Mental Health Delivery Service in a

Province in Nueva Ecija

JOHN RYAN A. BUENAVENTURA, RN, MAN, MHSS


Executive Manager
Philippine Mental Health Association Nueva Ecija-Cabanatuan City Chapter
pmhanechapter@gmail.com
(+6344) 463-76-30 | (+63) 927-5880702


President
Psychiatric-Mental Health Nurses Association of the Philippines, Inc.
pmhnap@yahoo.com | pmhnap2010@gmail.com

Background: Area of Study

Nueva Ecija
Region: III
Population: 1,955,373 (2010, Census)(45% Children)
Poverty Incidence: 23 % (Region 12.2)
Cities: 5
Municipalities: 27
Barangays: 849
Industry: Agriculture
Background: Philippine Health System
Specialty Hospital and Regional Hospital
Tertiary Level
General Hospital
Secondary Level
Municipal/Rural Health Units/Barangay Health Centers
Primary Level
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Objectives

describe profiles of mental health services in
the formal and informal sectors; and
identify issues on the local mental health
services

Study 1 Formal
Mental Health
System
Study 2 Informal
Mental Health
System
Design
Descriptive Quantitative Descriptive Qualitative
Sampling
Total enumeration Snowball (N=20)
Method
Survey, Interview and
Literature Review
In depth interview
Instruments
Interview schedule Interview guide
Period
January March 2011 April May 2012
Limitations
Covers only areas of
Cabanatuan City
Covers only Nueva Ecija
Non-generalizable
Funding
My Parents Ford Foundation
Formal Mental Health Care
*Regional
Mental Health
Hospital
Psychiatric Services
in General Hospital
Community Mental Health
(NGO)
Primary Care Services
Specialist (Psychiatrist, Psychiatric
Nurses, Psychologist, Social
Worker
Psychiatrists
(3 private/1 government) Outpatient Service
Out patient
Acute Care
Long Stay Service
Services
Team
Referral
Referral
Psychologist
Generalist
(GP, Nurses,
Midwifes, Barangay
Health Workers))
*outside the province
Informal Mental Health Care
Structural
Family Caregivers
Characteristics
Family Units
Characteristics
Perceived Access to
Formal Mental Health
System
Procedural
Management
Coping
Support Seeking
Outcome
Physical
Psychological
Social
Qualities of
Family
Caregiving
Structural
MH Consumer
Family
Caregiver
Family Unit
Formal Mental
Health System
Age (18-60); Gender (11male & 9female);
Marital Status (Not Married); Onset (15-26);
Years of Disability(3 to 29)
Age (35-65); Gender (female); Marital Status
(Married); Relationship (Mother); Education
(High School Grad); Function (Work; household
and caregiving)
Members (4-7); Income (3-5 USD/day); Living
Arrangement ( with Parents); Kin network
(nuclear and extended); Source of Income
(Skilled work and farm related)
Availability
Kind of Professional ( Multiple 18; Psychiatrist
17; Folk healer 9; Nurse 1)
Nature of Organization (Private 17; Government
16; traditional 9; non-government 2)
Level of Service (Private Clinic; Mental Hospital;
Traditional System)
Affordability (out of pocket for both
government mental hospital and private clinics)
Physical Accessibility (more than one hour travel)
Hindi kasi pareparehas ang oras ng pag-aalaga. Ngayon, hindi na siya
yoong alagain. Titingnan tingnan mo nalang. Hindi tulad dati na
ibibigay mo ang lahat. Yoong imomonitor mo. Halili-halili kami. Hindi
kami natutulog. Nakaduty kami na parang Nars

(Duration of caregiving for her varies. Now, we are just
observing her. Unlike before that you will monitor her. We
experienced having lack of sleep and we even have
shifting schedules like nurses.)

Sa Mariveles, bumiyahe kami ng alas singko ng medaling araw at
dumating kami doon ng halos alas-diyes. Mga lima hanggang anim na
oras pag walang trapik.

(We left here at five in the morning and we arrived at
Mariveles for almost ten. It was five to six hours travel if
there is no traffic.)

Procedural
Coping
Strategies
Support Seeking
Family
Management
Physical (39) Substance and
Food Restrictions; Assistance to
ADLs; Provision of Medication and
Treatment; Safety Provision &
Physical Punishment
Psychological (27)
Facilitating, Communicating,
Threatening, Educating, Role
Playing, Concealing, Diverting
Social (19) Avoiding
Relationships, Restraining
Freedom, Encouraging to work
Spiritual (10) Prayers for
death(end suffering), strength (for
the caregiver), healing (for the
care recipient)
Psychological (23)
Enduring, Avoiding, Withdrawing,
Permissive, Tolerating, Denying,
Accepting
Socio-economic (16)
Borrowing Money, Asking for
family support, Buying cheaper
medicines, Raising Live stocks,
Saving for medication
Physical (9)
Prioritizing medication,
Confronting verbally, Confining,
Hurting, Isolating
Spiritual (7)
Praying
Organization Support

Treatment
Discontinued, Involuntary

Medication
Pills (Caregiver Provided),
Injection (Psychiatrist
Administered), irregular/no
medication intake (n=12)


Tactical Support
Financial (14); Treatment(7) ;
Physical (6); Custodial (3);
Food Assistance (1);
Transportation (1)

Recruiting Support
Family
(Financial-14; Food-5; and
Physical Assistance-5)
Community
(Financial -6; Treatment 6;
Transportation 6)



Hindi ko na sinasabi iyong nararanasan ko. Kesa sa iba siya makasakit,
pinipigil ko ang kamay niya ay niyayakap. Ako ang sinasabunutan, sinusuntok
at tinatadyakan

(I am not telling to anybody what I am experiencing.
Instead of she hurting others, I am just hugging her.
In return, I am being beaten by her)

Kapag hindi siya nagpatulog, sinasampal ko siya. Tumitigil naman. Sa akin lang
naman siya natatakot

(If she disturbs other, I slap her on her face. She
stops because she fears me.)

