Fifth Regional Coordinating Committee Meeting on the Mental Health Programme, Manila, Philippines, 13-16 June 1995 : report

(WP)MNH/ICP/MND/OO2 Report series number RS/95/GE/Q7(PHL)

English only

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PORT

FIFTH REGIONAL COORDINATING COMMITTEE MEETING /j ON THE MENTAL HEALTH PROGRAMME

Convened by: WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC Manila, Philippines 13-16 June 1995

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Printed and distributed by World Health Organization Regional Office for the Western Pacific Manila, Philippines December 1995 L. itSi~AiI;li'

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NOTE The views expressed in this repon are those of the panicipants in the Fifth Regional Committee Meeting on the Mental Health Programme and do not necessarily reflect the policies of the World Health Organization.

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This repon has been prepared by the World Health Organization Regional Office for the Western Pacific Region for governments of Member States in the Region and for those who participated in the Fifth Regional Committee Meeting on the Mental Health Programme, which was held in Manila, Philippines, from 13 to 16 June 1995.

CONTENTS

SUMMARY ............................................................................................. 1 1. 2. INTRODUCTION ...................................................................................... 3 PROCEEDINGS ........................................................................................ 4 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 3. WHO mental health progranunes ............................................................. 4 Update of the review ............................................................................ 4 National mental health progranunes: Evaluation of the past five years ............... 7 Review of progress on psychosocial aspects of health in selected countries ......... 11 New horizons in mental well-being .......................................................... 13 Cooperation and collaboration ................................................................ 15 Nongovernmental organizations .............................................................. 15 Specific topics .................................................................................... 16

CONCLUSIONS AND RECOMMENDATIONS ............................................... 18 3.1 Conclusions ....................................................................................... 18 3.2 Recommendations ............................................................................... 19 ANNEXES: ANNEX 1 - LIST OF PARTICIPANTS ....................................................... 21 ANNEX 2 - OPENING SPEECH OF THE REGIONAL DIRECTOR ................... 25 ANNEX 3 - ANNOTATED AGENDA ........................................................ 29 ANNEX 4 - LIST OF DOCUMENTS .......................................................... 33 ANNEX 5 - MENTAL HEALTH PROFILE .................................................. 35 (COMPARISON ON HOSPITAL BED RATIOS 1983/1990) ANNEX 6 - RATE OF PSYCHIATRIC BEDS ............................................... 37

Keywords: Menial health I Menial health services I Technical cooperation I Western Pacific I Philippines

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SUMMARY

The objectives of the meeting were as follows: (1) to review the regional mental health profile;

(2) to review the progress of regional and selected national mental health programmes and to discuss ways to improve them; (3) to study ways of promoting cooperation among countries in the Region and between the Global Coordinating Group and major international and regional nongovernmental organizations working in the fields of mental and psychosocial health; (4) to advise the Regional Director on priorities for collaboration with Member States in mental health programmes. The fifth meeting of the Regional Coordinating Group on the Mental Health Programme was held at the World Health Organization (WHO) Regional Office for the Western Pacific from 13 to 16 June 1995. It was attended by 12 temporary advisers from 10 countries in the Region and observers from the World Federation for Mental Health and the World Association for Psychosocial Rehabilitation. Two short-term consultants collaborated in the preparation and conducting of the meeting and the Medical Officer, Division of Mental Health, WHO Headquarters, participated as a member of the Secretariat and gave the benefit of his global experience and views. The group reviewed the progress of the mental health programme over the past five years and discussed the approach to mental health in the context of the Framework New horizons in health. A special emphasis was given to psychosocial rehabilitation and the role of nongovernmental organizations. The group made summary, overall, specific and country-specific recommendations in the context of the preparation for life, the protection of life and the quality of life in later years. The overall recommendations covered the following areas: (1) the participation of consumers and carers in all aspects of mental health;

(2) the respective roles of government and nongovernmental organizations in the provision of mental health services and the response to psychosocial stressors; (3) (4) (5) (6) the recognition of psychosocial and cultural aspects of mental health; strategies to improve legislation; the collection and dissemination of mental health infotmation; workforce development in mental health;

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(7) (8) (9)

the development of socioculturally relevant services; mental health research, particularly multicentre studies on priority areas; communication between mental health experts in the Region.

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1. INTRODUCTION

The fifth meeting of the Regional Coordinating Committee on the Mentai Health Programme was held at the World Health Organization (WHO) Regional Office for the Western Pacific (WPRO) in Manila from 13 to 16 June 1995. The first, second, third and fourth coordinating group meetings were held in 1979, 1983, 1987 and 1991, respectively, in accordance with the resolution adopted by the Regional Committee in 1978. The Meeting was attended by 12 temporary advisers from 10 countries in the Region and observers from the World Federation for Mental Health and the World Association for Psychosocial Rehabilitation. Dr Geoff Elvy, Australia, and Professor Helen Herrman, Australia, collaborated in the preparation and conducting of the meeting as short-term consultants. Dr 1. Bertolote, Medical Officer, Division of Mental Health, WHO Geneva, participated as a member of the Secretariat and gave the benefit of his global experience and views. The list of members, consultants, observers and secretariat is attached as Annex 1. The Regional Directur, Dr S.T. Han, gave the opening speech, attached as Annex 2. In the opening session, the Regional Director proposed the following nominations, which were accepted unanimously by the group: Chairman Vice-Chairperson Rapporteurs Professor M.P. Deva (Malaysia) Professor L. Ignacio (Philippines) Professor N. Shinfuku (Japan) Dr Anthony Williams (Australia)

The annotated agenda is attached as Annex 3 and the list of background documents is attached as Annex 4. The objectives of the meeting were as follows: ( 1) to review the regional mental health profile;

(2) to review the progress of regional and selected national mental health programmes and to discuss ways to improve them; to study ways of promoting cooperation among countries in the Region and (3) between the Global Coordinating Group and major international and regional nongovernmental organizations working in the fields of mental and psychosocial health; (4) to advise the Regional Director on priorities for collaboration with Member States in mental health programmes.

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2.

PROCEEDINGS

2.1 2. 1.1

WHO mental health proirammes Global mental health programme in 1990s

The WHO Division of the Mental Health Programme has a new structure since January 1995, made up of three units dealing respectively with mental health promotion, mental disorders control and neurosciences. In addition, an epidemiological and managerial support and human resources for mental health care and research are attached to the Director's Office. In collaboration with the WHO Regions, it has several focused areas for action. These are the promotion of mental health; promotion of human rights of people with mental disorders; psychosocial rehabilitation; and neurological disorders (particularly epilepsy). A task force has been established on the global improvement of mental health care and has developed a series of activities revolving around issues related to mental health legislation and mental health care. Dr Boutros Gbali, UN Secretary-General, launched this initiative in May 1995 under a programme entitled Mental Health Care to Low-income People (MHCLIP). Within headquarters, there has been a substantial increase in the collaboration with other units, including the Programme on Substance Abuse (PSA), the Health Protection and Promotion (HPP), and Family Health (FHE). 2.1.2 Regional mental health programme

The activities are categorized into four major financial sources: PSF (Psychosocial and behavioural factors in the promotion of health and human development), ADA (Prevention and control of alcohol and drug abuse), MND (Prevention and treatment of mental and neurological disorders) and APR (Accident prevention). The objectives of the regional mental health programmes are: 1) to help develop national mental health policy of Member States; 2) to help develop manpower in mental health programmes in the Region; and 3) to promote coordination of research among Member States. In the past five years, the establishment of community-based mental health programmes which are humane, cost-effective and socioculturallY relevant has been encouraged in the Region. In addition, various workshops and conferences at national and international levels were supported by WHO/wPRO in the field of mental health and temporary advisers and consultants were recruited to attend such meetings. Fellowships were granted to help develop manpower in mental health of member countries. In addition, multicentre research projects have also been conducted to promote mental health. WHO collaborating centres have played a key role in promoting research and training in mental health and neurosciences. 2.2 2.2. 1 Update of the review Survey of mental health programmes in the Western Pacific Region

In 1994 a survey was undertaken by questionnaire of all countries and areas in the Western Pacific Region. The survey covered general mental health programme information and sought quantitative data on mental health workforce development, mental health facilities and treatment, morbidity and mortality data. By May 1995, nineteen completed questionnaires had been received and data entered into a newly-developed regional mental health database in WPRO.

