The set up of a national mental health program in Rwanda

Transcription

1 REPUBLICE OF RWANDA Ministry of Health The set up of a national mental health program in Rwanda ********* Dr. Achour AIT MOHAND Dr. Yvonne KAYITESHONGA

2 Outline Mental health context in Rwanda Key policy actions and strategies Challenges Lessons learnt

3 Rwanda MENTAL HEALTH CONTEXT:

4 Major depression and anxiety disorders lead the top five causes of years lived with disability (YLDs) The top five leading causes of YLDs in Rwanda are major depressive disorder, anxiety disorders, iron deficiency anemia, low back pain, and chronic obstructive pulmonary disease. (Global Burden of Disease Study The size of the colored portion in each bar represents the number of YLDs attributable to each cause. The height of each bar shows which age groups had the most YLDs in 2010.

5 Top 25 causes of DISABILITY ADJUSTED LIFE YEARS (DALYs) (Global Burden of Disease Study Bars going up show the percent by which DALYs have increased since Bars going down show the percent by which DALYs have decreased. Globally, Noncommunicable diseases and injuries are generally on the rise

6 Post Traumatic Stress Disorder (PTSD): 26,1% of general adult population (N. Munyandamutsa &al. 2009) Significant rate of co morbidities among people suffering from PTSD Major depression: 54% Drug abuse: 10% Headaches: 71% (principal somatic disorder)

7 Major depressive disorders prevalence: 15,5% of adult population (Bolton & al. 2000) Study emphasized that depressive symptoms were strongly associated with functional impairment in performing most daily tasks Epilepsy prevalence: 5% of general population (Ministry of Health 2005) Drug use (Gishoma, 2012) More than half of the youth in the sample have used substance/drug (52.4%), among them 7.46 % are dependent on alcohol, 4.88 % on tobacco and 2.54 on Cannabis. The age of onset is as low as 11 years

8 Most of mental disorders are related to the genocide in 1994 because of the magnitude of the destruction and loss Nearly one million of people were killed during 100 days (one seventh of the country's population). Approximately orphans (30% of children's population) Destruction of the socio economic system including the health system

9 MH in Rwanda KEY POLICY ACTIONS AND STRATEGIES

10 1 Developing and launching a national mental health policy Mental Health Policy (1995, reviewed 2011) Main intervention areas Decentralization of mental health care and integration into PHC, and promotion of community based approaches Integration of mental health care into community based health insurance (CBHI), availability of psychotropic medicines Improving the quality of mental health care Sensitizing on mental health issues and fighting stigma Developing human resources in mental health Promoting human rights and drafting a mental health law Development of specific programmes according to the epidemiological context

11 2 Decentralizing mental health care to District Hospitals All District Hospitals (43) have Mental Health Unit 11 District Hospitals have specific hospital beds set aside for the mentally ill clients Mental Health Units are staffed by at least two psychiatric nurses and one psychologist under the supervision of a physician trained in mental health care. Formative supervision and peer review sessions on cases are provided by mental health team from national referral structures.

12 3 Integrating mental health into PHC Integration of mental health care in District Hospitals and HC service package, The focus of the new system included the use of non specialists GPs and GNs are trained to improve treatment of outpatient care. At least one general nurse per health center was trained to deal with common mental health disorders.

13 Tools to facilitate follow up and referral between the different levels of care. Specific list of essential psychotropic medicines has been established for each level of the health system. Guidelines and protocols are used in each level to help teams during diagnosis and treatment. CHWs: trained to fight against stigma, early detection of mental health problems as well as how to orient families and patients throughout the mental health care system.

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15 Mental health care set up in District Hospital Mental Health Division support Norms & standards, Set up PBF indicators, HR, Mutuelle de santé, Essential psychotropic Medicines guidelines & protocols Supervision & mentorship, HMIS indicators... Etc.

16 4 Reinforcing accessibility and equity Decentralization of mental health care allowed better geographic access The number of unnecessary transfers to mental health referral structures reduced. Accessibility was also increased by integrating mental health care into the community based health insurance (CBHI) scheme: 10% co payment for psychotropic medicines and services & 90% per cent of mental health service costs met by CBHI.

17 Evolution of mental health activities in District hospitals Year HMIS 2013 HMIS Units 23 (27/32) Outpatient New cases ,461 26,757 Outpatient Consultations (Old & New cases) 19,000 31, , ,413 Inpatient MH care - 2,240 1,518 1,158 Transfers

18 5 Reinforcing quality of care and providing specialized mental health care MMed Psychiatry: Orientation: General Psychiatry Cascade supervision system Continuous training (CPD Program) 18

19 6 Inter sectoral collaboration Support trauma victims during genocide commemorations Program against drug abuse Integration MH component in care provided to people living with HIV/Aids Others

20 Interactions with other health programs, sectors, and stakeholders Sustainable MH care Mental Health Division Referral services Interactions with other health programs, sectors, and stakeholders Civil society, NGOs, families, Religious org DH HC DH HC DH HC Civil society, NGOs, families, Religious org Community

21 MAIN CHALLENGES & PERSPECTIVES

22 funds for mental health care are still limited; the number of qualified mental health professionals does not meet the burden of disease; stigma is still threatening people with mental disorders.

