Integration of Substance Abuse Disorders in National Rural Health Mission (NRHM)

1. Integration of Substance Abuse Disorders in National Rural Health Mission (NRHM) Dr. Rakesh Kumar, Dr. Kapil Yadav, Dr. Chandrakant S Pandav, Professor & Head, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi

2. It is easier to stay out than to get out Mark Twain

3. Outline Take Home Messages Background Public Health Approach to Substance Abuse Principles of successful integration Integration in National Rural Health Mission Take Home Messages

4. Take Home Messages Substance abuse is common in rural area. Huge prevention and treatment gap in substance abuse. Public health approach can bring high dividends Integration into National Rural Health Mission for efficient service delivery

5. Substance Abuse Changes in the functioning of human mind and more specifically leads to a state of intoxication

6. Spectrum of substance use Substance abuse is common in rural area. Huge prevention and treatment gap in substance abuse. Public health approach can bring high dividends Integration into National Rural Health Mission for efficient service delivery

7. Consequences of Substance abuse

8. Burden of substance abuse Source-NHS

9. Treatment and prevention gap

10. Control of Substance abuse Supply Reduction Demand Reduction To protect the health of people, particularly the most vulnerable, from the dangerous effects of drug use and from drug use disorders Health Care To reduce drug related diseases and social Consequences Harm Reduction

11. Clinical Vs Public Health In Public Health – Good work means no patients

12. Axioms of Public Health Prevention is better than cure Best should not be the enemy of good Good for many rather than best for few Primary health care is NOT primitive care

14. Strategies for Demand/Harm reduction Awareness and education Management through motivational counseling, treatment, follow-up and social reintegration of recovered patients Educated cadre of service providers – Drug abuse prevention and rehabilitation training

15. Organizational pyramid for mental health services

16. Advantages of integration

17. Integration is a process, not an event

18. Principles of integration Proper policy and plans Advocacy Manpower training Realistic tasks

19. Principles of integration Access to drugs Co-ordination with other sectors Proper support

20. NRHM Launched on 12 th April, 2005 with an objective to provide effective health care to the rural population, by improving access, enabling community ownership strengthening public health systems for efficient service delivery Enhancing equity and accountability Promoting decentralization

21. COMMUNITIZE 1. Hospital Management Committee/ PRIs at all levels 2. Untied grants to community/ PRI Bodies 3. Funds, functions & functionaries to local community organizations 4. Decentralized planning, 5. Intersectoral Convergence MONITOR, PROGRESS AGAINST STANDARDS 1. Setting IPHS Standards 2. Facility Surveys 3. Independent Monitoring Committees at Block, District & State levels NRHM – Main Approaches FLEXIBLE FINANCING 1. Untied grants to institutions 2. NGOs for public Health goals 3. NGOs as implementers 4. Risk Pooling – money follows patient 5. More resources for more reforms IMPROVED MANAGEMENT THROUGH CAPACITY 1. Block & District Health Office with management skills 2. NGOs in capacity building 3. NHSRC / SHSRC / DRG / BRG 4. Continuous skill development support INNOVATION IN HUMAN RESOURCE MANAGEMENT 1. More Nurses – local Resident criteria 2. 24 X 7 emergencies by Nurses at PHC. AYUSH 3. 24 x 7 medical emergency at CHC 4. Multi skilling

22. NRHM – Illustrative Structure Health Manager BLOCK LEVEL HEALTH OFFICE –--------------- Accountant Store Keeper Accredit private providers for public health goals 100,000 Population 100 Villages BLOCK LEVEL HOSPITAL Ambulance Telephone Obstetric/Surgical Medical Emergencies 24 X 7 Round the Clock Services; Strengthen Ambulance/ transport Services Increase availability of Nurses Provide Telephones Encourage fixed day clinics 30-40 Villages CLUSTER OF GPs – PHC LEVEL 3 Staff Nurses; 1 LHV for 4-5 SHCs; Ambulance/hired vehicle; Fixed Day MCH/Immunization Clinics; Telephone; MO i/c; Ayush Doctor; Emergencies that can be handled by Nurses – 24 X 7; Round the Clock Services; Drugs; TB / Malaria etc. tests 5-6 Villages GRAM PANCHAYAT – SUB HEALTH CENTRE LEVEL Skill up-gradation of educated RMPs / 2 ANMs, 1 male MPW FOR 5-6 Villages; Telephone Link; MCH/Immunization Days; Drugs; MCH Clinic VILLAGE LEVEL – ASHA, AWW, VH & SC 1 ASHA, AWWs in every village; Village Health Day Drug Kit, Referral chains

23. Accredited Social Health Activist (ASHA)

24. Possible role for Community level workers in demand reduction-1 Assessment of Community needs Identification of high risk individuals. Counseling and education of such individuals. Handling crisis situations in the families. Providing moral support.

25. Possible role for Community level workers in demand reduction-2 Organizing and participating IEC/ Awareness programmes for various groups such as high risk groups and schools. Linkages & Coordination with governmental health systems and non-governmental organization. Creation and operationalizing self help groups

26. Possible role for Community level workers in harm reduction-1 Early diagnosis (case finding / screening) and treatment of cases including referrals Helping the patient to identify substance abuse behavior and its consequences. Offering constant support to the patients. . Encouraging the patients to participate in treatment programme and continue.

27. Possible role for Community level workers in harm reduction-2 Referring the patients to appropriate agencies and organizations for seeking economic support for starting some vocation. Minimizing the stigmatization and discrimination against the patient by the community. Working in close liaison with governmental and non-governmental organizations for rehabilitation of the patients

29. Thank You