Third Regional Coordinating Group Meeting on the Mental Health Programme, Manila, Philippines, 16-20 February 1987 : report

(WP)MNH/ICP/MND/002

ENGLISH ONLY

REPORT THIRD REGIONAL COORDINATING GROUP MEETING ON THE MENTAL HEALTH PROGRAMME

Convened by the

REGIONAL OFFICE FOR THE WESTERN PACIFIC OF THE WORLD HEALTH ORGANIZATION Manila, 16-20 February 1987

Not for sale Printed and distributed by the Regional Office for the Western Pacific of the World Health Organization Manila, Philippines

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1'1 .s EP 19R7 July 1987

NOTE

The views expressed in this report are those of the members of the Regional Coordinating Group on the Mental Health Programme and do not necessarily reflect the policies of the Organization.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for the governments of Member States in the Region and for those who participated in the Third Regional Coordinating Group Meeting on the Mental Health Programme, held in Manila, Philippines, from 16 to 20 February 1987.

CONTENTS

1.

INTRODUCTION WHO'S MENTAL HEAL TH PROGR.AMME ••••••••••••••••••••••••••••• OVERVIEW, CURRENT SITUATION AND TRENDS •••••••••••••••••••• RECENT DEVELOPMENTS OF ACTIVITIES ••••••••••••••••••••••••• SPECIFIC TOPICS ••••••••••••••••••••••.••••••••••••••••.•••

1 2

2. 3. 4.

3 6

5.

8

5.1 5.2 5.3 5.4 5.5 5.6 6.

The betterment of mental health services ••••••••••••• Mental health legislation............................ Education and training in mental health •••••••••••••• Prevention of mental, neurological and psyc hosocial disorders ••••••••••••••••••••••••••••••• Information, education and communication (IEC) as a major component of mental health programme •••••• Problems of providing mental health services to isolated communities ..............................

8 8 10 12 13 13

PROTECTION AND PROMOTION OF MENTAL HEALTH IN THE EIGHTH GENERAL PROGRAMME OF WORK •••••••••••••••••••••••••• 6.1 Introduction .......... ..............................

15 15

6.2 6.3 6.4 6.5 7.

Mental health policy and programme promotion, coordination, evaluation and support ••••••••••••••••• Psychosocial factors in the promotion of health and human deve lopment ................................

15 17

Prevention and control of problems related to drugs and alcohol •••••••••••••••••••••••••••••••••••• Prevention and treatment of mental and neurological disorders ...............................

18 20

CONCLUSIONS AND RECOMMENDATIONS ANNEX 1 - OPENING SPEECH OF THE REGIONAL DIRECTOR ANNEX 2 - LIST OF MEMBERS, CONSULTANTS, OBSERVER AND SECRETARIAT ••••••••••••••••••••••••••••••••• ANNEX 3 - TERMS OF REFERENCE •••••••••••••••••••••••••••••• ANNEX 4 - AGENDA •••••••••..••••••••••••••••••••••••••••••• ANNEX 5 - LIST OF DOCUMENTS ••••••••••••••••••••••••••••••• ANNEX 6 - PROTECTION AND PROMOTION OF MENTAL HEALTH REVIEW AND EVALUATION OF RECENT DEVELOPMENTS PART I AND PART I I ••••••••••••••.•.•.•••••••••.•

21 27

29 33/34

35/36 37

39

ANNEX 7 - SUMMARY OF COUNTRY/AREA PROFILES ••••••••••••••••

49

INTRODUCTION

The third 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 in Manila from 16 to 20 February 1987. The meeting of the Regional Coordinating Group, which was established in response to resolution WPR/RC31.R12, is the most important activity in the mental health programme at the regional level as the Group recommends to the Regional Director future directions and priorities for WHO's technical cooperation. The first meeting of the Regional Coordinating Group in April 1979 and the second in 1983 both made invaluable contributions to the further development of mental health programmes in the Region and in the promotion of coordination between programmes at global, regional and national levels. Opening the meeting, Dr Hiroshi Nakajima, Regional Director, welcomed the leading experts in mental health and public health as well as the senior health administrators in the Region concerned with this important programme area. He expressed his particular concern with the need to upgrade mental health services in the Region within the framework of the Regional COmmittee resolution on mental health, adopted at its thirty-sixth session in September 1985. The opening speech of the Regional Director is attached as Annex 1. The meeting was attended by sixteen members from twelve countries or areas and one observer from a nongovernmental organization. Dr Pierre Bailly-Salin, France, and Dr Masahisa Nishizono, Japan, assisted in the preparation and conduct of the meeting as short-term consultants. Dr Norman Sartorius, Director, Division of Mental Health, WHO/Headquarters, 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 2. In the opening session, the Regional Director proposed the following nominations, which were accepted unanimously by the Group: Chairman: Vice-Chairman: Rapporteurs: Dr Eng-Seong Tan (Australia) Dr Estefania Aldaba-Lim (Philippines) Dr Basil James (New Zealand) Dr Donna Kippax (Fiji).

The terms of reference as well as the agenda of the meeting are attached as Annex 3 and 4 respectively. The list of background documents is attached as Annex 5.

- 2 -

2.

WHO'S MENTAL HEALTH PROGRAMME

WHO's programme on the protection and promotion of mental health has three main components dealing with: (i) psychosocial factors in the promotion of health and human development, (ii) prevention and control of alcohol and drug dependence, and (iii) prevention and treatment of mental and neurological disorders. Each of these components consists of a number of activities which are being carried out according to a medium-term programme. The medium-term mental health programme (MTP/MNH) currently being implemented covers the period of the WHO Seventh General Programme of Work (1984-1989). The programme reflects the regional programmes which compose it as well as specific tasks which are of global Significance (e.g. obligations under United Nations treaties and tasks which involve collaboration with several or all regions e.g. multicentre research aimed at the formulation of guidelines on mental health legislation). The activities of the programme can be grouped as follows: (i) (ii)

promotion of healthy psychosocial development; prevention of health impairment among groups at high psychosocial risk (e.g. the elderly, refugees, adolescents, etc.); development of methods to assess the psychosocial aspects of health care and to plan and evaluate relevant interventions; identification of untoward consequences of social change and their prevention; prevention and control of problems related to alcohol and drug abuse; treatment and management of drug and alcohol abuse problems; assessment, prevention and treatment of mental disorders; prevention and treatment of neurological disorders; disability prevention and rehabilitation; direct support to national policy and programme development.

(iii)

(iv)

(v)

(vi) (vii)

(viii) (ix) (x)

Activities composing the programme usually include such elements such as conceptualization, research aimed at technology development and the application of techniques shown to be useful.

- 3 -

The programme relies on multisectoral planning and implementation. To facilitate this, national coordinating groups composed of representatives of different sectors have been promoted and established in various countries. At regional level, coordinating groups are convened at regular intervals to review developments, agree on action and recommend measures to the Regional Director. The global coordinating group comprises the chairmen of the regional groups as well as the programmes' senior staff and consultants. It decides on the manner of implementation of the global programme and evaluates its progress. In the conduct of its activities, WHO works closely with a network of collaborating centres (officially designated in some fifty countries) with experts drawn from a large number of countries, and with nongovernmental and intergovernmental institutions. It stimulates and coordinates research and training activities; collects, validates and disseminates information; participates in policy and programme formulation in the field of health; and serves as the platform for collaboration among countries in the field of health. A detailed description of the programme is provided in the document MNH/MTP 83.19 and in the background paper on the topic distributed to the participants.

3.

OVERVIEW, CURRENT SITUATION AND TRENDS

Mental health is a relative late-comer on the health services scene. This is among the reasons why in most countries it is given a relatively low priority in the claim on the national budget. Other reasons include lack of awareness of the relevance of mental health by political parties, and even by health planners and administrators. In countries with deficits in basic living standards, the control of infectious diseases and malnutrition demanded priority. However, even in the more affluent countries, mental health often fares badly. Such low priority in spite of the vast range of problems, and the past tendency to focus only on the biomedical aspects of health has been expensive not only in terms of human suffering but also in economic terms. It is now clear that the psychosocial aspect is of great importance in all health, and many of the most challenging problem of the day are primarily psychosocial both in origin and expression. The behaviour of individuals and communities generates the disorder associated with smoking and with alcohol and drug abuse; sexually transmitted diseases, especially AIDS at the present time also focus attention on the necessity for behavioural intervention. The impact upon families of factors such as migration, urbanization and marital disharmony can be seen daily to be engendering serious problems for the future. Yet each of these problems may also be seen as points of opportunity to protect and promote health.

- 4 -

An example of what can be achieved in attaining priority is seen in the steps taken in China since the Cultural Revolution. In July 1985, a Joint Coordinating Committee for Mental Health at national level was formed by the Central Government with representatives from the Ministries of Public Health, Public Security (Police), Civil Affairs, Education, Labour, Finance, etc., to implement preventive measures on mental health and to coordinate mental health programmes. Similarly in the Philippines, a recently established task force has been charged with the responsibility for formulating strategies for the upgrading of the mental health programme. The country profiles comprising Annex 7 give other examples of encouraging developments in the Region. Problems The Region is vast, populous and culturally diverse, and the range of problems reflects this diversity. Some issues such as alcohol and drug abuse seem almost universal; with increased life expectancy in many areas, problems associated with aging are also emphasized. Poverty, urbanization, with the development of slums and rapid socioeconomic change, also highlight the psychosocial needs of children, women and adolescents. A number of South-East Asian countries are recently emerging from the ravages of war and even the most basic remedial technologies are in short supply. Downturns in the economies, of even the more affluent countries have led to problems such as those associated with unemployment. Were problems of such magnitude to emerge in the form of physical illness, there is little doubt that a sense of emergency would be experienced and huge resources mobilized to counter them. Against this background the traditional psychiatric disorders such as the psychoses constitute a constant demand on mental health services in all countries. It is a staggering fact that, the known prevalence of such disorders would suggest that there are an estimated 13.5 million people suffering from psychotic illness alone in the Western Pacific Region. Main thrusts Given the magnitude of these problems and the variability in the available resources, both currently and historically, it is to be expected that perspectives throughout the Region will differ greatly. Countries recognise the need to deploy existing expertise in the mental health field in ways that will produce the greatest benefit. The Group recognized, for instance, that contributions to the processes of policy formulation and legislative enactment can emphasize the role of such policies and laws in creating a psychosocial climate highly relevant to mental health. Similarly the Group felt strongly that integration of a strong mental health component into the primary health care system was essential. With regard to the treatment of established mental illness, those countries with long established services are placing emphasis on deinstitutionalization and decentralization, while those without such historical traditions are faced with the task (or opportunity) of deciding optimum strategies for the future. It was the consensus of the Group that,

- 5 -

where hospitals are being planned as an integral part of a spectrum of service, great care should be taken to avoid the mistakes of the past and instead to employ imaginative and creative design to accommodate changing concepts of treatment of both long-and short-term patients. It was further emphasized that even the most ideally designed hospital should be seen as only one part of an overall strategy, the major emphasis of which is the system of primary health care. However, while in some areas, such as New South Wales in Australia, it has been demonstrated that hospitalization can be avoided for most patients by using mental health teams which operate on a 24-hour basis in the community supporting the primary care team, it is to be noted that such activities are expensive in personnel and, while it may lead to closure of some facilities, it is not yet convincingly demonstrated that the overall cost is less. Constraints Shortage of personnel was seen as a near-universal constraint. In some countries such shortage resulted more from unavailability of funds to employ them than from actual absence of suitable persons. For some the deficit was so great that they fell below the critical areas even for effective advocacy to improve their situation. Other commonly reported constraints, in addition to shortage of resources of various kinds, lie in negative community and professional attitudes, maldistribution of resources and the problems of great cultural diversity, language barriers, etc. Future directions All participants stressed the view that an appreciation at national level of the magnitude and scope of the mental health problems, and a commitment to address it energetically, would of the greatest benefit. Many of the problems, those of psychosocial origin in particular, require wide intersectoral collaboration, and the formation of national coordinating groups was seen as an essential target. A strong mental health component within the primary health care system was identified as another important reality at which to aim. Many of the contributions to health protection which can be made by the mental health programme are best performed in association with workers in other health fields. Similarly, an increase in the mental health component of the curricula of health professionals was viewed as an effective way of strengthening the primary health care system from the view point of mental health. As far as services for the mentally ill are concerned, it is now clear that, although some physical facilities are clearly required, walls do not make the service. An adequate workforce of appropriately trained professionals working in association with voluntary groups and the community as a whole represented the vision of the majority of the participating members.