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Although there were limitations in the quality of data, useful infonnation was received on key issues. However, it was evident that statistics collected on mental health mortality and morbidity may not have been reliable unless the member country had conducted a more recent epidemiological study. In most cases, these data were not reported, as were the data on mental health budget and expenditures. It was also evident that in some cases the responses did not concur with data provided by regional coordinating group members at the time of the meeting. With increasing improvements in data collection methods, the survey was nevertheless an extremely useful exercise since it provided an empirical basis on which to monitor the progress on key issues over time. Although much more analysis can be conducted on current data, a comparison of hospital bed ratios with the necessary 1983 and 1990 survey figures is provided in Annex 5. The returned questionnaires reported useful infonnation on the number of psychiatric beds, the number of general hospital beds and qualitative data on mental health legislation for cross-country comparative purposes. Many countries were able to provide detailed infonnation on mental health expenditure, research, nongovernmental organizations, and workforce development. However, at the time of the meeting these data have not been fully analysed compared with previous survey figures. Generally, most countries reported a shortage of mental health staff, underdeveloped mental health facilities, educational and research organizations, and a continuous strong stigma against mentally ill patients. It also appears that in a few countries, mental health care is accorded a very low priority and in some instances there is no budgetary provision for mental health service delivery. However, the data acknowledged that there has been a significant overall improvement in the way many countries deliver mental health services, particularly in the following three areas: First, mental health legislation now exists in nearly all countries in the Region and most countries have been continuously amending legislation for improvements. Only Lao People's Democratic Republic, Macao and Marshall Islands did not report specific legislation. Second, the provision of accessible community-based psychosocial treatment is gradually being developed throughout the Region, and in the more developed countries this trend has also seen a reduction in the provision of institutional psychiatric services. Third, the awareness of the advantages of integrating mental health care into the primary health care services has grown. Data indicate that in some larger countries, the number of designated psychiatric beds has decreased, while the expenditure on community-based programmes has improved. Psxchiatrjc beds When comparing 1983, 1990 and 1994 data, the Republic of Korea is the only country which has shown a significant increase in the rate of psychiatric beds (Annex 6). In Australia and New Zealand, these rates have dropped significantly while in the remaining member countries the rates are relatively stable. It is notable that in Japan, the rate remains extremely high compared with other countries. The decrease in the rates in Australia and New Zealand is attributed to a deliberate policy of reducing institutional psychiatric care.

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Responsibility for mental health deyelQpment and service provision In all countries government authorities have the primary responsibility for mental health programmes, usually through delegating the supervision of programmes to national health or welfare organizations. The resources available for developing and implementing prograrrunes differ greatly in accordance with the priority governments give to mental health. With the exception of Hong Kong, Kiribati and Macao, all other countries reported varying degrees in the development of community-based mental health services. Recognized traditional healing services were reported in most Pacific island countries. Only three countries reported a profitmaking mental health private sector, and about half of the countries reported a well-developed voluntary sector. Budeet The Cook Islands and Kiribati reported that there was no national budget allocation for mental health as a component of the general health budget. As few countries possess adequate budgetary and expenditure information. valid comparisons and summary information are not made. Morbidity and mo~

In the 1994 survey. an attempt was made to capture morbidity and mortality rates under the ICD-lO classification. However. it was evident that few countries had access to or kept data on these classifications; until the quality of data can be improved valid comparisons on these data can probably not be made. Research structures Many countries were able to report on the availability of academic departments in psychiatry or allied health professions which were actively involved in mental health research, and it was clear that intercountry cooperation on this area has developed substantially over the last five years. Other data Although some countries provided good data in areas such as workforce development, mental health treatment and methodology, service delivery (including nongovernmental organizations). and the development of legislation, these countries were few in number and the data could not be analysed to capture a regional profile because of inadequate or missing data on a number of variables. 2.2.2 Discussion

Even given the constraints of data, it is clear from the 1994 survey that considerable progress has been made in the mental health programme for the Region with advances being made in mental health legislation, the development of community-based psychosocial rehabilitation, and in the organization of mental health services. It is clear that these positive trends are a result of national policy changes in member countries. However, it was noted that psychiatric bed numbers did not necessarily give a clear indication of the quality or accessibility of mental health services to the community.

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It was also noted that the 1994 survey, as in previous surveys, did not necessarily provide valid or reliable data from which to monitor progress on the regional mental health programme. In some instances, it may have been that questionnaires were completed by people with no access to data, while in others, significant epidemiological survey and other data were reported. Thus, future surveys should pay close attention to the methods of data collection and endeavour to improve the reliability of data provided.

Notwithstanding the constraints on data reliability and validity, there was a strong view that data from the previous year's survey should be entered onto a regional mental health database, along with other mental health data from consultants' reports, previous reviews of country profiles and research reports. Such data would play an important role in providing a valid database for comparative analysis of the development of mental health programmes in the Region, and for utilization by member countries. 2.3 2.3.1 National mental health PrQirammes· Eyaluation of the past five years Australia

Australia is in the third year of implementing its six-year National Mental Health Strategy. The strategy, a cooperative exercise involving national and state governments, consumers and other key interest groups, is comprehensive with aims ranging through enhancing human rights, improving treatment and a greater focus on prevention and promotion. Special funding has been provided by the national government over the period of the strategy to assist in service restructuring towards community-based services and away from excessive reliance on hospital and institutional in-patient care and to fund national projects which underpin structural reform. These include promoting positive community attitudes, legislative reforms, improved data collection, workforce development, research, national service standards, epidemiological studies, outcome measures and developing new approaches to funding to provide incentives for patterns of care consistent with the objectives of the strategy. Progress against the objectives of the strategy is being monitored and reported through annual reports. The second annual report published in June 1995, provides information on the first two years of the Strategy. It demonstrates a shift in resources away from in-patient to community-based services. Challenges for the future arise both from achieving more effective implementation of the strategy and from wider concerns including meeting unmet need, a greater focus on promotion and prevention and preventing youth suicide, and sustaining reforms in the longer term. 2.3.2 China Key elements in the Chinese mental health programme include: formulation of legislation for mental patients; research on psychosocial factors and mental health;

- training programmes on recognition and management of common psychological problems for general practitioners and primary health workers; - studies on the scientific evaluation of psychotherapy in Asia and in relation to cultural characteristics. treatment and prevention of substance abuse;

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- psychosocial rehabilitation of chronic mental patients; quality of life for the elderly; and

- the fire disaster in X.injin province (Klarmaii) which resulted in the death and injury of 200-3~ schoolchildren and severe stress and shock to children, parents, commumty and country. 2.3.3 Fiji

