Guyana- Integrated Health Care – Time to Transform Talk into Walk
The vast majority of Guyanese are willing to seek help for someone with a mental health issue according to a survey conducted by Dr. Vishnu Bisram on behalf of The Caribbean Voice. In fact 88% of the 1235 respondents indicated that they would seek help if they think someone is suffering from mental illness while 78% believe that people with mental illnesses can live normal lives. But 92% felt that government is not doing enough to address mental health.
We know from Government figures (Draft Mental Health Strategy 2015-2020), that 10 to 15% or 78,000 to 114,500 Guyanese suffer from a mental disorder at any one time, with 3 to 5% of the population having a severe chronic mental disorder. Also, approximately 20,000 Guyanese suffer from severe mental illness with unipolar depression as the fifth greatest contributor to disease burden in Guyana. These figures do not include people with epilepsy, mental retardation and alcohol abuse.
Given the cost factor involved in a comprehensive approach to mental health, and the scarcity of mental health professionals and other resources, it seems logical that Guyana should follow an integrated approach to health care as advocated by the World Health Organization. The Caribbean Voice suggests that such an integration be implemented using the Sri Lanka Project as an exemplar.
Sri Lanka and Guyana have similar and parallel health care structures. Sri Lanka had very high suicide rates, tremendous mental health needs and a Government funded health system that was decentralised – the Guyana equivalent of Regional Health Authorities. There was approximately one psychiatric consultant per 500,000 people, no specialised psychiatric nurses and very few psychologists, occupational therapists and psychosocial workers, as in Guyana.
Funded by the World Psychiatric Association (WPA), the Sri Lanka Project aimed at integration through a Train the Trainers program involving the Sri Lanka Ministry of Health, the National Institute of Mental Health and the WPA. People were specifically selected from each region of the country, based on their ability to roll out the training to others, and then provided with requisite training to be trainers. The project was a five-day course, over forty hours, which covered five modules.
Module one focused on mental health and mental disorders and their contribution to physical health and economic and social outcomes while module two covered communication skills, assessment, mental state examination, diagnosis and management, managing difficult cases, management of violence and breaking bad news. The third module encompassed neurological disorders, epilepsy, Parkinson’s disease, headache, dementia and toxic confusion states and the fourth covered psychiatric disorders based on the WHO primary care guidelines for mental health. The fifth module focused on health and other sector system issues of policy, legislation, links between mental health, reproductive health, HIV and malaria, roles and responsibilities, health management information systems, working with community health workers and with traditional healers and integration of mental health into operational plans.
The course was dynamic and taught through theory, practice, role-plays, discussions and WPA videos on depression, psychosis and somatisation. The emphasis was for trainees to acquire practical skills and competencies for assessment, diagnosis and management. Participants had to complete 25 supervised role-plays on different topics over the week and observe and comment on 25 role-plays conducted by others. Each participant was given both a hard copy print out and a CD of the guidelines plus all the teaching slides, role-plays and teacher’s guide.
TCV firmly believes that the implementation of the Sri Lanka type project can contribute to the development of national and institutional standards for overall health care in Guyana and underpin the Government’s realization of mental health care for all. Due to the scarcity of mental health professionals in Guyana, TCV suggest that the criteria for selection be expanded to include religious leaders, teachers, police, social workers, child care officers and other relevant personnel. Guyana has Regional Health Authorities under the control of the Ministry of Health and links with NGO’s that can be tapped to assist with the planning, organising and delivery of the training. Also while the modules and core concepts of the training programme are relevant to Guyana we do understand that changes may be required to include social and cultural differences and an understanding of suicide and related issues; causes, impact and preventative measures.
Within this context of an integrated mental heath-care approach, various strategies advocated over the last two years can be implemented to shore up overall health care. Among such initiatives are:
- The Gatekeepers’ Program, which was promised by government since mid 2015: The approach can be to use the ‘Train the Trainers’ concept to prepare a reservoir of trainers nationwide, who can then be tasked with providing first responders training to selected personnel from communities throughout Guyana, that would include suicide prevention and abuse in general – sexual, domestic, child, drugs and alcohol.