23 Future steps will focus on: Introduce psychiatric emergencies, day care, child psychiatry, specialized services for people suffering from addictions, etc.; Stimulate People centered care attitutde by health professionals Reinforce the management of certain mental and neurological disorders such as epilepsy; Day care center for care & continuos training Implementing the mental health law (draft available);

24 KEY LESSONS LEARNT

25 Political commitment and the establishment of a national mental health policy contributed to the success of the decentralisation and integration of mental health into primary care. The mental health division has played a key role in, integrating mental health into the system: strategies, norms, standards and indicators of ongoing programs of the MoH as well as facilitating dialogue and coordination with stakeholders. GNs and GPs can be trained to provide effective people centred mental health care including prescription of psychotropic medications.

26 The inclusion of mental health as part of the basic health care package was essential for sustainable integration Introduction of MH in community based health insurance scheme improved accessibility and reinforced equity.

27 Abstract Title: The set up off a nationall mental health program in Rwanda Authors: Dr Achour AIT MOHAND Psychiatrist, MPH, Belgian Development Agency, Technical Advisor at Mental Health Division, Rwanda Biomedical Center, Ministry of Health, Rwanda ( & achour.aitmohand@gmail.com) Dr Yvonne KAYITESHONGA Clinical Psychologist, PhD in Clinical Psychology, Manager of Mental Health Division, Rwanda Biomedical Center, Ministry of Health, Rwanda Abstract: Rwandaa faces an exceptionally large burden of mental health disorders. Rates off certain disorders have been reported at levels that exceed international averages. Most of them are related to the genocide in 1994 because of the magnitude of the destruction and loss. Rwandaa has developed a National Mental Health Policy supporting the decentralisation and integration of integration in general caree including health systems strengthening approach, capacity building and resourcee inputs, as well as good governance mechanisms. The purpose of this presentation is to identify systemic factors within institutional and policy contexts that facilitate the implementation of integrated mental health care in Rwanda as well as current challenges. Facilitative factors included the policy framework supporting the integration off mental health care into primary health care and national strategic plan that includes setting up mental health units in district hospitals which provide integrated care using a task sharing model.

28 Decentralizing mental health care in general hospitals and integrating mental health care into primary health care has been implemented in different ways such as establishing mental health units in all district hospitals across the country and strategies such as training various categories of health care professionals, a cascade supervision system, and by integrating mental health care and psychotropic medicine into the community based health insurance scheme. Other interventions have also been implemented to increase the accessibility and improve the quality of mental health services. Empowering psychiatric nurses at district hospitals, using non specialists such as primary care physicians and community health workers to deal with common mental health disorders, and promoting community mental health contribute to strengthen the health system. Also, strong leadership, vision and accountability mechanisms are vital for successful implementation of mental health policy. Challenges included the stigmatisation of mental illness, lack of budget dedicated mental health and the number of qualified mental health professionals does not meet the burden of mental health disorders. Keywords: Mental health, primary health care, integration of mental health care, Rwanda References 1. Heim, L. and Schaal, S. Rates and predictors of mental stress in Rwanda: investigating the impact of gender, persecution, readiness to reconcile and religiosity via a structural equation model. International Journal of Mental Health Systems. 2014, 8: Murthy, R.S. and Lakshminarayana, R. Mental health consequences of war: a brief review of research findings. World Psychiatry. 2006, 5: Ministry of Finance and Economic Planning, National Census Commission. Situation des enfants au Rwanda: Analyse des résultats du troisième recensement général de la population et de l habitat du Rwanda au 15 août Kigali: Ministry of Finance and Economic Planning, Available from: file:///d:/interim%20juillet/fev2015/doc%20ef/th%c3%a8me%2014%20situation%20des%20enfants1.pdf. 4. Overseas Development Institute Rwanda s progress in health: Leadership, performance and health insurance. London: Overseas Development Institute, Available from: rwanda health insurance performance based contracts development progress. 5. Institute for Health Metrics and Evaluation. Rwanda GBD profile. Seattle, WA: Institute for Health Metrics and Evaluation, Available from: pdf.

