Questions/Answers

The initiative, entitled Health Chats for Handling Mental Illness, was first developed at Tongas Community Health Centre (puskesmas) in Probolinggo District, East Java, Indonesia. It provides comprehensive health services for people with mental disorders through a new comprehensive, inclusive approach. Historically, sufferers of mental illness in Indonesia have been marginalised and made the target of discrimination. In Tongas sub-district, local people – like many others throughout the country – stigmatised people with mental disorders, believing them to be cursed or possessed by the devil. They were routinely mocked and, in some cases, physically attacked. Before this initiative was launched in 2014, more than 95% of mentally ill people living in Puskesmas Tongas’ catchment area (covering eight villages) remained untreated. Most came from families too poor to pay for treatment, while some sought relief through shamanic rituals or from non-medically tranined individuals. Due to the stigma surrounding mental illness, many families felt ashamed and hid their relatives away, while some even kept them chained up inside their homes. Compounding this problem, Puskesmas Tongas did not compile or record data on local cases of mental illness. The first “Health Chats”, which were born out of community habits across Indonesia to gather together to share the latest gossip, discussed how to address mental illness, how to challenge people’s thinking about it, and how to empower those affected to help them become independent and claim their full rights as citizens. Local community stakeholders also assisted Puskesmas Tongas in the treatment of mentally-ill patients. They helped with the early detection of such cases, encouraged families of those affected to seek medical attention for their relatives, monitored people under medical supervision to ensure they took their medicine, and offered former patients skills training to enable them to work and earn a living.

The overall objectives of this initiative are to: 1. Provide comprehensive medical services to the mentally ill, and to empower them to live independent, productive and confident lives within their communities, free from stigma and discrimination. 2. Protect the mentally ill from acts of harassment and violence, to create an environment that not only accepts them but also supports their recovery. 3. Offer guidance and skills training to those in recovery, to enable them to gain employment and earn a living. 4. Combat the longheld belief that mental illness cannot be treated, proving instead that with the appropriate care, those with psychological disorders can live fully- functioning lives. 5. Eradicate the stigmatisation surrounding mental illness, as well as the discrimination directed towards those affected. 6. Establish partnerships between the puskesmas and local communities, encouraging the latter to play an active role in overseeing the continued delivery of specialist medical services to the mentally ill. 7. Enable community members to assist with early detection, so that new cases can be handled and treated appropriately, and in a timely fashion.

This initiative fits within Category 1 (Reaching the poorest and most vulnerable through inclusive services and partnerships), as it has reached both disadvantaged and vulnerable members of society, specifically those suffering from mental disorders and their families, of whom 95% are poor, discriminated against, and whose marginalisation effectively prevented their access to adequate healthcare in the past. As a result of the Health Chats initiative, members of local communities and the families of those affected by psychological disorders no longer feel ashamed of them; instead, they are actively participating in and assisting efforts by Puskesmas Tongas staff and other health specialists to provide targeted, suitable services for them, as well as offering further support after their recovery to help them rebuild their lives. Such is the success of this new, inclusive approach that former patients who have undergone treatment and rehabilitation are now fully reintegrated into their communities. Furthermore, a substantial number of them have secured jobs and are productive members of their communities, not only in terms of contributing to their household economies but also by helping to reduce local rates of unemployment and overall poverty.

This initiative supports the realisation of the SDGs, particularly the following 2030 Agenda goals: (1) End poverty The provision of specialist treatment for the mentally ill, the majority of whom are poor, helps to combat poverty by assisting them to become fully productive members of society who can earn their own keep. (3) Promote well-being for all People with mental disorders receive comprehensive health services, enabling them to live full, healthy lives. Their families’ well-being is also improved due to their relatives’ new-found independence. (5) Gender equality This initiative provides services to men, women, children and the elderly in equal measure; it also empowers women to become resource persons during the Health Chats and in offering skills development to post-treatment patients. (8) Sustainable economic growth Former patients whose recovery is successful receive skills training, enabling them to obtain paid employment that contributes towards sustainable economic growth. (10) Reduce inequality This initiative reduces inequality, especially in terms of economic and discriminatory gaps, by providing comprehensive and inclusive services. (11) Inclusive, safe cities and human settlements Handling mental illness in an appropriate way helps to create sustainably safe and calm environments in cities and rural areas, where everyone can live in peace.