- The placement of counselors in schools: In an interview with the Guyana Times on Monday January 25, Minister of Education, Dr. Rupert Roopnarine had indicated that most aspects of the Central Counseling Body had been finalized and all was to be implemented within 10 days. According to the newspaper, the Minister was, among other things, referring to placement of counselors in all schools. Well that should have been done by February 5th. So why the holdup? After all the Hon. Minister did express support for a measure first mooted by The Caribbean Voice, that teachers be identified in schools and provided with the essential training, since employing psychologists would be far too expensive.
- Addressing pesticide suicide: TCV has been lobbying for the highly successful Shri Lanka Model with necessary adaptation, as one that is easy and inexpensive to implement. Besides it is well known that ingestion of poisons places a burden on the physical health care system, so steps towards reduction would positively impact overall healthcare.
Meanwhile we welcome the Pesticide Board’s intention to share out to farmers, 150 cabinets to add to the 150 distributed last year, but given that there are tens of thousands of farmers in Guyana, we suggest an urgent and extensive campaign to educate farmers about pesticide safety. That campaign must clearly propagate that pesticides/poisons be:
- purchased by someone very reliable (perhaps with some sort of official documentation), who would immediately safely store the chemicals upon reaching home, in cabinets/strong boxes;
- safely stored at all times with the key being held by the most reliable family member so that no one else can have access;
- only given to whoever needs to use them, on the days when they are to be used, usage is keenly supervised, unused pesticides/poisons returned to the safe and any empty containers be safely disposed of.
Additionally a boldly announced stakeholders forum to address suicide prevention is still to be realized, although a National Stakeholders’ Conversation is being held on April sixth. One outcome of such a forum should be a national coordinating committee that can help to foster collaboration, map all that is happening so as to avoid duplication, ensure follow up, maximize resource use and plug the gaps. This would ensure that a structured approach, and regular feedback, drive an ongoing national campaign and provide citizens with the wherewithal to save lives. Of course the Ministry of Health (MOH) would need to build a comprehensive database of NGOs and other stakeholders to foster the work of this committee
Perhaps too its time for the Guyana government to take a page from the book of Tanzania’s ‘revolutionary’ leader, John Magufuli who (among many other measures) declared that there would be no celebration of Independence Day on 9 December (last year) because it would be ‘shameful’ to spend huge sums of money on the celebrations when people were dying of cholera. Instead, the day was set as a national day of cleanliness, and the money went toward street-cleaning services. We are not advocating ditching the fiftieth anniversary celebration but we are saying that similar, if not greater, priority needs to be given to the integrated health care approach. And within this approach we also strongly suggest that a registry of sex offenders be established and that the age of consent be raised from sixteen to eighteen years since both these measures can help to reduce sexual abuse.
In fact, The Caribbean Voice has two ongoing petitions relating to these two measures and we appeal to all Guyanese to sign these petitions and send a powerful message to the government. To access the petitions please log on to our website at www.caribvoice.org. Under the first bold heading ‘What’s New,” item number contains links (in larger blue texts) that can be clicked on to get to the ‘Age of Consent’ and the ‘Registry of Sex Offenders’ petitions.
The Caribbean Voice also welcomes NGOs and other entities as petition partners to join in house to house campaigns to garner the required amount of signatures. Save Abee Foundation, GIVE Foundation and Golden Om Dharmic Youth are current partners. Also The Caribbean Voice recently launched a self esteem pledge entitled, ‘ME’ and we are willing to provide the pledge to all organizations and other entities that are willing to sign and share. The pledge reminds each individual that life has a purpose and that he/she should not give up. It also contains the suicide hotline numbers and so can be used as a reference document that can be kept in a wallet, purse, bag or pocket. This way anyone can call at any time, once someone is suspected of being at risk. Besides suicide, calls relating to all forms of abuse – domestic, sexual, child, alcohol and drugs – are also handled.
The bottom line is that it is better to err on the side of caution that to ignore a situation only to lament afterwards; it is better to make a mistake than to lose a life. For copies of the pledge or petitions forms, to partner or collaborate with The Caribbean Voice, or to seek our involvement or support in activity related to suicide prevention or related issues, please email firstname.lastname@example.org, email@example.com, firstname.lastname@example.org, email@example.com or phone 621-6111, 223-2637 or 627-4423 in Guyana.
Download article: Integrated Healthcare – transform talk into walk