29 6. Boris, N.W., Brown, L.A., Thurman, T.R. et al. Depressive symptoms in youth heads of household in Rwanda: correlates and implications for intervention. Pediatr Adolesc Med. 2008, 162 (9): Pham, P.N., Weinstein, H.M. and Longman, T. Trauma and PTSD symptoms in Rwanda: implications for attitudes toward justice and reconciliation. JAMA. 2004, 292: Munyandamutsa, N. Nkubamugisha, P. Gex Fabry M. and Eytan A. Mental and physical health in Rwanda 14 years after the genocide. Soc Psychiatry Psychiatr Epidemiol. Published online 9 March doi /s Bolton, P., Neugebauer, R. and Ndogoni, L. Prevalence of depression in rural Rwanda based on symptom and functional criteria. J Nerv Ment Dis. 2002, 190: Government of Rwanda. Third health sector strategic plan, July 2012 June Kigali: Government of Rwanda, Available from: Kanyoni, M. Gishoma, D., Ndahindwa V. Prevalence of psychoactive substance use among youth in Rwanda. BMC Research Notes. 2015, 8:190,DOI /s available from pdf 12. Mental Health Division. Mental Health Statistics Kigali: RBC/Ministry of Health, Sebera, F. and Nyiramazaire, H. Prévalence de l épilepsie au Rwanda : connaissance, perception, vécu et attitudes de la population et des professionnels de la santé. Kigali : Ministry of Health, Government of Rwanda. Health Sector Policy. Kigali: Government of Rwanda, Available from: Ministry of Health. Health Sector Policy. Kigali: Ministry of Health, Available from: World Health Organization. Mental health policy, plans and programmes. Mental health and policy service guidance package. Geneva: WHO, Ministry of Health. National Mental Health Policy. Kigali: Ministry of Health, Available from: National Mental health Policy 1.pdf. 18. Gatarayiha, F., Baro, F., Wagenfeld, M.O. and Stockman, R. Development of Mental Health Services in Sub Saharan Africa: The Case of Rwanda. J Soc & Soc Welfare. 1991, 18: Ministry of Health. Service packages for health facilities at different levels of service delivery. Kigali: Ministry of Health, Available from: PACKAGES FOR HEALTH FACILITIES AT DIFFERENT LEVELS OF SERVICE DELIVERY last version.pdf. 20. Mental Health Division. Mental Health Atlas Questionnaire Kigali: RBC/Ministry of Health, Ministry of Health. Liste des medicaments essentiels, 5th edition. Kigali: Ministry of Health, Available from: ESSENTIELS 1_.pdf. 22. Lu, C., Chin, B., Lewandowski, J.L., Basinga, P., Hirschhorn, L.R. et al. Towards Universal Health Coverage: An Evaluation of Rwanda Mutuelles in Its First Eight Years. PLoS One. 2012, 7(6): e doi: /journal.pone

30 23. Miles A. Tailoring care to individuals and populations within resource poor settings: A review and commentary on the World Health Organisation Report People Centred Care in Low and Middle Income Countries. The International Journal of Person Centered Medicine 2010 Volume 1 Issue 1 pp World Health Organisation. People Centred Care in Low and Middle Income Countries. Report of a meeting held on 5 May Geneva: WHO Available from:

31 Mental health session background Be-cause Health (Belgian Platform for International Health) Thursday, 10 September 2015 Integratedd Mental Health Care: finally a differentt perspective towards a more human healthh care? Dramatic events such as genocides or Ebola have an enormous impact on the Mental Health status of a population. These dramatic societal situations have witnessed the start of nation-wide mental health initiatives in several countries. But beyond thesee events, theree is huge, continuous need for adequate Mental Health Care at all levels of the health system, adapted to the needs of people, at a moment, in any country. Suffering and premature death, due to mental illness, represent a huge public health problem. This implies that healthh services have to broaden their scope from a clinical, facility-based approach towards a more person and family centred approach including aspects of health promotion, preventive activities and societal action. This session will present the development of integrated Mental Health care in three settings. The focus onn people-centred care in these experiences may serve as welll to facilitate a change of practice in general health care. The session will be introduced by Dr. Paul Bossyns (Head of the Health Unit of Cooperation in Brussels). the Belgian Technical Thereafter, Dr Yvonne KAYITESHONGA (Director of the Mental Health division in thee Ministry of Health in Rwanda) and Dr Achour AIT MOHAND (expert at the Mental Health Division) D will explain the set-up of a national mental healthh care program in Rwanda integrated at all levels of the health system. This is an ongoing process of more than 15 years initiated in the aftermath of the Rwandan genocide in It s a nice example of how a specific national program can be articulated with the existing health services at the different levels. Cambodia is equally suffering the consequences c of genocide, during the Khmer Rouge regime between Dr Khem Thann (Programme Manager at Louvain Coopération) has been involved, together with Transcultural Psycho-social Organization (TPO)) Cambodia in the integration of a non-medical approach of Mental Health Care at the level of three t referral hospitals and nine health centres c in the provinces of Kampong Thom and Kampong Cham. It shows s the added value of embeddingg Mental Health Care in a more comprehensive approach and respond to needs of people within their communities through activities such as community development, livelihood enhancement, gender-based violence, human rights and legall support. Shifting tasks from highly specialised to more general care takers is also an interesting aspect of this experience. Finally, Dr. Abdoulaye Sow (from Fraternité Médicale Guinée ) will sharee an experience of about 15 years in Mental health Care & Psychosociall Support at the first level of health caree (in three health centres) in Guinea Conakry. Coaching of nurses and general practitioners in preventing and handling Mental Health conditions c have led to a more integrated, global and continuous type of care. This approach a has remarkably proved its usefulness in the management of thee Ebola epidemic. The presentations will be followed by a panel debate driven by a set of key-questions.