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Integrating Care of Brain Disorders into Health Care Systems

This chapter describes the most promising vehicle for reducing the burden of brain disorders in developing countries: a comprehensive system of primary health care—primary care services supported by secondary and tertiary care facilities, physicians, and specialists. More detailed information on the challenges and opportunities for caring for specific brain disorders is presented in Part II of this report.

THE ROLE OF PRIMARY CARE IN ADDRESSING BRAIN DISORDERS

Over the last century, health care has increasingly been based on a public health approach that promotes health through prevention as well as treatment of disease. In developing countries, the need to provide affordable, accessible care for whole populations has guided the development of health systems based on primary care. The 1978 International Conference on Primary Health Care produced the Alma-Alta Declaration—a strategy promoting health for all that has been broadly accepted by both developing and developed countries. Under this strategy, primary health care is defined as essential health care based on practical, scientifically sound, and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination. Primary health care forms an integral part both of a country's



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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World 3 Integrating Care of Brain Disorders into Health Care Systems This chapter describes the most promising vehicle for reducing the burden of brain disorders in developing countries: a comprehensive system of primary health care—primary care services supported by secondary and tertiary care facilities, physicians, and specialists. More detailed information on the challenges and opportunities for caring for specific brain disorders is presented in Part II of this report. THE ROLE OF PRIMARY CARE IN ADDRESSING BRAIN DISORDERS Over the last century, health care has increasingly been based on a public health approach that promotes health through prevention as well as treatment of disease. In developing countries, the need to provide affordable, accessible care for whole populations has guided the development of health systems based on primary care. The 1978 International Conference on Primary Health Care produced the Alma-Alta Declaration—a strategy promoting health for all that has been broadly accepted by both developing and developed countries. Under this strategy, primary health care is defined as essential health care based on practical, scientifically sound, and socially acceptable methods and technology, made universally accessible to individuals and families in the community through their full participation, and at a cost that the community and country can afford to maintain at every stage of their development, in the spirit of self-reliance and self-determination. Primary health care forms an integral part both of a country's

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World health system, of which it is the central function and main focus, and of the overall social and economic development of the community.[ 1,2] Prior to the Alma-Alta declaration, an Expert Committee on Mental Health was convened by the World Health Organization (WHO) in 1974.[ 3] This committee recognized the scarcity of trained mental health professionals and the need for a tiered approach to treatment that is grounded in communities served by nonspecialized health workers and primary care nurses and physicians linked to specialist resources. Epidemiological research and programmatic development over the last 25 years have been guided by these findings.[4] Delivery of health care in developing countries varies with needs and resources, as well as with the availability of various types of medical professionals. However basic the staff and facilities, primary care represents the point of entry for the vast majority of people seeking medical care—and for many people, their sole access to medicine.[5] Thus, primary care is the logical setting in which brain disorders can begin to be addressed. Including care for brain disorders in the primary care agenda represents the surest way to promote their prevention, early detection, and timely treatment.[4,6,7] The incorporation of neurological and psychiatric care into the public health system is widely recognized as a way to improve coverage by providing a low-cost, accessible service that involves families and the community in patient care.[8,9,10 and 11] The integration of neurological and psychiatric services with primary health care is already a significant policy objective in developed and developing areas of the world.[12,13,14,15,16,17 and 18] Examples of this integration are found in low-income countries; one such example is described in Box 3-1. Other programs organized at both the national and local levels have been developed in India, Colombia, China, Iran, Malaysia, Tanzania, and Brazil.[19,20,21,22,23 and 24] Additional features of primary health care systems contribute to their potential for reducing the impact of neurological, psychiatric, and developmental disorders. As noted in Chapter 2, very few medical specialists practice in developing countries (see Figure 2-2). In China, for example, there are approximately 10 psychiatrists for every million people,[22] 5 psychiatrists are available for the 30 million people of Tanzania,[ 25] and in Ethiopia, about 10 neurologists serve a nation of more than 53 million.[22] Most of these specialists practice in urban settings, further reducing their availability to rural populations. Thus, most people in need of treatment for brain disorders must receive it at community health centers. As the gateway to health services in most middle- and low- income settings, primary care centers are well placed to recognize brain disorders and facilitate diagnosis and treatment of coexisting diseases. Research indicates that people with severe mental illness suffer higher-than-average rates of mortality from cardiovascular and respiratory diseases, cancer, and—in low-income countries—infectious diseases.[26,27,28,29,30 and 31] Additionally, findings show that patients

