Reconnaissance & Planning for Mental Health Capacity Building in Lao PDR Manivone Thikeo, MD, MPH., Ph.D. Candidate Paul Florin, Ph.D. Inger Helene Vandvik, MD, Ph.D. Marlene Goodfriend, MD. Advard Hauff, MD, Ph.D.

1
Reconnaissance Planning for Mental Health
Capacity Building in Lao PDR Manivone Thikeo,
MD, MPH., Ph.D. Candidate Paul Florin, Ph.D.
Inger Helene Vandvik, MD, Ph.D. Marlene
Goodfriend, MD.Advard Hauff, MD, Ph.D.
2
Lao PDR

• 5.5 million population
• multiethnic gt48 different ethnic
• groups
• rural 75 live in rural areas
• GDP per person US 443
• living on lt 1/day 27 percent
• Life expectancy at birth 55 years
• Probability at birth of not
• surviving to age 40 is 28
• Adult literacy is 68
• Primary school enrolment is 84

3

• Picture from the cover of a
• 2002 WHO situational
• analysis of mental health in
• Laos mental health issues are completely new
  for the country

• A UN Country Assessment in 2006 stated Mental
  health
• is an area that has been particularly
  neglected

4
Sponsoring Organization

• Health Frontiers (HF) is an all-volunteer
  outreach of health professionals, focused on
  global health and child development
• HF has worked with Laotian colleagues since 1991
  to establish residency training programs in both
  pediatrics and internal medicine
• Graduates of these residency programs (as of
  2008), 48 pediatricians and 23 internists, now
  work in all Lao provinces and are increasingly
  involved in teaching current residents
• Because the HF philosophy is built around
  volunteer health professionals who take a year or
  more out of their careers and serve gratis or on
  small living stipends, HF initiatives cost little
  and produce extraordinary return on investment

5
2009 Reconnaissance Team
Edvard Hauff MD, Ph.D.Professor of Transcultural
Psychiatry University of Oslo
Paul Florin, Ph.D. Professor of
Psychology University of Rhode Island
Manivone Thikeo, MD., MPH, Ph.D.
Candidate Clinical Psychology University of Rhode
Island
Inger Helene Vandvik, MD. Professor Emerita of
Child and Adolescent Psychiatry University of
Oslo
Marlene Goodfriend, MD Pediatric
Psychiatrist University of Florida Team Leader
6
2009 Reconnaissance Process

• In-depth interviews
• Meetings with medical faculty and primary care
  physicians
• Focus Groups
• Meetings with international organizations
• Trip to department of Psychiatry, Khon Kaen
  University, Thailand
• Trip to a Sayaboury province (PaulManivone )

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Dr. Sing MenorathVice-Rector, Post-Graduate
StudiesUniversity of Health Sciences

• Advocate for mental health policy
• statement issued in 2007
• The policy statement is a public
• recognition of need but neither
• describes specific steps nor allocates
• Favors the ultimate establishment of a
• 3 year post-graduate training program
• in psychiatry at the University
• Emphasized the importance of not
• limiting capacity building to the capital
• and the necessity of getting services to
• the people in the provinces

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Dr Sisouk VongphachanhHead, Mental Health
DepartmentMahosot Hospital

• One of two psychiatrists in Laos
• Works with six other doctors at mental
• health unit at Mahosot
• Main diagnoses are schizophrenia,
• depression, epilepsy, bipolar disorder
• Treatment primarily medication with
• some adjunctive counseling
• Invested in training Lao doctors in
• psychiatry (1) has translated a text
• book (2) has brought 11 doctors into
• capital from provinces (3) has recently
• provided five-day trainings to GPs and
• health workers in a couple of provinces

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Dr. Chantharavady ChoulamanyBasic Needs Lao PDR

• Only other psychiatrist in Laos
• Co-author of the 2002 WHO analysis
• Established Basic Needs, the first
• NGO to address mental health issues
• Employs a community mental health
• model (train village workers, GPs in
• active listening, provide outreach clinic
• monthly)
• Commenced in May 2007 with pilot
• community mental health projects in
• two communities within the
• Vientiane Capital Province
• Currently six sites in Vientiane
• Province

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Meetings with medical faculty and primary care
physicians

• Discussed mental health training for
• internists, pediatricians general
  practitioners
• Currently, any suspicion of a mental
• health problem, transfer to Dr. Sisouk
• or referred to Khon Kaen in Thailand
• However, only most severe or those
• with (who can go to Khon Kaen)
• Training to integrate mental
• health into primary health desired
• General topics should include recognition
• diagnostic categories, as well as treatment
• with medication and counseling
• Specific issues include behavioral problems,
• autistic spectrum, depression / suicide
• Model of combination of seminars with case
• conferences fit with their current training
  mode

11
Focus Groups

• Focus groups conducted with pediatric
• and internal medicine residents
• Report that currently there could be more
• training on mental health issues in
• curriculum
• Some concern expressed that once they
• have their degrees and are assigned to
• different provinces, they are on their own
• One (of ten) of the residents
• indicated that she would have had
• enough interest in mental health issues
• that she would have considered
• specializing in mental health and doing
• a psychiatry residency if it had been
• offered