- 6 -

4.

RECENT DEVELOPMENT OF ACTIVITIES

The Regional Adviser in Mental Health and Drug Dependence reported to tne Group the activities undertaken since the Second Meeting of the Regional Coordinating Group in October 1983. His reports are attached as Annex 6. In recent years, three resolutions have been adopted directly related to the development of the mental health programme as a whole in the Region, apart from the separate resolutions on drug dependence and alcohol-related problems. In 1978, a resolution on the Regional Coordinating Group on the Mental Health Programme was adopted, which urged Member States to formulate or review, as necessary, mental health policies within overall health policies, to consider establishing national coordinating mechanisms for mental health programmes, and to intensify collaboration with WHO. This resolution also requested the Regional Director to establish a coordinating group for the regional mental health programme in order to strengthen and facilitate collaboration with the global coordinating group as well as with Member States. Another resolution on the development of the regional mental health prugramme was adopted in 1980. In this resolution, the Regional Committee, considering that mental health and psychosocial development are of central importance to efforts to achieve health for all by the year 2000, requested the Regional Director to initiate or strengthen cooperation with countries in the accelerated development of mental health components within the general health services, using the primary health care approach, and also to provide training opportunities for the various categories of personnel involved in dealing with psychosocial problems. In September 1985, the thirty-sixth session of the Regional Committee adopted a resolution on mental health requesting the Regional Director to strengthen cooperation with countries in the development of national mental health programmes in specific areas of public health importance and to initiate, wherever possible, programmes dealing with issues of particular interest to countries in the Region, such as the promotion of child mental health, and prevention of mental retardation and senile dementia. Based on the resolutions, a series of working groups, training courses and workshops have been organized, various advisory services have been provided, and new research activities have been initiated related to mental health. The achievements of the regional mental health programme in recent years may be summarized as follows:

- 7 -

(1) Contribution to regional and national mental health policy formulation through the organization of regional and national meetings and provision of advisory services. Examples of these activities at regional level, which have shaped the basis at regional level, are the first and second meetings of the Regional Coordinating Group on the Mental Health Programme, held in Manila in 1979 and 1983, respectively; the Working Group on the Prevention and Control of Drug Dependence, in June/July 1983; the Working Group on Mental Retardation, in February 1985; the Working Group on Child Mental Health, in November 1985; and the Working Group on Drug-related Problems in Adolescents, in February 1986. (2) Development of manpower for programme implementation through the organization of regional/national training courses, seminars and workshops. A series of training courses, workshops and seminars have been organized to develop community-based mental health services in China, the Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam. In China, WHO has collaborated in the reorganization of the mental health services by providing consultant services and conducting workshops and seminars on such topics as psychiatric epidemiology (1980), psychiatric undergraduate education (1981), child mental health (1981), mental health in general health care (1982), psychosocial aspects of primary health care (1983), post-graduate training in mental health (1984) and mental health in the aged population (1985), and mental retardation (1986). (3) Promotion and coordination of research on problems of regional public health importance through the strengthening of WHO collaborating centres. WHO collaborating centres are instrumental in developing research and training in mental health and neurosciences. There are ten WHO collaborating centres in the field of mental health and neurosciences in the Western Pacific Region (five in China, two each in Australia and Japan, and one Malaysia). Most of these have been set up over the past five years. The main topics of research conducted by the collaborating centres have included: studies on the provision of mental health care; research on the mental health of vulnerable groups such as children; research on the epidemiology of affective disorders. In October 1984, a meeting of heads of WHO collaborating centres for mental health was convened in Tokyo to discuss ways of promoting coordination between the centres and to develop collaborative research activities and training.

- 8 -

5.

SPECIFIC TOPICS

5.1

Betterment of the mental health services

In the effort to improve the quality and quantity of the mental health services in most countries, a series of difficulties has been encountered. These include the problem of enlisting the support of politicians and decision-makers in the cause of mental health, the shortage of funding and the shortfall in the information of what other people in the same Region are doing in the same area of activity. While provision of treatment to people with mental illness is important, there is a broader need to encourage people to provide support of all forms to people with mental illness and an even broader need to promote mental health, such as promoting the activities of voluntary organizations engaged in the mental health field. The actual direction taken in mental health service development varies from one country/area to another and may even take opposite directions. While Hong Kong and the Republic of Korea are increasing the availability of psychiatric beds, Australia is reducing beds numbers. Singapore and Japan are developing hospital-based services, while Viet Nam and Papua New Guinea, with few psychiatric hospital beds, are developing community-based services. Cost reduction is often a motivation for the reduction of bed numbers. While the cost of keeping patients in hospitals may come down, the total cost of mental health service provision should not be reduced as the saving can be used to improve the quality of services and its coverage. It is essential to integrate the mental health service into the primary health care delivery system of the country. In some cases this integration may even extend upwards to include an integration of the whole mental health service into the general health services, as is occurring in some states in Australia in the process of decentralization and regionalization. While there is some advantage in doing this, it is still essential to maintain the identity of. and the advocacy for, the mental health services as such. There are special needs and differences in the perception of problems in each country and community. There is a need to take measures which will reduce problems related to alcohol abuse in New Zealand and Papua New Guinea, to control drug abuse in Malaysia. Singapore and the Philippines. to reduce the suicide rate in some sections of the population in Fiji and some of the island states of the South Pacific, and to cater to the problems of an aging population in China, Japan and Australia. 5.2 Mental health legislation

Legislation relevant to mental health can be considered under three headings, as follows:

- 9 -

(a)

Legislation contributing to the psychological well-being of the community as a whole, or the specific groups within it

The relevance of such enactments to community mental health is not always recognized, yet is contributes significantly to the psychological well-being of the communities it affects. Included in this group are laws relating to social issues such as unemployement or sickness benefits; to racial or other discrimination; to the needs of children or the elderly, to issues such as contraception, abortion, etc.; and to general social and community development. Legislation of this kind can serve to protect individuals from some of the secondary adverse effects of critical life events, such as redundancy or illness; ensure that basic human needs including developmental needs are met, and promote the dignity of the individual at all stages of life. The potential of such laws to achieve these objectives is enhanced by identifying the relevant mental health issues, and ensuring that consideration is given to them. (b) Legislation establishing mental health programmes and providing a requirement for adequate care and treatment of the mentally ill

Laws which set out a requirement to provide mental health services can be seen as public recognition of the need, and as a commitment to meet it. It is important that legislation relating to health and health services in general contains specific reference to mental health. Although the relevant provisions are usually stated in general terms, they can nevertheless serve as yardsticks by which achievements can be measured. Conversely, they can also be used to identify areas where the reality falls short of the legal undertaking, and in such cases are powerful levers for remedy. (c) Laws which govern involuntary admissions and detention for care and treatment of the mentally ill, and safeguard civil and human rights of the persons affected

Legislation of this type is currently the focus of attention worldwide by mental health professionals, civil rights groups and the community at large. The principles involved are sufficiently important to warrant prominence. Yet although they are traditionally entitled as Mental Health Acts or similar, and constitute a major element of the spectrum of laws relating to mental health and mental illness, their limitation with respect to the provision of adequate services must be recognized if the categories of legislative enactments described above are not also in place. The situation in the Western Pacific Region is varied, but the trends generally can be clearly seen to be in the direction of increased safeguards for civil rights of detained patients. Although it is to be expected that the nature and extent of such laws will differ from country to country according to existing social and cultural norms, nevertheless effective laws must address certain basic issues. Firstly, mental disorder for the purposes of the act should be defined in such a way that it not only reflects clinical reality, but also is sufficiently clear to serve as the criterion in which the lawfulness of an

- 10 -

individual's detention may be judged. Description of the characteristics of mental disorder should be supplemented by a quantitative element, indicating the degree and extent of illness which must be present to justify detention. A qualifying statement of "exclusion", listing characteristics of an individual such as religious or political beliefs, which would not by themselves justify detention, is increasingly seen as safeguarding against the abuses of psychiatry which are sometimes alleged. The requirement of formal evidence of the existing disorder in the form of a medical certificate would be expected. Although the manpower situation in some countries would render it difficult, such certificates given by two independent doctors is required in many existing statutes. Although the grounds for committal are medical, detention should be judged as lawful by a court. Although the duration of the detention is seldom specified, provision should be made for regular reviews of each patient's legal status, decisions on fitness by discharge being based on the principle of "least restrictive environment". Patients' rights should be specified and the right of the patient to know his or her rights, and the power to act upon them, is basic. There should also be the right to legal representation when requested. Review mechanisms should be specified, requiring regular clinical review, and the opportunity for review by an independent body should be provided at specified intervals. Attention should be given to the issue of consent to treatment. A generally accepted principle is that the impaired judgement implicit in the grounds for initial committal should not serve to prevent the patients disorder being treated. Safeguards exist if the committal process itself is thorough and open to scrutiny; if objections to treatment extend beyond an initial period of, say, one month, independent review should be required. The ability to manage one's affairs is not necessarily lost when a person is mentally disordered and should be the subject of separate consideration. In general, laws dealing with the detention of mentally disordered patients are satisfactory when they balance carefully the safeguarding of civil rights with the realities and practicalities of psychiatric illness and its treatment. Procedures should be carefully specified; loss of liberty and the right to self-determination should be for as brief a period as possible and should be subject to reasonable review and independent scrutiny. 5.3 Education and training in mental health

Education and training are integral parts of the health care d,elivery and educational systems of every country. Most countries of the world now face change at an unprecedented rate, often transcending national differences. Such changes effect the delivery of health care, as indeed mental health care. There is thus a need to reform the educational system to keep pace with such social changes.

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A number of factors accelerate social change in the community, and also the need to reform the educational system. These include changes in the pattern of diseases in the community, changes in the health care delivery system, the economics of health care, advances in technology, social changes within the community arising as a result of industrialization and urbanization, the development of the information sciences and computer technology, changes in the disease model used in psychiatry and, not least, a greater awareness of human rights in most communities. Health manpower policy of WHO At both the WHO Alma-Ata Conference in 1978 and the WHO/WPRO Conference in Tokyo in 1985, the need for reform in the development of health manpower was acknowledged in the declarations and recommendations of both these Conferences. Central to the strategies for reform is the principle of responsiveness; the education system must have the ability to respond to the changing needs in the community. Strategies for the reform of education and training in mental health Member States are encouraged to reform the educational programmes for the undergraduate medical student and the student nurse to include features such as the introduction of behavioural sciences in the preclinical stages of the curriculum, the introduction of community-oriented and problem-based learning, and the promotion of a broad general education. Member States are also encouraged to establish programmes of training and continuing education for specialist psychiatrists, non-psychiatric medical practitioners and all categories of allied professionals. Responsibility for the reform of the educational and training system for all categories of health personnel, including those in mental health, should rest: (1) at institutional level: with the universities and other educational institutions (2) at national level: with the government and nongovernmental organizations, and (3) at international level: with such organizations as the WHO, World Psychiatric Association (WPA) , World Federation of Mental Health (WFMH) , etc. Curriculum development A basic curriculum of training will have to be developed for each category of professional covering the three key areas of knowledge, skills and attitudes. The content of the curriculum will have to be appropriate to the social context in which the curriculum is used. These curricula will have to be translated into training manuals for each category of personnel at the various levels.