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World BOX 3-1 Integration of Mental Health Services and Primary Care in Guinea-Bissau After Guinea-Bissau became independent from Portugal in 1974, the government established a decentralized, preventive health policy implemented through a nationwide primary health care system. Before developing a plan to add mental health care, researchers conducted epidemiological, sociological, and anthropological studies to determine the prevalence of certain brain disorders, understand community attitudes toward treatment of them by traditional and orthodox practitioners, and assess the abilities of village health workers to diagnose and treat mental disorders and epilepsy. The researchers then established priorities for the training of Guinean health personnel to address psychiatric emergencies, including acute psychoses and agitation; depression and other neurotic disorders; and seizures, particularly those attributable to epilepsy. Training was focused on staff members (mainly nurses) at health centers, some of whom then trained and supervised volunteer village health workers. Flowcharts and role-playing vignettes were used to instruct personnel in the diagnosis and management of common mental disorders and seizures. After the seminar, the nurses received quarterly supervision focusing on case management and the use and distribution of medications. The training improved the health workers' abilities to diagnose major mental disorders and epilepsy from 31 to 75 percent and their prescription of appropriate treatment for psychosis and depression from 0 to 75 percent. Nurses were even more successful in learning to recognize and treat epilepsy; after 4 hours of instruction, they were able to correctly diagnose 95 percent of cases of generalized epileptic convulsions and treated 90 percent correctly. In 1985, 2 years after the start of the program, WHO declared Guinea-Bissau to be the first “third world” country to succeed in integrating a social psychiatric program into its basic health care services. Each dollar invested in primary mental health care in Guinea-Bissau served more than 50 citizens for a year. The cost was modest because the program was designed to meet local needs, was built on a solid foundation of primary health care, and was monitored for improvement. Since then, structural adjustment programs have adversely affected the supply and cost of antipsychotics and anti-epileptic drugs. Though no analysis has been conducted, one could presume that the overall costs of the program have increased as a result of changes in the drug supply. Continuing supervision by nurses and physicians from secondary medical centers was an essential component of program success. Many of the newly trained workers in the villages only began to implement their knowledge and skills after the initial visits with these professionals. This indicates the importance of supervision in the development of similar programs elsewhere. Source: [22]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World BOX 3-2 A Community-Based Rural Mental Health Program in Pakistan A demonstration project in Rawalpindi began in 1985 with the following objectives: To determine the feasibility of integrating mental health care into the primary care system. To involve the community in the planning and delivery of mental health services. To promote collaboration across sectors (e.g., health, education, local government, nongovernmental organizations [NGOs], religious healers). To establish two-way referral systems between primary health care providers and specialists. In the first phase of the program, researchers collected socioeconomic and demographic information. Then, primary health care staff were trained to provide care under supervision. Finally, a system of monitoring and evaluation of service delivery was put in place. Following adoption of a national mental health program by the government of Pakistan in 1987, the demonstration project was extended to all four districts of Rawalpindi (population 7.5 million). Compared to districts with no mental health component, the four districts showed the following results: Use of primary health care facilities (particularly by males) increased. Pregnancy rates consistently declined. Use of antenatal clinics increased and was accompanied by a significantly higher rate of assisted deliveries; infant and maternal mortality rates were reduced by nearly one-third and one-half, respectively. Immunization rates for children rose steadily. Detection rates of mental illnesses were significantly higher. As a result of these accomplishments, the incorporation of mental health care into primary care has been made a national priority and has been assigned specific funding. Additional benefits of this initiative include the indigenous development of teaching and training modules and information systems for use at all levels of primary health care, as well as the establishment of referral mechanisms. Sources: [38,39,40 and 41]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World with psychiatric disorders seek care from primary providers with greater-than-average frequency because of both increased physical illness and somatization of psychiatric illness.