Job K Joseph - SOCHARA Final Report.pdf · Community Health

Job K Joseph - SOCHARA Final Report.pdf

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extracted text: COMMUNITY HEALTH LEARNING PROGRAMME 2013-2014
SOCHARA, BANGALORE

Acknowledgement
I thank God almighty for his grace and guidance and strength throughout the year which I spend
with SOCHARA. Community Health Learning Programme facilitated me a tremendous learning
opportunity about people’s health. It is my great joy to express my gratitude to all those who
supported along the way. I take it as privilege to thank Dr.Thelma Narayan for her support,
guidance and encouragement at my every decisions. I am

Foundation of community health
My journey begins with SOCHARA on June 3rd 2013. I was curious to know about community
health. It was absolutely new filed for me. Like a child who explores the wonders in nature I started
slowly to know basic lessons in community health. Of course, I have learned medical social work
but never taught about community health. The whole discussions on medical social work in our
MSW class room were about institutionalized setting. I got trained in Medical social work in one
famous hospital in Bangalore but still I was not able to find the poor or needy gets benefits from
their service. If you have money and education you treated well, respected and given proper care.
A clear discrimination I observed at that setting. I was disturbed with this kind of hospital setting.
This led me to think about the health of the poor in different community. As I look back now I
realize the politics of health and inequality in health services. Community health learning was a
wonderful experience, encouraged by the visionaries of community health, supported by fellow
workers and mentors made me comfort as I continue in community health.
In search of meaning on community health
Collective sessions always given a platform to express ideas, learn from each other and to plan a
sketch for our journey. We began our journey by hearing the life stories of each fellow traveler.
As we crossed our life journey mile stones I understood a life can speak about community health.
in fact human is all about health it has a longing for wholeness, a complete health. The book Health
for all now! Was a guide in my path the book provoked my thoughts for action. We discussed,
reflected from the bible of community health.
Basic Lessons- “A reflection on Health for all now- people health source book”
The book helped me to have a current understanding of globalized world and health the inequity
and denial of justice to poor. It talked about beautiful concept of primary health care. It also taught
me challenges in achieving people’s health and well being. It took me to ‘a world where we matter’
shown me the whole picture of marginalized and vulnerable, women’s health focusing on the poor,
cruelty to children, the differentially able and un reached Aged.
Understanding what globalization dose to peoples health is very important as a community health
worker. Yes globalization dose widening the gap between the rich and the poor, it exploits and
mock at the poor by its redefined policies. The uneducated poor becomes the slaves of so called
developed countries. The World bank and International monitory funds lend their economic

support with or with out knowing. Third world countries sold it property of health into the hands
of them. The structural adjustment programme was designed to cut the government spending on
health and education and to privatise and to devalue the local currency. It encouraged to export
more to pay back loans open up foreign multi national companies and reduce tariff on imports. In
short it affected all the areas of human life from birth to death slavery to globalised world.
Understanding primary health care
Primary health care offers the social model of health and it must be implemented through the
Government. Understanding the politics of health and well being in a comprehensive manner helps
us to look into basic determinants of ill health. Malnutrition, unsafe drinking water and sanitation,
poor living condition, poor working condition, patriarchy, stress lack of good health services all
pointed to ill health, the Alma Ata Declaration accepted health as a fundamental human right. The
first step to reach people regardless their culture, cast or economic status. The bhore committee
report which was independent India’s charter on health begins with the opening statement “ no
citizen should be denied an adequate quality of health care merely because of His or Her inability
to pay for it. Primary health care offered a decentralized health planning and building panchayth
capabilities and facilitating community participation.
Making a life worth living
The third section of the book talked about the basic civic aminities, models of health care and basic
education and securing peoples lively hood. It also shown the womens struggle inorder to secure
the health of the family and children. Drinking water and sanitation remains the big challenge in
developing countries even that also privising so that poor can not reach. Education is one of the
major determinants of health. it is rather a socialization of health.
A world where we matter
The marginalized and vulnerable that are more prone to illness and more exploited, their special
needs to be treated in an equitable manner. the women health ignored starting from birth as we just
look at the sex ratio in India gives the depth of discrimination. Education, occupation,
empowerment of women is matter to a healthy family. Family planning targeted on women folk
showing the clear gender discrimination.
“Community” Reality and conceptual crisis