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In the development of these curricula, sufficient emphasis will have to be given to the psychosocial factors associated with the genesis, diagnosis and management of mental disorder, and the promotion of positive mental health. Developments in education and training in the Western Pacific Region In a recent survey of the profile of mental health services in the Western Pacific Region, it was evident that new training programmes for various categories of mental health professionals have been started in a number of countries in the last few years. Singapore recently started its own three-year training programme of training for psychiatrists. The Republic of Korea instituted its own system of certification of psychiatrists. In Australia and New Zealand, degree courses in nursing, including mental health nursing, have recently become available in tertiary educational institutions. 5.4. Prevention of mental, neurological and psychosocial disorders At least one half of mental, neurological and psychosocial seen in the world today are preventable by primary prevention. makers and the general public are often unaware of the existing possibilities and insufficient attention and investment in this area result in the continuous increase in magnitude and gravity problems. disorders Decision programme of these

In view of this the Director-General of WHO presented to the World Health Assembly a document listing measures which could be undertaken to prevent mental, neurological and psychosocial disorders. The document was also made available to the participants of this meeting. The paper first reviews the magnitude and nature of the problems; it then reviews measures which can be taken in the framework of health services listing measures which are of proven effectiveness, applicability and of a cost that is likely to be acceptable even in very poor countries. Next, measures which could be taken by other social sectors - e.g. education are listed. Two suggestions for research are given: first for studies of the distribution of problems and their changes over time; and second for studies on will assess the value of new preventive measures proposed for wide-scale application. The Annex to the document summarizes proposals, listing preventive measures grouped by problems which they prevent. The World Health Assembly reviewed the paper and noted its contents with satisfaction. A resolution was adopted which urges countries to implement the measures proposed and request the Regional Committees of WHO to discuss this topic so as to decide on measures to be taken at regional level. The World Health Assembly will review this matter again in 1989. The group noted the importance of these events and of the application of measures proposed by the Director-General.

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5.5

Information, education and communication (lEe) as a major component of the mental health programme

The mental health programme in many countries of the Region has been slowed down by lack of or insufficient awareness of the magnitude, and severity of the problem and of opportunities for its resolution. Multisectoral and interdisciplinary involvement, cooperation and coordination are still rare in national mental health programmes owing to insufficient information flow. Important proceedings and deliberations of expert meetings (e.g. psychosocial development of children), regional coordinating committee meetings, results of relevant studies and researches may not reach the professionals or those collaborat~ith national mental health programmes. The possibilities fo,: increased technical cooperation between countries via a network of WHO collaborating centres are not well known in the Region. However, there exist well-established collaborating centres in the Region which have demonstrated their usefulness and could be supportive of national efforts. Mental health has an 'image problem'. There is a need to change the attitude and perception of the public about mental health and mental illness. The community must be educated and the need for readily available and reliable information must be met. Mental health programmes have often operated in isolation from other health services and without collaboration with the most concerned social sectors such as social welfare, education and many voluntary organizations. Development of mental health in the context of primary health care today present serious constraints, mostly because there is no community orientation on mental health and a lack of valid information about mental health expressed in non-technical language for use by general health workers and others involved in health care. There is also an urgent need to enhance communication about mental health matters to the scientific community through national medical and scientific journals, presentations at professional meetings and so on. 5.6 Problems of providing mental health services to isolated communities

Many communities have adapted to living in geographically isolated situations. To do so, many of them have had to achieve a precarious adjustment to a fragile ecosystem. Their culture may have evolved into a unique form that requires specialized and imaginative planning when it comes to the provision of mental health services. The situation in a number of Pacific island areas illustrates these features. Many Pacific islanders live on small, isolated atolls or islands, widely scattered over hundreds or thousands of miles of ocean. Living on sandy fragments, sometimes a few acres only in size, these people have adjusted to survival in the face of water and nutritional shortages and repeated natural disasters. Nowadays, inter-island communication and with the larger islands that constitute their national headquarters, is relatively well-established. Despite their geographical isolation, they also have strong ties and affinities with large developed nations which have played a historical part in their regional development such as Australia, New Zealand, the United Kingdom, France, Germany and the United

- 14 -

States of America. For these reasons they are relatively easily integrated into the health programmes that are being developed in their own national centres. The greatest obstacle to receiving the benefits available to their fellow nationals are the logistics of providing services without disruptive relocation. Fiji, with a well developed community health care delivery system, may therefore provide a useful model of decentralized services for isolated communities of this type. Fiji is divided into four major divisions, each responsible for the administration of its own zones and areas. At the end of the line, each community, no matter how isolated, is provided with its own zone nurse, who is supervised by a district medical officer and district nurse(s). Radiotelephone, boat and air links maintain communication and emergency help. Decentralized mental health services can be developed by plugging into' the existing health care system in the following manner: (1) (2) The basic necessary unit is the health centre, linked to an already established health-care network. In-service training of health centre personnel, brought in centrally for intensive and refresher courses in mental health issues, includes the care of the acutely mentally ill. This can be given as a separate course or by appropriate contributions to other courses, such as reproductive health, child health, care of the elderly, and so on. Teaching materials are provided. Where appropriate, these should be in the local language, simple in form, easily referred to, and should provide step-by-step gUidelines. Health Centres provide a basic supply of psycho-active drugs, especially depot pipothiazine and fluphenazine. There is telephone or radiotelephone contact with central specialists for frequent consultations, together with airlift facilities for emergency cases. Regular mail liaison is provided with the central psychiatric facility, as well as support in taking over the long-term management of discharged patients.

(3)

(4) (5)

(6)

Essentially the same principles may be applied to the provision of services to isolated communities on large continental masses. Sharing of peripheral facilities and personnel with the general medical services, intensive training programmes and regular liaison with the central psychiatric facility will form the basis of the service. There may need to be an even greater emphasis on recruitment of mental health teams from the target population itself and on training such teams in teams of a specific cultural norms.

- 15 -

6.

PROTECTION AND PROMOTION OF MENTAL HEALTH IN THE EIGHTH GENERAL PROGRAMME OF WORK OF WHO

6.1

Introduction

The Eighth General Programme of Work covers the work of the Organization in the years 1990-1995. It gives broad gUidelines for the Organization's work, lists overall objectives and summary targets for each programme. The implementation of the General Programme of Work requires a further step in specification: the development of a medium-term programme. A medium-term programme statement (MTP) takes up the mandates for a specific programme (e.g. the resolutions of WHO governing bodies) and its objectives; it formulates targets (i.e. specific achievements expected by 1995) and approaches. The central chapter of the medium-term programme is that describing activities which will be undertaken. Further parts of the medium-term programme give a description of administrative managerial arrangements and of linkages with activities of other programmes. Medium-term programmes are of considerable managerial importance: they serve as the basis for the programme and budget proposals which are submitted to the World Health Assembly every two years. The regional medium-term mental health programmes encompass needs common to national mental health programmes; the global medium-term mental health programme, in turn, includes responses to needs common to regions; it is comparable to a mosaic of regional and global components, jointly providing a coherent aggregate of activities most likely to achieve the programme's objectives. The Group's deliberations and recommendations concerning the content of the medium-term mental health programme for the Western Pacific Region of WHO are summarized below. The activities necessary for programme development and coordination in general are listed first. This is followed by suggestions concerning the three programmes composing the major programme 3.10 Protection and promotion of mental health. In each instance the problems identified by the Group are listed first and activities proposed for their resolution next. Overall targets are given for each of the programme areas. 6.2 Mental health policy and programme promotion, coordination, evaluation and support Targets (1) To establish by 1995 national coordinating groups in at least 50% of the countries of the Region and to establish similar groups at subnational level where indicated.

-~

"

- 16 -

(2) (3)

To formulate by 1995 a comprehensive policy concerning mental health in at least 50% of the countries in the Region. By 1995, at least 50% of the countries will be regularly monitoring progress of their national mental health programmes and evaluating their effectiveness. Problems identified Activities (1) Collaborate with countries in the establishment of national multidisciplinary and multisectoral coordinating mental health groups. In this effort WHO can provide countries with relevant data, suggestions for strategic options for policy implementation and other material. Organization of regional and national colloquia for mental health leadership development. In preparation and follow-up of these colloquia, WHO should produce and disseminate relevant training materials.

(1)

There is lack of knowledge about the size and nature of mental health problems and about possibilities for their prevention and control.

(2)

Mental health is seen as having, and is given, low value priority in national health programmes.

(2)

(3)

There are few countries which have comprehensive policies concerning mental health.

(3)

Support to national workshops for the development of mental health programmes. WHO should compile experience and working materials from such workshops and make them available to the authority preparing them. Need for training on managerial skills. Organization of training in managerial skills necessary for the planning and evaluation of the programme. Development of indicators and evaluation procedures for mental health programmes

(4)

Collaboration between different social sectors in programme implementation is poor.

(4)

(5)

- 17 -

6.3

Psychosocial factors in the promotion of health and human development

Targets (1) By 1995, 25% of the countries will have implemented programmes using

psychosocial and behavioural technology in support of primary health care. (2) By 1995, information and knowledge about the psychosocial aspects of health and development will have been introduced into the training of health workers and planners in most countries of the Region and appropriate information will have been distributed to governments for the information of the general public. By 1995, research will have been initiated needed to (i) obtain better information about psychosocial factors affecting health care in the Region; and (ii) plan effective intervention. Problems identified (1) There is little or no use of knowledge about psychosocial aspects of health and health care in national health programmes. Thi's often leads to increased cost and decreased efficiency of such programmes. There are numerous situations in which psychosocial risks are a significant causative or contributory factor to morbidity. This includes situations such as homelessness, exposure to violence, migration, refugee status, unemployment, and rapid urbanization. (1) Activity Development of training materials on psychosocial aspects of health and dissemination of this materials to facilitate the introduction of relevant training of health workers. Support to national training activities

(3)

(2)

(2)

(3)

Special population groups are (3) under considerable psychosocial stress or exposed to excessive risks. These groups vary from country but often include children, the elderly adolescents and women. Insufficient attention is given to the predicament of such groups and to the prevention of health damage that may occur because of psychosocial factors. Some of these groups have recently increased in numbers (e.g. the elderly) and live under considerable hardship because of poverty, lack of understanding, disruption of social networks and inadequate legislation.

Development of strategies and techniques for intervention which will help to prevent or alleviate consequences of psychosocial risks. For the formulation of such strategies research may be necessary and will be supported, for eXample, on coping mechanisms, social network and support, etc. Training of staff and education of the public will necessarily complement this work.

- 18 -

(4)

In a number of countries health care is becoming increasingly dependent on medical technology and neglects the human dimension of the care process. This leads to poorer results of treatment and decreased satisfaction with care of the population. Service providers are often demoralized and perform poorly in this situation

(4)

Development of strategies and techniques necessary to stimulate and support programmes promoting healthy psychosocial development of children. This will involve collaboration with other social sectors (e.g. education).

(5)

Development of programmes dealing with psychosocial problems of the elderly. Development of programmes dealing with psychosocial risks in adolescence. Support to programmes launched at national and international levels to promote the health of women. The assessment and improvement of quality of life in patients with chronic illness. This may involve support to multicentre research and will require close collaboration with other medical disciplines (e.g. oncology).

