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. - PowerPoint PPT Presentation


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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.


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. – PowerPoint PPT presentation

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Title: 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.

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.
  • 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

  • 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
  • is an area that has been particularly

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

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
Inger Helene Vandvik, MD. Professor Emerita of
Child and Adolescent Psychiatry University of
Marlene Goodfriend, MD Pediatric
Psychiatrist University of Florida Team Leader
2009 Reconnaissance Process
  • In-depth interviews
  • Meetings with medical faculty and primary care
  • Focus Groups
  • Meetings with international organizations
  • Trip to department of Psychiatry, Khon Kaen
    University, Thailand
  • Trip to a Sayaboury province (PaulManivone )

Dr. Sing Menorath Vice-Rector, Post-Graduate
Studies University 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

Dr Sisouk Vongphachanh Head, Mental Health
Department Mahosot 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

Dr. Chantharavady Choulamany Basic 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

Meetings with medical faculty and primary care
  • Discussed mental health training for
  • internists, pediatricians general
  • 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

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

Visit to Khon Kaen University, Thailand
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)

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

Central Level MoH, University of health sciences,
National Hospital
17 Provinces
Intermediate Level Provincial Hospitals
Districts District Hospitals Village Health
Centers (thousands)
Peripheral Level District Hospitals and Village
Health Centers
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

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)

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

Concept Paper for Mental Health Capacity
  • 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
  • Build capacity in a pilot provincial project to
    serve as a model for mental health services to be
    established outside the capital, in the
  • Facilitate and document capacity building and
    outcomes by consistently gathering, analyzing and
    disseminating data at all steps in the process

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

  • 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
  • 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
  • Implementing full curriculum at UHS, however,
    will take many years and assumes significant
    funding from external source (13 years in
  • 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.

  • 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
  • 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
  • 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


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

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
Dr. Suchat, Chief of psychiatry, Khon Kaen
University , Thailand
Dr. Suchat, Chief of Psychiatry, Khon Kaen
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.

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
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
  • to Laos in November 2010.

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

Re-visit with Dr Sisouk Vongphacanh Head, Mental
Health Department Mahosot 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

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
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
Return to Sayaboury Province
Approval / planning for pilot project in
Sayaboury Province
Dr. Khamla, Deputy Director, Sayaboury Province
Public Health
Dr. Khamphiou, Director of Sayaboury Provincial
Carol Perks, Save the Children Australia
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