.M~nt~1 h.eal~h se,:,ices i~ Fiji are ?rga~ized centrally from.S~ Giles Hospital, a 190- bed psychlatnc I~stl~tlon sltuate~ In the capital City, Suva. It IS a Ministry of Health undertaking and the service IS free. Outside Suva, services are provided by the area medical officers, . physicians and district nurses on an outpatient basis. The readmisison rate since 1987 is about 71 % of all admissions per year. It is aimed to reduce this rate by 5 % per year to reach 50 % by 1998. A test project to meet this aim was implemented in 1994 by establishing a Community Psychiatric Nursing (CPN) Team in Suva but the project has been hampered by lack of availability of transport solely assigned to this project. In 1992, a Health Planning Unit was set up by the Ministry of Health; and a policy was formulated as follows: "mental illness will be recognized in Fiji as a disability required care and support with a major emphasis on community care and management. St Giles Hospital will cater for voluntary patients and act as a national referral and teaching centre" . The Ministry is committed to review of the Mental Treatment Act to reflect the expanded mental health services outlined in the Mental Health Policy; to allow for a change in the admission and discharge policy; to amend the role of the Board of Visitors to reflect the modern mental health services; to allow for the development of occupational therapy, social workers and counsellors pertaining to mental health services; to develop community psychiatry services in all the divisions; and to develop a psychiatry capacity in divisional hospitals. 2.3.4 Japan

The Mental Health Act enacted in 1988 contains two main points: respect for the human rights of mental patients; and the promotion of psychological rehabilitation services. In 1993, the Act was partially amended in order to promote rehabilitation services. In addition, the title was amended to the Mental Health and Social Welfare Act with the aim of improving mental health programmes. The Council for Health proposed immediate mental health measures in psychological rehabilitation, medical and psychiatric services, mental health emergencies and community mental health. 2.3.5 Malaysia

In the last five years, the mental health and psychiatric services in Malaysia have improved considerably through an increase in the numbers of psychiatrists of about 25 %. These psychiatrists are now deployed to most general hospitals, and a few district level hospitals, as well as the four mental hospitals. There are also new subspecialists in Child Psychiatry and Forensic Psychiatry working in the country. Undergraduate teaching in psychiatry has been revised to emphasize the teaching of psychiatry in primary care and medical and surgical settings.

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Due to changes in the deployment of new psychiatrists, more patients are seen in smaller general hospital psychiatric units than in the large mental hospitals. There is also greater emphasis on day treatment programmes and sheltered workshops for mental patients. Training of psychiatrists is now available in three centres, and training of occupational therapists and clinical psychologists is now available in the country. Training of general doctors in basic psychiatry is going on in many parts of the country to improve the care given to psychiatric patients in hospitals where there are no regular psychiatric clinics, or psychiatrists. The mental health laws are under revision to include admission of informal patients and setting up of private psychiatric hospitals. In the past five years the community mental health movements and community awareness of mental health illness have increased with greater media coverage on many issues including substance abuse, child abuse, HIV infection, depression and violence against women. There are over a dozen mental health associations and many counselling organizations . Problems and constraints relate to the physical structure and stigma associated with the restrictive environments of mental hospitals and units. There is also a shortage of subspecialists in psychiatry. The linkage of psychiatry to primary health care also needs more emphasis. The trend towards the setting up of nursing homes to cater for chronic mental patients in the community because families are not keen to care for them is a worrying one. The answer seems to lie in the wider availability of day rehabilitation services for the chronically mentally ill to enable families to care for them. 2.3.6 Papua New Guinea

The projected population of Papua New Guinea for 1994 was 4000000. The total number of all doctors in the country in 1994 was 796 including two specialist psychiatrists. The total number of trained psychiatric nurses in the same year was 45. The goal of the mental health programme is to develop the ability of the health services to recognize and care for the mental health needs of individuals, families and communities. There are several policy directions: (a) outpatient care, where possible. is preferable to in-patient care; (b) the care of patients does not end with their discharge from hospital but with their rehabilitation into society as full productive members of that society; and (c) diagnosis and treatment must take into account cultural factors. The Mental Disorders Treatment Ordinance No.9 of 1960 is outdated and urgently needs to be reviewed. Plans are under way to carry out a complete review of the existing mental health legislation. In the last five years the major trend in the Mental Health Services has been the training of mental health professionals and the future trainers. This training programme includes specialist psychiatrists, qualified psychiatric nurses. clinical psychologists and nurse-occupational therapists. PNG needs the assistance and support of WHO in these training programmes. The major constraint in the last five years (1991-1995) has been an acute shortage of all categories of mental health professionals, including psychiatrists, psychiatric nurses, clinical psychologists, psychiatric social workers and occupational therapists. The first citizen to qualify as a specialist psychiatrist was awarded the Master of Medicine degree in Psychiatry (UPNG) in November 1994. A second constraint is the lack of adequate time allocation for teaching psychiatry in the training programmes of all categories of health workers. There is also a lack of in-service training programmes in psychiatry for health workers.

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2.3.7

Philippines

Mental health programmes have been pursued by both government and nongovernmental organizations . The National Programme for Mental Health (NPMH) continues to pursue its activities in the decentralization of programmes and services and diffusion of capabilities. Decongestion of state mental hospitals and development of acute psychiatric units in general hospitals and community-based rehabilitation programmes is continuing and the appointment of mental health coordinators in all the regions of the country have facilitated this process. The NPMH has also facilitated the inclusion of psychosocial care in other government health programmes, such as disaster management, as well as at different levels of health care delivery. Two nongovernmental organizations have made a significant contribution to the development of mental health programmes in the country. The UP-PGH Psychiatrists Foundation Inc. (UPPFI) has pursued educational and research activities that have provided the basis for planning intervention in health and mental health care. Studies on mental health care in primary health care have been extended to health care programmes of the Department of Health. The Baseline Survey on Mental Disorders in a region of the country has generated results on the prevalence of the mental disorders necessary in planning relevant training and provision of services. UPPFI's psychosocial intervention programme during the recent disasters in the country has generated important information on mental health in the context of disaster. This has resulted in the publication of a book on psychosocial intervention in disaster management. The Philippine Mental Health Association (PMHA), a civic organization of community leaders concerned with mental health issues, has made a vital contribution through its public information and education programmes in mental health. It has created mental health awareness in at least a third of the population through these programmes. 2.3.8 Republic of Korea

Up to 1992, the mental health programme focused on increasing the numbers of psychiatric beds and mental health professionals. Since 1993, the need to consider the quality of mental health care has been gradually recognized by the Government. In 1994, the Ministry of Health and Social Welfare initiated a three-year research and development project which included the development of community-based mental health services. Unresolved problems still exist with regard to asylums, large mental hospitals, stigmatization of mentally ill patients and mental health-related laws. In the last two years, the motivation of mental health professionals with regard to community-based mental health and psychosocial rehabilitation for the mentally ill has markedly increased. Newly established nongovernmental organizations for the family, for dementia and for the psychosocial rehabilitation of the mentally disabled have begun to make valuable contributions to enhancing the cost-effectiveness and humanity of mental health services. 2.3.9 Viet Nam

With the establishment of the National Institute of Mental Health in 1991, many aspects of activities on Mental Health have been promoted. The foundation of the National Programme on Prevention and Control of Drug Abuse in 1993 has resulted in the development

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of the Primary Mental Health network in a large number of communes and districts throughout the ccuntry. Successful workshops were conducted on alcohol abuse (1994) and on drug abuse and human immunodeficiency virus (HIV) infection (1995). There has been fruitful cooperation with WHO on the Substance Abuse Programme and on the translation into Vietnamese and application of ICDlO (1992) and CIDI (1995). There has also been efficient joint cooperation with many French psychiatric institutions from 1992 up to the present. 2.4 2.4.1 Review of pro~ress on psychosocial aspects of health in selected Australia COUDtries

