PAKALVEEDU- THE KOLLAM EXPERIENCE

INTRODUCTION

The three processes involved in psychiatric rehabilitation — Diagnosis, Planning, and Intervention — are known collectively as the DPI Process. ¹ In the diagnostic phase, a mental health professional assesses the patient’s readiness for rehabilitation and determines the overall rehabilitation goals after a functional assessment of the patient and available resources. Based on this diagnostic information, in the planning phase, a rehabilitation plan is formulated, the goal of which would be to develop the person’s current skills and resources. Finally, that plan is implemented in the intervention phase which focuses on direct skill teaching, skill use programming, and resource coordination and modification.¹

DAY CARE CENTRES

Day Care Centres are one of the main components in psychiatric rehabilitation, and represent one of the important alternatives to inpatient care in rehabilitating the chronic mentally ill.² Some Day Care Centres, named Pakalveedu, are implemented in Kerala under a new scheme, ‘Comprehensive Mental Health Programme’. It is an integral part of DMHP (District Mental Health Programme) and CMHP (Community Mental Health Programme), and is implemented in each district with the support of District Programme Managers (DPM) of National Health Mission (NHM). Under this scheme, two centres, one each for men and women, are allotted to each district. An amount of 20 crores has been provided under Head of Account 2210-01-110-23 (Plan Fund) to implement the scheme during the financial year 2013-14. The split up of fund sanctioned is detailed in Table 1.

Monitoring of the Centres’ activities and appointment of staff are done by an Institutional Level Implementation Committee comprising of Nodal Officer of DMHP/CMHP, DPM, Superintendent of the Institution (usually District Hospital) where DMHP’s Nodal Office is based, and Deputy DMO in charge of mental health. The building where the Centre would be set up can be hired, and the maximum rent allotted is Rs. 25,000/- per month, including water and electricity. (The amount is in concordance with the Kerala Public Works Department rates.) If a vacant building attached to Primary Health Centre (PHC), Community Health Centre (CHC) or local Panchayat is available, it can be selected too.

Item	Unit Cost	Total/Month	Total/Year
Rent, water, electricity	25000	25000	300000
Iron cot	10000	10000x30	300000
Mattress	4000	4000x30	120000
Pillow with cover	300	300x30	9000
Bed sheet	500	500x60	30000
LCD TV with Dish	60000	60000	60000
Morning tea & evening snacks	25	25x35 (including 5 staff) =26250	315000
Lunch	80	80x35= 84000	1008000
Mobility service (vehicle)	2000	60000	720000
Newspapers & periodicals		10000	120000
Occupational Therapist	1 staff	15000	180000
Staff Nurses	3 staff	12000x3 = 36000	432000
Cleaning Staff	3 staff	8500x3 = 25500	306000
Medicines		30000	360000
Sports items			200000
Vessels for serving food			200000
Table, Chair, Bench with back rest etc.			520000

APPOINTMENT OF STAFF

Staff is appointed on contract basis, for one-year, in adherence with general norms for contract appointment. Except for the post of occupational therapist, only female candidates are selected for centres for female. Selection criteria for various positions are:

Occupational Therapist: Persons with degree/diploma/training in occupational therapy from an accredited institution are appointed. In the absence of qualified candidates, MSW (Medical and Social Work) candidates with Medical and Psychiatric Social Work as special paper will be selected, subject to the condition that they will get trained in the minimum occupational therapy skills relevant to the type of occupational activities selected for the concerned Centre.

Staff Nurse: Candidates with MSc Psychiatric Nursing, Diploma in Psychiatric Nursing, or retired Staff Nurses who had worked in Mental Health Centers are given preference.

Cleaners: The person should know to read and write Malayalam.⁴

DUTIES AND RESPONSIBILITIES

Day to day activities of the centers will be under the direct supervision of the Nodal Officer of the DMHP/CMHP.

In addition to the duties related to occupational therapy and its documentation, the Occupational Therapist also has the overall charge of administrative supervision of the Centre. One of the Staff Nurses is given the overall charge of patient care, and the cleaning staff is responsible for all the cleaning activities and other casual requirements in the Centre.

