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Integrating neuro-psychiatric disorders at the level of primary health care centres: Guinea

Author(s) Abdoulaye SOW1, Oury SY2, Amatigui DIALLO3, Abdoulaye KOULIBALY4, Mouctar DIALLO5, Binta BAH6.
Affiliation(s) 1Mangment, Medical fraternity Guinea, Conakkry, Guinea, 2Physian, Medical fraternity Guinea, Conakry, Guinea, 3Physian, Medical fraternity Guinea, Conakry, Guinea, 4Physian, Medical fraternity Guinea, Conakry,Guinea, 5Physian, Medical fraternity Guinea, Conakry, Guinea, 6research, Medical fraternity Guinea, Conakry, Guinea.
Country - ies of focus Guinea
Relevant to the conference tracks Chronic Diseases
Summary Mental, neurological, and substance use disorders make a substantial contribution to the global burden of disease. According to the World Health Report 2000 neuropsychiatric disorders (a component of mental health) are the second cause of disability-adjusted life years (DALYs), behind the infectious and parasitic diseases. Under the theme “Stop exclusion, Dare to care”, the year 2001 was dedicated by the WHO as the "Year of mental health”. Since ancient times, epilepsy has remained a controversial subject for many world populations. This is because mental illness has been perceived as socio-anthropological for many societies.
What challenges does your project address and why is it of importance? Primary health care strategy aims to make accessible to as many people as possible healthcare according to people’s needs, at an affordable cost and taking into account a country's given resources. Equity and social justice are the basic principles of this strategy.
According to the World Health Report 2002, neuropsychiatric disorders account for 13 % of the global burden of disabilities adjusted life years (DALYs). In Guinea, while significant progress has been made in primary health care programmes, little improvement has been measured in the field of mental health. The psychiatrist ratio per capita is one of the lowest in the world. A similar gap in the number of neurologists prevails throughout the country.
In order to address this gap, the Guinea Medical Fraternity (a Guinean association of doctors) opted for the integration of neuropsychiatric consultation into the daily work of the general practioners working in its health centers.
At the opening of its health centers in the 90's, one missing element was the lack of data about the number of patients who sought consultation for mental health problems. At that time, no information was available due to the lack of qualified human resources and poor access to medicines. To tackle this challenge, Guinea Medical Fraternity initiated the project SaMoa, and used 'action research.'
How have you addressed these challenges? Do you see a solution? The model of care employed is based on the three-dimensional approach used in outpatient mental health management: medical, socio-psychological and the community. These three dimensions are combined for almost all patients in our centers, without following neither a chronological nor a hierarchical order.
For the two groups of diseases described in this abstract, epilepsy and mental health disorders, a care package is offered to the patient. This includes: identification of fixed and advanced strategy for the patient, medical treatment (with antipsychotics and/or anticonvulsants), follow-up and psychosocial support (individual interview, with family members, home visits), family and community reintegration through discussion groups and reintegration workshops (graphical expression, apprenticeships) and finally social support interventions (such as supporting the recovery of a lost job or supporting patients in rebuilding a couple in crisis).
In order to ensure continuity of care, a number of materials have been developed.
These include:
• Personal health record (first visit and follow up)
• Home visit notebook
• Reintegration notebook (describing the patient personal project)
• Group workshops notebook.
• Monthly collection sheet.
• Monthly report
Regular inter-professional encounters have been established in order to promote synergies and complementarity among caregivers and has been used to foster continuous staff training. This framework is supported by:
• A joint consultation between a generalist and a specialist (neuropsychiatrist ) at the beginning of the project
• A daily joint consultation between doctors and social workers
• A weekly team meeting between doctors, social workers and community volunteers, to discuss specific cases
• A monthly coordination meeting, which brings together the heads of unit of each health center and the officials of the NGO.
How do you know whether you have made a difference? From January 2000 to June 2013, 7079 mental health problems were diagnosed among which 47 % were psychoses, 33% were epilepsy cases and the remaining 20% represented by depression, dementia, neurosis, social problems and cerebral motor deficiencies.
Among patients put under treatment, two main molecules were used for psychosis (different forms of Haloperidol and Akineton as corrector) and for epilepsy, four essential generic drugs (carbamazepine, phenobarbital, phenytoin and sodium valproate). We found a positive impact for both patients and their families, health care providers as well as for health centres.
For the patient, the impact is assessed by how much healthcare management has improved by integrating the socio-cultural context of the patient and his/her family, how much the intervention has strengthened patient-provider relationship and contributed to better adherence and how much the intervention has facilitated patients social reintegration and has strengthened their economic capacity.
At the level of health centers and providers: the impact is felt at many levels
 Improved patient-provider relationship (beyond mentally ill patients).
Indeed, GP’s trained to adopt a more holistic bio-psycho-social approach with psychiatric patients and spontaneously applied a similar approach vis-à-vis other patients, spending more time, listening and discussing with them and paying more attention to their psychosomatic problems.
 Improved relationships between health centers and the communities they serve.
Communities started to see healthcare providers and the health centres as partners and contributed to the development of the relationship.
 Improved relationships between primary health centers and referral hospitals.
Given the fact that the care package provided by the programme is not available in district hospitals, the project has reversed the usual pattern of the health pyramid that usually sees PHC centers referring their patients to a hospital. In this case, the opposite took place, hospitals sending their patients to the lower level of care.
 Implementation of several community initiatives around the health centres.
The momentum created by the project has allowed the emergence of community-led initiatives such as economic interest groups among intervention communities, involvement of young people in the village around health promotion activities and the establishment of patient support groups.
 Health centre as a training and internships for medical students in public health and community health workers. Successful health centres are coveted by academics whose students are engaged in the internships and the development of dissertations.
Have you or the project mobilized others and if so, who, why and how? The project involved several actors in different and various socio-medical fields.
In Guinea, networking is not integrated into the system. Each association operates in isolation and tries to protect its field of competencies as a private territory. Initiatives are confined to a limited territory or to a given intervention and do not benefit neither the beneficiaries nor field social workers. To break this single thought mindset, our project has created an inter-professional approach mobilizing a supportive and dynamic network of various health workers, social workers and human rights advocates in order to improve the management of heavy neuropsychiatric disorders.
Among the objectives, this initiative attempted also to demedicalize some health problems, to push healthcare providers to pay more attention to social problems and to involve other social stakeholders in medical work.
As an illustration, health centres provide care (medical consultations, nursing services and drugs) to all populations. Social centres provide services (psycho -social support, legal support, rehabilitation, social and professional reintegration) to the same populations. The interaction of these two levels of intervention can only be beneficial for patients, providers and medical-social structures.
Our methodology involves the organization of platforms for dialogue between actors, field visits, referrals of patients or target groups and the organization of joint actions.
The platforms are organized around a theme: clinical, social, results or best practice.
Field visits take place upon request in order to assess the social and/or medical situation of an identified patient, or to meet with an association that wants to share its experience and best practices or seek advice.
Social workers refer their clients to a healthcare professional for a medical condition and the healthcare professional refers their patients to social workers in order to be more effective not only in medical care but also to delegate certain activities (counseling, search of lost to follow up) in order to deal with other aspects.
Joint actions are put in place to identify, plan and agree upon a synergic mode of implementing activities that improve the quality of services offered.
When your donor funding runs out how will your idea continue to live? The project initially depended on single funding, but since its activities are integrated into health centres, it has become routine and no longer dependent on external funding. Yet, the fact that we are in the process of replicating and scaling up the programme in several other health centres, funding will be needed in order to train staff, provide a starting stock of essential generic drugs, conduct reintegration workshops and provide supportive teaching materials.