Australia is now a multicultural society with a significant non-English speaking population, and minority Aboriginal and Torres Strait Islander indigenous peoples. In the past the mental health services, under state control, were asylum-based. In the 19608, a major process of de-institutionalization occurred in the states with the concurrent development of general hospital psychiatric units, community-based services and a significant private sector. This process was, however, unevenly spread across Australia. In the last decade, the Government has, for the first time, developed a national mental health strategy following extensive consultation with key stakeholders in the mental health field. The philosophy of the plan is a comprehensive service with continuity of care of the least restrictive kind, which is culturally appropriate to the individual and his or her family. There is a biopsychosocial approach to training and services, and consumers are involved at all levels. Significant grants are being injected into the states services to achieve this. Currently, the national plan is being closely monitored, as services vary in its implementation. Special attention is being given to disadvantaged areas such as ethnic minority groups and rural and remote areas. 2.4.2 China According to a national survey, smoking rates are as follows: Male Female Total

% 1984 1993 61.01 69.50

% 7.04 10.75

% 33.88 39.05

The prevalence of alcohol-relatl'd mental disorders (alcohol abuse and dependence) are as follows: Sample size Male Female

% 1982 1993 38000 14383

% 0.037 7.75

%

Total % 0.0184 4.41

o 0.23

The prevalence of illicit drug (heroin and opium) use in five areas of high prevalence (Xian, Lanzhou, Anshun, Wenshan and Guanzhou) on average is l.08%, with the highest rate in Anshun, Guizhou province, l.60%, and the lowest rate in Xian, 0.69%. In China, HIV infections resulting from injecting drug use accounts for 70.8% of all AIDS cases. There are now more than 1000 recorded HIV infections, 14 of which have progressed to AIDS.

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A quality of life survey in 4000 families of different socioeconomic groups (workers, peasants, businessmen and intellectuals) has been undertaken by questionnaire on life status (physical, psychological and social status and living conditions) and satisfaction in these four aspects. A study of life events in the general popUlation, of children and aged people, college students, post-traumatic stress disorder, neuroses, psychosomatic diseases and suicide was conducted. Personal and family misfortune with vulnerable personality are the universal common psychosocial factors with impact on mental health. . Studies are proposed on the effects of traditional Chinese culture (Confucianism and Taoism) in coping with life stress, in behaviour modification and in moral education for improvement of psychosocial well-being in order to develop culture-specific cognitive psychotherapy. 2.4.3 Papua New Guinea

The National Health Plan for 1991-1995 defines a psychosocial factor as any factor which is accompanied by significant social change. Psychosocial factors have an impact on all parameters of health and are significant in the implementation and acceptance of all health care and promotional programmes. It is the declared policy of the Health Department that all health workers should be taught during their training the principles and skills of psychosocial counselling. To implement this policy, the Department of Health organized a series of counselling workshops followed by the publication of a handbook with the title, "Papua New Guinea Counselling Handbook and Manual for Health Workers", in October 1990. This handbook is now used for training more health workers and voluntary counsellors in preparation for an impending HIV / AIDS epidemic in the country.

Psychosocial counselling is practised in Papua New Guinea for the following health problems: alcohol abuse, drug abuse (especially cannabis abuse), HIV/acquired immunodeficiency syndrome (AIDS)/sexually transmitted diseases (STD) and civil war-related post-traumatic stress disorder due to the ongoing Bougainville crisis. There are a few facilities in the country for the psychosocial rehabilitation of both the mentally handicapped and physically handicapped. Most of the available facilities, such as sheltered workshops and occupational therapy, cater mainly for the physically handicapped, except Laloki Psychiatric Centre Rehabilitation Village which cares for the mentally handicapped only. There is a government appointed National Disablement Board, which is responsible for organizing the rehabilitation of all disabled persons. The Christian Churches operate throughout the country providing alcohol and drug abuse education and counselling, and HIV IAIDS/STD counselling for patients and their families. Rotary Club International is pioneering a programme called "Life Education" for the youth in Lae and the National Capital District. Alcoholics Anonymous (AA) is active in the psychosocial rehabilitation of persons with alcohol abuse problems in the National Capital District and Lae, the second largest city. Trained occupational therapists are needed to supervise these rehabilitation activities.

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2.5 2.5. I

New horizons in mental well-beine Introduction

. WH<?IWPRO .is giving new direction to the regional mental health programme as articulated m the regional document New horizons in health. New horizons in health was endorsed by the Regional Committee at its forty-fifth session in 1994. The document describes three groupings for focusing.activities. The first, Preparation/or life, emphasizes the child and w~t the young and family can do for themselves for healthy lifestyles, including mental well-bemg. In the second grouping, Protection 0/ life, practices that suppress and inhibit good heal~ thro~gh~ut life, such ~ ~Icohol ~d drug a~~se, are addressed. In the third group, Qua~lty o/lif.e In lat~r yea~s, It .IS recogmzed that It IS not enough just to live longer but that the qualIty of eXistence m addmg lIfe to years must be realized. In order to stimulate discussion and recommendations within these three groupings the following papers were presented. ' 2.5.2 Preparation for life: youth suicide prevention strategies

Suicidal behaviour among the youth should be considered as a cry for help and proper intervention should be started immediately. Suicide among the youth has been considered as an indicator of social stability. In order to prevent youth suicide, it is necessary to understand that suicide is a multifactoral phenomena relating to various biopsychosocial factors. The Centers for Disease Control, Atlanta, published a guide for youth suicide consisting of the following eight comprehensive strategies: school gatekeeper training, community gatekeeper training, general suicide education, screening programmes, peer support programmes, crisis centre and hotlines, means restriction, and intervention after suicide. There is still a strong stigma against speaking about suicide or asking for psychiatric help in Asian countries. If it is difficult to start the above-mentioned strategies on a full scale at present because of social constraints, at least high risk youth should be detected and offered psychological help. Much effort is still needed in order to develop effective suicide prevention programmes in Asia. 2.5.3 Protection for life: strategies for post-traumatic stress relief and psychosocial care

Studies and accounts of people who have been subjected to long civil war, repression and torture have revealed that the entire population experiences massive trauma. Extreme lack of food, water, shelter, health care, physical torture and brainwashing in such communities, where social institutions have broken down or have been abolished are among the psychosocial issues and concerns. Intervention strategies to address the need for psychosocial care cannot be effectively met by addressing the needs of individuals alone. Information was made available during the meeting on strategies to address the needs for psychosocial care of a population subjected to massive trauma including postgraduate and mental health education of qualified medical practitioners and the formation of a subcommittee on mental health at the Cambodian Ministry of Health. In Cambodia; there are no psychiatrists and psychiatric services at present and the need to address the clinical care of psychiatric patients is urgent. The severely mentally ill contribute to the prevalent social disorganization, which sometimes manifests as violence in the streets. Psychiatrists will also be expected to provide the professional leadership to address the current

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psychosocial issues in everyday life of these traumatized people and to receive referrals from other health and social welfare agencies working in the communities. It has been recommended to the subcommittee on mental health that simultaneous community-based programmes on mental health in primary health care and training programmes for health and community workers on psychiatric emergencies and family care programme for the chronic mentally ill are urgent. It is evident that multisectoral collaboration at national and local levels will be an effective psychosocial intervention strategy to address the urgent needs of the majority of the population traumatized by war. Experience with victims of natural disasters in the Philippines has resulted in development of framework for psychosocial intervention in disaster management covering psychosocial processing, education and information dissemination, training in psychosocial processing for facilitation and identification and management of psychiatric morbidity. 2.5.4 Protection for life: staff burnout syndrome

Staff burnout syndrome is a major problem in health services today. It is characterized by emotional exhaustion, disillusionment and withdrawal. It affects all types of health workers, at any level and is caused by a combination of factors related to the individual employee, the organizational environment and health services characteristics. At the level of the individual employee, stress is a major contributor to the burnout syndrome. Burnout is, to a great extent, preventable, through simple and affordable measures. These address individual stress management, through both individual and group interventions, and educational interventions at organizational level through job modification, supervisor development and organizational problem-solving. Guidelines on the primary prevention of staff burnout syndrome have been produced by WHO and are available upon request. 2.5.5 Quality of aging: dementia and mental well-being

