THE BELIZE MENTAL HEALTH SYSTEM

UNCLAS BELMOPAN 000370 SENSITIVE SIPDIS FOR WHA/CEN CHRISTOPHER WEBSTER, JENNIFER VAN TRUMP E.O. 12958: N/A TAGS: PGOV PREL PINR BH SUBJECT: THE BELIZE MENTAL HEALTH SYSTEM REF: BELMOPAN 120 ¶1. Summary. In Belize, mental health services are provided to citizens and residents through the Belize Mental Health Program (BMHP),which is coordinated and supervised by the Ministry of Health. The system is newly emerging, serves approximately 15,000 patients, and had its own approved, governmental budget for the first time in 2008. The system is staffed with only three doctors who are responsible for seven districts covering the entire country. Recently, the system has moved toward a decentralized model and is focusing more on increased community integration and family involvement with patients. End summary. ¶2. In Belize, mental health services are provided to citizens and residents through the Belize Mental Health Program (BMHP),which is coordinated and supervised by the Ministry of Health. The system is newly emerging, serves approximately 15,000 patients, and had its own approved, governmental budget for the first time in 2008. The system provides mostly out-patient but some in-patient care in seven hospital settings in the country and at one long-term care facility. In the future, the Director of the BMHP hopes to have a separate and private (confidential) in-patient and out-patient care center in every hospital of the system. Challenges include inadequate financial resources, limited number of partially-trained staff, gaps in service coverage for patient psycho-social issues, and a lack of focus on youth. ¶3. A particularly important design feature of the program is the autonomy given to Psychiatric Nurse Practitioners (PNPs),who are the backbone of the system and have the authority to assess, diagnose, and treat patients on their own. This design element led to the Belize Mental Health Program being selected as one of twelve best-practice sites from around the world in 2008 by the World Health Organization in their book "Integrating Mental Health into Primary Care." Generally the system director and other doctors of the program support the Embassy's efforts to care for AmCits who are in-country and in need of mental health services. -------------- Structure of the Belize Mental Health System -------------- ¶4. Delivery of services is divided among four regions covering all seven geographic districts of the county. There is a Central Region, which includes Belize City in Belize District; a Northern Region, including Orange Walk and Corozal Districts; a Western Region including Cayo District and Belmopan, the capital; and a Southern Region, which includes Punta Gorda and Stann Creek Districts. ¶5. Seven hospitals make up the mental health system and provide services. The Northern, Western and Southern regions each have two hospitals, while the Central Region has only one in Belize City. The hospitals include: Karl Huesner Memorial (KHMH) in Belize City, Southern Regional Hospital in Dangriga, San Ignacio Hospital in San Ignacio, Northern Regional Hospital in Orange Walk, Corozal Hospital in Corozal, Punta Gorda Hospital in Punta Gorda, and Western Regional Hospital in Belmopan. ¶6. All of the hospitals provide out-patient services; six of them have also committed to providing acute in-patient care on a very limited basis. In total there are only nine beds available nationally, one or two in each hospital. -------------- Staffing -------------- ¶7. The entire BMHP system has only three psychiatrists, 18 Psychiatric Nurse Practitioners (PNPs),and 22 other staff who provide domestic help, security, and administrative services. -------------- Psychiatrists -------------- ¶8. Currently, there are only three clinical psychiatrists who cover the entire country. Dr. Molina handles the Central Region, which includes Belize City; Dr. Cayetano covers the Southern and Western Regions and is also directs the entire program; Dr. Rodriguez is responsible for the Northern Region. Dr. Cayetano is a Guatemalan national Belizean resident who has worked in mental health services for many years. Dr. Molina and Dr. Rodriguez are relatively new the BMHP, both having started their work with the program in 2008. -------------- Psychiatric Nurse Practitioners -------------- ¶9. The PNPs are the mainstay of Belize's Mental Health Program. They provide almost all of the daily hands-on services. There are at least two PNPs stationed at each hospital. Unlike most programs in the world, Belize's program has PNPs providing full service to patients. They have the authority to complete client assessments, make diagnoses, and provide treatment. All PNPs are medically-trained nurses who also complete an 18-month program in psychology. In fact, this practice of having fully-trained and empowered PNPs is why the Belize Mental Health Program was selected as one of twelve best practice sites in the world in 2008 by the World health Organization in their book "Integrating Mental Health Into Primary Care." -------------- Constraints on Provision of Services -------------- ¶10. BMHP service provision suffers from insufficient staffing. In the entire system, there are no psychologists, psychiatric social workers, or occupational therapists to assist patients with discharge plan follow-up that would support reintegration into the local community, improve relationships with their families and friends, and help them make more effective connection with other positive support systems. Limited number of staff also means "walk-in" and emergency services are