Staff Nurses are in charge of the transportation of patients — one of the Nurses accompanies the patients, in the same vehicle, on pick up, and another Nurse, in rotation, accompanies them on their way back.⁴

FUNCTIONING OF THE CENTRE

The working time is from 10 am to 4 pm. Vehicle for the project is outsourced, as per the procedure usually followed by DMHP and CMHP. The vehicle starts from the Centre by 7.30 am to pick the patients from their homes, and takes them back by 4 pm. All details of the patients and their relatives, including passport size photos of the patients, are kept in the Centre’s office.⁴

TREATMENT

DMHP/CMHP team conducts monthly clinics in each Centre. Psychiatric drugs are supplied by DMHP/CMHP, and any psychiatric drugs not available through that route are obtained from Kerala Medical Services Corporation Limited (KMSCL) through annual intend. Non-psychiatric drugs can be procured from the nearby Karunya Pharmacy, Community Pharmacy or Supplyco-run Neethi medical stores, by local purchase based on actual requirement.⁴

RELEASE AND UTILISATION OF FUND

As per the original order,⁴ the fund was to be released to the Nodal Officers through DPM of the concerned district, based on request from the former, and the fund released to the DMHP was to be kept in the TSB account/Bank account of the concerned DMHP/CMHP. Separate accounts had to be opened to keep the fund for this project. The DPM was to make the necessary arrangements for procurement of materials, based on the request from the concerned Nodal Officer, and then the actual payment was to be done by the latter.

However, as per the latest circular from Director of Health Services, Kerala dated 25/11/2014, the financial transactions of the program have to be managed through a TSB joint account or through a joint account in a nationalized bank with RTGS (Real Time Gross Settlement) / NEFT (National Electronic Fund Transfer) facility by the DPM and Deputy DMO in charge of mental health, except for Palakkad district. The reason for the change was the lack of ownership among officials who are stakeholders for the implementation of Ccomprehensive Mental Health Program. Kollam DMHP has already started following this new order.

Nodal Officer has to keep contact with the administrators and leaders of the District/Block/Grama Panchayats and credible NGOs of the locality, and try to involve them in activities of the Centre. The Centres have the freedom to accept sponsored items, like building or occupational therapy unit, from NGOs or other credible agencies.

DAY CARE CENTRES IN KOLLAM

The Centre for males started functioning on 4^th August 2014 at a building provided by Block Panchayat, Mukhathala. The building, which was originally constructed as an old age home, is located in 54 cents of land. The Centre for females started functioning at a building provided by Grama Panchayat, Clappana, on the premises of PHC, Vallikkavu on 30^th March 2015.

Staff were appointed, as per the norms, by the Implementation Committee. In both the centers, as no Occupational Therapists turned up for the interview, Social Workers were appointed in their place. Vehicles (16-seater mini bus and Tempo Traveller) were hired for both the Centers, on contract basis, for one year. Necessary equipment like chairs, tables, cupboards, office record books, utensils for serving food, sports items and mats were purchased. Television for both the Centres, wooden stools, dining table, one iron cot for the male centre and two sewing machines were received as sponsored items. Food in both the Centres is being provided by Kudumbasree units in the locality, on contract basis for one year.

PATIENT SELECTION

We selected patients from our own DMHP Clinics and also from the locality near the Centers. Social Worker and a Staff Nurse screened the patients from the locality, and the patients thus selected were further scrutinised by both the Team Psychiatrist of DMHP and the Nodal Officer.

SOME STATISTICS

(Since the maximum number of patients allowed is only 30, from those who registered we selected 30 who were willing to come on a regular basis.)

Table 2: Diagnostic break-up of patients attending both the centres. MR = mental retardation

ACTIVITIES IN THE MALE CENTRE

In both the Centers, we focus mainly on the intervention phase and teach new skills.

The major activities include agricultural activities, making medicine covers and X-Ray covers, recreational activities, and yoga and exercise. Vegetables are grown in grow bags and the available land. So far, cauliflower, ladies finger, tomato, brinjal, peas, chillies, spinach, tapioca and plantain have been grown, and the vegetables cultivated are distributed to the patients themselves.