WHO has defined quality of life as "a person's perception of his/her position in life, in the context of his/her goals, expectations, standards and concerns". The definition stresses the person's "perception" of his/her circumstances in several domains of experience, including both positive and negative dimensions. This definition has been used as the basis of a project to develop a WHO quality of life assessment instrument (WHOQOL). This work builds on the extensive work already available, panicularly in the English language, on quality of life assessment. However, WHOQOL is developed cross-culturally in nearly 20 field centres around the world, has equivalent versions developed in a range of languages and represents the views of practising health professionals and patients. It will be useful in vulnerable groups and in a variety of health care settings, and will have different forms for different uses. It will be applicable, for instance, to: those suffering from chronic illnesses such as epilepsy, cancer and diabetes; caregivers of the ill or disabled; those living in highly stressful settings such as institutions, camps or a state of homelessness; and those with problems communicating, as with severe mental illness or intellectual disability. WHOQOL will have uses in medical practice, research, audit and policy-making. A lOO-item field trial form of WHOQOL now exists.in 15 languages after pilot testing of a longer instrument. Different versions, including a shoner form, will be developed and a method and manuals now exist to develop different language versions and to develop a number of specific modules to use together with the core instrument, for example for the vulnerable groups mentioned above and children.

- 15 -

The assessment of quality of life will assume increasing importance in development of plans for health and social services and health promotion programmes for elderly people because, in this way, a component of health gain for this group can be measured. In a period of increasing "social disintegration" and increasing cultural diversity in many communities and despite economic growth, the needs of elderly care-givers, cultural minorities and elderly people needing care for disabilities and pain are relevant to mentally healthy aging. The care of persons with dementia includes institutional and family care; the need of family care-givers' for support also has to be recognized. 2.6 Cooperation and collaboration

WHOIWPRO has provided support to training and research programmes in China, Hong Kong, Japan and Philippines to support the development of national comprehensive programmes in mental health. In 1991 a workshop on reducing high suicide rates was conducted in Samoa, and WHO has collaborated with China in providing training and education on psychosocial aspects of health as part of medical education. Several multicentre research projects have been supported (Annex 8) with centres in Beijing, Chengdu, Hong Kong, Kuala Lumpur, Manila, Seoul, Shanghai, and Tokyo. These training and research programmes are aimed at ensuring that adequate attention is given to psychosocial needs in health care. 2.7 2.7.1 Non~oyernmental or~anizations

World Federation for Mental Health

The '.'.orld Federation for Mental Health is a multiprofessional, voluntary, international, nongovernmental organization of diverse individuals and associations. It includes consumers of mental health services, professionals of all categories and other volunteers. WFMH works through regional councils, topic-oriented committees and university-based collaborating centres. Its method of work is through advocacy and education for the general public, institutions, government agencies and the United Nations. Specific vehicles include conferences, world congresses and regional meetings. The international mental health agenda of the Federation aims to improve the quality of mental health services and the life circumstances of those who suffer from mental illness, distress, and disability; promote and protect the human rights of persons defined as mental ill; and prevent mental/emotional illness, distress, durability and less than optional function, both in the general population and in vulnerable groups at risk. For 1993-1995, the International Mental Health Agenda has focused on the mental health of refugees and other migrants, providing direct help and training in Cambodia, Croatia, Bosnia and Central America; and improving the quality of mental health services: The Federation first proclaimed World Mental Health Day in 1992. In 1995 following the Kobe earthquake the Federation distributed information on psychological assistance for earthquake victims. 2.7.2 World Association for Psychosocial Rehabilitation

The World Association for Psychosocial Rehabilitation was formed in 1986 in Vienne, France, after 16 years of negotiations and discussions among interested persons from all over the world. An estimated 50 million people suffering from chronic mental illnesses and many millions more living marginally with emotional problems need rehabilitation. This is

- 16 -

particularly true in the less developed regions of the world where rehabilitation services are very scarce. To this end, W APR with its 44 member international Board of Directors, have organized training institutes and conferences on psychosocial rehabilitation throughout the world including Africa, the Americas, China, Europe, India, Indonesia, Malaysia, and Philippines. WAPR has also held four World Conferences that are the focal point of discussions on the recent advances in the area of psychosocial rehabilitation. There are W APR national secretaries in 86 countries and regional vice-presidents in the six WHO regions who enhance national and regional activities of W APR. WAPR has nongovernmental organization status with WHO, United Nations, UNESCO, and ILO and relations with the European Commission and the African Rehabilitation Institute. Although it has limited funds, WAPR has cooperated with WHO, especially in the Western Pacific Region, in its efforts to spread expertise on psychosocial rehabilitation to needy areas of the world. The next World Congress on psychosocial rehabilitation will be held in Rotterdam in April 1996 and it is hoped that there will be a strong participation from the Western Pacific Region. 2.8 2.8.1 Specific topics Mental well-being following disasters

Professor N. Shinfuku, Professor in International Health and Epidemiology, KObe University Medical School, Kobe, Japan, presented his experiences of the Hanshu-Awaji earthquake and its psychological effects. He discussed a series of psychological problems that were manifest after the earthquake and stressed the need for psychological care for victims. He stressed the importance of mobilizing volunteers and lay health workers since there had been few psychiatric specialists. Professor Ignacio, Philippines, echoed the need for training of general health workers for bereavement work for victims of disaster. She drew attention to the book "From Victims to Survivors" which describes the experiences of Philippine mental health workers following the Baguio City earthquake and Mount Pinatubo volcanic eruption. Profession Shen, Beijing, discussed the experience of similar relief activities during the catastrophic explosion in Shenyang Province. 2.8.2 Interventions for alcohol problems in primary care

Alcohol and drug misuse cause a number of mental and physical problems, and impose a major burden on the economies of many countries. In the Western Pacific Region per capita alcohol consumption is increasing rapidly in most countries, with corresponding rises in alcohol-related problems. In Australia for instance, approximately 6500 deaths are attributed to alcohol annually and the economic cost from alcohol misuse amounts to US$ 4.5 billion. Although there are no adequate data, it is likely that this experience is paralleled or exceeded in many countries in Asia and the Pacific, where alcohol consumption had been traditionally high in selected populations, and where alcohol is now replacing traditional indigenous substances. This has created a host of problems for which many countries lack appropriate laws and the economic capacity to respond adequately. World-wide, the response to alcohol problems is being influenced by new two major policy directions. The first emphasizes prevention and early detection rather than treatment of persons with late stage problems. The second identifies primary care as the most important setting for intervention rather than specialist services.