(6)

(7)

(8)

6.4

Prevention and control of problems related to drugs and alcohol

Targets By 1995: (1) Policies and programmes for the prevention of alcohol and drug abuse will have been incorporated into the national health and where possible overall development planning in all countries of the Region. Alcohol and drug abuse problems will have been reduced in at least 25% of the affected countries and the current unfavourable trend will be arrested in most other countries.

(2)

- 19 -

(3)

An effective network of information exchange about alcohol-and drugrelated problems, their prevention and control will have been in operation in support of country programmes. Problems identified Activities Support to action aimed at increasing awareness about alcohol and drug abuserelated health problems at national level.

(1)

There is insufficient (1) awareness about health consequences and problems related to alcohol and drug abuse. This leads to a lack of commitment of authorities to the development of policies and to the implementation of programmes. Partly for the same reason the general public is insufficiently supportive of the health sector's efforts and does not participate in it. Comprehensive national (2) policies concerning drug and alcohol use and abuse and related problems seldom exist. As a result action at national level is not effective and the cost of programmes is high. Different social programmes compete rather than collaborate. Measures for the prevention (3) and treatment of health problems related to alcohol and drug abuse are insuffficiently well developed. There is not enough collaboration within and between countries active in this area.

(2)

Advocacy of the public health interest in decision making about alcohol and and drug issues.

(3)

Cooperation with countries in the development of national policies concerning alcohol and drug abuse. In this effort, it will be necessary to collect and analyze the experience of countries, prepare training materials and guidelines for the review of legislation, etc. Research and other action necessary to develop or adapt methods for the prevention and treatment of alcohol and drug abuse problems.

(4)

There is also little sharing (4) of data about the size and nature of problems and effects of measures undertaken. In part, this is because of lack of commonly agreed definitions and terms; in part because indicators of effectiveness of measures are poorly developed.

- 20 -

(5)

Problems arising because of the abuse of psychotropic drugs are not well recorded and insufficiently well known. This makes the fulfilment of WHO's responsibilities under United Nations treaties difficult and impedes service development.

(5)

Development of indicators of effectiveness of measures undertaken to prevent or control alcohol and drug problems and of a common data base.

(6)

Improvement and use of methods for the collection of data about psychotropic drug abuse.

6.5

Prevention and treatment of mental and neurological disorders

Targets By 1995: (1) At least 50% of the countries in the Region will have formulated specific national plans for dealing with mental and neurological disorders within the framework of their health care delivery system with specific targets for coverage, quality of care and reduction of disability. At least 50% of the countries in the Region will have put into operation comprehensive and specific plans for the prevention of mental and neurological disorders. Problems identified (1)

(2)

Activities Development of guidelines for the treatment of mental disorders of public health importance, with particular emphasis on the management of these disorders in general and primary health care (e.g. depression). These guidelines should also foresee appropriate techniques for the education of the public. Development of guidelines for the management of selected neurological disorders and in particular epilepsy and neurological problems in cerebrovascular disorder.

Specific techniques for the (1) treatment of a number of mentally and neurological disorders have been developed and tested; however these are insufficiently widely used. Plans for the application of these techniques are rarely explicit and funds for this are therefore not provided in many countries. Public attitudes to mental disorders are often negative and prevent active programme development. Mental retardation is one of (2) the very frequent causes of disability. Appropriate action with a broad involvement of different social sectors is not well coordinated, often because the technology for this work is not clearly specified.

(2)

- 21-

(3)

Many mental and neurological (3) disorders can be prevented at a low cost and with measures that are effective and acceptable to the population.

Development of guidelines for the management of mental retardation for health and other social sector workers (e.g. welfare and education staff) and collaboration with countries in the implementation of relevant measures. Collaboration with countries the wide application of measures for the prevention of mental and neurological disorders. Stimulation of and coordination of research, at national and regional level to obtain knowledge necessary for the implementation of programmes aimed at control of mental and neurological disorders. In this respect, studies of suicide behaviour (both longtitudinal and cross-cultural) deserve particular attention.

(4)

While much is known about mental and neurological disorders, their causation and management, there are significant gaps in knowledge about their prevention.

(4)

(5)

7.

CONCLUSIONS AND RECOMMENDATIONS

The Regional Coordinating Group reviewed the progress of the regional mental health programme and took note of recent developments in mental health programmes globally. It was impressed by the significant progress made since the second meeting of the Group. In a number of countries active mental health programmes have been developed in collaboration with the Organization. Intercountry activities dealing with a number of priority mental health problems have been initiated. These include workshops, support to the network of WHO collaborating centres, training courses and fellowships, the distribution of information and support to research. The Group took note of the recent decisions and resolutions of WHO governing bodies. These inc.luded resolutions of the World Health Assembly regarding the prevention of mental, neurological and psychosocial disorders (WHA39.25) and reduction of drug abuse (WHA39.12) and of the Regional Committee on mental health (WPR/RC36.R17) and alcohol and drug abuse (WPR/RC36.R7).

- 22 -

A series of working papers was presented to the Group on topics of particular interest. These dealt with mental health services, training in mental health, legislation for mental health programmes and the prevention of mental/neurological and psychosocial disorders. Having reviewed this material and after intensive discussion, the Group made recommendations about immediate action and about activities to be included in the medium-term mental health programme accompanying the Eighth General Programme of Work of the World Health Organization. (1) National coordinating groups have proved to be useful and effective in the development of national mental health programmes. The Group therefore recommends that the Regional Director should continue to support the establishment and functioning of national and subnational multi sectoral and interdisciplinary mental health coordinating groups. In this respect direct support to the organization of national workshops, provision of relevant information and guidelines and training in managerial processes for key national advisors may be particularly helpful. (2) Although a number of countries reported significant improvement of mental health care, the Group felt that the development of humane, socioculturally relevant, community-based and cost-effective mental health deserves continuing attention and support. The Group recommends that the Regional Director should undertake the necessary steps to (i) publish a description of the situation regarding care of the mentally ill in the countries of the Region, and (ii) on the basis of the analysis of this material and the experience of other countries, develop guidelines for the use of countries in the development of their mental health services. (3) National laws exert an important influence on mental health, and may serve also to ensure appropriate care and treatment for the mentally ill. The Group felt that three types of legislation deserve WHO's attention: legislation governing admission and treatment of the mentally ill, legislation governing the organization and provision of care to those ill and their families, and legislation dealing with other social issues directly relevant to mental health and development (e.g. provisions concerning adoption and divorce procedures). Countries in the Region need information in all three areas, and an active effort by WHO would be timely and useful. The Group recommends that as a first step, the Regional Director should obtain information about mental health legislation in Member States and publish it together with guidelines about issues to be considered in drafting new legislation or reviewing it. (4) Shortcomings of current systems of education and training in the field of mental health and other social sector workers continue to be a major constraint to programme development. Certain advances have however been made. In the light of this and in the light of newly emerging concerns, the Group recommends to the Regional Director to concentrate his .further efforts on supporting countries in: (i) the development of curricula and manuals for the training of general health workers in mental health;

- 23 -

(ii)

surveys on training about psychosocial factors and health in medical schools with a view to developing appropriate support; training on ways to prevent disability from mental and neurological disorders.

(iii)

(5) At least one half of mental, neurological and psychosocial disorders seen in the world today are preventable. Decision makers and the general public are often unaware of existing possibilities for amelioration. Insufficent attention and investment in this programme area result in a continuous increase in the magnitude and gravity of these problems. In view of the forthcoming discussion of the Regional Committee on the possibiities for the prevention of mental, neurological and psychosocial disorders, the Group recommends that the Regional Director should:

(i)

involve experts and institutions from the Region and elsewhere in the preparation of country-specific proposals and proposals for action at regional level as soon as possible; review measures already taken at national and regional levels; and include activities dealing with the prevention of the mental, neurological and psychosocial disorders of public health importance in the Organization's present Programme of Work and in the medium-term programme covering the period 1990-1995.

(ii) (iii)

(6) The effectiveness of mental health programmes in many countries/areas of the Region could be greatly increased if all those concerned were made better (and sooner) aware of the results of the work of the WHO mental health programme. The Group, therefore recommends that the Regional Director should develop strategies to enhance dissemination of information emanating from WHO about mental health matters to the governmental, nongovernmental and voluntary bodies, to the general public and to the scientific community. As a first step in this exploration, the Group recommends that a small task force of advisers should be entrusted with the development of specific options and that these be applied and evaluated in one or two countries of the Region interested in this matter (New Zealand and possibly one other country). (7) The provision of mental health services to geographically isolated populations is a problem facing many countries of the Region and, outside. The experience gained in tackling this problem by some countries in the Region (and elsewhere), the information on this experience is insuffiCiently well known or inaccessible.

- 24 -

The Group therefore recommends that the Regional Director should:

(i) (ii) (iii)

assemble and publish relevant country experience; produce guidelines which can be drawn from it; and undertake the necessary action to assess the needs of such populations in the countries of the Region.

(8) Problems related to alcohol and drug dependence are of serious concern to a number of countries in the Region. In view of this and the recent resolutions of the World Health Assembly (WHA36.12 and WHA39.14) and the Regional Committee (WPR/RC36.R7) urging the Organization and Member States to take action in this field without delay, the Group recommends that the Regional Director, in addition to current activities should: (i) (ii) mobilize research and training institutions in the Region to assist in the WHO programme; intensify support to training in the management of those problems at national level.

(9) The Group highly commends the success in the implementation of the activities recommended at the first and second meeting of the Regional Coordinating Group. The Group found that the Regional Coordinating Group is a most useful mechanism for the review and development of regional mental health programmes, for coordination between global, regional and national mental health programmes, and for the development of cooperation between countries. The Group therefore recommends to the Regional Director that the Regional Coordinating Group should be convened at regular intervals. (10) The detailed review of the situation in the countries, the guidance of the governing bodies of WHO and the material provided to the Group have permitted a consideration of possible activities for inclusion in the medium-term mental health programme covering the period 1990-1995. The Group has proposed specific targets for each of the programmes comprising programme 10 on protection and promotion of mental health and for the programme as a whole. Further, it has specified major problems which countries experience in their effort to develop mental health programmes and proposed activities for inclusion in the Organization's medium-term programme likely to be useful to Member States' efforts. These deal with: (i) policy and programme promotion development and evaluation (raising awareness about the size and nature of problems covered by the programme; establishment of national mental health coordinating groups; leadership training and development);

- 25/26 -

(ii)

psychosocial factors in the promotion of health and human development (development of strategies to prevent health damage in high risk situations e.g. urbanization and population groups, e.g. adolescents; development of techniques for the assessment and improvement of quality of life in chronic illnes; development of relevant training materials); prevention and control of alcohol- and drug-related problems (collaboration in national policy development concerning . these problems; development of prevention and treatment techniques; development of relevant data bases and indicators); prevention and treatment of mental and neurological disorders (development of guidelines for the prevention and treatment of mental and neurological disorders of public health importance; and for the prevention and management of mental retardation; stimulation and coordination of research).

(iii)

(iv)

The Group recommends that the Regional Director should include these proposals and the relevant portions of this report in the development of the medium-term mental health programme for the period 1990-1995.