Medicines covers and X-Ray covers are being purchased by nearby Taluk hospitals and PHCs. DMHP Clinics too utilise these covers to distribute medicines. The amount thus earned is equally distributed amongst the patients.

Recreational activities include indoor games like caroms and outdoor games like cricket, badminton, and volleyball. Exercise and yoga too are being regularly practised.

ACTIVITIES IN THE FEMALE CENTRE

The major activities include carpet making, medicine cover making, OP Book making and agricultural activities. Making carpets and mats is the main activity. Old cotton sarees are cut into small pieces and interwoven into small mats. More than 50 mats have already been sold, and the amount thus generated has been distributed among patients as an Onam advance. OP Books are utilized by DMHP Clinics. Vegetable cultivation is also being done, albeit in a small scale. As we had received two sewing machines as sponsored items, we plan to teach stitching to some inmates.

In 2015, Onam and Independence Day were celebrated in both the Centres. A function was organised in connection with the first anniversary of the male centre — it was inaugurated by the Jila Panchayat President, and other local leaders too participated.

CHALLENGES FACED

It was very difficult to find the buildings, and we had to search for more than six months. Since preference was given to vacant buildings attached to local Panchayats or PHCs/CHCs, technicalities like NOC, and concurrence of both the ruling and opposition parties had to be obtained. Since the female centre was started in the subsequent financial year, sanction had to be obtained for re-appropriation of funds.

As already mentioned, we had to appoint Social Workers as Occupational Therapists. Actually, only a few Occupational Therapists are available in the state.

Apart from the Nodal Officer, only one Psychiatrist (Team Psychiatrist of DMHP) is associated with the project and he has to cover all the DMHP Clinics in the entire District (both the Psychiatrists are from Health Services). It would be better if a post of Medical Officer is sanctioned in DMHP too, the way it has been done in CMHP.

In the initial stage, there was a lack of co-ordination between various implementing agencies. A better coordination between the implementing officers would yield more fruitful results.

In the beginning, some parents were reluctant to send patients to the centres due to the fear of getting branded as insane. But the situation slowly changed, as is evident by the increasing number of patients in both the centres. This is mainly because of the confidence earned by our Staff in the locality and the patients getting involved in activities.

SOME CRITICAL COMMENTS

1. As per the fund allotted, there is provision to buy 30 iron cots with mattresses, pillow and cover — which amounts to Rs. 4,20,000. Since the patients are brought to the Centres to do some activities and not to take rest, it is better that a maximum of 3-5 iron cots are provided per Centre. Rest of the amount can be utilised to provide occupational therapy.

2. Similarly, the initial amount provided to buy sports items — Rs. two lakhs — is too high. Instead, a fixed annual amount may be sanctioned, as the items can get damaged through usage.

3. Salary of the Staff Nurse or the Occupational Therapist is not at par with Public Service Commission (PSC) appointment in government sector. This could be rectified by using the excess fund sanctioned for other items like sports items.

4. There should be uniformity between DMHP (state fund) and CMHP (NHM fund) in allotting funds and in other requirements. If both can come under a common platform, it will help in smoother conduct of the Centres.

CONCLUSION

Day Care Centers (Pakalveedu) have added a new dimension to mental health care and rehabilitation in the state. They were proposed for benefit of the cured mentally ill who needed regular follow-up, rehabilitation and ongoing medical care. The programme is first of its kind in the state and is in the developing stage. Obviously, it will take time for the Centres to become fully functional. Kollam experience shows the project to be a success, since the number of patients is increasing and the drop-out is almost negligible. Some patients have been successfully rehabilitated back to the society — two were able to take up regular jobs, and their social and occupational functioning dramatically improved. As a result, the families were empowered and their attitude towards mental illness changed. The Centres need to be further strengthened through better co-ordination between the implementing agencies and an uninterrupted supply of resources.

Diagnostic Break-up	Male Centre	Female Centre
Schizophrenia	10	7
Mood Disorders	5	7
MR with Psychosis	8	3
MR with Epilepsy	5	10
Organic Mood disorder	1	2
Dementia	1
Total	30	29