[32,33,34,35,36 and 37] Moreover, because they work in the community, primary care teams are well placed to recognize factors such as stigma, family problems, and cultural factors that affect treatment for brain disorders. DEVELOPING A SYSTEM OF CARE Primary Care Provision of services for brain disorders in conjunction with established primary care services builds on existing human and financial resources to promote practical clinical and social outcomes for these disorders.[ 52] Limited yet significant evidence from developing countries that have established such programs indicates that a feasible and cost-effective means to meet this goal may be to provide diagnosis and, in many cases, treatment for brain disorders at the first point of entry into medical care, in conjunction with secondary and tertiary support.[ 43,44 and 45] Such a system of care should be staffed by appropriately trained personnel whose level of training and responsibility will vary with the needs and resources of different communities and countries and is best determined by rigorous operational research. Limitations in the diagnostic and treatment skills of nonspecialized providers of mental health care have been observed in several studies in both developed [46,47,48,49 and 50] and developing countries.[51,52,53 and 54] To guide the development of efficient and effective training methods, similar such assessments must be made as programs develop. Following are descriptions of several essential personnel in such systems. Community health workers. In some communities, community health workers provide primary care services. These workers need a minimum of some high school education; basic training in health care; and additional training in the diagnosis and treatment of brain disorders, the dispensing and monitoring of medication, support for community rehabilitation, prevention of disorders, and means of reducing stigma and discrimination. Their role is to recognize patients who may need neurological or psychiatric care, to consult regularly on such cases with a specialist nurse or physician, and to provide care under the supervision of a physician or specialist at the closest secondary care center. Nurses. In some communities, nurses provide primary care services under the supervision of a physician or specialist at the closest secondary care center (see Box 3-2). Their qualifications typically include a high school education, general nursing training, and some specific training in neurological and psychiatric care. Specialist nurses have extensive training in neurological and psychiatric care, and in some countries provide oversight of primary care clinics, making monthly or other regular visits.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World General physicians. Since it is not possible to assign physicians or specialists to many primary care facilities, physicians and specialists at secondary and tertiary centers have an essential role in the planning, training, and oversight of each primary care center. The same physicians provide care for severe or complex cases and, whenever possible, initial diagnosis and treatment of critical or chronic cases. Specialists. Specialists in neurology, pediatrics, psychiatry, and related fields, such as psychology, physiotherapy, social work, occupational therapy, and speech therapy, have important roles. They can contribute to the formulation of relevant health care policies, bringing to bear their specialized knowledge about cost-effective methods of control, treatment, and rehabilitation. They may also oversee policies and procedures at health care facilities and staff training programs. In several developing countries, mental health care has been organized in line with the principles of public health.[22,24,42,55] Key features of the WHO model guiding primary mental health care may be adapted to address the broader range of brain disorders and may include the following objectives[56]: Formulation of a national policy on brain health and establishment of a national or regional brain health department; Financial provision for the employment and training of personnel; An adequate supply of essential medicines; A network of facilities linked by appropriate transportation; Data collection to support planning of programs, monitoring of outcomes, and epidemiological research; Integration of care for brain disorders with general health services and collaboration with relevant nonmedical agencies; Use of workers without specialization in brain disorders, including primary health care workers, nurses, medical assistants, and physicians, for basic care; and Training of brain health professionals who train and support nonspecialized health workers.