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Researches Community health care

Vũ Thị Minh Hạnh,  Trần Vũ Hiệp,  Vũ Thị Mai Anh,Trần Thị Hồng Cẩm,  Hoàng Thị Mỹ Hạnh, Hoàng Ly Na

Place of publication: Health Strategy and Policy Institute
Year of publication:  2010

1. Review the Community-based mental health project, 2006-2010;
2. Explore lessons learnt, existing gaps and challenges in the implementation of the Community-based mental health project, 2006-2010; 
3. Recommend specific directional strategies for the community-based mental health program by 2020.
Location: 5 provinces/cities (Cao Bang, Nam Dinh, Phu Yen, Kon Tum and Tien Giang). 
Methodology: Collection and analysis of secondary data, 43 in-depth interviews, 37 focus groups, data collection through statistical templates for 63 provinces/cities, and surveys on 1700 households in the five provinces/cities.
Implementing  process
The program operates based on a relatively fully-fledged legal framework, with numerous normative documents released by the government and various ministries and line agencies.
Decentralization and implementation: At the national level, the project is run by the National target program for health executive board and project management board. On the regional scale, the National psychiatric hospital No. 1 is in charge of 31 Northern provinces/cities, and the National psychiatric hospital No. 2 is responsible for 32 Southern provinces/cities. The provincial level project is led by the local Health Departments, in collaboration with mental hospitals and social diseases information and communication centers. At the district level, the project has a district project board and district health center/preventive health center. At the commune echelon, the commune health center is the local implementing unit, with the participation of outreach workers.
Monitoring and evaluation take place on a regular basis every six months (national - sub-national monitoring), every quarter (province – population level monitoring), and once in 1-3 months (district- commune monitoring). Monitoring work takes relatively diverse forms, including one-to-one coaching, supervision through reports, telephones and so on. Unfortunately, this activity remains rather spontaneous, non-formulaic, poor in contents, while human and equipment constraints prevent more regular monitoring efforts.  
Record-keeping and reporting in the project system have been maintained regularly at all levels as required. Local record-keeping and data management follow the old-fashioned way, without the use of computers in the management, archiving and transfer of data and reports. Book-keeping and data update at the commune level remain bulky and inconsistent, while the reporting capacity of population level health workers is to be improved.
Project management units have been established at all levels, involving psychiatric specialized hospitals and various related line agencies, mass organization and civil society. The service delivery network features the national psychiatric hospitals No. 1 and 2, the National mental health institute, mental hospitals and psychiatric department of the Social diseases center, mental health centers, psychiatric departments of municipal general hospitals. The current national ratio is 1.03 psychiatrists for every 100,000 population, but not equally distributed among the North and South. Medical staff with specialized training in psychiatry takes up the majority (44%), followed by those majoring in epilepsy (36%). Among them, 60.8% had regular training. 
Training and capacity building take place regularly over the years. The largest number of training courses delivered and participants is recorded for the second and third years (2007 and 2008). Training mostly centers on two areas of management/monitoring and technicality. Most participants received technical training, and people from districts and communes took more courses than those from the national and provincial levels. Most participants agree that the training provided by the program is useful.
Program budgeting arrangements follow the plans, with the net disbursed amounts increasing year on year, mostly from the national target program for health. Most provinces face financial constraints in implementation. Allocated funds takes up a relatively low percentage of the actual need of provincial level psychiatric hospitals (60%). 
Ongoing activities include information and education, drug supply and use, screening for early detection of mental illnesses, record-keeping for community-based management, rehabilitation, reintegration follow-ups, and procurement of equipment for treatment.
The program has achieved nationwide coverage. Provinces with a psychiatric hospital, however, remain few in number (33/63), as provinces with psychiatric hospital beds only account for more than 50% (39/63). The percentage of participating communes has increased over time.
The percentage of health workers identifying correctly symptoms of depression is quite low. Medical staff knowing the concept, telling correctly the symptoms and saying correctly how long the symptoms last take up a significant ratio. Medical staff knowing the concept, telling correctly the symptoms and saying correctly how long the symptoms of epilepsy last take up a significant ratio. 
Community members hearing and knowing about the community-based mental health program in Kon Tum show the highest percentage (74.3%), much higher than the upland counterpart province of Cao Bang (41.6%). About 38-51% of the interviewees know the clinical signs and how to take curative and preventive care for mental patients. Various channels exist locally to provide knowledge on how to protect the community’s mental health. Television and firsthand education are the two most favored information channels for community-based mental health care (with ratios of 72.5% and 50% respectively).
Basically for the period of 2006-2010, the community-based mental health hospital project (CMHH) has been completed and even with flying colors compared to the set targets.  
Achievements and drawbacks of the community-based mental health (CMH) project, 2006-2010
Achievements: The project has been underway consistently and homogeneously from the national to commune levels, with a continuously improved organization and network. The project has gained the initial interest, commitment and support from leaders and executive officials of various government levels and line agencies. The project being introduced in all provinces/cities in the country has benefited 70% of the communes. The financial returns of the project in practice are enormous. The project helps improve the quality of services in the health system by relieving the workload for provincial level psychiatric hospitals (if any) and national level hospitals.
Drawbacks: Provincial level mental health care facilities remain inconsistent and inter-compatible in terms of organization. The districts are without hospital beds and psychiatric units for management of acute cases. Human resources are both insufficient in numbers and inadequately qualified throughout the network, especially in Southern provinces and at the population level. The existing mixed approach in the management of schizophrenia, epilepsy and depression patients is less than optimal. The program’s coverage for different mental illnesses is falling behind the actual needs. As available funds only cover 53.7% of the estimated costs for the whole period, only 50-60% of the actual needs are met. Resources are thinly spread and at times inappropriately allocated. Joint Circular 147 creates multiple barriers, while training for population level staff remains cursory, with insufficient technical and operational manuals and guidelines. Training fails to cover all the designated target groups: patients’ families, physicians at consulting rooms of general hospitals and so on. Available funds for education remain limited, as the focus is mostly on the patients and their families. Educational materials are poorly developed both in substance and format. The role of various line agencies, mass organizations and civil society is minimal. The bidding process for medication procurement is slow. Drugs are insufficiently listed. Some commune health center staff members still make mistakes writing drug names in patients’ records.
A national strategy for CMH by 2020 and vision to 2030 needs to be developed and submitted to the government for enactment. The community mental health care network should be streamlined across the country. The psychiatric hospital model needs to be taken to scale in all 63 provinces/cities. This will provide a stepping stone for the development of private mental hospitals. Psychiatric units can be established at district level general hospitals, with about 5-10 hospital beds. The mental health workforce should be developed nationwide both in size and capacity to meet the increasing needs for mental health care of the community. The project needs to expand to cover other emerging mental illnesses, including alcohol-related psychotic disorders, anxiety, depression, autism, among others. Prescription deficiencies should be corrected. The quality of monitoring should be improved. Community-based education should be further emphasized and accelerated. Modifications of budget-related and allocation schemes are also needed.

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