- 27 -

ANNEX 1

OPENING SPEECH OF THE REGIONAL DIRECTOR TO THE THIRD REGIONAL COORDINATING GROUP MEETING ON THE MENTAL HEALTH PROGRAMME MANILA, 16-20 FEBRUARY 1987

Distinguished Participants, Dear Colleagues, Ladies and Gentlemen, It gives me great pleasure to say a few words at the opening of the Third Regional Coordinating Group Meeting on Mental Health. As you very well know, this Regional Coordinating Group Meeting is the most important meeting to be held in this field at the regional level particularly as the Group will recommend to me future directions and priorities for WHO's technical cooperation. Therefore, I am very happy to note that the meeting has gathered together leading experts in mental health and public health as well as the top level health administrators in the Region concerned with this important programme area. The first regional coordinating group meeting in April 1979 and the second one in October 1983 both made invaluable contributions to further developing mental health programmes in the Region and also to fostering coordination between the global, regional and national mental health programme. Since the second meeting in 1983, the regional mental health programme has expanded its activities and organized a series of working groups, workshops and training courses at both regional and national levels on various related subjects, provided a number of advisory services, and supported several research proposals in accordance with its recommendations. As a result, regional programme activities have been conducted in most of the countries or areas in the Region. Just to mention a few, WHO has provided technical cooperation in mental health to China, Malaysia, Lao People's Democratic Republic, Philippines, Papua New Guinea, Republic of Korea, Viet Nam and several Pacific island countries during 1985-1986. Experts from developed countries in the Region such as Australia, Japan and New Zealand have collaborated actively in the development of regional mental health programmes and contributed in the area of technology transfer. Thus, as a result, there has been marked progress in the past several years in the growth of mental health programmes at the regional and national levels. However, much remains to be done. I would like to express my particular concern with the need to upgrade mental health services in the Region within the framework of the Regional Committee resolution on mental health, adopted at its thirty-sixth session in September 1985.

- 28 -

Annex I

The resolution urged Member States, among others, to develop community based mental health services in the context of their national health programmes. Severe mental illnesses such as schizophrenia, depression, epilepsy and mental handicap pose a serious burden on the affected individual, his family and the community as these diseases tend to become chronic or recurrent in the absence of well-developed community based programmes in most countries or areas. WHO's collaboration with Member States should be directed towards the integration of mental health services in the general health services and community involvement, as opposed to institutional care. The new policy calls, among others, for changes in education and training for health professionals, changes in legislation related to mental health and, above all, changes in the attitude of the community toward mental illness. As you are aware, it is not easy to achieve these changes and to develop a more humane, culturally relevant and cost-effective mental health service in the Region. I look forward, therefore, with keen interest to receiving the outcome of your deliberations on these topics. I also 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. Your recommendations will be taken into serious consideration during the formulation of the regional and global mental health programmes. Before I conclude, let me express my sincere thanks to Dr Masahisa Nishizono, from Japan and Dr Pierre Bailly-Salin, from France for their continuous support to the regional mental health programme and, in particular, for their assistance in the organization of this meeting as WHO consultants. I would also like to extend my warm welcome to our colleague from Headquarters, Dr Norman Sartorius, Director, Division of Mental Health, whose collaboration in giving us the benefit of his global experience and views will be of great assistance to our work. I wish you all an enjoyable stay in Manila.

- 29 -

ANNEX 2

LIST OF MEMBERS, CONSULTANTS, OBSERVER 1. MEMBERS

AND SECRETARIAT

Dr Basil James Director Division of Mental Health Department of Health P.O. Box 5013 Wellington New Zealand Dr Donna Kippax Senior Clinical Tutor in Psychiatry Fiji School of Medicine Tamavua c/o Private Mail Bag Suva Fiji Dr Chung-Kyoon Lee Professor and Chairman Department of Psychiatry College of Medicine Seoul National University 28 Yeungundong, Chongroku Seoul 110 Republic of Korea Dr Ho Young Lee Professor and Chairman Department of Psychiatry Yonsei University College of Medicine C.P.O. Box 8044 Seoul Republic of Korea Dr Estefania Aldaba-Lim Immediate Past President World Federation of Mental Health 9th Floor, Apt. 9H Legaspi Towers 500 Corner Roxas Blvd. and Vito Cruz Manila Philippines Dr Wai Hoi Lo Consultant Psychiatrist Hong Kong Psychiatric Centre David Trench Rehabilitation Centre 9B Bonham Road Hong Kong

- 30 -

Annex 2 Dr Leonida Mariano Medical Center Chief National Center for Mental Health Mandaluyong Metro Manila Philippines Dr Shiroe Miura* Professor and Chairman Department of Psychiatry Tokyo Medical School Shinjuku 6-1-1 Shinjuku-ku Tokyo Japan Dr Yasuaki Nakagawa National Institute of Mental Health 1-7-3 Koonodai, Ichikawa City Chiba-ken Japan Dr Kerry Josef Pataki-Schweizer Associate Professor Behavioural Science and Medical Anthropology Department of Community Medicine University of Papua New Guinea P.O. Box 5623 Boroko Papua New Guinea Dr Peng Ruicong Vice President Beijing Medical College Beijing China Dr Antonio Perlas Chief Department of Psychiatry The Medical City General Hospital Mandaluyong Metro Manila Philippines Dr Pham Song Vice Minister of Health 138 A. Giang Vo Hanoi Socialist Republic of Viet Nam

*Unable to attend.

- 31 -

Annex 2

Dr Eng Seong Tan Professorial Associate The University of Melbourne Department of Psychiatry St Vincents Hospital Fitzroy, Victoria 3065 Australia Dr Teo Seng Hock Medical Director Woodbridge Hospital Yio Chu Kang Road Singapore 1954 Professor Tai-Hwang Woon Head Department of Psychological Medicine Faculty of Medicine University of Malaya 59100 Kuala Lumpur Malaysia Professor Yan He-qin Director Shanghai Mental Health Center 600 Wan Ping Nan Road Shanghai 200030 China

2.

CONSULTANTS

Dr Pierre Bailly-Salin Medical Director Mental Health Centre Seventh District of Paris 39, Rue de Varenne 75007 Paris France Dr Masahisa Nishizono Professor and Chairman Department of Psychiatry Fukuoka Medical School Nanakuma, 7-45-1, Jonan-ku Fukuoka Japan

- 32 -

Annex 2

3.

OBSERVER

Dr Romualdo S. Anselmo World Psychiatric Association Suite 226, Mezzanine Floor Santo Tomas University Hospital Manila Philippines

4.

SECRETARIAT

Dr Norman Sartorius Director Division of Mental Health World Health Organization Geneva Switzerland Dr Naotaka Shinfuku (Operational Officer) Regional Adviser in Mental Health and Drug Dependence WHO Regional Office for the Western Pacific Manila Philippines

- 33/34 -

ANNEX 3

TERMS OF REFERENCE

The terms of reference of the Third Coordinating Group were as follows: (1) to update the review of mental health problems, mental health services, training and research in countries of the Western Pacific Region; to discuss strategies for developing effective programmes in dealing with the psychosocial aspects of health, alcohol and drug abuse, and mental and neurological disorders; to advise on the development of the regional medium-term programme on mental health of the Eighth General Programme of Work (1990-1995); to advise the Regional Director on the development of collaboration in mental health programmes at global, regional and country level, based on priority needs and areas for WHO technical cooperation in mental health.

(2)

(3)

(4)

- 35/36 -

ANNEX 4

AGENDA

1. 2. 3. 4. 5. 6. 7.

Opening ceremony Adoption of agenda Introduction of WHO mental health programme Country/area profile Review and evaluation of the recent developments Medium-term programme of the Eighth General Programme of Work on mental health Specific priority topics 7.1 7.2 7.3 7.4 Promotion of mental health services in the Western Pacific Region Mental health and legislation Education and training in mental health Other topics

8. 9. 10. 11.

Collaboration and cooperation in mental health Formulation of recommendations Review and adoption of the draft report Closing ceremony

- 37 -

ANNEX 5

LIST OF DOCUMENTS

1.

INFORMATION BULLETINS WPR/MND/IB/1 WPR/MND/IB/2 - INFORMATION BULLETIN NO. 1 - INFORMATION BULLETIN NO. 2 (PROVISIONAL LIST OF MEMBERS. CONSULTANTS. OBSERVERS AND SECRETARIAT) - OBJECTIVES OF THE MEETING

2. 3.

OBJECTIVES PROVISIONAL AGENDA WPR/MND/87.1 Rev.1

- PROVISIONAL AGENDA - INTRODUCTION TO WHO MENTAL HEALTH PROGRAMME - by Dr N. Sartorius - by Dr N. Shinfuku

4.

AGENDA ITEM 3 3.1 3.2 GLOBAL LEVEL REGIONAL LEVEL

5.

AGENDA ITEM 4 WPR/MND/INF./1 WPR/MND/INF./2 WPR/MND/INF./3 WPR/MND/INF./4 WPR/MND/INF./5 WPR/MND/INF./6 WPR/MND/INF./7 WPR/MND/INF./8 WPR/MND/INF./9 WPR/MND/INF./10 WPR/MND/INF./11 WPR/MND/INF./12

- COUNTRY/AREA PROFILES AUSTRALIA CHINA FIJI HONG KONG JAPAN MALAYSIA NEW ZEALAND PAPUA NEW GUINEA PHILIPPINES REPUBLIC OF KOREA SINGAPORE VIET NAM

5.

AGENDA ITEM 5 PART I PART II

- REVIEW AND EVALUATION OF RECENT DEVELOPMENTS - JULY 1983 - JUNE 1985 - JULY 1985 - JUNE 1987 - REPORT OF THE SECOND REGIONAL COORDINATING GROUP MEETING ON THE MENTAL HEALTH PROGRAMME, MANILA. 25-31 OCTOBER 1983

- 38 -

Annex 5

6.

AGENDA ITEM 6

- MEDIUM TERM PROGRAMME OF THE EIGHT GENERAL PROGRAMME OF WORK ON MENTAL HEALTH

7.

AGENDA ITEM 7 WPR/MND/INF./13 - PROMOTION OF MENTAL HEALTH SERVICES IN THE WESTERN PACIFIC REGION BY DR ENG-SEONG TAN - MENTAL HEALTH LEGISLATION BY DR BASIL JAMES - EDUCATION AND TRAINING IN MENTAL HEALTH BY DR MASAHISA NISHIZONO

WPR/MND/INF./14 WPR/MND/INF./15 8.

BACKGROUND DOCUMENTS WHA39.25

- PREVENTION OF MENTAL, NEUROLOGICAL AND PSYCHOSOCIAL DISORDERS - PREVENTION OF MENTAL, NEUROLOGICAL AND PSYCHOSOCIAL DISORDERS - REPORT BY THE DIRECTOR-GENERAL - MENTAL HEALTH - SUB-COMMITTEE ON THE GENERAL PROGRAMME OF WORK: ALCOHOL AND DRUG ABUSE - ALCOHOL CONSUMPTION AND ALCOHOL-RELATED PROBLEMS: DEVELOPMENT OF NATIONAL POLICIES AND PROGRAMMES

WHA A39/9

WPR/RC36.R17 WPR/RC36.R7 WHA36.12

- 39 -

ANNEX 6

PROTECTION AND PROMOTION OF MENTAL HEALTH

REVIEW AND EVALUATION OF RECENT DEVELOPMENTS PART I - JULY 1983 - JUNE 1985

In many countries of the Region, the increasingly rapid social changes brought about by economic development have had a detrimental effect on mental health with such undesirable consequences as juvenile delinquency, alcohol and drug abuse, social violence and unhealthy life-styles. WHO collaboration in this programme area is aimed at reducing problems related to mental and neurological disorders and alcohol and drug abuse, and enhancing the level of mental health knowledge and understanding in the context of general health care and social development.

