Building Community Mental Health Competence in Western Uttar Pradesh: Successes and Challenges

SHIFA, a community mental health project of the large non-profit faith-based organisation the Emmanuel Hospital Association (EHA) (www.eha-health. org), started in April 2012 in Sadoli-Kadim block (an administrative unit of around 150,000 people) in Saharanpur district, Uttar Pradesh (UP), at the upper reaches of the densely populated Gangetic plain. SHIFA is supported by an Australian community development funder, and had been supporting community health and development initiatives, including community organisation, reproductive and child health, and micro-credit savings groups in the Sadoli- Kadim area in the previous nine years. They had moved to focus on promoting mental health and disability rights after building relationships with multiple families affected by disability and mental illness who described complete lack of access to care and support (Varghese et al. 2015) and requested support from the project. Saharanpur is a relatively poor district with 3.5 million people (40% Muslim, 60% Hindu) and a literacy rate of 53%. Health indicators for the district are lower than national and UP state averages. Western UP has been a recent flashpoint for communal violence (Bhatt 2013; Times of India 2014).

While a District Mental Health Programme (DMHP) was launched in India in the 1980s, it has been imperfectly and incompletely implemented across the country (Jain and Jadhav 2009; Sarin and Jain 2013). In Saharanpur district, there are no mental health services provided by the government, no psychologists, and one private psychiatrist. The second author is linked to the project through her work as a mentor and technical advisor. The following discussion reports on data gathered through observational and support visits to the project, and interviews with people with mental distress and other community members.

At the start of the SHIFA project, the biggest areas of felt need described by the community were for support to caregivers, knowledge, skills in mental health, and access to care for people with mental distress. The community also described significant social exclusion and stigma for people with seizure disorders and mental distress.

The overall vision of the SHIFA project was to empower communities of Sadoli-Kadim block, in the universal promotion of mental health. This included strengthening the community voice to advocate for care and support through the formation of community-based disabled persons groups (DPGs), and increasing awareness and knowledge among 35 mental health volunteers

Table 11.2 Success Factors and Challenges in Building Community Mental Health Competencies in SHIFA Project, Uttar Pradesh

Success factors

Challenges

Knowledge

Knowledge and awareness led to referral networks and normalised experiences (Petersen et al. 2012)

High commitment to training of community volunteers and peer educators (frequent trainings, curriculum, resource development with support from psychiatrist)

Lack of explicit training in conscientisation for project staff and community volunteers

Lack of confidence/training/skills in leading community discussions using rights-based frameworks

Safe social spaces

MHVs and PEs representative of minorities in community enabled acceptance and participation of these groups including people with disabilities (less for people with mental distress)

Care plan prioritised felt needs of client increasing their agency and participation in their own recovery

Enduring social hierarchies and scant 'horizontal dialogue'(Freire 1973, Campbell and Jovchelovitch 2001)

Frequently changing government functionaries and lack of will in district health officers to provide access to services for people with mental distress

Partnerships

and

collaborative

actions

Fortnightly clinic provided platform for nonpharmacological and biomedical therapy, awareness, knowledge building, street theatre, and social interaction

Lack of historical precedents of communitisation Recent communal violence in the district discouraging loud voices seeking to bring change.

(MHVs) and 140 trained peer educators (PEs). Further objectives were to strengthen the public health system through community monitoring and to increase access to primary mental health care, using the framework of the United Nations Convention for Persons with Disabilities (CRPD) (United Nations 2008). After 15 months of project implementation, the SHIFA project started a fortnightly mental health clinic, led by the EHA psychiatrist and a primary care physician located nearby (Table 11.2).

 
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