Introduction

According to the World Health Organizations The Global Burden of Disease (GBD) 2004 update (World Health Organization (WHO), 2004) almost half of the disease burden even in low and middle income countries like Sri Lanka is due to non-communicable diseases. Even among the Non Communicable Diseases (NCDs), mental health disorders seem to be taking a quite an important place as evident by the GBD 2004 update according to which Unipolar depressive disorder alone ranks third when considering the overall causes of the disease burden both communicable and non-communicable thus first in non-communicable diseases. To further exemplify the high contribution of the mental health disorders to the burden of diseases and its relation to the Sri Lankan context it would be worthwhile to note that in middle income countries Unipolar depressive disorder ranks right at the first place among the causes of disease burden (WHO, 2004). People with mental health problems are one of the most marginalized groups in Sri Lanka. Three main issues have been identified which contribute to the marginalization of people with mental health problems: (a) Social discrimination - people with mental health problems are frequently ostracized from society due to ignorance, myths, false beliefs and lack of awareness of their rights. (b) Inadequate access to mental health services, resulting in lack of treatment and rehabilitation - mental health services which exist are concentrated in urban areas with little or no services in rural areas, and specialized services for the elderly and children are extremely limited (c) Economic barriers - families of people with mental health problems are often poor and are not provided with welfare benefits to address their psychosocial needs. Underpinning all of the above causes is Sri Lankas out-dated mental health legislation, which is over 100 years old. More than 100 yrs old mental health Act (1873) is an obsolete policy given the present mental health situation in Sri Lanka. Horrific contributions from devastating Tsunami 2004 and just ended destructive 30 yr old war have made am huge impact on Mental Health requirements in Sri Lanka. Further, other natural disasters and two insurrections (1971-1990) too have immensely impacted on Sri Lankan population. Therefore, after a thorough study of the present Mental health situation in Sri Lanka a 10yr work plan was prepared. Thus, new Mental Health Policy was created. In order to address those mental health issues the new Mental Health Policy is being implemented to cater to the needs of the Sri Lanka society.
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Issues with Mental Health Policy Compare to Real Situation.

Although it has mentioned about 30 beds ward for every general hospital, we cannot find a these kind of ward in most of hospital .and there are some hospitals without even psychiatric doctor. The separation for some therapies can be seen only in few of hospital. As an example NIMH-Angoda. Although they mention about counseling, psychological, relaxation, occupational and other therapies, there is no such positions functioning in the healthcare system. There is no any recruitment process for Social Workers, Psychologist, etc. There is no Promotion hierarchy for Paramedical officers while having medical officers. Since there are no paramedical officers, there is no one to do a follow up process in treatment plan Social Workers and other relative officers are the main step to going an identify the patient in the community but since there are not appointed such officers one there to identify and examine people Educating people is more important to patients safety and avoid stigma. That is a responsible of social worker to educate every family member and educate community level. Since there is no social workers position, no one there to get this responsibility.

Organization of services.
A broad range of rehabilitation and psychosocial care services will be developed at district level close to the community to support ongoing rehabilitation. Units will be diverse, depending
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on identified levels of local need, initially supported by data including the Community Placement Questionnaire (CPQ). Rehabilitation, intermediate care units will be no larger than 20 beds, and the target duration of stay should not be more than 6 months. Staff trained in psychiatric nursing and/or psychosocial rehabilitation will be appointed to work in these units. Focus of care is on psychosocial rehabilitation activities to ensure that patients maintain or develop essential skills to return to society. Family involvement will be required. Where patients cannot be integrated with families and communities a suitable alternative should be found through inter sectoral mechanisms. The CPQ exercise in Western Province so far, has shown the need for a range of continuing care accommodation. These include staffed and unstaffed homes, sheltered nursing homes and secure facilities. Health staff will also visit the remaining range of other types of accommodation provided; many of these facilities will be provided by NGOs, with appropriate funding arrangements.

