I traveled recently with a team of Karuna Trust social workers and doctors to two rural primary health centers (PHCs) managed by the Trust: Pattanayakanahalli PHC and Mallapura PHC.  The team had scheduled meetings with PHC staff, including the medical officer, PHC administrators, auxiliary nurse midwives (ANMs), accredited social work activists (ASHAs), and male health care workers (similar to the ASHAs but based at the PHC rather than out in the field conducting home visits).  The purpose was to explain the Trust’s ideas about integrating mental health care services into the PHCs, receive feedback from all of the health care practitioners at the PHC, and then to facilitate the PHC staff organizing that feedback into an action plan for the integration process.  In addition, the team interviewed two PHC mental health patients at each facility.  In each case, one of the patients had been treated at the PHC for mental health issues and been compliant with treatment and the other patient had been treated, but had not been compliant. The same set of questions was asked of each category of patient, the intention being to begin to develop an understanding of the patient’s point of view and why he or she felt confident or did not feel confident in the PHC’s management of their condition.

The integration of mental health services into PHCs is a priority of Karuna Trust. If this initiative is managed well, it holds the promise of increasing the efficient allocation of limited health care resources, increasing the likelihood of early identification and treatment of mental illness (in turn increasing the probability of positive treatment outcome) and, increases the opportunity for patients to receive treatment within the supportive context of their own families and communities.  The hope is that most cases will be treated successfully locally, with only the most servere cases referred to the closest hospital for additional evaluation and treatment.  In a country like India, with 70% of the population living in rural areas, any hospitalization involves significant travel for the patient.  Transportation costs may be quite substantial (especially since family members are likely to accompany the patient), as is the threat of lost wages (again, possibly for multiple family members).  Further, even if the hospital treatment is free to the patient, he or she is often still expected to pick up the cost for medications and food while in the hospital.  Unfortunate, but true, is the additional reality that the patient’s family may also have to set aside funds for bribes to hospital staff for good care.  Overall, a hospitalization can create a great burden for a poor, rural family, especially if the hospital stay is lengthy. 

Staff input at the two PHCs I visited was fairly consistent.  They were engaged in participating in the mental health care integration brainstorming process and believed in the objectives and advantages of the approach. Their concerns focused most heavily on the following issues:

• Training to recognize the range of mental illness symptoms and thoroughly understand the medications and their side effects.  PHC health care workers do not currently feel confident in this area and designing a good training process will be critical to the success of this initiative.
• Transportation so that thorough follow up of patients is possible (this includes transportation for the ASHAs to make more frequent home visits, as well as transportation of patients to the PHC if necessary). Transportation is a huge issue in rural areas for any health care need.  After bumping along rural roads for hours (in a car, which was a luxury) to get to the PHCs I have a very deep appreciation for the distances involved and how having to rely on infrequent buses, hitching a ride in the back of an ox-cart, or walking for miles would discourage any but the most determined person from seeking care, let alone returning for regular follow-up visits.
• Technological resources to allow consistent and easy access to reliable mental health information.  This includes telephone access to district medical officers and psychiatrists for consultations, as well as video-conference capability to conduct regular specialized trainings.  Video-conference or video-streamed training would not be a replacement for annual or semi-annual in-person trainings, but a necessary supplement to them and, given the transportation issues mentioned in the bullet above, is an absolute necessity to ensure all PHC staff are trained consistently and have equal access to information.
• Incentives for ASHAs should be realigned with the mental health objectives so that they are compensated not just for identifying mentally ill patients and getting them to the PHC for evaluation, but also for following up with those patients to assure treatment compliance.  ASHAs are married women of the community who have at least a fourth grade level of education, are trained in basic health care, and make home visits within a section of the community (there is one ASHA per 1000 population). Evaluating ASHA compensation in light of this new initiative is important for two reasons — one is to make sure they are compensated fairly and not absorbing an undue burden related to the launching of the program and the other is to see that patients receive proper follow-up care.  Patient compliance with treatment in mental health care often requires lengthy follow up. If ASHAs are only compensated for identification of patients this will skew the incentives away from rewarding long-term follow up. Karuna Trust is going to look at this as part of the pilot launch.  (There are precedents for this already. One example from last week’s newspapers is a new initiative around reproductive health. ASHAs who successfully encourage women to choose IUDs as their birth control method are compensated one year from the date of the insertion, rather than at the time of the procedure.  This encourages ASHAs to support the women through the first year of adjusting to the device if necessary and rewards them for successful adoption and avoidance of unplanned pregnancies, rather than only the initiation of an easily reversible procedure.)
• Public health education on mental illness to de-stigmatize it within the community and encourage the rural population to seek medical care for a family member’s erratic or confusing behavior (or seizures, since epilepsy is one of the neurological conditions included in these conversations).  Stigma attached to mental health diagnoses is not unique to India; however, there is an added twist here.  Because arranged marriages are still very common, a diagnosis of mental illness or epilepsy is especially damning for a young person. It marks him or her as genetically tainted and therefore less marriageable. This is a common reason that families avoid seeking treatment until symptoms become severe.

Karuna Trust’s pilot project for intensively rolling out a plan for integration of mental health services in PHCs will initially involve five PHCs, selected primarily based on their geographic location (within 300 kilometers of Karuna Trust’s Bangalore HQ).  The two mentioned here, Pattanayakanahalli and Mallapura are among the five.  The Trust will complete their PHC visits by the end of June. They will then analyze the five action plans developed by the PHC staff at each site to synthesize the information and develop an intensive mental health integration plan that will work effectively for all five PHCs.  Should it make sense to customize any of the PHC integration plans to a specific PHC they will consider that option as well.  Karuna Trust intends to begin implementation of the mental health integration plan with the five pilot PHCs during the month of July, evaluating progress regularly every few months, with a final evaluation at the end of two and a half years, and thereafter a scale-up to all PHCs managed by the Trust.

On a side note, I briefly crossed paths at Pattanayakanahalli PHC with Alex Ryu, a 2010 CASI-Karuna Trust intern.  Alex is back in Karnataka this summer, this time working with his sister on a project to deliver text message appointment reminders to women PHC patients regarding standard maternal and child health care. They are piloting the system at the PHC this summer.  For more information on their project see: http://news.harvard.edu/gazette/story/2011/04/texting-their-way-to-better-health/. It is great to see last year’s internship experience inspiring Alex to develop a new project to address the health care needs of Karnataka’s rural poor..

On a second side note, with three siblings living in Colorado I was delighted to see “Fort Collins” emblazoned on the Pattanayakanahalli PHC ambulance (see photo).  How unusual to be halfway around the world from them and have this unexpected reminder of the ways in which people’s lives intersect around our planet.  The people of Fort Collins should know that their contribution is being put to excellent use and is much valued.

Clare Leinweber
Karuna Trust – Mysore