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World BOX 3-3 Role of Nurses in Primary Health Care in South Africa In the mid-1990s the Hlabisa district in KwaZulu-Natal, South Africa, used a nurse-led primary health care program to target four major noncommunicable diseases: hypertension and diabetes (key risk factors for stroke), as well as epilepsy and asthma. Nurses at primary care clinics in the mostly rural region coordinated management of these disorders with a goal of increasing adherence to treatment. The Hlabisa district, with a population of 250,000, was served in 1993 by a 300-bed district hospital, 10 satellite village clinics staffed by nurses and visited once monthly by a doctor, and a nurse-staffed mobile clinic service. The Zulu population lived in scattered rural homesteads and was dependent on subsistence farming, pensions, or migrant work. Patients in the district could attend the primary care clinic of their choice for a fee of US$0.75 per consultation, which covered tests and prescribed drugs. Nurses at the primary care clinics were trained to use diagnostic and treatment algorithms for hypertension, diabetes, asthma, and epilepsy, based on the available evidence, clinical experience, and, when available, WHO protocols or national guidelines adapted to local conditions. The algorithms provided clear descriptions of essential aspects of diagnosis, monitoring, and treatment adherence for each disease. Upon seeing a new patient with one of these disorders, the nurse made a provisional diagnosis using the algorithm and recommended a plan for initial management, including referral to the district hospital if necessary. The patients were subsequently seen by a doctor at the primary care clinic to confirm the diagnosis and check for complications. Complex cases werre reviewed by a doctor until they were under control. Once a patient's condition was controlled, he or she received a prescription card that could be used to obtain medications for 6 months, after which time the case was reviewed and the treatment adjusted, if necessary. Primary care nurses were authorized to prescribe a limited list of drugs for hypertension, asthma, and non-insulin-dependent diabetes. Doctors prescribed additional medications for these conditions, if needed, as well as all drugs for insulin-dependent diabetes and epilepsy. During the first 2 years of the program, nurses using the protocol achieved a control rate of 68 percent for hypertension cases (this later increased to 92 percent); for non-insulin-dependent diabetes, 82 percent (which increased to 96 percent); and for asthma, 84 percent (which increased to 97 percent). Doctor-led treatment controlled 80 percent of epilepsy cases and 83 percent of cases of insulin-dependent diabetes; thereafter, these cases were managed by nurses. Adherence to treatment, as

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World measured by patients' reports, occurred at a rate of 79 percent after the first visit and increased to 87 percent after a later visit. This model demonstrates that nurses supervised by physicians can manage some common brain disorders appropriately, even in a resource-poor setting. The simplification and rationalization of diagnosis and treatment allowed patients to be seen and their conditions managed through local clinics. This approach made optimal use of limited health care resources, and provided accessible care for chronic, often asymptomatic disorders, thereby increasing patient adherence to treatments. Source: [57] The Role of Secondary and Tertiary Care Primary care centers are limited in their ability to adequately diagnose and treat certain brain disorders. The complexity and chronicity of some of these disorders necessitates access to medical expertise and technology that are not ordinarily available in a primary care setting, particularly in developing countries.[58,59 and 60] When possible such cases can be recognized in a primary care setting and referred for early intervention to a higher secondary level of care to provide the best chance for successful treatment or rehabilitation. Early recognition and intervention can prevent the costly complications that arise when these more serious conditions are not addressed until they become critical.[61,62] Secondary care is provided in district or regional hospitals. These are usually staffed by several general physicians, medical technicians, and nurses. These facilities are capable of treating severe or complex medical conditions and may contain computed tomography (CT) scanners, heart monitors, incubators, and laboratory facilities for blood analysis. District and regional hospitals can also support care for a broader range of illnesses than can be treated in primary care alone. Neurologists in India have proposed that district hospitals provide essential medicines and mobile care teams to improve the ability of community health care workers to identify, diagnose, and treat epilepsy.[63] This approach could be adapted to include care for schizophrenia, depression, and other disorders, along with the provision of periodic and continued supervision and training. Secondary care centers could also provide technical and administrative support for primary care clinics in their district or region. Continuing education, which has been shown to improve the performance of community health workers, should include instruction on the symptoms of major brain disorders and ways to help patients maintain proper treatment.[ 24,64,65] This training could be provided by medical professionals from secondary facilities who, during regular visits to primary care centers, also monitor the care provided by primary care workers and consult on specific cases.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Tertiary care is the most specialized form of diagnosis, treatment, and rehabilitation, and is often provided in teaching hospitals. Tertiary care hospitals also serve as facilities for clinical research, collection of epidemiological data, and the creation and distribution of health educational materials. Because resources are limited and the operating costs of tertiary centers are high, most developing countries can support only a few such centers. However, studies conducted at these influential institutions —on such topics as identification of risk factors, prevention strategies, and treatment options, can provide the evidence base for determining national health priorities and community health care. The training curricula developed at these centers can also be adapted for health care personnel at secondary and primary care levels.