restricted. ¶11. Additionally, there are no child psychologists - an incredible constraint for a country with a huge portion of its population aged in their early 20's and below. Lack of staff with experience related to young people means little mental health education or early guidance counseling is provided in schools. As a result, mental health issues are not usually addressed in communities and later develop into problems that are more difficult for the system to manage for individual patients. In particular, the BMHP needs volunteers to assist with all levels of program services, and especially volunteer counselors to assist with emergency services, education and outreach to youth, and support for patients with discharge or out-patient service plans. ¶12. To support each other, BMHP staff members meet in a system-wide, general session each month. At this session, the staff brings their challenges of providing local services to the table for discussion of potential solutions with their colleagues. While the BMHP has received support from some external organizations, there is only limited in-service training available for staff who attend this meeting. As with service provision, volunteer assistance with training opportunities would greatly benefit the BMHP. -------------- Program Funding and Support -------------- ¶13. Although mental health services have been provided in Belize officially since 1995, the BMHP did not have a dedicated budget until the 2008-2009 fiscal year. The annual budget totals approximately 66,400USD at the ministry level. The salaries for Drs. Rodriguez and Molina and the Psychiatric Nurses, as well as other mental health activity expenses, are combined with other health and hospital expenses in the respective district budgets for each region. ¶14. All operational funds come from the Government of Belize. However, some donations help sustain the program. In particular, the Director of the BMHP was able to negotiate a Memoranda of Understanding (MOU) with Homewood Health Center, a mental health program located in Canada. Through the MOU, the Center has supported the BMHP for ten years and provided medical and psychiatric instruction and updates (in-service training) for 17 BMHP PNPs in Canada. Homewood Health Center has also sponsored relevant workshops in Belize and provided the BMHP with computers for their offices. ¶15. The BMHP has also received office furniture donations from the Belize Mental Health Association and was the beneficiary of workshops sponsored in Belize by the Pan American Health Organization. Additionally, the BMHP has had observed visits and training in Chemical Dependency at the Jefferson Alcohol and Drug Center in Louisville Kentucky, as well as in-service workshops and medication donations from Harvard University Medical School. The program has also had a collaborative training program with Mount Sinai School of Medicine in New York. Additionally, Occupational Therapist students from Queens University in Canada assisted with the development of a procedures manual for day-services in Belize City. -------------- Emergency Evacuation -------------- ¶16. Because of its geographic location, Belize is particularly vulnerable to hurricanes for almost six months of the year -- from early June to late November. According to the BMHP evacuation plan, most mental health in-patients generally remain at their hospital during a hurricane, since it is safer than most other locations to which they might be transferred. However if necessary, the location to where a patient is transferred will depend on where a hurricane is expected to land. In the event Belize City needs to be evacuated, Karl Heusner Memorial Hospital patients will be brought to Western Regional Hospital in Belmopan. Generally, the Western Regional (Belmopan) and Northern Regional (Orange Walk) Hospitals will not be evacuated. -------------- Long-Term, Chronic Care: The Palm Center -------------- ¶17. The BMHP system includes one long-term care facility for the country. The Palm Center is set on 58 acres on the outskirts of Belmopan City in an area known as Maya Mopan. There are houses, for more independent living, still under construction at the site, as well as an occupational therapy center. The Center itself has shared sleeping rooms for pairs of patients, a waiting room, staff lounge, kitchen, laundry room, staff offices, meeting rooms and a quiet room. There is also a small fenced-in, outdoor patio and a large central hall. ¶18. The facility opened in 2008 and represents a great shift in how people with mental health disabilities will be cared for in Belize. It is the permanent home of approximately 40 people who have mental health issues and whose families do not have the ability to care for them. ¶19. Unfortunately the center was officially opened earlier than planned based on the need to evacuate staff from harm's way due to flooding during the 2008 hurricane season. Consequently, the Center opened without beds for patients to sleep on, without curtains for the shower rooms, etc. Since the opening, there have been many delays in acquiring all the resources needed to properly run the program. Staff of the Center is trying to develop a DVD library for residents, and is also collecting books, old magazines, games, and other items patients can use for social and developmental activities. The BMHP welcomes donations of food, clothing, toiletries, books, videos, magazines, and other items for the center. ¶20. While spacious and better designed as a full-service institution than the previous facility, the Palm Center is already showing signs of physical wear and was