10.1

Psychosocial factors in the promotion of mental health human development

Rapid social change is a striking feature of many countries in the Region. As a result of constantly evolving socioeconomic conditions, life-styles are changing and mental pressures are increasing. It can be expected, therefore, that some families will fail to meet and overcome the new challenges and stressful conditions, and that in many situations socially mediated psychological disorders will develop. There is very little knowledge of the processes by which sociocultural factors affect mental health and few instruments exist to define and to measure them. For these reasons, the main thrust of WHO collaboration has been to stimulate the wareness and concern of health workers regarding the importance of psychosocial factors in health and to promote multidisciplinary research and training in psychosocial skills and techniques. As a major social movements have occurred, it has become evident in many parts of the Region that psychological disturbances among children have increased as have the adjustment problems of adolescents. In the area of child mental health, studies have been initiated on the interaction of the housing environment, family function and child mental health in Shanghai, China, and Singapore.

- 40 -

Annex 6

It is also increasingly clear that the psychosocial needs of a growing number of patients suffering from chronic physical illness, particularly in the terminal state, are not being met. In this context, support was provided for a national workshop on quality of life in cancer patients in Tokyo in November 1984. The workshop noted the importance of the psychosocial aspects in health care, and proposed the inclusion of this topic in the training curricula of health professionals at all levels. The first meeting of the WPACMR Sub-Committee on Behavioural Science and Mental Health in 1983 noted the scarcity of resources for research and training in behavioural science and mental health in the Region and recommended the identification and maximum use of these resources as a first step. In the light of this recommendation, collaboration was extended to seven countries in the Region in 1984 for the identification of resources for behavioural science research and the review of significant health-related behavioural science research activities. In spite of the increasing awareness among health professionals of the importance of psychosocial aspects of health, countries have, generally speaking, given insufficient attention to this programme area, and in particular to the training of general health workers in psychosocial aspects of health. The lack of information and technology hampers the work of primary health care workers who have responsibility for dealing with those sociocultural factors which adversely affect health. Collaborative efforts will, therefore, focus on promoting awareness of these problems and developing national capabilities in this area. 10.2 Prevention and control of alcohol and drug abuse

In certain developing countries or areas of the Region that are experiencing rapid socioeconomic change, alcohol-related problems such as health impairment, family disruption, child abuse, social violence and road traffic accidents are becoming a major public health issue. The nonmedical use of narcotic and psychotropic drugs also presents a serious social and health problem in many countries. However, the lack of reliable data and the absence of consistent and coordinated policies on drug abuse have sometimes hampered efforts to develop national programmes. The main objective of the programme is, thus, to monitor changes and trends in the alcohol and drug abuse situation at regional level with a view to facilitating the development and implementation of prevention and control programmes based on primary health care in individual countries. In this connection, and in accordance with resolution WPR/RC33.R15 on alcohol as a major public health problem, a regional workshop on alcoholrelated problems was convened in Manila in August 1983 at which a practical framework for the design, implementation and evaluation of alcohol prevention programmes as an integral part of the health-for-all strategy was prepared. Similarly, a regional workshop on national policy and programme formulation for the prevention and control of alcohol-related problems was convened in Auckland in November 1984.

- 41 -

Annex 6

In the same context, cooperation was extended to Guam and the Trust Territory of the Pacific Islands (Republic of Palau) in the formulation of effective national control programmes on alcohol and drug abuse. In Guam, a training programme was organized to develop the Employee Assistance Programme on prevention of alcohol-related problems. In the field of information exchange on drug abuse, a meeting of the Working group on the prevention and control of drug dependence was held in Manila in June-July 1983 to review the situation and to make recommendations on ways and means of improving the exchange of information and expertise in the area of drug abuse control among experts in the Region. Although there is agreement that the problems related to alcohol are of major public importance, exact data are obtainable in only a few countries in the Region. It is considered that the development and routine use of an appropriate methodology for case detection, adapted for use in individual countries, would be of great value. In this connection, WHO supported the epidemiological study of alcohol-related problems in selected countries of the South Pacific. A serious weakness in this programme area is the lack of adequate training of health workers, including primary health care workers, which would enable them to recognize problems related to alcohol and drug abuse, and to respond to them effectively. Special attention needs to be given to curriculum development and to the training of health workers to overcome deficiencies in these aspects of the programme. 10.3 Prevention and treatment of mental and neurological disorders

The mental health services have been largely neglected in most of the developing countries or areas of the Region. Where they do exist, they tend to be institutionalized and custodial in nature. The main thrusts of the programme have thus been to promote communitybased mental health services in the context of primary health care, oriented towards prevention and control, and to coordinate the development of mental health programmes in countries or areas of the Region. WHO collaborated in the development of community-based mental health services in China, Lao People's Democratic Republic, Papua New Guinea, the Philippines and Viet Nam through the provision of advisory services, supplies and equipment and support for national workshops. A second meeting of the Regional coordinating group on the mental health programme was held in Manila in October 1983 to review, among other things, mental health problems in countries of the Region and, in particular, emerging psychosocial problems in developing countries, with particular reference to priority needs and areas for WHO technical cooperation in mental health and the development of collaboration in mental health programmes at regional and national level.

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Annex 6

WHO collaborating centres have been instrumental in developing research and training in mental health and neurosciences. A meeting of heads of WHO collaborating centres for mental health was convened in Tokyo in October 1984 to discuss means of promoting coordination between the centres and to develop collaborative research activities and training. The meeting reviewed the main achievements, present status and future plans of collaborating centres. Based on the recommendations concerning priority areas for collaborative research, studies on mental health delivery systems were initiated involving several centres and institutions in the Region. A meeting of the Working group on mental retardation was held in February 1985 to formulate a regional programme to address this rather neglected health and social problem. After reviewing available data and information on the epidemiology of mental retardation in the Region, the Working Group identified priority areas for intervention in order to reduce the prevalence and severity of mental retardation, including measures for prevention, early detection, mental stimulation and treatment of epilepsy. Despite some progress during the biennium, much remains to be done. National coordinating groups, which could help to achieve greater intersectoral collaboration in the provision of mental health care as well as improve the planning and evaluation of mental health programmes, are still too few in the Region. Mental health is still regarded as the exclusive concern of specialists while the broad concept of mental health as a WHO programme encompassing psychosocial factors is not well accepted either by mental health professionals or by general health workers. Considerable efforts are needed to increase the awareness of policy makers, medical educators, members of the social service professions and the general public about the potential and usefulness of mental health programmes and the need for their fuller application.

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Annex 6

PART II - JULY 1985 - JUNE 1987

Psychosocial and mental health problems in many countries of the Region are increasing. Alcoholism, drug abuse, behavioural disorders of children and adolescents, and mental health problems of the aged are becoming major public health and social issues in many developing as well as developed countries. Severe mental illness such as schizophrenia, depression, epilepsy, and being mentally handicapped, poses a severe burden on the affected individual, his family and the community, as these diseases tend to be chronic or recurrent. There is a lack of well-developed community based programmes in most of the countries/areas in the Region. The Regional Committee at its thirty-sixth session in September 1985, urged Member States, to develop community based mental health services to deal with mental and neurological illness and the psychosocial aspects of health in their national health programmes. 10.1 Psychosocial factors in the promotion of health and human development

Rapid social change resulting from economic development, industrialization and urbanization, has profound effects on the psychosocial well-being of individuals, particularly of those in high risk groups such as children and the elderly. During the biennium, special efforts have been made to initiate and develop programmes related to child mental health, the mentally handicapped, health problems of the elderly, in coordination with the other WHO programmes concerned. A first Regional working group on child mental health was convened in Singapore in November 1985 with the collaboration of the Government of Singapore and the Singapore Mental Health Association and with the participation of twelve leading experts on child mental health in the Region. Recommendations were made for the development of programmes on child mental health in the Region, including the strengthening of manpower training in child mental health at primary health care level and the promotion of collaborative research at regional level. Regional collaborative research on the emotional and behavioural problems of children was iriitiated between four countries in the Region, namely: Australia, China, Japan and Republic of Korea.

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Annex 6

As a follow up of the Regional working group on mental retardation held in Manila, February 1985, a national workshop on mentally handicapped was organized in Nanjing, China in May 1986. The workshop was an important stepforward for the training, research and the service development for the mentally handicapped in China. In August 1986, the Nanjing Mental Health Research Institute was designated as a WHO Collaborating Centre in Research and Training in Child Mental Health. Likewise, the Pediatric Department of the Shanghai First Medical School was designated as a WHO Collaborating Centre for Physical Growth and Psychosocial Development of Children. The programmes related to mental health of the elderly are still in the initial stage of development, in spite of the emerging magnitude of the problem in the Region. However, a national workshop on the epidemiology of mental health problems of the elderly was organized in Beijing in July 1985 and the technical and financial support was provided to the Beijing Institute of Mental Health to undertake the epidemiological study of mental health problems of the elderly in urban district of Beijing. Preparation has been made to develop programmes for the prevention and care of the mentally handicapped in Viet Nam and selected countries/areas in the Pacific. 10.2 Prevention and control of alcohol and drug abuse

As the outcome of the visit of the Sub-Committee on the General Programme of Work to New Zealand and Papua New Guinea, the Regional Committee at its thirty-sixth session recognized that there are widespread and increasing alcohol-and drug-related problems in many developed and developing countries of the Western Pacific Region. In the field of alcohol, activities were directed towards the development of national policies and community based programmes for the prevention and control of alcohol-related problems. In September 1985, WHO/South Pacific Conference on Alcohol-Related Problems was convened in Noumea, New Caledonia. The Conference attended by more than 100 participants from the Pacific Islands produced comprehensive recommendations to reduce alchol-related problems. In addition, consultancy services were provided to French PolyneSia, Republic of the Marshall Islands and the Republic of Plaua. In the area of training, national training courses on mental health and alcohol were organized in three provinces of Papua New Guinea to develop community based mental health programmes including prevention and control of alcohol-related problems. WHO collaborated with the Government of Fiji to organize a national Workshop on Alcohol-Related Problems in Suva in August 1986 which involved various sectors such as those concerned with education, social welfare and law enforcement, as well as the health services.

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Annex 6

In the field of drug abuse, continued efforts have been made for the prevention and control of abuse of narcotic and psychoactive substances with focus on adolescents. Due to the multifactorial and multisectoral nature of the problem, special attention has been made to increase collaboration with other United Nations Agencies such as UNFDAC, governmental and nongovernmental organizations. In 1985, the People's Republic of China ratified the Single Convention on Narcotic Drugs and the Convention of Psychotropic Substance and most countries or areas in the Region are now in a postion to provide information on the consumption of dependence-producing drugs to the United Nations. A working group on drug-related problems in adolescents was organized in Tokyo in February 1986 in collaboration with the Japanese Government and attended by temporary advisers from 12 countries/areas in the Region. The group reviewed the present situation, exchange of information and discussed the guiding principles for prevention and management. The group, noted the alarming increase in the abuse of organic solvents, psychotropic drugs, cannabis, amphetamine, as well as the abuse of heroin among adolescents in the Region, and stressed the need for WHO to intensify collaboration with Member States in implementing regional and national activities in this field. In line with the recommendations of the working group, a consultant visited four countries/areas in the Region in 1986, namely: Philippines, Malaysia, Singapore and Hong Kong, to review and develop educational materials for drug abuse prevention. The WHO Regional Office participated and contributed to the First expert programme on narcotic control for the Asian countries organized by JICWEL (Japan International Corporation for Welfare Services) held in Tokyo in November 1986 and to Eighth Conference of the NGOs for the Prevention of Drugs and Substance Abuse held in Sydney in December 1986. The Regional Office together with the Division of Mental Health in Headquarters executed the UNFDAC supported programme for the prevention of drug dependence in China which includes a study tour, fellowships, workshops on psychotropic drugs, and research on dependency for a period of three years starting in 1985. In line with the resolution of the thirty-sixth Regional Committee meeting in September 1986 (WPR/RC36 .R7), WHO will make efforts to collaborate with Member States to develop comprehensive long-term national policies on alcohol and drug abuse as an integral part of health for all strategies. The WHO programme needs to collaborate with countries in defining clearly the role of the health sector in alcohol and drug abuse, in supporting training of health workers, and in establishing proper mechanisms for intersectoral coordination at the policy and operational level.