Before the Health Chats initiative was implemented, health centre staff had no accurate knowledge about how many mentally-ill people lived in their catchment area as they did not compile such data; they were only aware of the few who managed to present themselves for treatment. Even then, the common response by puskesmas staff was to refer patients to other institutions, which were ill-equipped to assist them in a meaningful way. Following the launch of this initiative, puskesmas staff – in collaboration with local communities and health volunteers – identified the true number of potential patients and set about providing them with a range of comprehensive, high-quality mental-health services. For their part, community members discussed the successful recovery of mentally-ill patients, which not only helped to combat previously-held prejudices but also motivated them to encourage others in need to obtain similar treatment. The relatively high number of cases, together with the initiative’s positive results, persuaded Puskesmas Tongas to extend implementation to every village in its work area. This means people with mental disorders can more easily obtain health services that are both close-to-hand and free, while those that are poor and vulnerable are specifically targeted to receive the best, sustainable care available.

During the first three years since the launch of the Health Chats initiative, the number of people with mental disorders given comprehensive, inclusive medical care increased by 300%. In 2014, three people were provided with medical treatment; this rose to 15 people being treated in 2015, then up to 84 people in 2016, and up again to 101 people (57 men and 44 women) in 2017. The therapy they received resulted in 67% going on to lead productive lives (57 are in paid employment, seven are housewives, and three are newly-married), and contributing to a reduction in overall poverty. All those with mental illness in Puskesmas Tongas’ catchment area have benefitted from this new approach. Former patients living in the region are now fully accepted by their local communities, where greater understanding has led to the dismantling of formerly-held views. The successful treatment of mentally-ill patients, releasing them from their shackles, enabling them to become independent and fully incorporated within their local communities, free from stigma and discrimination, and supported by a range of stakeholders in their personal recovery are the tangible results of this initiative, which has become a benchmark for the handling of mental illness across Probolinggo District.

The Health Chats initiative is innovative in that it draws on a local custom among Probolinggo residents, who love to gossip, and uses it to promote the provision of comprehensive, inclusive medical services to effectively reach out to and treat mentally-ill patients. Through wide-ranging partnerships, the initiative goes beyond purely treating psychological damage to empower patients to regain their independence, while at the same time combating poverty, stigmatisation and discrimination within communities. In Indonesia, handling mental illness usually means doing nothing more than waiting for patients to seek healthcare without offering any follow-up services, which means a significant number suffer relapses and are returned to their chains, while those who are poor often receive no help whatsoever. This new initiative presents an entirely new approach by providing outreach services directly to patients in villages with the help of health volunteers, local communities, religious leaders, security personnel (village-level police and military), and religious organisations at village-based healthcare facilities, making up a mental-health community known locally as the “Happy Heart Huts”. They also help to empower recovered patients (in line with their potential), via cross-sector partnerships, to access a range of promotional, preventative, curative (counselling, health checks, psychological treatment) and rehabilitative activities.

This innovation is original, and is the first of its kind in Indonesia. It was inspired by efforts to release people suffering from mental illness in Probolinggo from being chained up, but it also sought to offer the poor and vulnerable high-quality healthcare services, as well as eradicating the stigma surrounding mental illness. Staff at Puskesmas Tongas already dealt with affected patients who presented themselves at the clinic, but the services were inadequate – with most patients merely referred to a local mental hospital. As a result, they were effectively denied access to treatment, leaving them unable to change their situation or improve their lives. The success of this innovation has made it a key reference for the handling of mental illness throughout Probolinggo, which still has many afflicted people hidden away by their families, chained up and not receiving appropriate healthcare.

1 General practitioner 10 nurses 12 midwives 178 healthcare volunteers (provided with training on mental illness) at local integrated service posts and 8 mental-health volunteer coordinators 2. Cross-sector Support: Participating institutions include the LG’s offices for Health, Social Welfare, Community Empowerment, Regional Development Planning (Bappeda), together with village heads and their staff, Sub-district Health Forum, security personnel, and community and religious leaders. 3. Financial: a. Health Centre Operational Assistance A total Rp. 13,125,000 (US$986,000) has been used to disseminate information about the initiative and to replicate it throughout Puskesmas Tongas’ catchment area. b. Donations A total Rp. 1.2 million (US$90) has been used to fund Happy Heart Hut activities, including the purchase of mental health-related skills materials. c. LG Assistance The Social Welfare Office provides funding for rehabilitation therapy, livestock assistance, and the provision of healthy food for patients, while the Agriculture Office provides plant seeds, fertiliser, guidance on farming techniques, and training on industry-related skills. d. National Health Insurance A total of Rp 5.6 million (US$420) has been used to provide additional food for patients and improve their diets.