Psychosocial support is the process of meeting a person's emotional, social, mental and spiritual needs. All of these are essential elements of positive human development. Psychosocial support is needed by all mentally ill people. They might be depended each other. Psychological support promotes their psychological and emotional wellbeing, as well as their physical and mental development. Psychosocial support helps to build resiliency in those who are affected. It also supports families to provide for the physical, economic, educational, and social and health needs of patient. Patients are resilient, but when faced with extreme adversity and stigma, they and their families can need extra support. Psychosocial support builds internal and external resources for patient and their families to be able to understand and deal with adverse events. Thats why there should be a rehabilitation process. Some patients need specific, additional psychosocial support. These interventions usually target those who have experienced extreme stigma or without under control, or who are not receiving the necessary support from caregivers. Such interventions should be provided in addition to any

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ongoing support from community level and rehabilitation vise. That is what above policy tries to explain. They have mention about psychiatric nurse and other psychological support team. But at the present situation it is not functioning. They have focus on care services of the patient to ensure that patients maintain/develop essential skills to return to society, but without social worker, psychiatric nurse or relevant to that profession, no one there to follow up these patient. When we talk about mental health, most of time it is connecting to family or society, because of a social break down, one person can be affected to kind of mental problem, finally one person can be a mentally ill. then although we treat them using drugs, after going back to their own place again he need to face to same problem and issue then problem can be worst again and again. Thats why we called there should be a follow up to rehabilitate situation and send back service user to own place. Family intervention is more important while dong treatment, and even after the treatment. The reason is family is the most powerful and closer one to patient. It can be the most useful step to treat to patient. Family members should now some information about the patient and how to look after him as an observational mind until patient fully cured. But in Sri Lanka there is no such a culture in our health care system. Not only patient, but also their family members cant talk with doctors and have knowledge about the problem. One side is doctors are so busy and they dont have time to explain and other side is they dont like to explain about patient according to Sri Lankan culture they think they are in superior level. So that is the place there must be a person to get that responsibility. But no one there at the movement although it is explains by the policy. Policy must not write on a paper that must be active in the society. Medicine can cure up to certain level but cant fully, that is why there should be multidisciplinary team combine with psycho social support and medical staff. But at the movement they are only written sentences. Health is a state of physical, mental & social wellbeing & the mental health services should be provided as part of primary, secondary & tertiary health services. Mental well-being is a fundamental quality of life. Mental health services should aim to enhance peoples well-being & it should be function in a flexible way. Furthermore, it should enhance protective external factors such as social integration, empowerment, social support & social responsibility. The constitution of the Democratic Socialist Republic of Sri Lanka 1978 provides freedom from degrading treatments & discrimination, quality by the law & protections of its citizens as well.
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According to the Mental Health policy of Sri Lanka 2005-2015, it is stated that, organization of services, mental health services will be rearranged & distributed & it provide care for all age groups. To make that process easy, each district have a network of services as follows; Acute in patients units Intermediate care services Community support centers/ day centers/ clinics for every MOH area A resource center Community based care

Hospitalization for children is the policy for children, which is included in the Mental Health policy. According to that in each hospital there should be a separate ward for children with mental illnesses. They should not be hospitalized in adult wards. Each district will have one Community Support Centre (CSC) per MOH area & day centers as well. CSC is very important because through that place all activities for mental well being can be coordinated. The development process is doing by other ministries & organizations. Moreover, as part of the development of services, an independent strategic review of the future of Angoda, Mulleriyawa & Hendala hospitals in Western province is on process. Also, the patients are transferring from the mental hospitals in Western province to new district or other provisions in the community, including commissioned care from registered NGOs. Specialized services such as; alcohol & other substance abuse services, high secure forensic services, specialist child mental health services, mother & baby services, family services & liaison psychiatry should be developed as its on the mental health policy in Sri Lanka. Mental health care in prisons & other facilities which are providing by the state will be improved. It shall be equipped to provide mental health services as need, in accordance with prescribed regulations.

Function of the services.

The function of the above services is in a satisfactory level all over the country, but there can be seen some weaknesses as well. Health is given by free for Sri Lankan people. Therefore, the government tries to provide an effective service for the people. Actually, when compare with other South Asian countries, Sri Lankas health system is on the top. The government is
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implementing new legislation & policies under the service provision of health. Under health, there are certain services which are providing by the government. Among them, there can be seen a variety of service provision under mental health because as physical health, mental health is also very important. The mental health services are functioning in a satisfactory level. But there cant be seen a spreading of mental health services all over the country. For example, there are only three mental hospitals in Sri Lanka & all of them are located in Western province. They are Angoda, Hendala & Mulleriyawa hospitals. Therefore, for far away people its bit difficult to travel all the way to Colombo for the medical treatments. On the other hand, most of the times, all the services & doctors are limited only to the main provinces. Even though it is said in the mental policy that there should be separate psychiatric wards in each hospital & community support centers in each MOH area, there arent so, even though the government established those wards & centers most of them have to be closed due to lack of staff & resources. But, when concern about the entire system, its very clear that the mental health service provision is functioning well by providing a better service to the patients. For the better service, the reasons are the promotion, prevention & community services. The government works in close collaboration with other ministries departments, institutions, NGOs & private organizations to implement & develop programs for medical staffs training & a support is given help to improve the standard of them. The ministry of health conducts regular monitoring & evaluation of prevention & promotion programs to determine their effectiveness. The Mental Health Advisory council functions for the purposes of upholding the rights & duties established under the act. Furthermore, it provides advices, policy & recommendation to the ministry regarding the eservices. There are district review committees to examine the mental health services in district levels & do the alternatives what they required. Rather than being a failure, Sri Lanka provides a model of psychiatric care for low-income and middle-income countries.