12
Visit to Khon Kaen University, Thailand
13
Department of Psychiatry
Dr. Suchat, Chief of psychiatry

• Has offered 3-year post-graduate
• training in psychiatry since 1999
• Currently 9 psychiatric residents
• Has provided 3 month training for
• Lao MDs in past (but must read
• English well)
• Offered a new scholarship paid for
• by Khon Kaen University for one Lao MD
• per year to participate in two years of
• residency (provision they return to Laos)

14
NGOs (Non-governmental organizations)

• Met with WHO, International Organization for
• Migration (refugees, trafficking)
• Save the Children Norway (education)
• Save the Children Australia (primary
• health care in one province)
• Supportive but emphasized importance of long
• term on the ground commitment

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PRIMARY HEALTH SYSTEM IN LAO PDR
Central Level MoH, University of health sciences,
National Hospital
National
17 Provinces
Intermediate Level Provincial Hospitals
Districts District Hospitals Village Health
Centers (thousands)
Population
Peripheral Level District Hospitals and Village
Health Centers
16
Provincial Visit(Manivone and Paul)

• Sayaboury Province

• Remote Mountainous Province
• Western side of Mekong River
• Shares border with Thailand
• Population of 330,000
• Ten districts within province
• Hundreds of villages

17
Sayaboury Province

• Save the Children Australia
• working on primary health care
• in the province since 1991
• Implemented entirely by Lao
• government staff with support
• from only one health advisor
• (Carol Perks)

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Strong primary health care

• Evaluations have shown that
• 92 of households have access
• to a health care facility
• (compared to 61 nationally)
• Infant and child mortality rates are less
• than 1/3 national rates
• Maternal mortality has decreased 50
• Includes mobile health teams that visit
• each village twice a year
• Save the children Australia (Carol
• Perks) moving on to a new province
• She would welcome the integration of
• mental health issues with primary care
• The Director of the Province Hospital
• also indicated she would be willing to
• bring MDs and nurses from each District for
• multi-day training in Sayaboury

19
Concept Paper for Mental Health Capacity
Building

• Principles for the development of the initiative
• Build capacity in a participatory manner,
  incorporating infrastructures and initiatives
  previously built by Lao colleagues
• Build capacity simultaneously from the bottom
  up, by integrating mental health into the
  existing primary health care infrastructure,
  while pursuing longer term top down development
  of specialized training such as a psychiatric
  residency
• Build capacity in a pilot provincial project to
  serve as a model for mental health services to be
  established outside the capital, in the
  countryside
• Facilitate and document capacity building and
  outcomes by consistently gathering, analyzing and
  disseminating data at all steps in the process

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NATIONAL PRIMARY HEALTHCARE CONTEXT

• Increased integration of behavioral
• healthcare services by GPs and
• Pediatricians at District Level
• Mental Health Consultation at
• District Hospital Level

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NATIONAL PRIMARY HEALTHCARE CONTEXT

• Series of short trainings (2-week to 1-month)
  from visiting faculty easy to implement but may
  have little sustained impact (need evaluation)
  
• Systemic change will require new personnel
  /structures
• Training starting 2011at Khon Kaen in
  psychiatric residency
• A short training curriculum may be
  institutionalized at UHS over time, with the
  establishment of a mental health coordinator who
  can support training with follow-on technical
  assistance.
• Implementing full curriculum at UHS, however,
  will take many years and assumes significant
  funding from external source (13 years in
  Cambodia)
• An estimate for having enough graduates of a
  fully implemented psychiatric residency in place
  at Provincial Hospitals to provide mental health
  services is over a decade.

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• Focus on Perinatal Depression
• Studies indicate prevalence rates in low-income
  countries from 20-30
• WHO states it can be reasonability expected
  that perinatal mental health
• problems are both under-identified and
  under-treated.
• A simple CBT intervention delivered by
  community health workers has
• demonstrated effects in a controlled trial in
  rural Pakistan
• The intervention promotes the WHO concept of
  task shifting a process whereby
• specific tasks areshifted to health workers
  with shorter training and fewer
• qualifications.
• A valid self-report screening instrument is
  available for use in the project which
• has been translated into Thai, understood in
  Laos
• Perinatal depression and its impact on children
  is an excellent fit with the strong
• maternal / child focus of Sayabourys primary
  health care system supported by
• Save the Children Australia

PROVINCINCIAL PILOT PROJECT SAYABOURY PROVINCE

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March 2010 Follow-up and Planning Team
Inger Helene Vandvik, MD Professor Emerita of
Child and Adolescent Psychiatry University of
Oslo
Manivone Thikeo, MD., MPH, Ph.D.
Candidate University Of Rhode Island
Paul Florin, Ph.D. Professor of
Psychology University of Rhode Island
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Fortunate Timing !

