Mental health education for primary health care

The Alma Ata Primary Health Care Conference in 1978marked a watershed in global health care policy and specifically a fundamental milestone for mental health. Not only was mental health defined as a right and an integral part of health generally, but also its promotion was a major recommendation of the conference. The key to the goal of Health for All by the Year 2000 was Primary Health Care, which was described as a system operating at a number of levels. The pri mary level, which was the first contact between patient and health services, was to be supported by referral to higher, increasingly specialised levels. The provision of advice, support and supervision was in turn to flow from the upper levels downwards. Primary Health Care was defined as a health system which was scientifically sound, socially acceptable, accessible and affordable, encouraging participation by communities themselves. A radical move away from a centralised, still largely custodial, mental health service to a more local service characterised by early identification and out-patient treatment, early discharge following in-patient care and community-based rehabilitation, was to be the hall-mark of a mental health system incorporating preventive, promotive, curative and rehabilitative strategies. No longer was mental health to be the Cinderella of the health services, clothed in stigma and huddled in a dark corner.


The psychiatrist in primary health care
There was now the increasing recognition by many countries of the need for integrated psychiatric services extending from hospitals in cities, down to health centres in rural areas and their village com munities.
Psychiatrists were seen as having a cardinal role in the development of these services. Thus the task of the psychiatrist was now understood as multipronged, requiring not only clinical expertise, but also health planning, administrative, managerial and health promotional 'skills. Often the resources, human and material, are limited, and psychiatrists are required to adopt innovative approaches in order to make more effective use of existing resources and to encourage self-reliance. They must ensure that the basic principles of mental health care can be dissemi nated widely to, and assimilated by, health staff working at all four levels of health care.
The ability to design, with others, mental health modules for basic training, in-service workshops and seminars is essential. This should enhance the orien tation and sensitisation of health workers, improving their identification and management skills (including referral and rehabilitation).
The psychiatrist should also expect to have a major role in outlining preventive policies, mental health planning and promotive strategies and integrating these with other health specialities. For this there must be close cooperation with colleagues in other health disciplines, including obstetricians, paediatri cians, nurses and village health workers. This role calls for the collaboration of the psychiatrist at Head Office with officiais at the Ministry of Health Head Office and other Ministries (e.g. school teachers, police, magistrates, prison officers, agricultural extension workers, social workers), as well as with non-governmental organisations and traditional healers.
National psycho-social problems, such as alcohol and drug abuse or child abuse, require a coordinated, multi-sectoral approach. The psychiatrist should thus be able to organise health sector reviews to collect baseline data and present it in a variety of formats for research and other purposes (e.g. information for schools, the mass media and project proposals regarding funding, etc.).
Finally, the technology of programme formu lation, programme budgeting, monitoring and evalu ation is a further necessary skill.

The Diploma in Psychiatry
In 1986 an opportunity presented itself to include a primary health care approach in the training of psychiatrists at the Institute of Psychiatry in London.
The Institute already had longstanding international links through its postgraduate training and was aware of the need to expand the number of psy chiatrists, especially in developing countries, where the ratio could be one psychiatrist per 500,000 to 1 million population (Lenz, 1982).
The Diploma in Psychiatry had earlier been inau gurated at the Institute with the first examination being held in 1983. The exam was designed to be equivalent in content and standard to the MRCPsych but to emphasise social psychiatry and mental health planning in an international context and also basic clinical neurology. Thus it was felt to reflect training and career needs beyond those of psy chiatrists practising only in the UK. The training programme overlaps with much of the MRCPsych course, requiring a total of three years' clinical experience, of which two years must be spent at the Maudsley or Bethlem Royal or an approved training hospital in Britain.
The content of the exam mirrors the content of the MRCPsych, having followed its 1987 reorganis ation. Thus Part A is primarily a test of basic clinical knowledge in both psychiatry and neurology. Part B covers all clinic topics and basic sciences. In particu lar, the evolution of the Part B exam has stressed the importance of mental health planning and the teaching courses described below have developed in conjunction with this increasing emphasis.