Limitations of the organization of mental health services.

There are limitations in the service provisions of mental health in Sri Lanka. Even if the mental health act & mental health policy included all the necessary facts considering the entire population & their needs still there are limitations when putting it in to action. Here are some major limitations which can be identified:

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Community placement questionnaire exercises (CPQ) has been functioning only in Western province so far. This must be widespread to all the provisions in the country because through this the ministry can identify many important facts regarding the mental health & its provisions. There arent separate mental health ward for children in any base hospitals. This is one of the main limitations which can be seen in the Sri Lankan context. A child with a mental illness has to stay in a normal childrens ward when the child was hospitalized. There are not mental health communities functioning in each district. The major reason is the government failed to appoint relevant workers who are specialized on this relevant field. Sometimes, the staff who works there are not qualified, so they fail to keep the interest of the patients & provide a better service to them. Each district doesnt have mental health community support centers (CSC) per MOH area. Sri Lanka has a free national health service but the main reason for the inadequate mental health care was the shortage of mental health specialists. There are not separate mental health wards in many government hospitals. There are mental health wards only in major hospitals which are mostly situated in towns but not in rural areas. Behind that, there arent qualified staffs in many hospitals except a few. There arent mental health hospitals in any other provisions except Western province. All three major hospitals Angoda, Hendala, Mulleriyawa are situated in Western province around Colombo. So, its a quite disadvantage for the patients who live in out station to reach for treatments. There is not much development on specialized services such as;

Alcohol & other substance abuse services. High secure forensic services. Specialist child mental health services. Mother & baby services. Family services. Liaison psychiatry.

The mental health care & other facilities in prisons are not well developed. At least two prisons in the country shall have a designated mental health unit plus it shall be equipped to provide mental health services as need according to the rules & regulations.
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The above mentioned facts are the main limitations which can be identified in mental health service provision. Actually, this service provision is functioning under the government legislation & policies, therefore, there can be seen the impact on those policies in the service provision. Even though it has some limitations, the impacts of policies help to provide an effective service.

Impact of the mental health policy

The socio-political troubles faced by Sri Lankans seem to have adversely affected their mental health. Tragically, mental health had not been included in Sri Lankan policy considerations earlier, though the issue now appears to be gaining political recognition. Sri Lankan health policy make in collaboration with WHO came up with national mental health policy in 2005. Sri Lankan mental health policy has mental health action plan for next 10 years. Sri Lankan mental health policy explicitly states that if a region has a higher burden of mental problems, regional authorities can plan and provide health services accordingly.

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In many developing countries, mental health services are not considered a part of primary health care18. Such services in Sri Lanka were also only available in large cities at a few tertiary care hospitals. However, the current mental health policy prioritizes decentralization and the development of community-based mental health services. Additionally, medicines to treat mental ailments will be made available in primary health care centers. The Sri Lankan mental health policy has also developed strong ties with the social and education sectors in order to make these patients productive members of society again. The Sri Lankan policy has however been less successful at targeting populations that need more specialized services. Pediatric and elderly mental health has been ignored in developing countries. While the national health policy of Sri Lanka had announced that programs to provide health for the elderly population would be introduced, but mental health policy lacks programs specific for mental health of elderly. Overall, the Sri Lankan mental health policy is a step in the right direction.

Mental Health Legislation.

New mental health legislation was implemented & a new Authority was established under the Mental Health Act. The main components of the act: To identify & confirm rights to treatments & care for mentally ill within both national & district services. To safeguard human rights of patients. To ensure that informed consent is given. To establish procedures for the compulsory detention, treatment & discharge of patients.
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New mental health legislation was implemented & a new Authority was established under the Mental Health Act. The main components of the act: To identify & confirm rights to treatments & care for mentally ill within both national & district services. To safeguard human rights of patients. To ensure that informed consent is given. To establish procedures for the compulsory detention, treatment & discharge of patients.

The Mental Health Authority have to establishing & monitoring standards of care, standards of dignity & privacy of the patients, establishing committees at a local level separately to monitoring & reviewing the progress & provide annual reports to Parliament. By studying the above facts its clear that the legislation focused on the entire subject.