• First Mekong Sub Region Community Mental Health
  Forum held March 11-12th in Vientiane
• Convened over 100 mental health leaders from
  Thailand, Cambodia, Vietnam and Laos
• Funded by Thai Ministry of Health, Hosted by
  University of Health Sciences, Laos

25
Reconfirmed Fellowship Offer from Khon Kaen
University, Thailand
Dr. Sing, Vice-Rector Post Graduate
Studies University of Health Sciences
Dr. Sisouk, Head, Mental Health Dept Mahosot
Hospital
Dr. Suchat, Chief of psychiatry, Khon Kaen
University , Thailand
Dr. Suchat, Chief of Psychiatry, Khon Kaen
University
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Established Official Agreements of Cooperation

• MOUs of cooperation among all parties signed at
  Mekong Sub Region Community Mental Health Forum.
• This will permit Thai, Cambodia and Vietnam
  mental health staff to collaborate on initiatives
  for mental health capacity building in Laos.

27
Re-visit with Basic Needs

• Funding from EU for three
• additional years received
• Currently six fully functioning
• community sites within
• Vientiane Province
• Recent expansion to a pilot
• project in Borikhamxay
• Province
• Dr. Chantharavardy ready to
• collaborate with Dr. Manivone
• working as Health Frontiers
• Mental Health Coordinator

Dr. Sunbaunat Ka, psychiatrist and dean of
Cambodia medical school
28
Re-visit with World Health Organization

• Team met with WHO staff Drs. Asmus Hammerich
  (Programme Management Office for Health Systems)
  and Supachai Doaungchack
• Dr. Ingre Helene presented official letter of
  recommendation from Dr. Edvard Hauff of Norway
• Dr. Paul presented powerpoint project briefing
• WHO very supportive of the mental health
• initiative and will seek seed money from
  regional office in Manila, Philippine for Dr.
  Manivone to serve as a WHO mental health
  consultant for Laos
• WHO will coordinate with Dr. Manivone upon her
  return
• to Laos in November 2010.

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Obtaining Official Approval

• Written copies of needs assessment report and
  concept paper had been sent in writing ahead of
  time to Laotian and International NGO colleagues
• A series of meetings presented the plan verbally
  in order to obtain official governmental
  approvals from National and Provincial levels
  (both are necessary), as well as approval from
  International NGO colleagues
• Presentations were primarily made in Lao language
  by Dr. Manivone to Laotian colleagues

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Re-visit with Dr Sisouk VongphacanhHead, Mental
Health DepartmentMahosot Hospital

• Dr. Sisouk has official responsible
• for mental health portfolio within
• Ministry of Health
• Dr. Sisouk approved the plan and said
• working in Sayaboury Province was
• welcome because he had been receiving
• increased referrals from that Province
• Dr. Sisouk reiterated his commitment to
• work with the team to establish the
• criteria for candidates to attend training
• at Khon Kean University
• Dr. Sisouk arranged for Dr. Manivone
• to present plan to Deputy Minister of
• Health

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Approval of plan by Deputy Minister of Health

• Dr. Vongvichith was very supportive
• of the mental health capacity building
• project
• Dr. Vongvichith offered support and
• guidance to Health Frontiers to establish
• the legal documents to expand its
• mission in Laos to include mental health
• Dr. Vongvichith recognizes that, at the
• national level, training and technical
• assistance will need to come from
• international aid, coordinated by Health
• Frontiers
• Dr. Vongvichith approved the pilot project
• in Sayaboury province to be officially
• established under the auspices of Health
• Frontiers (also included in legal document)

Dr. Eksavang Vongvichith Deputy Minister of Health
32
Official approval of coordination of provincial
pilot with Save the Children Australia
John Reinstein Country Director, Laos Save the
Children Norway
Mathew Picard, Country Director, Laos Save the
Children Australia
33
Return to Sayaboury Province
34
Approval / planning for pilot project in
Sayaboury Province
Dr. Khamla, Deputy Director, Sayaboury Province
Public Health
Dr. Khamphiou, Director of Sayaboury Provincial
Hospital
Carol Perks, Save the Children Australia
35
Next Steps

• Dr. Manivone will return (permanently) to Laos
  with her family in November 2010 as a half time
  mental health coordinator for Health Frontiers
• Dr. Manivone will also work half time as a WHO
  mental health consultant for Laos
• Dr. Manivone will collaborate with reconnaissance
  team, Health Frontiers, and WHO in an effort to
  find funding to support psychiatry residency
  training for Laosdoctors.
• At the national level, Dr. Manivone will begin by
  collecting and comparing psychiatric curricula
  from all Mekong Sub Region countries and
  curriculum examples from within Laos (e.g., those
  used by Dr. Sisouk and Dr. Chantharavardy).
• At the National Level, an initial goal is to
  institutionalize a standard set of trainings
  with follow-up technical assistance for internal
  medicine and pediatric residents within 18 months
• At the Provincial level, Dr. Manivone will begin
  trainings for the pilot perinatal depression
  project in Janurary 2011.
• Provincial Hospital Staff will be trained first,
  then District Hospital Staff and then at Health
  Clinic Level (70 health clinics in Province).
• Government Staff at District and Health Clinic
  levels will then train volunteer village health
  coordinators and birthing volunteers
• At the Provincial level, goal is to be fully
  operational within 18 months