- 17 -

The emphasis on prevention is imponant because by the time persons with alcohol problems seek treatmen~. dependence is usually well established. and the prognosis at this stage IS not good. The effectiveness of treatments such as residential rehabilitation. therapeutic communities and outpatient counselling has been called into question. Generally. the longer an individual remains in rehabilitation the better the prognosis but only a small number of dependent individuals can be persuaded to enter such a programme. In developing countries. inpatient care can absorb a disproportionate part of the health budget and. given that they attract only a small number of patients. are thus oiten considered poor value for money. Another reason why prevention is important is because the larger proportion of persons with alcohol problems in a community. will have hazardous or harmful use but will not be dependent. Such individuals rarely seek treatment. and a preventive or early intervention approach is more realistic than attempting to provide individualized treatment. This shift is also reflected in the more general reorientation of achieving health outcomes at a general population level. where health promotion and disease prevention are expected to achieve significant gains. There are several reasons why primary care services potentially have a key role to play in a population-based response to substance abuse problems. Accessibility and ayailability: In many countries primary care givers represent the most accessible point of contact with the health system. with up to 80% of patients seeking the services of a primary care worker annually. Usually there is little waiting time compared with specialist services which allows the patient to approach the primary health worker at times of crisis when the intervention for alcohol problems may be particularly effective. patient expectations and lack of stiima: Surveys indicate that patients are comfonable raising questions about substance use with their primary care worker and consider it to be the responsibility of the health worker to give advice about drinking. No stigma is attached to a primary care consultation whereas there may be with visiting a specialist substance abuse service. A whole person perspective and continuity of care· As alcohol problems are neither solely medical nor solely social concerns. the primary care worker is well placed to offer an intervention which addresses a range of influences that may be impinging on the individual. dealing with the whole person and enlisting the support of family. friends and a wide variety of other health workers. At present, the potential for prevention is greater than the actuality. Primary care workers have little training in this area and traditionally have not offered intervention services for substance abuse problems. Early intervention aims to prevent the development of dependence and other forms of harm from hazardous and harmful alcohol use. It combines the systematic detection of persons with alcohol problems and brief therapy. which is typically offered at the first point of contact. This approach was endorsed by a WHO Expert Committee in 1980 and three collaborative studies involving many developed and developing countries worldwide have been undertaken since then. In the first study. a simple screening instrument. the Alcohol Use Disorders Inventory Test (AUDIT), was developed. AUDIT is a self-administered questionnaire with three questions on alcohol intake. three on alcohol dependence. and four on complication of drinking. Responses to each question are scored from 0 to 4 giving a range of scores from 0 to 40, with a cut-off point of 8 to identify hazardous or harmful drinking. Studies indicate that AUDIT can detect 92% of persons drinking at hazardous and harmful levels (specificity 94%). Many other studies of the use of the AUDIT have validated it as a useful and reliable screening instrument for alcohol problems.

- 18 -

In the second study, persons identified as drinking at hannful or hazardous levels by AUDIT were offered brief intervention in a randomized control trial in a range of primary care settings. In the study design, the brief interventions involved simple advice over five minutes, advice and counselling for 20 minutes, and advice and counselling over 2-3 sessions. Significant reductions in alcohol intake of 28 %, 29 % and 38 % respectively were obtained approximately one year later. This finding has panicular relevance to the primary care setting, as the fonns of intervention do not require specialist training and can be offered at minimal cost. By the early 1990s the essential elements of a successful early intervention strategy had been finalized, with a simple screening instrument and a five minute intervention shown to be effective. However, the history of health care is full of examples of interventions which have been shown to have positive outcomes but which have not been implemented. Thus, in the third study, social marketing strategies to promote early intervention in primary care were developed and trailed, again in many developing and developed countries around the world. These strategies involved direct mail, telephone marketing and personal marketing, with each strategy emphasizing the benefits of engaging in early intervention. Preliminary results from Australia indicate that about 80 % of 628 primary care workers were willing to use the screening and intervention strategy when approached using the telemarketing and personal marketing conditions. It is likely that the telemarketing approach will be the cheapest and hence the most cost effective. Also yet to be evaluated is the actual utilization of the screening and intervention package. In many countries primary care is in a process of redefining its role and health care workers are expressing a desire to take on a more planned and proactive role to emphasize a preventive approach to reducing substance abuse problems at the community and population level. The primary care intervention programmes described here, merit consideration of their application in the countries of the Western Pacific Region.

3. CONCLUSIONS AND RECOMMENDATIONS

3. I

Conclusions

The group was impressed by the steady development of community-based mental health services in the Region, panicularly in developing countries and the widening scope of action in psychosocial aspects of health. The group hoped that continuous suppon would be provided for training and research in mental health at regional and national levels. It was concluded that, in developing and strengthening mental health programmes, countries should work towards improving the preparation for life, the protection of life and the quality of life in later years, as aniculated in the guiding principles of New horizons in health. Also, member countries should recognize the effectiveness and efficiency of managing mental, neurological and psychological problems, including the care of psychiatric emergencies and chronic mental disorders, in multidisciplinary primary health care settings, giving special consideration to the contributions of nongovernmental organizations and consumer groups. Finally, countries are encouraged to develop and strengthen accessible community-based psychosocial treatment and rehabilitation programmes for mental, neurological and psychosocial problems, and to improve the quality of essential inpatient services.

- 19-

3.2

Recommendations

(I) Member countries should adopt strategies to ensure meaningful participation of consumers and carers in all aspects of mental health. (2) Government and nongovernmental organizations should be involved in the provision of mental health services and the response to psychosocial stressors (e.g. poverty, unemployment, family breakdown, homelessness, migration and man-made and other disasters). (3) Countries and areas should acknowledge the importance of psychosocial and cultural aspects of health and adopt strategies to ensure their incorporation into all health care. (4) Countries and areas are urged to improve legislation and strategies in the spirit of Resolution A/RES/46/119 adopted by the United Nations General Assembly in December 1991 on the protection of the rights of those with mental disorders in society and the improvement of mental health care. (5) WHO should support the collection and dissemination of information on mental health.

(6) WHO should encourage workforce development in mental health and psychosocial aspects of health. (7) WHO should support the development of socioculturally relevant services.

(8) WHO should continue to promote mental health research, particularly multicentre studies in priority areas of concern. (9) WHO should support better communication between mental health experts in the Region.

- 21 -

ANNEX 1

LIST OF PARTICIPANTS

1. MEMBERS

Professor M. Parameshvara Deva Head Department of Psychological Medicine Faculty of Medicine University of Malaya 59100 Kyala Lumpyr Malaysia Professor Lourdes L. Ignacio Professor in Psychiatry Department of Psychiatry and Behavioural Medicine University of the Philippines Manila Dr Felix Y. Attah Johnson Associate Professor of Psychiatry Department of Clinical Sciences Faculty of Medicine University of Papua New Guinea PO Box 5623 Boroko Papua New Guinea Ms J. Lipscombe Assistant Secretary Mental Health Branch Department of Human Services and Health Commonwealth Government Canberra ACT 2601 Australia Professor M. Nishizono Professor and Chairman Department of Psychiatry Fukuoka University School of Medicine 7-45-1 Nanakuma. Jonan-ku Fukyoka 814-01 Japan

- 22-

AMex I

Professor Bou-Yong Rhi Chainnan and Professor Department of Neuropsychiatry Seoul National University Hospital Seoul 110-744 Republic of Korea Professor Shen Yucun Professor and Director Institute of Mental Health Beijing Medical University Beijin~ 100083 People's Republic of China Professor N. Shinfuku Professor International Health and Epidemiology International Center for Medical Research Kobe University School of Medicine 5-1 Kusunoki-cho, 7-chome Chuo-ku, Kobe 650 Japan Dr V.I. Singh Acting Consultant Psychiatrist St Giles Hospital PO Box 105

S1ria Fiji Professor Nguyen Viet Director National Institute of Mental Health Bach Mai Hospital

Hano.i Viet Nam Dr Anthony T. Williams Director New South Wales Institute of Psychiatry 5 Fleet Street North Parramatta, NSW 2161 Australia

- 23 -

Annell

Professor Derson Young Mental Health Institute Hunan Medical University 156 # Remin Road CbanKsba, Hunan 410011 China

2.

CONSULTANTS

Dr Geoffrey Elvy 27 Meredith Circuit Kambah Canberra ACT 2902 Australia Professor Helen Herrman Professor and Director of Psychiatry University of Melbourne Department of Psychiatry St Vincent's Hospital Melbourne Australia

3.