[66] Health systems vary immensely within and among countries.[67] The capacity of the current health care infrastructure, local health priorities, and financial resources will play a major role in determining the extent and speed with which neurological and psychiatric care can be incorporated into the primary care system. In many communities, primary care providers have rudimentary training and few essential medicines and diagnostic tools. Yet even under these circumstances, primary care may have the ability to fulfill its mission, given sufficient support, training, and supervision by medical professionals at secondary and tertiary facilities.[22,24,55,68,69] BUILDING CAPACITY THROUGH TRAINING Training of staff is a key aspect of expanding existing health care services to address brain disorders. Since the responsibilities of community health workers, nurses, and physicians vary widely, the training must be tailored to the needs of specific countries or regions. A general training framework would be based on existing evidence regarding the provision of health care. The existing body of evidence is described and cited below. However, additional operational research is needed to identify cost-effective ways of training health care personnel at all levels to provide appropriate care for brain disorders. Community health workers. As front-line caregivers in countries such as Botswana,[11] Guinea Bissau,[22] India,[70] Iran,[71] Nepal,[72] and Tanzania,[55] community health workers need to receive both basic training and regular continuing education in basic diagnostic skills and basic treatment and rehabilitation protocols. Basic training in neurological and psychiatric care should cover general skills, such as interviewing a patient, recording appropriate information, referring a patient to a higher level of care, and consulting with a physician who oversees operations, diagnosis, and management of specific disorders, including the use of medication and monitoring for side effects. Such training should also address daily responsibilities, increase awareness, and improve management skills while avoiding unnecessary details and technical jargon. WHO training manuals are a useful source of training guidelines.[73,74]

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Although it should be directed more toward improving skills than enhancing knowledge, training should raise health workers' awareness of the importance of psychosocial factors in health and disease. Flowcharts and simple screening devices can be effective in training primary care providers to recognize developmental disabilities,[ 75] depression,[33] schizophrenia,[10] and epilepsy.[43] Health care workers can be trained to use a simple screen to detect significant deviations from developmental norms or milestones as well as sensory or motor impairments, such as cerebral palsy.[70,76,77 and 78] They can also be trained to identify common mental disorders [20] and stroke.[78] However, it is essential that diagnostic and management tools be adapted to local conditions.[43,70] It is also important to recognize that primary care providers are likely to find assessment tools, such as symptom and behavior checklists more useful than instruments (such as intelligence tests) that do not indicate the action needed.[79] It is important to note as well that in many cases, primary care providers should be trained to recognize the need for referral to more specialized treatment rather than trying to make a diagnosis. Nurses. Primary health care in low-income countries has always relied heavily on nurses, but they could play an even larger role in the system of care envisioned here (see Box 3-3). Physicians in secondary care facilities in developing countries may spend only a few minutes per patient visit. Under these conditions, it is unrealistic to expect them to diagnose any but the most overt cases of brain disorder. Nurses trained to conduct more detailed first interviews may be better able to recognize common mental disorders, such as depression, and to identify risks for stroke, such as hypertension and diabetes.[57,80,81] In regions where there are few physicians in primary care, specialist nurses may be called on to diagnose and treat brain disorders; however, such efforts are likely to fare best if overseen by neurologists and psychiatrists. In a specialized psychiatric treatment center, periodic visits from psychiatrists were found to improve the ability of psychiatric nurses working in the Botswana bush to care for chronically ill patients, a finding that may apply in the primary care setting as well.[82] Other experience indicates that primary care nurses, using appropriate guidelines provided through a program of continuing education, can also provide effective management for mental disorders.[62,65,83] Primary care nurses also have many opportunities to promote brain health, and it is appropriate that they receive instruction in simple techniques for managing emotional distress (e.g., physical activity, talking over problems, assertiveness training, and relaxation techniques), and for giving advice on cessation of smoking and adhering to a healthy diet Similarly, providing mental health education to nurses who serve as birth attendants could help improve the rates of diagnosis and treatment referral for postpartum psychosis and severe depression. Physicians. Physicians get most of their medical training in teaching hospitals, where tertiary health care is emphasized. Since the cases that present in a hospital are generally more complex and may be further complicated by noso