Yes

The Health Chats innovation was launched in Sumendi Village and in 2016, was replicated to the seven remaining villages in Puskesmas Tongas’ work area. Also in 2016, all 32 remaining puskesmas across Probolinggo District engaged with staff at Puskesmas Tongas through dynamic group discussions to learn lessons relating to the handling of patients with mental disorders. Since the start of 2018, several of these health centres have begun to replicate the initiative, with mental-health staff from integrated health-service posts providing targeted activities to new patients living in local villages. On December 8, 2017, representatives from Mojokerto District (also in East Java) conducted similar discussions with Puskesmas Tongas, with a view to implementing the same kind of participatory and sustainable programme to handle and treat mental illness in their own region. The initiative has also attracted the attention of local media (Pro TV) and a number of national media outlets (Metro TV, Kompas TV and Trans TV) since its launch. Information about the innovation that was broadcast in 2016 helped to disseminate the programme’s good practices far and wide, so the hope is that it will be replicated in other regions across Indonesia, where stigma surrounding mental illness still persists.

The Health Chats initiative has already produced significant results in the handling and treatment of mental illness. The key contributory factor towards the programme’s sustainability is the wholehearted support it receives from all stakeholders involved in its implementation. The LG in Probolinggo has provided tremendous economic support through the provision of training and development assistance for patients from its Social Welfare, Farming and Agriculture offices. The recent introduction of new LG policies (see Part B below) will help to ensure that this financial and practical assistance continues. Meanwhile, the intiative’s social and environmental sustainability is reinforced by the combined efforts of local people, former patients and their families, and community and religious leaders, who remain committed to actively collaborate to safeguard the progress already made, as well as to identify new patients and assist them in obtaining the comprehensive medical services and ongoing support that they need. Members of the communities where the Health Chats intiative has been introduced fully appreciate the benefits of this new inclusive approach to mental illness. Those who were once afflicted by mental disorders are no longer a burden on their families; nor do they suffer the stigma and discrimination that were commonplace in the past. Instead, they enjoy the full support of their neighbours and wider communities as they work to rebuild their lives, and it is this community-based support that offers the strongest foundation for this initiative’s sustainability.

This innovative approach to mental illness has been implemented effectively for three years; the likelihood of its continued implementation for years to come has been boosted by the issuance of several district and sub-district regulations. Probolinggo’s District Head, who is strongly committed to the Health Chats initiative for the way in which it addresses mental illness in conjunction with local communities, issued in 2017 two District Head Instructions – Nos. 2 and 3 – on the Treatment of People with Mental Disorders. These followed on from a previous regulation, District Head Decree No. 440/1714/426.12/2014, which called for an end to the practice of keeping mentally-ill persons in shackles. He also takes an active interest in the initiative’s continued performance by receiving regular monitoring and evaluation (M&E) reports from the respective heads of the Health Office and Puskesmas Tongas, as well as other village-based partners. The initiative’s positive results also led to a multiparty agreement by the respective heads of Tongas Sub-district, relevant villages and the head of the Probolinggo Health Office to continue the programme’s implementation. This collective commitment to sustainability was strengthened by the introduction in 2017 of a joint decree (No. 56/136/426.423/2017) by the village and sub-district heads. Meanwhile, the head of Puskesmas Tongas has made clear to all health-centre staff, including health practitioners at the village level, that their adherence to the comprehensive handling of mentally-ill patients will be incorporated into their periodic performance appraisals. Any staff member who does not support the initiative’s activities will be sanctioned (by being rotated, denied promotion or, in the case of contract workers, having their contract terminated). The puskesmas head also collaborates with sub-district counterparts to show their appreciation for village-based volunteers, especially members of community-level Happy Heart Huts, to secure their continued commitment to and active involvement in the programme.