New training courses
In the 1987-88 academic year, an extensive training course has been introduced in mental health plan ning and development. Its chief components are: a 10-week series of lectures and discussion groups on mental health development studies, run for one session per week throughout the full-time intro ductory course for new overseas postgraduates; a 10-week series of presentations by new post graduates of details of their own mental health services, similarly running throughout the intro ductory course; a 10-week course of seminars on international issues in mental health, taking place in the spring term and open to all students and staff. Single events and lectures on the MRCPsych/Dip Psych course add to the teaching on the subject. The overall purposes of these courses are: (a) to provide practical and theoretical training of value to the Institute's postgraduate trainees; (b) to begin the evolution of a comprehensive examinable curriculum in mental health development; (c) to give prominence within the Institute's overall teaching programme to this interna tionally crucial area.

Hollander, Checkley and Appleby
The content of each teaching series will now be described briefly.

Developing mental health systems -an overview
This lecture deals with Alma Ata, Health for All by the Year 2000 and its relationship to mental health. The problems of mental health relating to stigma and to the centralised, predominantly curative and custo dial services are touched upon. The objectives and structures of mental health services at primary, secondary, tertiary and quaternary levels are out lined. The strategy for achieving goals is described, and issues such as decentralisation, integration, edu cation and training, monitoring and evaluation, and research are raised.

The role of the psychiatrist in the development of services at all levels
The second lecture examines in more detail the indir ect and direct role of the psychiatrist in supporting and supervising the health workers at primary, secondary, tertiary and quaternary levels of health care.
The psychiatrist has an important role in motivat ing and encouraging the preventive, curative and rehabilitative efforts of workers in mental health at these levels, and in facilitating the multi-disciplinary, intersectoral cooperation and coordination required. The crucial role of a Department of Mental Health at Head Office in providing technical advice for policy options, planning and implementation, coordi nation, monitoring and evaluation is highlighted.

The mental hospital and its role in the delivery of primary health care
The third lecture concerns itself with the transform ation of the centralised, previously inward-looking, mental hospital into a major resource centre. A visit ing multi-disciplinary team travels to surrounding hospitals and clinics as part of the decentralisation process, providing technical support, continuing education and mental health promotion. The mental hospital is active in rehabilitation procedures. It serves as a mental health training institute. Its staff develop feasible monitoring and evaluation pro cedures.

Community-based rehabilitation (two lectures)
The development of rehabilitation services at all levels and the role of the psychiatrist in training staff, supporting programmes and developing the infra structure are discussed.

Managerial issues in mental health
This lecture describes the historical development of the organisation of the British National Health Service, its financing and the new system of manage ment. The students contrasted this with the systems in their own countries in discussion: the concepts of effectiveness, efficiency and need being seen as areas for further exploration. Strengthening management at the secondary level of health care as a vital support for the primary level worker was recognised.

Drug treatment in mental health primary health care
It is important for psychiatrists to have knowledge about essential drug lists, good manufacturing practices, quality control, criteria for the selection of drugs for primary mental health care, the use of drug kits in rural areas. If there is to be successful treatment of the mentally ill at primary and secondary levels, health workers at these levels will require training and arrangements for moni toring and supervision of this work need to be established.

Manpower development and training
This is arguably the most important lecture of the series since it raises the questions: who is to be taught? who is to teach? and what is to be taught? Our impression is that it is this lecture which brings home the message that the trained psychiatrist cannot be an island, but is the nucleus and driving force to ensure that health workers at all levels are trained in mental health concepts. It is at this juncture that he or she may realise that he or she is largely responsible for the production of training materials and training programmes.
The training of mental health nurse tutors was shown to be essential if manpower needs at all levels were to be met.
Many workers require mental health education, including: (a) health workers (psychiatric and non-psychi atric health professionals); (b) workers in areas related to mental health, wellbeing and personal growth (teachers, social workers, rehabilitation officers, workers in children's homes, etc.); (c) those whose duties bring them into contact with mental health problems (police, judicial personnel, local government employees, etc.). For these groups mental health education needs to be incorporated into basic training, and for all those already qualified, short courses should be made available, possibly through day release. The concept of multi-disciplinary training modules for the smooth working together of multi-disciplinary teams was emphasised. An exchange of teachers between developed and developing countries was desirable and to be encouraged.