OBSERVERS

WORLD FEDERATION FOR MENTAL HEALTH

Mrs Regina G. de Jesus (Designated representative by WFMH) National Executive Director Philippine Mental Health Association Quezon CitY

WORLD ASSOCIATION FOR PSYCHOSOCIAL REHABILITATION

Professor M.P. Deva President-elect World Association for Psychosocial Rehabilitation . University of Malaya Kuala Lumpur

- 24-

Annex 1

UNIVERSITY OF THE PHILIPPINES

Dr Cornelio Banaag Chainnan. Departtnent of Psychiatry and Behavioural Medicine University of the Philippines ManHa

4. SECRETARIAT

Dr Y. Takahashi (Operational Officer) Acting Regional Adviser in Mental Health and Drug Dependence WHO Western Pacific Regional Office Manila Dr J. Bertolote Medical Officer Division of Mental Health WHO Headquarters Geneya

- 25 -

ANNEX 2

OPENING SPEECH OF THE REGIONAL DIRECTOR Fifth Regional Coordinating Committee Meeting On The Mental Health Programme, 13-16 June 1995, ManDa

DISTINGUISHED PARTICIPANTS, COLLEAGUES, LADIES AND GENTLEMEN, It gives me great pleasure to say a few words and to welcome you here today to WHO's Regional Office for the Western Pacific, to take part in the Fifth Regional Coordinating Committee Meeting on Mental Health.

As you know, the Regional Coordinating Group meeting is the most important meeting be held in mental health at the regional level. These meetings have been held in 1979, 1983, 1987 and 1991, in accordance with a resolution adopted by the Regional Committee in 1978. Global Coordinating Group meetings have been held every two years since 1976, alternating between WHO headquarters and the six WHO Regions. The last such meeting was held in China in 1994. The meetings have played an invaluable role in developing mental health programmes in the Region. They have fostered coordination between the global, regional, and national mental health programmes. As a result, programmes have expanded, and increased attention has been given by Member States to important areas in mental health, such as: the development of community-based mental health services; the formulation of national mental health plans, policies and legislation; the promotion of psychosocial rehabilitation for the mentally disabled; and the initiation of mental health programmes for specific population groups such as the elderly, children and victims of disasters. These developments have broadened the scope of the delivery of mental health services to the benefit of the wider community. Since the last Coordinating Group meeting in 1991, WHO has conducted activities in mental health in most of the countries and areas in our Region. For instance, we have collaborated with Member States to provide several training and research projects on family training and patient education in China, the Lao People's Democratic Republic, the Philippines, and Viet Nam. New collaborating centres in mental health have been established in Japan and China and research activities have been supported in Malaysia and Hong Kong. In addition, national substance abuse prevention and treatment policies and programmes have been strengthened in China, Fiji and Papua New Guinea, and workshops have been held in China and Viet Nam. A joint meeting on demand reduction programmes for drug abuse in China, Hong Kong and Macao was held in Macao in 1993, leading to two substance abuse training courses in Hong Kong.

- 26-

Annex 2

With WHO support. mental health experts from member countries in the Region have collaborated actively in the development of regional mental health programmes and contributed to the area of technology transfer. In this meeting you will have the opportunity to review the progress of mental health programmes at the global. regional. and country levels. and to make recommendations for future directions. as there is still much to be done. As you are aware. well-developed community mental health services are able to reduce the number of chronically mentally-ill people through the prevention of relapse and social breakdown syndromes. However. there are still countries in our Region which are unable to provide adequate mental health care. When services do exist. they sometimes tend to be hospital-based and inhumane. Also. the strong community stigma attached to mental disorders and the low priority given to mental health by some governments. are common obstacles in many countries. We are fortunate that the need for psychosocial rehabilitation using a community-care model has been recognized by many mental health professionals in our Region. with the result that more countries have initiated community-based mental health services. This strategy needs replication and extension throughout the Region. as does the need for the training of community health workers in this area and the further development of nongovernmental organizations in psychosocial rehabilitation. In this regard it is pleasing to note that we have. in the Coordinating Group. world leaders in psychosocial rehabilitation. including the President Elect of the World Federation for Psychosocial Rehabilitation. Professor Deva. and Professor Rhi, President of the newly formed Korean Association for Psychosocial Rehabilitation. Accordingly, I would like to express my own interest in the promulgation of communitybased psychosocial rehabilitation in our Region. I believe this has a valuable application in developing countries, as it offers a way of extending and organizing primary care services for the mentally-disabled without the extensive reliance upon skilled professionals. I look forward, therefore. to the outcome of your deliberations on this topic. I am proud of the momentum gained in our regional mental health programme in the last fourteen years. This must be maintained and be made to accelerate in order to strengthen and extend the benefits already achieved. In the Western Pacific Region. we are endeavouring to give direction to these efforts through our regional document New horizons in health. This document, which was endorsed by the Regional Committee at its forty-fifth session in 1994. outlines my view of appropriate approaches in health for the next century.

- 27 -

Annex 2

In New horizons in health, three groupings are proposed for focusing activities. In the first, the preparation for life, the emphasis is on the child. It seeks to encourage what the young and the family can do for themselves, and stimulates them to seek support from the health services. In the second grouping, the protection of life, practices that suppress and inhibit good health throughout life, such as alcohol and drug abuse, are addressed. The quality of life in later years is the third group, in which we recognize that it is not enough just to live longer but that the quality of existence in adding life to years must be realized. Each of the three groupings in New horizons in health requires full support from mental health specialists to build on current mental health programmes and resources available in member countries, and to emphasize the measures individuals can take to protect and improve their mental and physical well-being. You know already that it is not easy to achieve these changes to develop more humane, holistic and culturally-relevant services and programmes in the Region. Given the scarcity of trained personnel and resources, it is especially important for WHO to give continued direction to the planning, development and implementation of mental health programmes and services. For this reason, I would like you to view your deliberations in the context of New horizons in health. I expect to receive your recommendations on the directions and priority needs for WHO's collaboration in the field of mental health for the coming years. These recommendations will be taken into careful consideration during the formulation of the regional and global mental health programme. Before I conclude, I would like to express my sincere thanks to Dr Geoff Elvy and Professor Helen Herrman from Australia for their assistance in the preparation of this meeting as WHO consultants. I again extend a warm welcome to all of you, and especially to our colleague from headquarters, Dr Bertolote, Division of Mental Health, whose global experience and perspective will be of great assistance to your work. I wish you a successful and productive meeting and an enjoyable stay in Manila.

- 29-

ANNEX 3

ANNOTATED AGENDA

1.

Opening ceremony 1.1 1.2 1.3 1.4 Opening speech by the Regional Director Self-introduction Election of Chairperson, Vice-Chairperson, Rapporteurs Administrative announcements

2.

Introduction of the meeting 2. 1 2.2 2.3 2.4 Adoption of the agenda Objectives of the meeting Global mental health programmes of WHO (Dr J. Bertolote) Regional mental health programmes of WHO (Dr Y. Takahashi)

3.

Update of the review of mental health/substance abuse problems in the Region 3.1 Update of regional mental health profiles (Dr G. Elvy).

4.

Evaluation of progress on national mental health programmes (past five years) 4.1 Evaluation of progress on national mental health programmes 4.1.1 4.1.2 4. 1.3 4.1.4 4.1.5 4.1.6 4.1. 7 4.1.8 4.1.9 4.2 Australia (Ms J. Lipscombe) China (Professor Shen Yucun) Fiji (Dr V.I. Singh) Japan (Professor M. Nishizono) Malaysia (Professor M.P. Deva) Papua New Guinea (Professor F. Y. Attah Johnson) Philippines (Dr L. Ignacio) Republic of Korea (Dr B. Y. Rhi) Viet Nam (Professor Nguyen Viet)

Summary discussions 4.2.1 4.2.2 4.2.3 Major trends Problems and constraints Future directions

- 30-

Annex 3

5.