Session on community was a thought that challenged the existence of community in reality. It
helped me re examine the definitions I studied back in my sociology classes. The understanding
of concept of community as a group of people living in a defined geographical area and having
common sense of belongingness and we feeling and common goals. As we look at closer the
existence of community its self challenged with its diversity and there comes the need of building
a community in reality.
Community health
Health can be a meaningful, productive and quality life without disease and involves emotional
social and spiritual balance. Community health is building on everyone’s needs through
participation. It is an organized way of attaining health. Equal opportunity to livelihood balanced
with ecology. My personal perspective of community health can be defined as “Community health
is sate where people have the right to access healthy environment, utilization of resources in an
equitable manner in order to have physical, mental and social and spiritual well being.” To achieve
this aspiration community health there has been many struggles and movements.
Axioms of community health
As we look at community health the ten axioms which proposed in the book named as community
health in search of alternative process. It is important to consider because any efforts on community
health is based on those. Community health is not only observed as right but also it is a
responsibility that ensures people participation in it. As community health workers we enable
people to demand their rights. And more importantly people should have autonomy over health in
terms of opportunities, knowledge and supportive structure which makes health possible.
Integration of health and developmental activities, health cannot be viewed as an independent
entity. It must be integrated with education agriculture or whatever field that he or she works.
Building a decentralized democracy at community and team level, people in the action decision,
action and evaluation process gives the meaning for decentralized democracy. Building equity and
empowering community beyond social conflicts. Conflicts are natural phenomenon in any
community but an equity principle and empowering needy have to take into consideration.
Promoting and enhancing the sense of community. A sense of belongingness and we feeling need
to be encouraged in order achieve health. Confronting Bio-Medical Model with a new attitude
skills and approaches, over emphasis on bio medical concepts and the sovereignty of medical
professional in primary care should be confronted and the as possible the roles and responsibilities

must decentralize. Confronting the existence of medical structure of health care, the lack of more
people oriented, more community oriented, more socio epidemiologically oriented more
democratic and more accountable health systems should come into place.
Learning from the community health movements in India
As I observe a movement is any collective form of organized activism with the participation of
people to achieve a common goal. The struggle to achieve community health started even from
pre independence. In 1946 the bore committee set the guiding principle which recognized the right
to have a healthy living paved the way for community health movements.
Community health values
Values must be valued and valid in community health in order to realize the concept of health for
all. As PAHO document states the importance of values as “values are essential for setting
national priorities and for evaluating whether or social arrangements are meeting population
needs and expectations. They provide a moral anchor for policies and programmers enacted in
public interest.” As we explore the values it could be different in deferent situations. But there are
common values to be discussed. Equity, first and foremost value of community health, reaching
the unreached and equal treatment for all subjects, It is social inclusion of all and reaching beyond
the geographical barriers. Gender, health is closely linked with the role and responsibilities which
is mostly referred in terms of gender. The exposure and risk vulnerability associated with social
constructed roles often lead to health issues which we need to address. Solidarity, it is working
together to achieve a common good. Building solidarity is one of the strength in community health.
Social justice, the un just socio economic political cultural system causes ill health and equality
of opportunity to poor and disadvantaged should ensure by the health system. Health as a right,
ultimately health is right of every individual it must be recognized and valued.
Plurality of health systems
India has a rich heritage of medical pluralism. Identifying various medicines and the integration
of it
Involving community in Health Action
People’s participation in community health action will definitely helps in effective implementation
of any health activity. It makes a sense of responsibility and ownership which helps community to

use it effectively and efficiently. It is more sustainable than any welfare activity implementing by
anyone without people participation. Therefore the people need is higher and must be respected.
Participatory Rural Appraisal (PRA) as Participatory approach
To perceive peoples actual need we need to engage with people by developing a mutual trust and
understanding. In PRA any development worker must be playing the role of a careful observer.
Participation is the power to talk and PRA should be based on the principles of democracy for the
people by the people and of the people. He reminded us about that the almost all PRA’s conducted
in the country for some kind of NGOs, Government and not for the people. So PRA meant to be:
➢ Help people to understand their problem
➢ Help them to identify the solution
➢ Help them to implement the solution
Guiding principles
➢ Make an extra effort to come down (Be one among the people)
➢ create an environment where people can speak
➢ Make sure people are interested in the process
➢ Understand PRA tool as Quantitative there for try to picture form so that everyone could
able to understand.
➢ Start with the place where the process begins lead queries what next?
➢ make sure that people themselves are engaged in the process
➢ it should be immediately evaluated and locally corrected
➢ Do not bring all the people at first phase, two or three people enough to start with.
➢ create a tool which could useful afterwards
PRA has another Expansion that is Poke and Run Away! He mentioned that this is what happening
most of the time.
It was an insightful learning which more emphasized on peoples need and participation. Social
mapping is a tool to understand and prioritize need. Social map is different from other regular map
in significant ways, for one it is made by local people and not by experts, for another it is not drawn
to scale. It depicts what the local people believe to be relevant and important for them.
Health and constitutional rights

