District Mental Health Movement:

A Silent Revolution in Sri Lanka

Nalaka MENDIS-Emeritus Professor of Psychiatry, University of Colombo

During the last few decades, the governments of many countries have increasingly recognised the pain, distress, disability, death, burden, stigma and economic loss due to mental disorder on both the individual and the family. Mental health systems have evolved to meet these emerging trends by significantly reforming the traditional centralized psychiatrist-oriented mental hospital-based specialized care.

Emerging changes include increasing emphasis on psychosocial distress and mental health, providing more accessible care through local delivery, widening of interventions to include a range of psychosocial approaches, increasing integration of mental health into general health, involvement of general health workers and others having psychosocial orientation in mental health activities, and broadening the responsibility of different sectors to contribute towards mental health development.

Health services

Over the past years Sri Lanka has attempted to introduce such developments through far reaching recommendations by Professor Edward Mapother in 1938, Dr. W G Wickremasinghe in 1966 and again through a series of informal initiatives during the nineteen eighties and nineties.

These developments could not be implemented or sustained fully for an adequate period of time to bring about any meaningful reforms to improve mental health care or access to services. This was largely due to a failure of successive governments to develop long-term implementation strategies which led to a dearth of professional staff and inadequate allocation of funds.

As a consequence mental health services stagnated and sometimes even regressed over the years. The Angoda and Mulleriyawa mental hospital complexes continued to provide valuable services for the chronically ill and acutely disturbed patients from different parts of the country because facilities for such patients were not available at provincial and district level centres. In the absence any initiatives by the government to improve access to mental health services, most psychiatrists opted to focus on clinical work and maintain their professional status making use of the little resources available within the service.

Can the present government which is committed to develop the country in an equitable manner by uplifting deprived communities and regions reverse the above trend? This will entail accepting the challenge of providing the necessary leadership, resources and a development strategy to upgrade and upscale the emerging 'district mental health movement' which has been unfolding during the last decade?

Social care workers

This new mental health movement aims to provide comprehensive mental health services targeting the needs of those living in a given geographical unit or a district.

This unique movement with great potential has led to a major improvement in access to mental health care during the last decade.

What is unique about the district mental health care movement in Sri Lanka? For the first time in Sri Lanka an attempt is being made to provide comprehensive services within the district to meet the needs of those living within its boundaries.

Community-oriented activities

To realize this objective the approach to care has gradually changed from an 'institutional and psychiatric focus' to one based on 'community-oriented, person centered' mental health care.

This process entails providing a range of services including curative, preventive, promotional and rehabilitative services aimed at the population in a given district.

While psychiatrists and medical officers with a shorter period of training in mental health have made an attempt to provide care for the mentally-ill they also together with the general medical staff, public health staff and social care workers have attempted to provide mental health services to the individuals and communities.

The present local movement evolved organically by the initiative of a group of psychiatrists who apart from engaging in their routine clinical work undertook a series of initiatives to improve access in response to the local needs of communities based on universal principles.

This process of integrating mental health services into general health care, public health services and social welfare has resulted in a large pool of workers acquiring necessary skills to respond to mental health needs of the individual and the communities.

For generations mental health care has been synonymous with Angoda and Mulleriyawa mental hospitals. The silent shift of mental health service provision through general, provincial, district hospitals, outreach clinics and health centres has not been recognized by many.

The improvement of access to basic mental health services resulting from this shift has helped those living in remote areas of the country thus minimizing the need for them to travel to Colombo or other big cities seeking care. The benefit of this development has mostly been to those in greatest need coming from socially and economically impoverished backgrounds living in remote areas.

Very few countries in the region and elsewhere with similar socioeconomic conditions can match Sri Lankan achievements in providing basic services to its people.

Medical officers

Most district leaders including psychiatrists and provincial administrators increasingly see as their responsibility to provide a range of services within the district. District mental health teams and committees have evolved and are functioning.

Over the last decade all districts have established at least basic services consisting of one or more inpatient units, a large number outpatient and outreach clinics and other specialized services including for alcohol dependence, childhood mental illness, and rehabilitation and counselling services.

Apart from the above individual services community-oriented educational and promotional activities have also been initiated in many districts.

The professional staff including psychiatrists, medical officers in mental health and diploma holders amounting to more than two hundred and fifty conduct services in different locations in the district in order to provide services close to the homes of patients in collaboration with public health services, social and community agencies. Many districts have established self help groups to facilitate advocacy and support activities.

The strengthened and more visible Mental Health Directorate now located in the Ministry premises facilitates district level activities by coordinating and reviewing the district services. International organisations now provide direct grants and other resources to districts unlike in the past. Though information is sparse it is estimated that out of those consulting public services more than nearly eighty percent make use of local psychiatric facilities.

This transformation is largely an outcome of a responsive and development-oriented decisions of the Ministry of Health based on a healthy partnership between the Ministry, the professionals and the community agencies with the leadership of the President of Sri Lanka at the time and the Minister of Health. Dr. A. Beligaswatte then Director-General of Health Services created a responsive climate for the professionals to test out their approaches and later when found to be successful decided to integrate such approaches to the regular health services. Such initiatives included the establishment of a cadre of Medical Officers of Mental Health, and Diploma in Psychiatry programmes, facilitation of district based services, empowerment of the Mental Health Directorate and allocation of resources to develop local services.

The result was the gradual emergence of provincial and district level service networks provided by the district level mental health team supported by the district administration. The psychiatrists who pioneered the district concept also inspired a new generation of psychiatrists and administrators who continued the reforms necessary to improve access to care.

Today even the Mannar district has an inpatient psychiatric facility with four outreach clinics. The Badulla district, in addition to an inpatient facility, has more than 20 outpatient and outreach clinics spread out in the district. The picture is similar in many other districts but this has not been a uniform achievement throughout the country - there are districts where the reforms are marginal. In a few districts in the absence of a qualified psychiatrist the services are provided by the medical officers of mental health or those with diploma in psychiatry qualifications. In contrast almost all major hospitals in the western province have qualified psychiatrists with support staff.

The major determinants of success of the district mental health movement include the degree of enthusiasm and commitment of the district psychiatrist to improve access, his loyalties to the district in which he serves, the degree of cooperation extended by the Regional Director to develop the district network of services and the availability of regional funds.

We in Sri Lanka need to evolve a modern, accessible, affordable and high quality mental health service to meet the changing mental health needs of the whole population. There is now strong evidence to suggest that in Sri Lanka basic, general and most of the special mental health services could be provided at the district level.

A competent and a well trained workforce based in the districts, adequate facilities and the necessary funds are absolutely essential to develop and sustain such a district service by up scaling and upgrading the present district mental health movement. We cannot ignore the fact that the success of the mental health programme also depends on the extent of input from original research, high quality training, highly specialized clinical services and good management strategies.

Such activities should be the responsibility of special centres or units managed by those with competence and expertise who are able to think creatively and innovatively on the basis of evidence. In an era in which mental health issues are coming to the fore of health care it is important for the government to bring about the necessary reforms to upgrade and upscale the present services so that the benefits of new developments are accessible to all citizens of in Sri Lanka.