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World comial factors, physicians who supervise primary health care personnel must have experience with the diagnosis and treatment at that level.[ 15,26,61] Training should emphasize preventive measures against such brain disorders as mental retardation and stroke, and provide interview skills that can facilitate the diagnosis of depression and other psychological disorders.[5,84] General physicians should be able to evaluate and treat common neurological and psychiatric disorders as well as respond to emergencies, such as head injury, stroke, epileptic seizure, and psychotic episodes. A program to improve training in neurological disorders for primary care physicians in developing countries was launched in 1997 by WHO and the World Federation of Neurologists.[85,86 and 87] Physicians who supervise or train other primary care providers also need instruction in effective communication skills in order to develop the skills of community health care workers. The supervising physician should regularly work alongside health workers and receive case referrals from them. Given the increasing recognition of the common origins of many brain disorders, psychiatrists should be conversant in neurology and exposed to patients with neurological disorders, while neurologists should have a basic command of psychiatry and experience with patients suffering from major mental disorders.[88] COLLABORATION WITH OTHER HEALTH AND NONHEALTH SECTORS The formation of alliances between public health care providers and private physicians, schools and educators, community-based rehabilitation (CBR) programs, other community organizations, and traditional healers is another way of improving health care.[89] Their roles in primary care are discussed below. Private Physicians Decentralization of health care services in many developing countries has been required by numerous development programs over the last two decades. The growth in private health care facilities as a result of these initiatives has created an important role for this sector in addressing brain disorders. In India, private practitioners are estimated to provide half of all primary care, and up to 80 percent in some states.[90] Many of the rural and urban poor consult with private practitioners because of their relatively low consultation fees and accessibility, as well as negative perceptions of the quality of public health care. The recent imposition of user fees for public health care services in India is likely to increase the proportion of care provided by private practitioners. In the least-developed regions of India and sub-Saharan Africa, which tend to be underserved by government-provided health care, the principal providers of health care are community-based NGOs, which offer such care as part of a broader development agenda. Some NGO providers focus on specific psychiat-

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World nancial. The methodologies of HSR are influenced by existing medical knowledge as well as sociocultural factors and represent an attempt to facilitate communication between health care providers and patients.[ 93] Thus, one tenet of HSR is the need to understand patient-explanatory models, since simple agreement on a diagnostic label for a patient 's condition may be no guarantee of agreement on the condition's etiology or treatment; on the contrary, it may give a false impression of consensus.[93] HSR also emphasizes implementing research programs in representative settings as well as focusing on mitigating the social risk factors for disease, such as poverty. By stressing the use of HSR in the study of neurological and psychiatric disorders in particular, centers for training and research could not only foster greater awareness and provision of services for brain disorders in developing countries, but also lead to the evolution of strategies with international relevance. A crucial step toward developing a worldwide network of national centers for training and research is to secure initial funding. Given their broad role, these centers should attract funding from a wide variety of sources, including international donor agencies, foundations, NGOs, development banks, industry, and health care advocacy groups. Two initiatives established by WHO in 1997—the Action Program on Mental Health for Underserved Populations [93] and the Global Initiative on Neurology and Public Health [3]—could be key resources. It will be important to ensure, however, that funding for the centers is not diverted from funding for local health services. Strengthening local health care capacity and quality is the fundamental goal. With the commitment of the best specialists, these centers could advance the effort to reduce the total burden of disease in the developing world by championing cost-effective treatment and prevention of long-neglected brain disorders. CONCLUSION Integrating care for neurological, psychiatric, and developmental disorders into primary care-based health systems stands as the central challenge in reducing the impact of these disorders in developing countries. Given the existing constraints on resources, building comprehensive health care systems capable of addressing increasingly prevalent brain disorders must proceed gradually in most settings. However, intermediate steps toward this goal appear likely to provide rewards that can encourage further progress. Several programs in developing countries have achieved a successful, if limited, integration of neurological or psychiatric care into primary care services. The successes and limitations of these programs suggest what needs to be done in the future. International collaborations and partnerships can play an important role by increasing the capacity of developing countries for delivery of neurological and psychiatric care as well as for locally relevant research on brain disorders. Local evaluations of priorities and resources can best guide communities and countries