HEALTH IN ACTION
Community Action for Health in Tamil Nadu
Community action for health in Tamil Nadu keeping in mind NRHM goals and strengthening
approaches covered various part of the state to ensure reducing infant mortality rate, maternal
mortality rate through community involvement capacity building, flexible financing, human
resource management, and monitor against agreed milestone. Training to enhance the capacity of
panchayathiraj members to control and manage public health services. Village health and
sanitation committee to monitor health services availability through specialized tools. It also
strengthens PHC and CHC.
I was also encouraged to observe the inter-sectoral coordination in the matter of health. People
fighting for their rights as well performing their duties through the intervention of community
action for health, through the process of data collection to understand the implementation by using
various technique like Opinion were collected from services provider via PHC infrastructure,
equipment, institution based services monitoring Peoples opinion on the institution was collected
through voting Cell phone technology was used to digitalise the data – SMS based data entry
system
This programme is one of the successful intervention helped Panchayath members to be more
concerned about health system and is helpful in building a good rapport between health and
panchayth. There are now forums for discussing health and related issue at these levels where
information can be shared and concerns can be expressed. Communities are now more aware of
their entitlements and this considerably strengthens the demand side. While institutional
strengthening is happening, sometimes the community continues to have misconceptions about the
services, quality and availability etc. and continue to underuse the services. Communities able to
identify gaps in service provision
THE ANT – the action northeast trust
Hearing from an NGO works for the north east development initiatives was an encouraging
session. Empowering women, education and health personal in order to build a healthy society in
the north eastern land of India. The name caries hard working small but pretty efforts, organized
work in the community, edurance and so on. The ant started with an objective of Start development
work which is sustainable and focused on rural poor of all communities. The six wings of ant dose

work at village level developmental work including better health, women empowerment,
alternative livelihood, quality education, child and youth development, peace building and justice.
Starting from livelihood and promotion of traditional craft empowering women to take action
engaging youth in health action

REFLECTIONS ON
WORKSHOP, SEMINARS AND TRAINING PROGRAMMES
PSYCHO SOCIAL SKILL TRAINING
PLACE: SHANTI SADAN, BANGALORE

Introduction

Approximately 75 million people live in India with mental illness and we have a very few
professionals and paraprofessionals to care them. We have well structured systems, programs,
policies, laws but still the intervention in mental health is lacking. Yes its need of the hour! Basic
Need India is a NGO strives for promotion and community based rehabilitation of mentally ill
patients. Basic needs India was established with a mission to actively involve person with mental
illness and their care givers to enable them to meet their basic needs and to ensure that their basic
rights are respected and fulfilled.
Psycho social training aimed at to understand the basics psycho social aspects and mental health
is inseparable and moved on to what we need in order to work in this field- the major learning was
we need self awareness as well awareness about human behavior.
Self awareness and human behavior
Right attitude, awareness of self and human behavior and skills are very essential in psycho social
intervention. Understanding of various things that influence human behavior through group
discussions helped to draw seven areas like Values and beliefs, Genetics, Health , Past experiences,
Childhood , Family Situation
In every society human behavior are influenced by various factors like above stated and as we
understand an individual we have to keep in mind the situations that influence one person it helps
us to reach in an empathetic understanding. To understand our self we also did a test. There was a
psychological test which looks at our control on ourselves and others control on us. 24 questions
parallel which is little confuses every one. But it was good to get to know the thinking pattern and
maturity level of participants.
An insight through Johari Window
Understanding Johary window helped to discover h psychological dimensions and understanding
of self at various levels. Open self as the one which I know as well as everybody knows. Hidden
self in individuals says that there are things which I know but others don’t know (Secret self).
Blind self gives there are things which we do not know but others knows. Dark part is the unknown
part which nobody knows. Better self understanding helps us to engage ourself with better psycho
social interventions.
Defense mechanism