already at full-capacity when it opened. With little room for expansion without additional construction work, there is not space to admit new patients at this time. Even so, the Palm Center represents a huge leap in the level of care compared with what was provided from the older Rockview Mental Health Hospital, which was located in Rockville, Belize District and is now closed. -------------- The Kolbe Foundation and Mental Health Care -------------- ¶21. Ironically, the largest concentration of mental health service provision in Belize is not at any hospital or the Palm Center, but is instead found at the Kolbe Foundation (Hattieville Prison) in Hattieville, Belize District. The BMHP estimates it now has approximately 54 patients who are inmates there. Many of them are now in the "special populations" unit of the prison, and are incarcerated or remanded because of illegal activities that may or may not be related to their mental health. ¶22. At Hattieville Prison, mental health services are provided twice monthly, including visits by a psychiatrist once a month or as requested by prison staff. During visits the psychiatrist conducts new inmate assessments, makes inmate re-assessments, or follows-up on inmate care and progress. Inmates receive the medication they need via direct observation therapy (DOT). ¶23. Hattieville prison administrators are proud of the services they provide to inmates with mental health issues and feel their services may surpass what is provided at some hospitals. Hattieville provides security to inmates, on-site health services, and medical and dental referral processes. Prison staff feels their vocational, rehabilitation and personal development programs, as well as socialization activities, also contribute to the well-being of inmates with mental health issues. The BMHP and Hattieville administrators do note, however, that prison personnel do not have the training to meet the standards of care equal to that of the PNPs. See reftel for more information on Hattieville Prison. -------------- Challenges with Provision of Medications -------------- ¶24. The BHMP has a long-standing challenge regarding acquisition and supply of medications. Generally, there is only a narrow range of medicines available and an inconsistent supply; mostly old-style psychotropic medicines. Because of this, medications that a patient may be accustomed to may not be available. As a result, patients, including AmCits, are often given whatever appropriate medicine the hospitals have on hand for their needs. This also means patients may have to take a medication having uncomfortable and unaccustomed side effects. -------------- Basic Necessities for Patients -------------- ¶25. While hospitals provide what they can to patients, the hospital system is based on a reliance on family members who can care for patients. Hospital amenities remain quite limited and family and friends are relied upon to provide daily living needs for patients who are in care. -------------- Mental Health Care for AmCits -------------- ¶26. Embassy staff has met with and continues dialogue with Dr. Cayetano, the Director of the BMHP, regarding care for AmCits who develop mental health emergencies while in Belize. Discussion topics have included: access to care, medication availability, living needs, security, and repatriation. -------------- Access to Care -------------- ¶27. When Rockview Mental Health Hospital was open, all visiting AmCits were provided care at that facility, unless there were legal issues that required the citizen to be remanded to Hattieville Prison. The current agreement with the BMHP calls for AmCits who have mental health issues to be cared for in any one of the following three hospitals used by the mental health system: Karl Huesner Memorial (Belize City),Western Regional (Belmopan) or Northern Regional (Orange Walk) Hospitals. ¶28. While access, monitoring, follow-up, and coordination of services would be easier for the Embassy if AmCits were treated in only one hospital, according to Dr. Cayetano the BMHP uses many factors in determining where patients receive care. In particular, these three hospitals were chosen because of staff and resource availability. ¶29. Placing AmCits in one of these three hospitals better ensures they will get crisis and/or medical care if needed and hospitalization. Karl Huesner Memorial Hospital has many staff trained in psychiatric care and has a larger medical staff. Additionally, the hospital agreed to provide up to two beds for any patients with psychiatric issues who need to stay in-house. Similarly, Western Regional Hospital in Belmopan has offered the BMHP program two beds; Northern Regional Hospital in Orange Walk has offered one. Also, each of the three psychiatrists in Belize is stationed directly at one of these hospitals; Dr. Molina is at Karl Huesner, Dr. Cayetano at Western Regional, and Dr. Rodriguez at Northern Regional. Post feels that this arrangement will ensure that AmCits will have better access to the psychiatrists for services. However, for Consular staff to see patients, this decentralized design will certainly require more travel time and more Embassy coordination with mental health staff. -------------- Availability of Medication for AmCits -------------- ¶30. In humanitarian cases, the Embassy will look at authorizing an Emergency Medical and Dietary Assistance (EMDA) II loan for short term treatment of psychiatric or physical conditions to stabilize a patient sufficiently for their return to the U.S. In the unlikely event of a loan for a large amount being required, the Consular section in Belmopan