Eh ayaw man namin siyang ikulong, wala kasi kaming magagawa eh. Noong kasing
mga nakaraang panahon, hinahabol siya ng mga kabataan at niloloko. May pag
kakatan pa na pinaso siya sa tagiliran.

(Even though we do not like him confined, we cannot do
anything because there are times that he was bullied by
children and harmed by others.)

Kapag pasaway at maingay, ako ang humaharap diyan. Sinasabi ko na haharumbangin
ko iyang nguso niya para matakot

(If he gets uncontrollable, I am the one who deals with her. I
told her that I will punch her mouth to fear me.)

Ngayon ay nakatali siya pero may plano kami na ikulong siya. Iyon ang payo ng mga
manggagamot. BAwal daw ang pag tali at hindi daw bawal pag nakakulong.

(The folk healer adviced us that instead of tying him, it is
better if we put him in a cage because it is more acceptable.)
Outcomes
Social
(40)
Psychological
(28)
Physical
(23)
Contribute to financial
difficulties (15),
Affects social
relationships (12),
loss of productivity
(10),
Social benefits (3)

Feel emotions of
fear(11), Pity(5),
Anger(4), Guilt(1),
Sadness(1)
Think of killing the
patient(2), worrying
about the continuity of
care(2), think of
receiving more benefit
Perceive of getting
insane (2)
Reduced Sleep and Frequent
headache (9), Reduced physical
mobility and experienced body
weakness (4), Reduced Weight (2),
increased blood pressure (1),
abnormal tissue growth (1)
Physical Outcomes
(neurologic, musculo-skeletal, body injuries,
nutrition, cardiovascular, and abnormal tissue
growth)

Kung hindi pa siya natutulog, hindi ako natutulog.
Kahit masakit na iyong ulo ko sa antok, hindi ako
nauunang matulog sa kanya.



Psychological Outcomes
Hindi mo naman masasabi lalo na kung babae
na mauto siya ng lalaki at pasok siya sa bahay
at mapagsamantahan. Iyon ang hindi ko
kayang tanggapin.

(You cannot tell that she cannot get harmed and
abused by others. If that happens, I cannot
accept that.)


Social Outcomes
Pag may anak kang ganyan, kasiraan yan. Kahihiyan ng
pamumuhay.
(If you have a child with schizophrenia, it causes no good.
It puts us into shame.)

Para bang iniiwasan ka ng ibang tao. Napapnsin ko na
iba na sila at hindi na nagpupunta sa bahay.
(People are moving away from me. I noticed that they are
not anymore visiting us at our home.)



Local Mental Health Situation

*Regional
Mental
Health
Hospital
Psychiatric
Services in
General
Hospital
Community Mental
Health
Primary Care Services
Family Caregiving
Self-Care
Sole provider of acute psychiatric center
Limited services (acute and long stay psychiatric care)
Mainly Private Provider
in Private Hospital
Unavailability of Services
High out of pocket expense
Received limited support from Local Health
(Education, Treatment and Social Support)
Burdened Physically, Psychologically and
Socio-economically
High Treatment Discontinuation
Unutilized Primary
Health Care System
PROJECT DESIGN: MAG B-P
(BAGONG PAG-ASA) TAYO
Community Mental Health: Assertive
Community Treatment

This project aims to bridge the gap of mental health system and make
use of existing resources in the communities to optimize mental health
service. Specifically, it aims to:

Increase treatment adherence through lowering cost of care
Provide comprehensive mental health care with family and
community support
Utilize existing resources such as social services, livelihood
programs and health providers in the community for mental health
cause

Project Framework

Advantages of the project
Lower cost of care for up to 50 %

Cost of Care Private CMH
Direct Cost 700.00 500.00
Indirect 300.00 50.00
Total 1000.00 550.00
Opportunity
Cost
High Low
Advantages of the project
More Care Benefits

Kind of Care Private CMH
Consultation Yes Yes
One on One
Education
Yes (Short) Yes (Moderate)
Family Education None Yes
Group Dynamics None Yes
Community
Participation
None Yes
Resource Utilization None Yes
Advantages of the project
Utilization of Community Resources
Agencies like
Education (ALS program),
Health (primary health care),
Social services (livelihood program) and
Civic participation (organized community group)

Advantages of the project
Work for the nurses in the community

Provider Number of
Barangays
(week/month)
Number of Client
for 4 days (5
clients per day)
Cost per
client
(share of
nurse)
Total
Revenue
Nurse A 2/8 20 100 2000
(400/day)
Nurse B 3/12 20 100 2000
(400/day)
Nurse C 4/16 20 100 2000
(400/day)
Nurse D 5/25 20 100 2000
(400/day)
Example Schedule of Work
Time Monday Tuesday Wednesday Thursday Friday Saturday
8-10 Home
Visit
Home Visit Home Visit Home Visit Group
Psycho
Education
Case
Conferen
ce with
other
team
members
10-12 Home
Visit
Home Visit Home Visit Home Visit Individual
Skills
Building
1-3 Home
Visit
Home Visit Home Visit Home Visit Group
Productivit
y
3-5 Docu Docu Docu Docu Docu
Location Barangays Barangays Barangays Barangays Rural
Health Unit
or
Communit
y Center
PMHA
Center

Acknowledgment
SALAMAT PO