Defense mechanisms are a set of unconscious ways to protect one's personality from unpleasant
thoughts and realities which may otherwise cause anxiety. The notion of defence mechanism is an
integral part of the psychoanalytic theory. Although often described as detrimental and negative
ways that an individual deals with overwhelming stressors; these mechanisms can also be applied
positively when dealing with conflicts. Used sparingly, they help people face difficult life
situations. However, a defense mechanism can also lead to a neurosis if it causes a person to adopt
ineffectual or inappropriate coping strategies. There are various kind s of defense mechanisms that
helps in the psycho social practice.
Understanding mental illness
The theoretical input of what do we meant by mental illness is given as is when someone lacks
the ability to manage day to day events and/or control their behavior so that basic physical and
emotional needs are threatened or unmet. Mental illness is a physical condition just like asthma
or arthritis. But still society believes that a person who is mentally ill needs to show more will
power to be able to pull them out it.
Psycho social impact of mental illness
Psycho social impacts of mental illness on individual, family and care giver, individual with
disability are discussed in various groups. It was an eye opener to understand the networking of
problems that arises out of mental illness. People with mental illness distressed with their own self
and the family has to take care the person often the lack of scientific knowledge about mental
illness and stigma related to it even worsening the condition of mentally ill. In treating mentally
ill patients there should be followed timely medication and psycho social intervention at three
levels includes: family, neighbors and the community. Often the lack of early identification and
treatment of the illness leads into complications and sudden out burst of behavioral symptoms.
Psycho social interventions
The wider understanding of psychological state of persons living with mental illness and their
families helped to think about the intervention through and empathetic form of understanding.
Stabilizing the bio chemical imbalance through timely and regular medication, insight into illness
and motivation to improve, family collaborations, supportive environment, productive
involvement in activities, regaining lost life skills and role will definitely help patients to recover
from their illness and lead a normal life.

Personal Reflection

This training was helpful in exploring self (skills, attitude and
knowledge)
Psycho social competencies and skills discussed
team work brings various ideas on psycho social practices
encouraging and motivating each others
individual, family and neighborhood could be a network that
attacks the complexities of mental illness
understanding of treatment modalities and challenges helped to
equip myself with skills and knowledge
well organized learning

TRAINING ON TRANSACTIONAL ANALYSIS

Introduction
The understanding of human transaction of communication was interesting session where we
learned to respond to various situations in more effective way. Transactional analysis is universally
useful for anyone who wants to be real autonomous person. Autonomous person is the one who
speaks and behaves spontaneously in a rational and trustworthy manner with decent consideration
for others. This training helped to understand the play of parent and child communication which
is unhealthy in many time and ends with some troubles or issues. As community health workers
analysis of our transactions are very important as we approach people at various level starting from
administration to people in the community.
Learning’s
Personal Reflections

❖ Understanding of theoretical aspects of Transactional

Medico friend circle 40th annual meet

INTRODUCTION
Medico friend circle is grown as the India’s largest health debates network over the past four
decades. People with different ideas, thoughts and actions gathered together in the 40th annual meet
of Medico fried circle held at Indian Social Institute, Delhi from February 13-15, 2014. The theme
of this year was on Social discrimination and health.
KNOWING MFC
The Medico Friend Circle (mfc) is a nation-wide platform of secular, pluralist, and pro–people,
pro-poor health practitioners, scientists and social activists interested in the health problems of the
people of India. Since its inception in 1974, mfc has critically analyzed the existing health care

system and has tried to evolve an appropriate approach towards health care which is humane and
which can meet the needs of the vast majority of the people in our country.
The existing system of health care is not geared towards the needs of the majority of the people,
the poor and the rural segments of our society. Thus, it requires fundamental changes. Since the
health care system is only a part of the total system, these would occur as part of a total social
transformation in the country. We believe that, to achieve this goal, measures however small have
to begin here and today, in all spheres of human social life. mfc is trying to build a nation-wide
current committed to this philosophy. Briefly outlined here is mfc's position on the existing healthcare system in India.
After independence there has been a rapid growth in health care services organised by the
government. Yet, the private sector has increasingly become the major provider of medical care in
India. However, like any other commodity in the market it is accessible only to those who have
the money to pay. Medical care now resembles any other commercial sector and therefore, medical
professionals are increasingly becoming driven by profit rather than by concern for wellbeing of
people. Commercial competition and personal interests of doctors lead to several kinds of
malpractice.
This behaviour is encouraged and promoted by profit-oriented drug companies, which dump many
useless or even harmful drugs on to the consumer through the doctors. All the above tendencies
will be exacerbated with further privatization of medical services and medical education.
MFC believe that medical and health care must be available to everyone irrespective of her/his
ability to pay. This requires strengthening of public services. Also that medical intervention and
health care be strictly guided by the needs of our people and not by commercial interests.
TRAVEL TO DELHI
I personally had a time of fun, discussions, debate on Health and discrimination on our way to
Delhi. Since I come from so called developed state Kerala I thought why to talk about
discrimination and health. Even though I understand the nature of discrimination I was reluctant
to accept in its full form. As I crisscrossed the country I saw the rich and poor, normal and
abnormal, hardworking men and lazy fellows and diversified culture and religion. Then I found
meaning in the topic discrimination and health. As we arrived at Delhi, It shown me another picture