will request approval from Consular Affairs at Main State. Issuance of EMDA II Loans will depend on the eligibility of the AmCit, the availability of the medication in Belize, a declaration by the hospital saying the medication is mandatory for the AmCit, and other factors. -------------- Living Necessities for AmCits -------------- ¶31. Because of the limited ability of hospitals to provide daily care items for patients, the Consular section cares for AmCits who are hospitalized for mental health issues in the same way as incarcerated AmCits. If available through donations or our own supplies, the section provides basic toiletries, clothing, snacks, and some foods. Consular staff also checks with family or friends of the AmCits (if a privacy act waiver is signed) regarding wiring money to pay for some of the necessities the AmCit may receive. -------------- Repatriation Processes -------------- ¶32. The biggest area of frustration for BMHP staff was the length of time sometimes required for the Embassy to facilitate the repatriation of AmCits. Because of this, the Embassy educated BMHP staff further regarding the multiple stages required to process repatriations - including citizenship verification, acquiring a Privacy Act Waiver (PAW),confirming repatriation loan eligibility, and coordination with Consular Affairs in Washington, International Social Services (ISS),Belize Immigration, staff at the facility where the AmCits is located, and with the three main airlines in Belize used for repatriation cases. Further meetings between the Belmopan Consular section and BMHP are needed regarding detailed processes for repatriating patients. -------------- Security of Valuables for AmCits -------------- ¶33. The BMHP Director has assured Embassy staff that systems are in place at hospitals regarding patient belongings. Currently, the hospitals advise patients not to keep valuables (or anything not needed) on wards. It has been reported to the Embassy that hospitals have areas that can be locked to keep belongings safe, and the items are inventoried by nurses upon patient admission. Patients sign an inventory and must "sign-out" any items for which they gain access. Only once in the past year has the Consular section had questions regarding an AmCit's belongings at a hospital. -------------- -------------- Continued Follow-up between Embassy and BMHP Staff -------------- -------------- ¶34. In the future, CONS staff will need to visit the facilities at Karl Heusner Memorial, Western Regional, and Northern Regional Hospitals to strengthen professional relationships with respective staff and gain a better understanding of the level of services provided at each hospital. Additionally, the Consular section plans to attend one or more of the BMHP general work sessions to meet staff of the various hospital programs, further educate BMHP staff regarding Embassy assistance available to AmCits with mental health issues, and learn more about BMHP and GoB services and processes for patients. Consular staff also needs to meet and build a relationship with Dr. Rodriguez at Northern Regional and Corozal hospitals. -------------- BMHP Goals for 2009 and Beyond -------------- ¶35. According to Dr. Cayetano, the development of mental health services is among the highest priorities of the Ministry of Health. Besides the continued development of the Palm Center, the BMHP is moving forward with its plans to decentralize services among the seven hospitals providing care throughout the country and expand their services in the community, including services for adolescents, the homeless, and the elderly. -------------- New Acute Care Unit -------------- ¶36. Recently the BMHP applied for a Humanitarian Grant sponsored by the U.S. Military Liaison Office (MLO). The request for USD 240,000 was for the physical redevelopment of a four-bed in-patient mental health unit that will provide acute psychiatric services. The prior unit, which was established in 2001, was closed to accommodate the expansion of the Western Regional Hospital's maternal and child health services. This new grant would recreate an expanded acute care unit, which the BMHP hopes will serve as a model for all the hospitals in the system. Plans for the unit include a main reception desk, private counseling rooms, visitor access areas, meeting space, offices, living and dining areas, bathrooms, sitting areas, and a small ward of beds. The Western Regional Hospital administrator supports plans for the new clinic and the application for funding. -------------- Community Treatment Program -------------- ¶37. The BMHP also hopes to build a stronger Community Treatment Program (CTP). The goal of this program is to help reduce relapse and ensure patients are adhering to their treatment long-term. The program would help the BMHP with improved disposition (release plans) and proper follow-up, community education, and services for homeless individuals and the elderly. It would also provide a means for the BMHP to put a special emphasis on community instead of custodial care. ¶38. Because of the isolation of some of the psychiatric services in hospitals and the remote location of the Palm Center, a long-term goal of the BMHP is to normalize mental health services so that patients can go to a hospital and be admitted with all other patients. This will require an increase in the numbers of nurses and/or nurse aides and more training of staff in the general wards of hospitals with regard to bedside nursing in psychology. ¶39. The POC at post is David M. Jones, tel. 011-501-822-4011, extension 4219, email jonesdm@state.gov. THUMMALAPALLY