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Annex 6

10.3

Prevention and treatment of mental and neurological disorders

The resolution on mental health adopted at the thirty-sixth Regional Committee urged Member States to give increased attention to programmes designed to improve mental health. including the setting-up of national coordinating groups on mental health and to develop community-based mental health services to deal with mental and neurological illness and the psychosocial aspects of health in their national health programmes. There exist few national policies addressed to the problems covered by the mental health programme, and intersectoral and multidisciplinary collaboration is still insufficient in many countries. In promoting mental health programmes, the establishment and organization of national coordinating groups on mental health and similar mechanisms are considered as having high priority. In this context, the first national coordinating group meeting on mental health of the People's Republic of China was convened in Beijing in July 1985. The multi-sectoral and multidisciplinary meeting provided a useful forum to review present situation and to discuss future direction of mental health programmes in China. Also in November 1985. a National workshop on comprehensive mental health policy was convened in Seoul. The workshop attended by about 30 leading Korean psychiatrists and top level administrators made discussion on wide range problems to develop comprehensive mental health policy including formulation of mental health law in the Republic of Korea. WHO provided three foreign experts as resource persons. The workshop enabled to formulate needed bridge between health administrators and psychiatric academicians and gave a strong impact to develop comprehensive mental health policy in the Republic of Korea. In 1987, support was also provided to the Mental Health Task Force of the Philippines to strengthen mental health training for district health workers and to decentralise mental health services. Training of health workers is a priority health issue in many countries. There has been a major shift in policy on mental health care away from institutional form of care toward the integration of mental health services with the general health services and community involvement. The new policy requires the increase training of health workers in mental health knowledge and skills. The shortage of trained workers in mental health is acute in developing countries. With a view to strengthen training in mental health needed to develop community based mental health services, consultant services were provided to Lao People's Democratic Republic and Papua New Guinea.

I

- 47148 -

Annex 6

Research is an essential and important factor in the understanding of problems related to mental health. It involves the development of instruments, methods and approach which are scientifically valid and comparable. WHO has provided continuous support for epidemiological research activities in mental health. Regional collaborative study on affective disorders were initiated in three cities - Nagasaki, Shanghai and Seoul to identify the magnitude and nature of affective disorders, e.g. depression, neuroasthenia, neurosis, in three different countries. Support was provided to the Republic of Korea to carry out the epidemiological survey to develop community-based mental health programmes in Kanghwa Island. The Department of Psychiatry of the University of Western Australia, Perth, which was designated as a WHO Collaborating Centre for Research and Training in Mental Health in November 1986, is expected to increase the research and training capabilities of the regional mental health programmes. In February 1987, the Third Regional Coordinating Group Meeting on the Mental Health Programme met in Manila to review the progress made in the field of mental health since the Second Regional Coordinating Group meeting in October 1983, and to make recommendations on future directions and priorities of the regional mental health programmes. The meeting attended by leading experts in mental health and public health in the Region discussed the coordination between global, regional, and national mental health services, mental health and legislation, education and training in mental health. In many countries/areas in the Region, mental health services are still hospital-centered and custodial. There is a lack of coordination between mental health workers and general health workers and the appropriate knowledge and information to develop sound community-based mental health services are not sufficiently provided for both general health workers and mental health specialists. The regional programme should continue to collaborate with Member States to develop comprehensive and community-based mental health programmes, to promote training and to support research appropriate to the promotion of regional and national mental health programmes.

- 49 -

ANNEX 7 SUMMARY OF COUNTRY/AREA PROFILES

AUSTRALIA

Major Problems 1. 2. 3. 4. 5. 6. Alcohol and drug related morbidity, especially alcohol-related ones "No growth" budgetting of health services Rising cost of health service provision Social pathology arising out of unemployment Provision of service to groups with special needs: the aged, ethnic and linguistic minorities, isolated communities Maldistribution of health manpower

Emphasis in national policy 1. The coordinated nationwide approach to alcohol and drug problems by means of legislation, public education and better service provision The integration of mental health services into general health services The regiona1ization of all health services - decentralization The de-emphasis of hospital-based in favour of community-based services The promotion of voluntary and self-help groups The emphasis on integrated services for the aged

2. 3. 4. 5. 6.

Constraints 1. 2. Financial limitation on the funding of programmes Stagnation of the economy

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Annex 7

Main thrusts 1.

Decentralization - regionalization De-institutionalization Promotion of community care and community participation Focus on problems of the elderly and on problems of alcoholism and drug abuse

2. 3. 4.

Recent developments since 1984 1.

Programme of public education on alcoholism and drug abuse New mental health legislation in some status Recruitment of ethnic psychiatrists Crisis service for emotional problems, mental disorders and victims of sexual and physical abuse Further decentralization of mental health services in same status I ,

2. 3.

4. 5.

CHINA

Major problems 1. 2. 3. 4. 5. More than 10,000,000 major psychoses need treatment on time, supervision and rehabilitation Mental health work integrate in primary health care Increase alcoholic and other related behaviour problems Medical education insufficent in mental health knowledge The emergence of child and elderly mental health problems

- 51 Annex 7

Emphasis in national policy 1. Setting up the seven 5-year programme of Mental Health (19861990) Drafted ordinance of Mental Health law Setting up the coordination committee of mental health in various level Epidemiology survey of mentally handicapped To train qualified mental health workers: psychologists, special therapists Psychiatrists, nurses,

2. 3. 4. 5.

Constraints 1. 2. 3. Shortage of manpower, especially qualified psychiatrists, nurses, psychologists, social workers Lack of monitoring and evaluation of mental health services Social prejudice towards mental patients

Main thrusts 1. 2. 3. Increasing trainees in mental health work Evaluation scientifically of mental health services To inform the public and policy makers of the importance of mental health and promote mental health education in school and family To develop liaison psychiatry

4.

Recent developments 1. 2. 3. 4. 5. 6. Founded National Mental Health Work Coordination Preparatory Committee and Expert Consultative Committee Second National Mental Health Work Conference was held in October 1986 Epidemiological survey of 12 sections was carried out throughout the country Through various channels efforts have been made to solve the problems of difficulty of consultation and hospitalization Founded National Mental Health Association Started concern for child and elderly mental health

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Annex 7

FIJI

Main problems 1. Lack of knowledge on the part of the general population concerning mental illness and the role of psychosocial processes in preventing mental and physical ill health Lack of knowledge on the part of doctors and other health professionals concerning the treatment of common mental disorders and the role of psychosocial processes in preventing mental and physical ill health Increasing urbanization and acculuration with its concomittant disruption of traditional values, identity and role crises, increasing sense of anomie A largely unrecognized abuse of a variety of psycho-active substances; kava, benzine (in the young), tobacco, alcohol and the clinical drugs Paucity of facilities for the treatment of the mentally ill, and the concentration in one urban area, of existing facilities such as they are. Facilities are less of a problem than manpower, since a well-organized network of community-based health centres is already established.

2.

3.

4.

5.

Emphasis in national policy 1. 2. 3. 4. 5. Provision of basic health needs to all Family planning Maternal and child health care Development and decentralization (community care model) of mental health services National coordinated intersectoral approach to alcohol-related problems

Constraints 1. A relative lack of awareness at all levels of bio-psycho-social factors in preventing mental and physical ill health

- 53 -

Annex 7 2. 3. Lack of trained manpower Lack of finance

Main thrusts 1. 2. Utilize existing services and facilities for development of community-based mental health programmes Educate fellow-professionals, concentrating in the first place on doctors and nurses who staff the network of regional health centres Train health-care personnel in mental health matters Involve the community in mental health awareness programmes

3. 4.

Recent developments 1. Mental health problems As stated above, but with an increasing recognition of the problems of child abuse and neglect, domestic violence, rape, incest, alcoho-related crime (especially violent crime) and substance abuse. 2. Components of mental health programmes Establishment by a Women's Group of a Rape Crisis Centre. This also offers assistance to victims of domestic violence. A counselling course is taught at University of the South Pacific. 3. Legislation No changes in actual legislation but a greater awareness by the judiciary of the psychological harm done to victims of rape and incest. This is reflected in a move toward harsher and more consistent sentencing. 4. Training and education Introduction of a psychiatry course into medical undergraduate training. Reproductive Health Education Programmes commenced for doctors and nurses from community-based health centres. Family Life Education Porgrammes commenced for teachers and community leaders.

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Annex 7

HONG KONG

Major problems Rapid change in socio-economic structure and high density living as a result of intense industrialization and urbanization have been responsible at least in part for: 1. 2. 3. A steady increase in psychiatric morbidity Declining support to the young and the aged by the family Prevalence of alcohol and drug abuse

Emphasis in national policy 1. Planning ratio of psychiatric beds is 10 beds as against present provision of 7.3 beds per 10,000 population. Further provision will come from building more psychiatric units in general hospitals Psychiatric centres with full time outpatient clinic and day hospital care are being provided to pursue the practice of community psychiatry. Re-integrating chronic patients into the community by establishing community work and after care unit in hosptia1s and provision of more half-way houses and sheltered workshops. Development of proper child and geriatric psychiatric services Drug and alcohol abuse as a priority issue.

2.

3.

4. 5.

Recent developments since 1983 1. Expansion of community psychiatric nursing service from 3 community psychiatric nurses (CPNs) in 1982 to 37 CPNs in 1987 with offices in various parts of the territory 24-hour hot-line service manned by psychiatric staff was started in 1984 with the objective of advising the public on urgent psychiatric problems A second medical school opened a 72-bedded psychiatric unit in 1984 which provides 10 weeks' full-time attachment for medical students

2.

3.

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Annex 7

4.

A post-graduate training course has been organized by joint effort of the University Departments of Psychiatry and Government Mental Health Service Public education on mental halth has been intensified in past few years Efforts in various aspects on drug abuse including publicity campaigns, law enforcements, treatment and rehabilitation are being kept in full swing Most psychiatric centres are provided with facilities for seeing child cases, albeit on a part-time basis A day hospital for psychogeriatric patients will be available in 2-3 years 200 mentally handicapped beds will be available in 2 years and more assessment centres are being planned Major amendments of the existing Mental Health Ordinance have been propose, which include the establishment of a Mental Health Review Tribunal Psychiatric epidemiology study is being carried at the Chinese University of Hong Kong

5. 6.

7. 8. 9. 10.

11.

Constraints 1. 2. Shortage of professional staff which has affected improvements and expansion of service Biased attitude on the part of the public against the mentally ill which has affected the discharge of patients

JAPAN

Major problems 1. 2. Increase of the mental health problems among the aged Long standing abuse of amphetamine and the abuse of organic solvent among the urban youth

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Annex 7

3. 4. 5.