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World in their choices of appropriate interventions, local staffing, and oversight. Effective primary care programs will require strong support and periodic and continued supervision from providers of secondary and tertiary care, particularly where resources are limited. The balance between primary and higher care levels should be determined by rigorous programmatic evaluation on the basis of cost-effectiveness. It is crucial that such programs—and indeed all future efforts to reduce the impact of brain disorders —include the capacity for rigorous evaluation. Providing optimal care for these often complex and difficult disorders will necessarily involve an iterative process of testing a program, evaluating it, and redesigning it for improvement. There is no endpoint in this process: demand, delivery, and innovation must be constantly monitored and incorporated to provide the best possible health care to the greatest number of people. REFERENCES 1. WHO (World Health Organization). Alma-Ata Declaration. International Conference on Primary Health Care, 1978. 2. T.B. Üstün and R. Gater. Integrating mental health into primary care. Current Opinion in Psychiatry 7:173–180, 1994. 3. M. Isaac, A. Janca, and J.A. Costa e Silva. A review of the World Health Organization's work on primary care psychiatry. Primary Cae Psychiatry 1:179–185, 1995. 4. World Health Organization. Organization of mental health services in the health services in the developing countries. Technical Report Series 564. Geneva: WHO, 1975. 5. R. Jenkins. Mental health and primary care-implications for policy. International Review of Psychiatry 10:158–160, 1998. 6. R. Giel and T.W. Harding. Psychiatric priorities in developing countries. British Journal of Psychiatry 128:513–522, 1976. 7. A. Mehryar and F. Khajavi. Some implications of a community mental health model for developing countries. The International Journal of Social Psychiatry Winter-Spring;21(1):45–52, 1974–1975. 8. O. A. Abiodun. Knowledge and attitude concerning mental health of primary health care workers in Nigeria. International Journal of Social Psychiatry 37:113–120, 1991. 9. M. Freeman. Mental health care in crisis in South Africa. Center for the Study of Health Policy, Johannesburg. Johannesburg: Witwatersrand, 1989. 10. V. G. Ngubane and L. R. Uys. The social support network for black psychiatric inpatients. Curationis 17(2):6–9, 1994. 11. D. I. Ben-Tovim. A psychiatric service to the remote area of Botswana. British Journal of Psychiatry 142:199–203, 1983. 12. M. Shepherd. Mental health as an integrant of primary medical care. Journal of the Royal College of General Practitioners 30:657–664, 1980. 13. B.J. Burns, D.A. Regier, and A.M. Jacobson. Factors relating to the use of mental health services in a neighborhood health center. Public Health Report 93(3):232–239, May-Jun 1978.

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Neurological, Psychiatric, and Developmental Disorders: Meeting the Challenge in the Developing World Strategies For Addressing Brain Disorders To reduce the disease burden now: Increase public and professional awareness and understanding of brain disorders in developing countries, and intervene to reduce stigma and ease the burden of discrimination often associated with these disorders. Extend and strengthen existing systems of primary care to deliver health services for brain disorders. Secondary and tertiary centers should train and oversee primary care staff, provide referral capacity, and provide ongoing supervision and support for primary care systems in developing countries. Make cost-effective interventions for brain disorders available to patients who will benefit. Financial and institutional constraints require selectivity and sequencing in setting goals and priorities. The continued implementation of these interventions should also be informed by ongoing research to reveal the applicability and sustainability of such programs. To create options for the future: Conduct operational research to assess the cost-effectiveness of specific treatments and health services in local settings, along with epidemiological research to monitor the incidence, prevalence, and disease burden of brain disorders in developing countries. Create national centers for training and research on brain disorders in developing countries. Link these centers with institutions in high-income countries through multicenter research projects, staff exchanges and training, and Internet communication. Create a program to facilitate competitive funding for research and for the development of new or enhanced institutions devoted to brain disorders in developing countries. This effort should be global, and spearheaded by the Global Forum for Health Research, the World Health Organization, and well-funded research centers, such as the U.S. National Institutes of Health and the Centers for Disease Control and Prevention. To ensure the sustainability of the program, major donors—such as the World Bank, foundations, and governmental and nongovernmental aid organizations—must commit initial investments to this effort, and longer-term annual budgets must be established.