mental health of primary health care workers in Nigeria. International Journal of Social Psychiatry 37:1 13-120, 1991 .
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From page 88... ...
Integrated primary mental health care. West Indies Medical Journal 24 (Supplement4~:31-33, ]
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From page 89... ...
Ellison. The frequency of mental disorders in the outpatients of two Nyanza hospitals.
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From page 90... ...
Malkawi. Prevalence, recognition and management of mental disorders in primary health care in Northern Jordan.
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From page 91... ...
Development psychiatry: Mental health and primary health care in Botswana. London: Tavistock Publications, 1987.
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From page 92... ...
al. Primary health care and immunization in Iran.
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From page 93... ...
Recognizing common mental disorders in primary care in Africa: Should we drop ~'mental'. altogether?
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From page 94... ...
Primary health care and donor dependency: A case study of nongovernment assistance in Burkina Faso. International Journal of Health Services 25(3)
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From page 96... ...
:This ~ effort :should be glob I ~ ~ - ~ - GIo;bal ;Forom for Health Research, the W Ed ~ i a i : funded researc such as he U.S Naiona Ini itues of Health an the Centers for~ontrol and Prevention. To ensure the sustainability i- -of he prog , m ~ n ~ ~ a I ; k ; I- governmental and nongovernmental al :o i ai ~ - ~ i Hi :: : ::: :investments to this effbi t.~- -and ionne~term -annual far.....
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