of poverty and richness the one part of Delhi especially near the railway track I found people who
took bath sat down on railway track. Children who roaming around carelessly and rag pickers open
defecation. The other side where the MFC meet happened Lodi Garden one of richest area in Delhi
clean and neat not crowded. Houses so furnished and beatified in its own way. The immediate
question crossed my mind was; is that not discrimination? I hopefully and eagerly moved ahead to
hear, learn and to contribute something to MFC.
MEETING THE MFC MEMBERS
Experts, students on community health from all over India gathered at ISI to discuss about
Discrimination and health. It was really exciting to know they were from different background and
with different ideology starts from Gandian to extreme Marxism. Dr. Binayak Sen most respectful
personality I ever met in the public health field. To name there are many who committed to
community health and visionaries of healthy India. In fact it was four generation who gathered
there. Handing over lamp from generation to generation, I was proud to be a part of that session
and hopefully it enlighten my future as I go forward. The way that introduced MFC to me by the
convenor was so interesting “for the past many year MFC was interested in the discussions of
socio-political epidemiology of health, it’s thought current here happens electrified debates”.

OBSERVATION VISITS
KANKPURA
Green foundation, seed bank, organic farming, traditional cultivation methods attended
sanitation training
NIMHANS WELLNESS CENTER
SAKKALWARA PHC
RAJENDRA NAGAR SLUM, BANGALORE
HAKKI PIKKI COLONY

Reflections on Research articles, Journals and Books
1) Insecurities of Roaming working children- A case study of Kolkata; Article by
Anwesha Paul ; published in Economic and political weekly January 4,2014
An exploratory study of children who live on the street without any contact with their
families or those who are roaming working children looks at the relationship that these
children share with the people around them and the insecurities in this relationship. The
children develop friendship with complete strangers which influence their life style and
decision making process.the study was located in and around seadah railway station where
many such children lives. This article says about the street children friendship, protection
and support, risk taking behavior, spending and saving, power, abuse and sexual exposure
under the title if friendship and insecurities. Relationships are on a temporary basis.
As I reflect on this article street children’s are in their own world of making relationships
even though it’s temporary. These children’s are often used by antisocial people and some
save money some spend money lavishly. The unconditional love each other share is very
interesting.

2) A tragedy unfolding: Tribal children dying in Attappady by Manikandan AD,
January 11, 2014
This study brought out shocking evidences on malnutrition in Kerala. It happened in
attappady a tribal block there were many studies which compined in this article a study by
kerala institute of local reveals that 48% of the tota;l tribal households are poor. Recent
survey conducted by Thampu, a non governmental organization dealing with tribal rights,
found that out of 300 tribals affected by malnutrition two hundred were children. K.V
venugopal the district medical officer said that 412 cases of anemia and 67 cases of
malnutrition had been noticed by the health department.
This article also discussed about causes of malnutrition the main cause foundwas extream
poverty the shift from traditional agricultural practices, land alleniation of tribls, poor
performance of MGNREGA, this report reaveals that a state with remarkable achievement
in human social indicators has excluded the tribal group from its so called achievements.
3) Closing the gap in a generation: health equity through action on the social
determinant of health (source: www.thelancet.com) Vol 372, November 2008.
The study report summarise the key finding and recommendation which the commission
on social determinant of health brought out. This study shows the inequity in health
services.
4) Narrative Research methods in palliative care contexts: two case studies; published
in journal of pain and symptom management, vol.37, 5 may 2009

This article helped to understand significance of narrative research method through semi
structured interview with terminally ill patients. Narrative research methods invite people
to talk or write about their experiences in naturalistic and storytelling manner. The two
cases described in the article brought out the interwoven nature of problems. It was an indepth analysis which helps the readers to understand the attitude, behavior and responses
of their chronic patients into their situations.
As I reflect on the article it helped me to know the writing of a narrative research article.
And this kind of interview might help the patients to express their feeling.

DISTRICT MENTAL HEALTH PROGRAMME
THIRUVANATHAPURAM, KERALA
“Team work is dream work.”

DMHP TEAM WITH RESOUCERS PERSONS

UNMISTAKABLE SIGNS OF
HOPE IN THE MIDST OF
GLOOMS AN EXPERIENCE
WITH DMHP- THIRUVANATHAPURAM , KERALA
Mental health is one of the crucial milestones on the road to individual health. It is the driving
force in the development of a community or society. Unfortunately it is the ignored, associated
with taboos and is alienated, therefore focused attention must be given at the grassroots level. On
this accord The Government of India initiated the National Mental Health Programme in1982 with
the objective of improving mental health services at all levels of health care (primary, secondary,
and tertiary) for early recognition, adequate treatment and rehabilitation of the patients with mental
health problems within the community and in the hospitals. Our country also implemented a
District Mental health Programme (DMHP), under the National Mental Health Programme 1996–
97, which was successfully developed and implemented by National Institute of Mental Health
and Neuro Sciences (NIMHANS), Bangalore at Bellary district of Karnataka, and later conceived

as a model and adopted by all States for implementation. This was one of the historical mile stone
in the promotive, preventive, curative and rehabilitative aspects of mental health.
The objectives of this programme are:
a. To provide sustainable basic mental health services to the community and to integrate
these services with other health services;
b. Early detection and treatment of patients within the community itself;
c.