Rising trend of alcohol consumption and alcochol-related problems, particularly among the women Scandals at a few mental hospitals such as the abuse of the human right of the in-patients Disease oriented education and training in psychiatry

Emphasis in national policy 1. 2. Prevention and care of alcoholics and amphetamine dependent Treatment and care of the elderly with dementia

Constraints 1. 2. 3. Insufficient mental health resources Shortage of personnel and finance Low priority of mental health services in the national health policy

Main thrusts 1. 2. 3. Promotion of mental health service Prevention and treatment of alcoholic and drug dependents Promotion and strengthening of mental health education

Recent developments 1. 2. 3. 4. 5. Broadening knowledge of proper drinking of alcohol and prevention by consultation and guidance of alcoholics annonymous groups Promotion of rehabilitation for the chronic schizophrenics Reforming of educational and training system in mental health Development related to the revision of mental health law Opening of National Centre of Neurology and Psychiatry

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Annex 7

MALAYSIA

Major problems 1. 2. 3. 4. 5. Substance abuse - alcohol and drug abuse Child and adolescent emotional and behavioural problems - from child abuse, delinquency, suicide to violence Youth, adult and elders with behavioural, educational, familial, religious and vocational problems Psychosocial problems among the physically sick Mental illness

Emphasis in national policy 1. 2. Prevention and control of Dadah (heroin dependency and addiction) Promotion and integration of mental health in primary health care programme

Constraints 1. 2. Lack of sustained intersectoral action oriented programmes and evaluation Lack of trained mental health workers ranging from nurses, social workers, psychologists, administrators to psychiatrists and the counselling component of health-related workers and volunteers.

Main thrusts 1. Ministry of Health, Social Welfare, Education, Home Affairs (Prime Minister Department and Police Department) are moving more towards intersectoral coordination of efforts in prevention and control of mental health related problems Increased efforts towards tain1ng of mental health personnel, e.g., psychiatric nurses and psychiatrists

2.

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Annex 7

Recent developments The period of 1983-87 witnessed greater intersectoral collaboration between the Ministry of Health and other Government and non-Government agencies in all mental health related programmes in the following areas: 1. Psychosocial aspects of health and human development 1.1 The Maternal and Child Health unit of the Health Division of the Ministry of Health organized an intersectoral workshop on problems and needs of adolescence, 17-24 November 1986 in Malacca, involving Ministries of Education and Social Welfare. The Ministry of Health and University Hospital, Kuala Lumpur (under Ministry of Education) have policy changes resulting in improved services for child abuse, survivors of sexual molest and assaults. The Royal Malaysian Police and National Council for Women Organization are training women police officers and volunteers to participate in crisis intervention teams. The First National Workshop on the Health of the Elderly, Kuala Lumpur on 8-10 July 1986. The national population and family development board is training doctors, health and education workers

1.2

1.3 1.4 2.

Prevention and control of problems related to alcohol and drug abuse 2.1 The Ministry of Health and Anti-Dadah (Narcotic) Task Force of the Prime Minister Department held an intersectoral "Symposium involving professional and para-professional worker in medical and health areas in the prevention and control of Dadah in September 1986. Among the recommendations were greater emphasis on prevention via improvement of the curriculum of medical schools, nursing courses, etc. Two national conferences on Alcoholism by a private organization which provides in the provision of educational, residential and out-patient management ASH (Anti-Smoking for Health Programmes of the Malaysian Medical Association) continued to organize training workshops for trainers and smokers.

2.2

2.3

II

3.

Prevention and management of mental and neurological disorders

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Annex 7

3. Prevention and management of mental and neurological disorders A workshop on "Promotion of Mental Health through Primary Health Care Programme" was organized by the Malaysian Psychiatric Association and the Training, Health and Hospital Divisions of Ministry of health with support from local universities.

NEW ZEALAND

Major Problems 1. 2. 3. 4. Health needs of minority cultural groups Alcohol and poly-drug abuse Violence Needs of special groups e.g., the offender, the intellectually handicapped, the elderly, the residually psychiatrically disabled

Emphasis in national programme 1. 2. 3. 4. 5. Design of health services using primary health care approach Culture-based health programmes Normalization of intellectually handicapped Moderating alcohol consumption Emphasis on health protection

Constraints 1. 2. Inertia of existing systems Competing priorities

Main thrusts 1. 2. De-institutionalization with community care programmes Concommitant upgrading of in-patient programmes

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Annex 7

3. Service guidelines employing P.M.C. philosophy 4. Intersectoral government collaboration 5. Increasing collaboration of voluntary and state sector Recent Developments 1. 2. 3. 4. 5. 6. Development of culture-based programmes Unification of hospital and public health sector in some regions National committee on violence Continued reduction of hospital populations Review of mental health laws Review of psychiatric treatment in persons

PAPUA NEW GUINEA

Kajor Problems 1. 2. 3. 4. 5. 6. 7. Alcohol abuse in relation to both individual and family health Adolescent psychosocial health and behaviour Gratuitous violence and antisocial behaviour Child development including nutrition-related aspects Accidents increase including motor vehicles Suicide increase in urban areas More broadly psychosocial and psychocultural problems related to rapid change

- 61 -

Annex 7 Emphasis in national policy 1. 2. 3. 4. Decentralization of responsibilities to premises, including many health functions Overall policy emphasizes economic development Lack of national staff and difficulty of recruiting qualified appropriate individuals Three-tiered health delivery systems of hospitals/health centres and sub-centres/aid posts emphasizes horizontal linkages

Emphasis in national policy 1. 2. 3. 4. Decentralization of responsibilities to premises, including many health functions Overall policy emphasizes economic development Lack of national staff and difficulty of recruiting qualified appropriate individuals Three-tiered health delivery systems of hospitals/health centres and sub-centres/aid posts emphasizes horizontal linkages

Constraints 1. 2. 3. 4. 5. Staffing: retention insufficient funded positions and difficulty in staff

Geography and language diversity render access to populations difficult Lack of national staffing in specialty areas Sociopolitical instability in certain provinces Voluntary organizations carry many counselling services

Main thrusts 1. 2. 3. 4. Programme emphasis on local and community level Clinical services at hospital wards Primary health care focus by Department of Health Concern for training appropriate to country needs by university medical faculty

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Annex 7

Recent Developments 1. 2. 3. 4. 5. 6. 7. Second National Health Plan draft including mental health section Provincial health plans by provinces Protocol developed for provincial mental health profiles Two psychiatrists recruited (Department of Health and University of Papua New Guinea) Psychiatric nurse training programme resumed Development of mental health modules for training of allied health personnel Linkage between traditional curing and clinical mental health treatment under assessment

PHILIPPINES

Major problems 1. 2. 3. 4. 5. De-institutionalization and the re-integration of the chronic mental cases into the community Inadequate number of mental health facilities and its maldistribution Problems related to increasing cases of children at risk and families in crises due to different sociological issues Limited services for those with special needs: and the intellectually handicapped Rising cost of health service station the drug abuser

Emphasis in national policy 1. Collaboration with nongovernmental organizations and non-ministry of health experts to formulate policies and programmes in mental health

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Annex 7

2. 3.

Rationalization of the national programme for the care of the mentally ill involving organizational and functional design Decongestion of mental wards around the country through the facilitation of discharges, as well as a more rational admission process The establishment of psychiatric facilities in the government general hospitals around the country Encouragement of efforts towards more community involvement in the care of the mentally ill Emphasis in psychosocial factors in manpower development and patient services

4. 5. 6.

Constraints 1. 2. 3. 4. 5. 6. Due to lack of funds, community mental health facilities are not enough to meet the growing needs of the country Lack of trained manpower for mental health and their maldistribution Inadequate public information Referral system is not well structured Coordination and collaboration with non-governmental agencies is not maximized Mental health laws are not updated

Main thrusts 1. 2. 3. 4. Decentralization De-institutionalization Promotion of community mental health education Training of primary health care workers for mental health care

Recent developments 1. De-institutionalization of chronic mental cases is intensified through "home conduction" of patients and through improved linkages with other agencies

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Annex 7

2.

Creation of a "crisis intervention unit" at the National Centre for Mental Health to meet the needs for urgent care and avoid long-term hospitalization Dissemination of community mental health education is given more attention and priority as a mental health programme activity Integration of mental health into the primary health care approach was implemented and is being promoted through practical training of these primary health care workers in all regions Researches encouraged Collaboration with voluntary organizations is being strengthened Coordination of different mental health programmes and activities are now done by the Project Team/Task Force Ministry of Health A national mental health programme relevant to the present situation is now being drafted at the Ministry of Health.

3. 4.

5. 6. 7.

8.

REPUBLIC OF KOREA

Major problems 1. 2. 3. Shortage of mental health facilities, particularly psychiatric beds Lack of adequate mental health programmes in custodial protective facilities Maldistribution of mental health facilities

Emphasis in national policy 1. 2. 3. Improvement of public and private mental health facilities in quantity and in quality Establishment of a mental health delivery system integrated general health delivery system Enactment of mental health legislation with

"

- 65 -

Annex 7

Constraints 1. 2. 3. No mental health authority in government Specialization of psychiatric service and lack of coordination with related fields Strong stigma attached to mental disorders

Main thrusts 1. 2. 3. 4. To educate people and government about the importance of mental health programmes To assist and communicate with government officials to re-draft the mental health law To initiate model community mental health services To continue to increase the number of psychiatric beds and mental health manpower

Recent developments There has been a steady improvement of the awareness of the government for mental health needs. The number of psychiatric beds is increasing due to active support by the government. A bill for the nationwide medical insurance passed the National Assembly, which covers the treatments of mental disorders. A bill for mental health legislation is still pending corrections and modifications. Excellent nationwide, as well as, community oriented epidemiological studies were done in the last two years.

SINGAPORE

Major Problems 1. 2. 3. Rehabilitation and maintenance of chronic schizophrenics in community Recidivism in heroin abusers Prevention and treatment of inhalant abuse

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Annex 7

Emphasis in national policy 1. 2. 3. 4. Providing a full range of mental health services Active involvement of community and patients' families in after care Upgrading of existing facilities and skills Prevention

Constraints 1. 2. 3. Manpower Finance Stigmatisation of the mentally ill

Main thrusts 1. 2. 3. Promoting mental health education More stress on promotion of positive mental health by the psychiatric services Minimize period of hospitalization

Recent developments The main mental health problem have not changed. The move toward a more community-based treatment programme is being consolidated with the setting-up of 3 psychiatric units in general hospitals in 1986. The plan to rebuild the main psychiatric hospital is going ahead. The University Department of Psychological Medicine is fully established at the National University Hospital. The post-graduate training course for psychiatry has been implemented and the first examination was held in 1985. Training programmes have been intensified for all staff. More stress is put on Mental Health education and the First National Mental Health Week will take place in March 1987. There is no plan to revise existing mental health legislations which are considered adequate. Legislation is being considered to control inhalant abuse.

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Annex 7

VIET NAM

Major problems 1.

Limited network of mental health service is still not within reach of all mental patients Shortage of mental specialists Shortage of medicaments, equipments, and facilities for mental hospitals

2. 3.

Emphasis in national policy 1. 2.

Integration of mental health in primary health care Mental health education should be promoted by joining efforts with local administrations, various branches and organizations to solve some social problems that may affect mental health such as: alcohol abuse smoking superstition

Recent betterments of mental health 1. 2. 3. 4. Constant growth of material basis of the mental health service Number of patients put under supervision is up by two and a half times over 1980 Nearly all former drug addicts have been helped to give up their habits and resume their productive lives Social activities like outdoor health clubs for pensioners and the campaign of "the new culture family", etc. have contributed to promoting better mental health in various societies

Constraints 1. Mental health protection is not yet understood by all as a social question of both immediate and long-term significant for a nation

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Annex 7

Main thrusts 1. Continuing to develop network of mental health services priority for psychiatric dispensaries at district level and caring for patients at the community levels; integratiaon of mental health care in primary health care 2. 3. 4. Mental health education in the people Organization of the mental health protection committee at provincial level Training of mental health personnel and involving general practitioners in the management of mental patients