Child and adolescent strategies in primary health care
The lecture provides the opportunity to review an integrated approach to health care at primary, secondary, tertiary and quaternary levels. The numbers of children and adolescents mentally dis turbed or at risk underline the importance of provid ing training for health workers employed in these areas, where worthwhile preventive work may be undertaken.

Mental health planning, budgeting, implementation, monitoring and evaluation
The historical background of mental health planning and its improved status, with advances in the treat ment of psychiatric disorders and the emergence of the Alma Ata declaration, is described.
The importance of preliminary health sector re views, the formalising of policies, goals and the intersectoral collaboration for the drawing-up of a mental health plan of action as part of the Master Plan of Action is outlined. The principles of resource alloca tion programme budgeting are given and realistic, broad-based targets and detailed programming and programme formulation explored. Implementation, procurement, maintenance, monitoring and evalu ation are amongst the topics discussed. Monitoring and evaluation issues were raised and required more time for examination.
The drawing up of sensible three, five or ten year plans, and practice in producing project proposals and presenting ideas to advantage are now seen as an essential part of the psychiatrist's training.

Problem-oriented small group discussions
Each seminar was followed by a half-hour problemorientated small group discussion, which was en thusiastically tackled.
Topics include the following: How can the psychiatrist integrate mental health into: (a) maternal and child health care (b) general medical care?
What can the psychiatrist do to coordinate tra ditional and scientific mental health practices? What is the role of the following organisations in the development of mental health services?; Agriculture, Education, The Police, Justice, Local Government, Voluntary organisations. A preliminary evaluation carried out after the autumn series of lectures showed that nearly all the respondents thought the topics were very helpful and had given them a new understanding of their role within the broader context of primary health care.

National presentations
The students in autumn 1987 came from the follow ing countries: Bahrain, Brazil, Dominican Republic, Egypt, Hong Kong, Japan, Korea, Portugal, Saudi Arabia, Spain, Sudan, Thailand, Uganda. National presentations were given one afternoon each week. These provided the students with the opportunity to present their own country's health and psychiatric services within the framework of that country's physical, historical, socio-economic, political, demographic and cultural background. The students took a great deal of trouble over their presentations, which were fascinating in their variety, so much so that they may form the basis of a future publication. A modification into the form of written dissertation has been proposed as a further examinable development. On return home such presentations should provide an impetus for consideration of these influences on health devel opment.

Seminars on international issues
Seminar topics have covered a broad range of issues from training of medical and non-medical workers, through planning, financing and evaluation to inter national cooperation on policy and research. The specific subjects are given below: Training of non-medical staff for psychiatric practice overseas; training of medical staff for psychiatric practice overseas; the team approach in developing countries: interscctoral and multidisciplinary prac tice; mental health legislation round the world; mea suring mental health: epidemiology and screening; how good is the service? -evaluating a psychiatric service in the developing world; how to talk to poli ticians -advising governments on mental health policy; getting the money you need -national health policies and how to finance them; regional collabor ation on mental health; international research in mental health.

Hollander, Checkley and Appleby
Speakers from outside and within the Institute recounted their experience and opinions. The sub sequent discussion provided a broad international perspective to each subject. Attendance was good (around 40) and increased as the series progressed. The audience was primarily medical, comprising postgraduate students, researchers and hospital staff, but representatives of psychology, nursing and social work were also present.

Conference
A one-day symposium with international speakers on 'Psychiatric Services Round the World', included topics on 'culture and mental Illness', 'developing a community oriented service in a multi-cultural setting', planning, implementing and evaluating a service and training. It is planned to hold another such all-day symposium on 'Mental Health and Urbanisation'.

Future improvements
Though mental health development is at an early stage as a teaching subject, it will expand and im prove in the next few years. Our postgraduates come from a variety of countries and have a variety of needs. The national composition of our student population continues to change. For these reasons, no course can afford to be static.
The ultimate purpose of this teaching programme is to reflect the global needs for psychiatric education and mental health provision. The goal to work towards, as the Alma Ata declaration stated, was Health for All.