To ensure that patients and their relatives do not have to travel long distances to go to
hospitals or nursing home in cities;

d. To take the pressure off from mental hospitals;
e. To reduce the stigma attached towards mental illness through change of attitude and public
education; and
f.

To treat and rehabilitate mental patients discharged from the mental hospital within the
community.

On my journey to Thiruvanthapuram, the capital city of Kerala, as soon as I walked out of railway
station I saw a man walking though the street- suddenly I stopped and looked at him and murmured
to myself which I later jotted down on a notepad. Here are the lines of this reflection:
O I see the wandering mind at the street...
Weared toned cloths, unshaved, unclean, wanderers of a dreamy world..
Some of them are lonely... and depressed....
Who made them lonely... Who made them mad...
don’t they had a beautiful childhood where they dreamed reality...
Didn’t their mothers dream a beautiful future for them...
But we just ignore... Seale them as mad....
Just to see them as human, just to accept them as they are...
Unless we do that we are mad...
Just because we do not accept reality
Meeting the team
It was my privilege to meet the team led by Dr.Kiran the Nodal officer and psychiatrist of DMHP,
and professionally assisted by Ms. Amrutha who is the clinical psychologist, Mr. Vinod the
Psychiatric social worker, Mr. Santhosh the Psychiatric nurse, Ms. Megha the clerk and Mr.
Pathmarajan the attender. As they move across the district they visualize ‘team work is dream

work’. The integrity and quality in service, equity in reaching rural poor and tribal, empathetic
understanding and action are the core values I could observe from the team. Moreover they enjoy
their journey and work. I must not ignore school mental health team, trainees and other volunteers
who join with them in this journey for a short period of excellent training and to contribute to
DMHP services. This collective action spreads throughout the district offering different forms of
psychiatric services.
Care for patients
One of the major services is conducting outpatient clinics in collaboration with Primary health
center, Community Health Center and Taluk hospitals in the district. Treatment, counseling,
psycho-social education to patient and care givers, maintaining case record, functional services,
and referral to mental health center are the main activity in these clinics.

Patients receive the treatment regardless cast, gender, age and economic status. The goal of
primary health and mental health care to all is realized through case detection with the help of
student trainees under the guidance of ASHA workers, mental health camp including three review
camps, maintenance of case records, and initiative of medical officers of concerned centers for
rehabilitation of patients to ensure a comprehensive and complete treatment.
Information, education and communication
Stigma existing at the community level prevents those with mental illness to receive treatment
therefore DMHP is engaged with providing information, educating and communicating to general
population and also grass root level community workers such as ASHA, ICDS, Kudumbasree,
self-help groups etc. These awareness programmes are conducted as street plays, puppet shows,
art and essay competitions, exhibitions, and presentation of mental health awareness chart in all
health care centers. It increased health seeking behavior to a large extent. This programme brings
an end to ignorance about government mental health services and to remove the stigma attached
to mental illness. It also helps in building support systems.
Targeted interventions and more

School mental health (Thalir)
A unique programme developed by DMHP Thiruvanathapuram, Thalir, helps in addressing the
mental health needs of children in the district. It includes awareness creation at school level
through puppet shows, documentary screening, and classes by trained professionals, life skill
education, teachers and parents training, school counseling camps, and case detection and referral
to DMHP clinic. This covers preventive, reconstructive and rehabilitative aspects. So far this
programme has reached more than 115 schools across the district. The major issues at school level
are scholastic backwardness, low I.Q, Attention deficit hyper activity, anti-social behavior, issues
related to relationships, family disharmony, financial problems, alcoholism in father; single
parenting issues, internet and porn addiction, poor inter personal skills etc. This programme
provides the children a space to resolve their issues with the help of counselors and teachers.
School mental health could be consider as mental health promotion it helps in developing personal
skills of students and also provides a creative supportive environment by providing education to
teachers and parents. This programme also helps in reorienting health services includes making
aware and enable them to access curative services.
Geriatric mental health (Thanal)
Ageing become another daunting challenge in Kerala, though increased life expectancy is a good
sign of health there is an another side to it. Lack of attention given to the aged has led to them
having a poor quality of life. The migration of Keralites to all over the world has led to the aged
being left alone at the home s(empty nest syndrome). Mental health of aged must be promoted and
cared for. The problems like memory loss, dementia, deteriorating physical health and related
stress are common among the elderly. DMHP as a team visits various old age homes run by
government and conducts health check up, dementia screening, counseling and recreational
activities.
Occupational Rehabilitation
I was privileged to visit one of the rehabilitation center run by DMHP in association with mental
health authority and local self-government at Mangalpuram Panchayat. Mangalapuram
rehabilitation center was established on 1st September 1998 with an aim of rehabilitation of people
with mental illness especially those who back home after treatment from mental health centers.