Review of progress on psychosocial aspects of health in selected countries 5.1 5.2 Introduction (Dr J. Bertolote and Dr Y. Takahashi) Presentations 5.2.1 5.2.2 5.2.3 5.2.4 5.2.5 5.2.6 5.3 Australia (Dr A. T. Williams) China (Professor DersonYoung) Fiji (Dr V.I.Singh) Japan (Professor M. Nishizono) Papua New Guinea (Professor F. Y. Attah Johnson) Others

Summary discussions

6.

New horizons in mental well-being 6.1 6.2 Introduction (Dr G.Elvy) Preparation for life Youth suicide prevention strategies (Dr Y. Takahashi) 6.3 Protection for life Strategies for post-traumatic stress relief and psychosocial care (Professor L.Ignacio) 6.4 Quality of aging Dementia and mental well-being (Professor H. Herrman) 6.5 Summary discussions

7.

Cooperation and collaboration 7. 1 7.2 7.3 7.4 7.5 7.6 Intercountry training programme (Dr J. Bertolote and Dr G. Elvy) Multicentre research (Dr Bertolote, Dr Y.Takahashi, Professor Shen Yucun and Professor B.Y. Rhi) World Federation for Mental Health World Association for Psychosocial Rehabilitation Others Summary discussions

- 31 -

Annex 3

8.

Specific topics 8.1 8.2 8.3 8.4 Mental well-being following disasters (Professor N. Shinfuku) Interventions for alcohol problems in primary care (Dr G. Elvy) Syndromic treatment of mental disorders in primary care settings (Dr P. Lowry) Others

9.

Recommendations 9.1 9.2 Preparation of draft recommendations Adoption of draft recommendations

10.

Draft report 10. 1 Review of draft report 10.2 Adoption of draft report

11.

Closing ceremony 11.1 Closing speech by the Regional Director 11.2 Remark by temporary adviser 11.3 Closure by the Chairman

- 33 -

ANNEX 4

LIST OF DOCUMENTS

1.

INFORMATION BULLETINS WPR/MND/MNH(I)/9S/IB/I WPR/MND/MNH(I)/9S/IB/2

INFORMATION BULLETIN NO.1 INFORMATION BULLETIN NO.2 PROVISIONAL LIST OF MEMBERS, CONSULTANTS. AND SECRETARIAT

2.

PROVISIONAL AGENDA WPR/MND/MNH(I)/\?S.1

PROVISIONAL AGENDA PROVISIONAL ANNOTATED AGENDA

3.

AGENDA ITEM 2 WPR/MND/MNH(I )9S/INF.l1 WPR/MND/MNH( I )9S/INF.l2 GLOBAL MENTAL HEALTH PROGRAMMES OF WHO REGIONAL MENTAL HEALTH PROGRAMMES OF WHO

4.

AGENDA ITEM 3 WPR/MND/MNH( I )9S/INF ./3 UPDATE OF REGIONAL MENTAL HEALTH PROFILES

S.

AGENDA ITEM 4 WPR/MND/MNH( I )9S/INF.l4 EVALUATION OF PROGRESS ON NATIONAL MENTAL HEALTH PROGRAMMES - AUSTRALIA - CHINA - FIJI -JAPAN - MALAYSIA - PAPUA NEW GUINEA - PHILIPPINES - REPUBLIC OF KOREA - VIET NAM

WPR/MND/MNH(I)9S/INF.IS WPR/MND/MNH(I)9S/INF.l6 WPR/MND/MNH( I )9S/INF.l7 WPR/MND 1M NH (I )9S/INF ./8 WPR/MND/MNH( I )9S/INF.l9 WPR/MND/MNH(1 )9S/INF ./1 0 WPR/MND/MNH(1)9S/INF.111 WPR/MND/MNH( I )9S/INF .112

- 34-

Annex 4

6.

AGENDA ITEM 5 WPRlMND/MNH(1)95IINF.l13 :

WPR/MND/MNH(1)95IINF.l14 WPRlMND/MNH(1)95IINF ./15 WPR/MND/MNH(1)95IINF./16 WPR/MND/MNH(1)95/INF./17 WPR/MND/MNH( 1)95/INF .118 7. AGENDA ITEM 6 WPR/MND/MNH( 1)95/INF .119 : WPR/MND/MNH(l )951INF .120 : WPRlMND/MNH(I)95/INF.l21 :

REVIEW OF PROGRESS ON PSYCHOSOCIAL ASPECTS OF HEALTH IN SELECTED COUNTRIES -AUSTRALIA - CHINA - FUI -JAPAN - PAPUA NEW GUINEA

NEW HORIZONS IN MENTAL WELL-BEING PREPARATION FOR LIFE - YOUTH SUICIDE PREVENTION STRATEGIES - STRATEGIES FOR POST-TRAUMATIC STRESS RELIEF AND PSYCHOSOCIAL CARE -STAFF BURNOUT SYNDROME - QUALITY OF AGING DEMENTIA AND MENTAL WELLBEING

WPR/MND/MNH(I)95/INF.I** : WPR/MND/MNH(I)95/INF.l22 :

8.

AGENDA ITEM 7 WPR/MND/MNH(1)95/INF./23 : WPR/MND/MNH(1)95/INF.I** : WPR/MND/MNH(I)95/INF.l25 : WPR/MND/MNH(l )95/INF .126 : COOPERATION AND COLLABORATION RESEARCH AND TRAINING WORLD FEDERATION FOR MENTAL HEALTH WORLD ASSOCIATION FOR PSYCHOSOCIAL REHABILITATION

9.

AGENDA ITEM 8 WPR/MND/MNH(1)95/INF.l27 : WPR/MND/MNH(l )95/1NF .128 : WPR/MND/MNH(1)95/INF.l29: MENTAL WELL-BEING FOLLOWING DISASTERS INTERVENTIONS FOR ALCOHOL PROBLEMS IN PRIMARY CARE SYNDROMIC TREATMENT OF MENTAL DISORDERS IN PRIMARY CARE SETTING

- 35 -

ANNEX 5 MENTAL HEALTH PROFILE COMPARISON OF PSYCHIATRIC HOSPITAL BED RATIOS 198311990

ma apan

a aYSla ew Zealand n.a. Ilppmes n.a.

- 37 -

ANNEX 6

RATE OF PSYCHIATRIC BEDS Population (million) (1991)

Psychiatric beds

Psychiatric beds

BedsJ

100,000 (1994) 0 8,959 na

1

American Samoa Australia . CambOdia , China Cook Islands French Polynesia Hong Kong Japan .

0.05 17.6 7.1 1,151 0.02 0.12 5.9 124 0.07 43.1 4.2 0.38 18 0.05 3.5 0.02 3.9 65.8

1 7,500 0

0.02 0.51 0.00 0.07 0.00 0.53 0.72 2.87

85,116

na 0 63 4226

na na na 355,334 0 12,241 na na

na O· na 15 32 6306 0 1539 8 212 na

Kiribati Korea Laos Macao Malaysia Marshalls New Zealand Palau Papua New Guine Philippines

0.28

om 0.08 0.35 0.00 0.44 0.40 0.05 0.10

4,100 na

2,790 na

208 6,836

- 38 -

Annex 6

RATE OF PSYCHIATRIC BEDS Singapore Solomons Tonga Western Samoa Viet Nam 2.9 0.4 0.1 0.16 67.7

na na na na 5,670

3,093 27

1.07 0.07 0.24 0.04 0.08 II

24 4

na

1.

Using latest available data, May, 1995 Beds are not counted as patients lay on the floor

2.