INTEGRATING MENTAL HEALTHCARE INTO PRIMARY HEALTH CARE SERVICES: A CALL TO STRENGTHEN THE PRIMARY HEALTHCARE LEVEL
By Peter Eyram Kuenyefu, Snr. Physician Assistant, Comfort Ofedie Memorial Clinic, Nkonya- Ahenkro
“Primary Health Careis an essential health care based on practical, scientifically sound and socially acceptable methods and technology which is 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”. (Article VI)
Alma Alta Declaration was proclaimed as a major milestone of the twentieth century in the field Public Health, and it identified Primary Health Care as the key to the attainment of the goal of Health for All.
Health is now widely acknowledged as having both a physical and mental health dimension and was indeed captured in the World Health Organization constitution in 1948.
The first key declaration at the conference was reaffirming that health which is a state of complete physical, mental ad social well- being, and not merely the absence of disease or infirmity, is a fundamental human right and the attainment of the highest possible level of care is a most important worldwide social goal whose realization requires the action of many social and economic sectors in addition to the health sector.
Mental Health on the other hand is defined as a state of well- being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community.
With all the above encapsulation, Primary Health Care systems in countries around the globe including Ghana focus only physical care, failing to provide mental health care to their populations.
Mental Health Disorders such as Depression, Psychosis, Epilepsy, Substance Abuse Disorders, Child and Adolescent Mental and Behavioral Disorders, and Self -Harm/Suicide are predominantly in all countries are contributing to immense hardships, poor quality of life, increased mortality and astronomical economic and social costs. In view of the above, mental health can no longer be ignored in contemporary health systems.
Forty years after the Alma Alta Declaration, the world is still battling to reaffirm that Primary Health Care is the essential healthcare, universally accessible to individuals. There is therefore the need as a country to make concerted efforts to change the current state of affairs.
Indeed, a fundamental shift needs to occur in our healthcare paradigm, from one of human rights violation and poor health outcomes associated with care delivered through psychiatric institutions, to one which respects human rights and promotes good health outcomes and recovery through the delivery of Mental Healthcare/ services in a well -structured, robust and well- resourced Primary healthcare settings.
It is paramount therefore to emphasize that mental healthcare be delivered in Primary Healthcare is much more likely to be effective and sustainable if complimented by a strong secondary level of care to which PHC workforce can turn to for referrals, as well as support and supervisions. In furtherance, having a strong informal community ,mental health services and support groups run by NGOs and faith based organizations can help compliment and strengthen the services provided through PHC.
THE NEED FOR INTEGRATION
The merits of integrating Mental Health into Primary Health Care are enormous.
- Integration ensures that the population as a whole has access to Mental Healthcare that they need early in the course of their disorders and without disruption.
- When people access care in PHC facilities, the likelihood of better health outcomes, and even full recovery as well as a maintained social integration is enhanced or increased.
- Better access to care is achieved through PHC as it is the first and foremost level of contact of individuals, families and the entire community with any country’s health system. PHC also happens to be the closest and easiest form of care available, located near to the people’s homes and communities. On the other hand, psychiatric institutions or hospitals where mental healthcare services are provided are mostly situated in towns and cities, a long way from home and consequently many individuals seek to the care they need.
- People who do seek treatment in psychiatric hospitals often find themselves isolated as they live far away from their families, removed from their emotional and social support systems and no longer in a position to maintain their daily living activities and jobs, thus compounding economic situations for the whole family. Meanwhile, mental healthcare available and delivered through PHC provides the golden opportunity for people to be able to access treatment and care that they need near their homes and keep their families together, maintain support systems and remain integrated and active in the community in order to contribute productively to their households.
- Mental Healthcare also delivered through the PHC is cost effective and affordable. The cost associated with travelling to the cities/ towns and catering for a relative while accessing care in the specialized institutions is removed entirely or minimized.
- Stigmatization is reduced as PHC services are not associated with specific health conditions. The fear of being branded “mad”, bad and dangerous or marginalized from the community and discriminated against is reduced, thus making this level of care apt, more acceptable and accessible for most service users.
- Mental Health services delivered in PHC setting are also more acceptable because they reduce the risks of human rights violations people are exposed to when seeking care at psychiatric hospitals.
- Better health outcomes are assured when Mental Healthcare is delivered through the vehicle of Primary Health Care. In terms of clinical outcomes, it has been found out that for many mental disorders, PHC can offer good care and certainly better care than that is provided in psychiatric hospitals. Recent evidence indicates that mild, moderate and even severe depression can be effectively diagnosed and managed at primary care settings. There are several reasons why management of mental disorders in primary health care settings results in better outcomes.
- Mental Health is often co-morbid with many physical health problems such as Malaria, Hypertension, Diabetes, Tuberculosis, HIV/AIDs, among others. The presence of substantial co-morbidity has serious implications for identification, treatment and rehabilitation of affected individuals. By attending to the physical health needs of someone with mental disorder, or alternatively, to the mental health needs of someone with a physical problem, primary healthcare worker is in a better position to provide treatment and care in a holistic manner that immensely increases the likelihood of a good health outcome.
- Primary healthcare practitioners are in the unique position of rendering care throughout people’s life cycle. It is worth noting that treatment in a primary care setting allows for continuity of care beyond the mere “one off” consultation and treatment (which is characterized by poor adherence to treatment regimens).
- Moreover, the fact that people needing are able to continue living with their families in their communities means they are more likely to maintain strong links with society as well as with sectors that are important to mental health such as social welfare, education and labour, all of which is conducive to recovery.
THE WAY FORWARD FOR INTEGRATING MENTAL HEALTH INTO PRIMARY HEALTH CARE
- Policy, Plans and Laws:There is the need for Ghana as a country to operationalize Policies, Plans and Laws that have been drafted and legalized so as to actively integrate mental health in Primary Health Care.
- Strengthening Primary Healthcaresystemsto serve as the vehicle for the delivery of all healthcare services to the population. Particular attention need to be paid Sub- District Health Systems which happen to the weakest level of structure in Ghana’s Health Systems. Provision of effective mental healthcare at the PHC level is highly dependent on the pre-existence of well functional PHC systems.
- Human Resource Development and Training:Ghana as a country must put in more efforts aimed at addressing Human Resource shortages to deliver mental health service interventions. Physician Assistants, Midwives, Public Health Nurses, Registered General Nurses, Community Health Nurses, Enrolled Nurses, Counselors must be equipped with the requisite skills and competences to identify Mental Health disorders, provide basic medications and psychosocial intervention, undertake crisis prevention and refer to specialist mental health worker where appropriate.
- Provision of the requisite logistics (Drugs):The Mental Health Authority must take pragmatic efforts in providing psychotropic drugs at the peripheries if only we as a country are serious of integrating mental health in non- specialized health facilities (Primary healthcare level).
- Supervision and Support of Primary Healthcare workforce and a robust and functional Referral Systems:For integration of mental healthcare into PHC to be achievable and sustainable, supportive supervision and other logistic support must be readily available by the secondary healthcare level workers or specialized staffs. Also, there must be a robust and functional referral linkages between the two levels for prompt and appropriate referral of clients
Integration of Mental Healthcare into Primary HealthCare is long overdue. The benefits of integration are enormous and the clarion call is for all managers of health to operationalize this noble idea.
The time is now. Let us begin it in any small way in our respective health centres across the districts and municipalities in GHANA
The writer is a practicing Physician Assistant, who has interests in Sub District Health Management, Public Health and Obstetrics and Gynaecology.