One of the former state mental health authority secretaries Dr.Surajmani and Dr. Najeeb (former
Medical officer of Magalapuram PHC) have set up a community board for the implementation of
rehabilitation center. DMHP has been implementing occupational based rehabilitation at the center
for the past few years. The main activities undertaken are medicine cover making and gardening.
This model is currently being tried in other parts of the district.
There are other various programmes like Bodhana stress management programme, Jeeva Rakshasuicidal prevention and so on. It is really an unmistakable hope given that India has shortage of
psychiatrists, less number of paramedical professionals.

I believe that we have a strong

programme in DMHP, and if it is implemented in a proper manner like DMHP
Thiruvananthapuram it gives us hope for the current and future mental health wellbeing of India.
This is an unmistakable sign of hope in the midst of gloom.

Activities of DMHP at a Glance

Clinics

Mental health
training

DMHP
Tvpm

Targeted
interventions
programmes

PHCs, CHCs, Taluk hospitals and After
Care homes.

Primary Care Doctors, Paramedical
staff.

School Mental Health,
Geriatric Mental Health,
Suicide Prevention,
Stress Management,

IEC Activities
Awareness Classes: To create
awareness among general public;
Govt.Servants, Media persons, Local
self Govt. representatives.

Rehabilitation
Activities
Occupational Therapy Units

Functional levels of Primary Care under DMHP Tvpm

Monthly DMHP clinics
Referral

For follow ups

Medical officers of concerned PHCs, CHCs

Reporting drop out cases

Bringing them to

Health workers (JHI, JPHN, HI, LHI)
Reporting

Asha and
anganwadi
workers

Case
detection

Ensuring regular follow ups
and helping in rehabilitation.

Mental health issues and cases in
community.

(Source: Prepared by DMHP Tvpm 2011)

PRIMARY CARE INTEGRATION

Primary care integration in psychiatry has significant importance at the community level since
India lacking mental health professionals and Para professionals. Thiruvanathapuram DMHP
became the first model of primary care integration model as it claims completed training training
and implementation. From March 2012, after the successful implementation of Psychiatric care
through Primary care centers, trained Medical officers of 21 PHC’s,CHC’s,THQH conducts 3
weekly psychiatric clinics and medicines are dispensing from pharmacies of concerned hospitals
itself. Cases of relapse or which need detailed evaluation referred back to DMHP clinics. DMHP
conducts monthly Psychiatric clinics as before to the 22 centers of Tvpm district. Case sheets of
the patients are filled and kept under the supervision of pharmacists.
Primary care integration was done in 3 phases.

PHASE I (Initiation)
1. Training for Doctors, Nurses, Pharmacists, Health workers, and ASHA workers of hospitals
where DMHP conducts clinics (22 in number).
2. Trained doctors to conduct Psychiatry OP in each hospital.
3. Psychiatric drugs to be dispersed by concerned trained pharmacist of each institution.
4. Case sheets to be prepared for each patient to be kept in concerned PHCs & CHCs.
5.
PHASE II (Consolidation)

1. Consolidation of the integration process
2. Assigning follow-up cases to weekly psychiatry OP conducted by trained primary care doctors.
3. Preparation of Case taking Performa and Treatment protocol for Doctors.
4. Preparation of Case detection forms and Follow up form for Health workers.
5. Preparation of Posters and Leaflets on signs and symptoms of mental illness and treatments
available, to be distributed and displayed in Primary care institutions across the district.