Human Resources Development

Consultant Psychiatrists will be the technical leaders of each district mental health care network. The Ministry of Health will appoint at least one psychiatrist in every district. Until this is possible, appropriate arrangements will be established, including the proper use of the existing transfer scheme. There will be a lead psychiatrist in every District from which the Provincial Council in concurrence with the Ministry of Health will identify a lead psychiatrist for the Province.

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Medical Officers of Mental Health (MOMH) will be the focal point for services for each MOH area within districts, coordinating patient care both in hospital and in the community. One MOMH will be appointed for every MOH area by 2010. Until that time MOMHs may be allocated more than one MOH area. Incentives may be provided to attract candidates to apply for posts in hard-to-recruit areas. A career structure will be developed for MOMHs. In addition to the current establishment of nurses in hospital units, further staff will be appointed. All these staff will require in service training appropriate to a range of care settings, including acute and rehabilitative care. A minimum of two nurses will be appointed to each MOH area to work for MOMHs. Longer-term development of a new cadre of Psychiatric Nurses with appropriate mental health training will be implemented. But psychiatric social workers are not appointed in every district level hospital. And also there should be Psychiatric Social Workers (PSWs) or equivalent for every acute ward and intermediate unit. And there are not enough clinical psychologists. Counselors are not required to do their job in proper way. Service users are expecting fruitful solutions for their problems. But counselors are not qualified. So a comprehensive training plan should be developed with particular attention to undergraduate and post graduate medical education and registered counseling training and other groups of staff training. All Mental Health professional training should require review and syllabus revision. In addition, in-service training and continuing professional development for all care staff should be provided. As an example, National Institute for Mental Health in Sri Lanka will manage specialist mental health services determined by the Ministry of Health. Such services are those which will not be provided in more than one location. National Institute for Mental Health will be responsible for the development of special expertise in mental health care, and the provision of training and research. The development of training will be in collaboration with the Post Graduate Institute of Medicine and other appropriate bodies. And also institute is providing every facility to the service user. There is a multidisciplinary team. But in rural areas people cannot get the service for mental health. So every district level there should be a psychiatric unit with a multidisciplinary unit. In Sri Lanka around 3,000 patients live in Mental Hospitals around Colombo, including about 800 female patients in NIMH most of whom are not longer mentally ill. Many of them have stayed in these hospitals over several years, and have lost contact with their families and communities. Over 70% of these persons have the potential to be reintegrated into society. To
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do so, it is necessary to provide conditions that would adequately facilitate and supplement patients economic self-reliance and ultimately their integration into the Sri Lankan social structures and prevent eventual stigmatization. This involves the implementation of activities such as, vocational training and the creation and establishment of networks with patients families.

Research and promoting mental wellbeing

In Sri Lanka, researches on mental health level are rarely done. Only National Institute Mental Health has done a research on that. But that is not enough for provide proper service to the patients and in large scale including rural, suburban and urban level that research should be done. Government should allocate more money to mental health side. Everyone should take equal service. Through research only can identify needs of the people. By promoting mental wellbeing will support multi-sectoral collaborations within districts to establish Community Support Centers which promote community based rehabilitation, support in finding employment, and/or in engaging in appropriate livelihood activities. These services are aimed
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to ensure that individuals suffering from mental illness receive treatment and follow-up care in their communities, to protect them from human rights abuses and at the same time, to enable them to engage in meaningful activities within these communities. This country has one of the highest suicide rates in the world. Further, misuse of alcohol is frequent, especially in areas affected by disaster and other communities. It is estimated that 3% of the Sri Lankan population suffer from some kind of mental disease. So in Sri Lanka mental health wellbeing programmes on family level and community level should be done.

Conclusion

Do not carry through decision of the advisory council. Do not pay allowance regularly for mental health patients from the department of womens empowerment and social welfare. There are more than 20 beds in a one ward. No any wards for children who are having mental illness. Do not manage mental health budgets. Do not have community support centre per MOH area. MOMH may be allocated more than on MOH area. The career structure will be not developing MOMH. No any further staff will be appointed.
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Will be not PSWs. No any national strategy will be designed and implemented to reduce stigma and discrimination. Do not safeguard human rights of mental health patients. Do not have separate requirements for treatment of children.

References

http://www.whosrilanka.org/LinkFiles/WHO_Sri_Lanka_Home_Page_Mental_Health_F actsheet.pdf (20/04/2012 - 09.48pm)

http://www.health.gov.lk/HealthPolicy.htm

(20/04/2012 - 10.14pm)

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