PHASE III (Extension)

1. Extending the integration process to all other PHCs & CHCs in the district.
2. Doctors, Pharmacists, Nurses and Health workers in these institutions to be trained in primary
mental health care.
3. Weekly Psychiatry O.P to be conducted in all PHCs & CHCs by trained doctors.
4. Follow-up cases in the first 22 clinics (of Phase -I) to be re-assigned to their nearest PHCs or
CHCs.
5. This will reduce the number of follow-up cases in each institution to 10-50 (from the current 100180 patients)
6. DMHP team will conduct clinics in 22 CHCs.
7. New cases and follow-up cases which are symptomatic to be referred by primary care doctors to
nearest DMHP clinic. After regular follow-ups, once these patients become stable, they will be
referred back to the doctor of concerned PHCs.
8. Mental Health Awareness and orientation regarding primary care integration to be given to all staff
members of PHCs, CHCs and also to elected representatives of Local Self Governments.

DMHP – SCHOOL MENTAL HEALTH PROGRAMME ADOPTED MODEL FOR
KERALA STATE
School mental health scheme in all Kerala districts
The Health Department has decided to scale up the School Mental Health Programme, currently
implemented in Thiruvananthapuram, to all districts from this academic year. ‘Thalir,’ the school
mental health project being implemented as part of the District Mental Health Programme (DMHP)
in Thiruvananthapuram for the past three years, has been chosen as the model for replication across
the State. The training of personnel to lead the programme in other districts is expected to start this
month itself. The programme is being scaled up across the State utilising a part of the funds —
Rs.20 crore — allocated to Kerala by the Union Ministry of Health for the implementation of a
Comprehensive Mental Health Programme in the State under the 12th Plan. Each district will be
allocated Rs.39 lakh for implementing Thalir, while the rest is to be utilised for mental health
rehabilitation projects in districts.
‘Thalir’ is one of the successful targeted intervention programmes launched by the DMHP in the
district. It has covered over 22,000 students in 112 schools. The programme aims at the holistic

development of schoolchildren by making them aware of the importance of mental health along
with physical well-being, offering them counselling, and addressing behavioural issues. The
programme works in coordination with the Adolescent Reproductive and Sexual Health
programme and the School Health Programme being implemented in schools by the National Rural
Health Mission.
Acting as a link
“We train school counsellors and School Junior Public Health Nurses to be the link between
students and teachers and the DMHP unit. Thalir is implemented as a total package for teachers,
parents and students,” says P.S. Kiran, nodal officer for DMHP. Counsellors and teachers receive
training from the panel of resource persons of the DMHP on how to identify problems among
children and how to respond to these as part of the programme. School counsellors receive
continuous training inputs from DMHP team.
Focus areas
‘Thalir’ focusses on addressing behaviour and emotional issues among children, helping them stay
away from substance abuse, suicide prevention, stress management, life-skills education, and also
managing childhood problems like learning disability and conduct disorder. Students are
encouraged to seek help from school counsellors.As part of scaling up the programme across State,
counselling centres will be opened in 1,926 schools this year.
Private schools have not been excluded from the programme, though government schools will
have the priority. K.O. Ratnakaran, Principal of Navodaya Vidyalaya, Vithura, points out that most
parents are aware of the psychological stressors that children are up against. Demand for regular
school-based counselling has been coming from parents themselves. “As teachers, we are trained
to recognise issues that children may have but as part of Thalir, all of us were given a new
perspective into the way children react psychologically to problems. The issues of today’s children
certainly require a more sensitive handling,” Dr. Ratnakaran says. “In the initial year, we had a lot
of trouble persuading schools to take up the programme. In the second year, though more schools
were willing to try it out, they were not keen on involving teachers and parents. But we do not
offer ‘Thalir’ to schools if the teachers or PTAs are not willing to be part of the programme,

because parents and teachers play a crucial role in molding a child’s personality and attitude,” says
Dr. Kiran.
Community based Rehabilitation - Occupational therapy Units at primary care settings
Rehabilitation and mainstreaming patients with severe psychiatric illness are key issues when we
are focusing quality health care to all. There are many patients under treatment for mental illness
who do not have active illness and are in remission. These patients need not be in hospital but
should be cared for at home so that they can slowly be brought to the mainstream. But very often,
after being discharged, these patients end up being a burden on their families. Unemployment and
rejection could drive them to alcohol or drugs; they could miss medication and finally end up in
hospital again. Occupational therapy helps them to build their self-esteem, confidence and also
help them to come into the main stream of life like any other individual.
Objectives
➢ To rehabilitate the patients who are under treatment but in remission.
➢ To provide occupational opportunities so that the patients can be gainfully employed.
➢ Helping people acquire the skills to care for themselves.
➢ To impart basic skill so that the dignity and self-worth of the individual can be sustained
through receiving remuneration for the skilled work done.

This is best achieved by establishing occupational therapy units in Primary Care Settings. DMHP
Tvpm started the first community based Occupational Therapy unit (‘Santhwanam’) in Kerala at
PHC Mangalapuram,Tvpm on19th march 2012.

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