Yes

The initiative’s impact is periodically evaluated via formal evaluations, which are carried out by the Health Office, Health Centre and health volunteers/community members as follows: a. Probolinggo’s Health Office conducts M&E every six months to assess the effectiveness of the handling of mental illness cases, via the Health Chats innovation. Office staff also check and validate relevant data. b. Quarterly M&E is conducted by Puskesmas Tongas in all the villages where the initiative is implemented. These efforts aim to assess the implementation of health services across the health centre’s network at the village level. c. Monthly M&E is conducted by various health practitioners and health volunteers at the village level to identify and routinely record any and all developments in patients’ mental health during and after treatment. Records are kept in the Happy Heart Huts Community Mental Health Activity Book, as well as patients’ medical cards.

The impact on patients, their families and local communities is as follows: Patients: • All those who have undergone treatment have improved their quality of life; they are now living “normal” lives, free from the chains that used to bind them, free from harassment, and enjoying a whole new, safe way of life; • They are independent and free to seek the healthcare that is right for them; • They have been reintegrated into their communities; some have married, and all have regained their identity and rights as citizens; • They can earn a living (up to Rp. 1.6 million/month, on average). Families: • They are released from mental stress, and the costs of looking after their relatives; • Household incomes have risen, as former patients who can work contribute financially to their families; • They are proud as their relatives can have their own homes, marry and have children; • They enjoy cross-sector support in ensuring their relatives follow their treatment and continue to thrive in a positive environment. Communities: • Free from disturbances casued by people who were afflicted with mental disorders; • There has been a change in mindset; the stigma surrounding mental illness has gone; • Communities are re-energised; all residents work and contribute towards eradicating poverty.

Indicators to assess patient recovery: a. Patients are able to socialise and interact; b. They can assume the responsibility of employment; c. They are capable of earning a wage; d. They can marry; e. They are aware of their own condition if they experience a recurrence (such as hallucinations) and immediately self-medicate; f. They no longer disturb the peace and order of their communities. Indicators to assess poverty reduction: a. Increases in family/household incomes; b. A fall in the number of unemployed (among the mentally ill); c. The securing of health insurance. Indicators to assess improvements in mental-health services: a. All patients are recorded, their health monitored, and provided with comprehensive services; b. Access to services is available in each village, and community members are trained (health volunteers) to become partners in handling such cases; c. No person suffering from a mental disorder is kept chained up; d. Patients regain their identity and status as citizens (including identity cards, health insurance cards).

Government: 1. Puskesmas Tongas Medical staff, including village-based nurses and midwives, worked on the frontline delivering services to patients across the puskesmas’ work areas. 2. Village and Sub-district Administrations As regional leaders, they are responsible for ensuring the continuation of the Health Chats initiative. 3. Health Office Provides necessary medicine that is administered for free, and regularly assesses the initiative’s performance. 4. Bappeda and Offices for Organisation and Governance Each played a role in development planning, policy-making and implementation, as well as promoting innovations to improve the quality of public services. 5. Offices for Social Welfare, Farming and Agriculture Provided financial capital for training, livestock assistance, and issuing patients with their own Healthy Indonesia Cards. 6. Security Personnel Assisted puskesmas staff and health volunteers in handling challenging cases when patients received no support from their families or local community. Civil Society: • Sub-district Health Forum Engaged as part of the early detection team, forum members helped to promote Health Chats in collaboration with health staff, volunteers, and cross-sector organisations. • Community and Religious Leaders Helped to educate communities about mental illness and how to handle such cases, as well as combating stigma. Religious leaders involved patients in religious ceremonies and offered spiritual guidance to strengthen their faith and psychological well-being. Community leaders provided skills training to enable patients to secure jobs. • Health Volunteers They actively monitored the delivery of health services to patients (medicine regimes, provision of nutritious food, creating a healthy lifestyle), invited community members and patients’ families to join activities and gatherings at the Happy Heart Huts, and supported patients’ ongoing recovery. • Private Sector National and local media (Metro TV, Kompas TV, Trans TV, dan Pro TV) broadcast information about the initiative’s success in treating people with mental disorders and releasing them from captivity inside their homes.

The key lessons learned are as follows: • An important first step is to build awareness among health staff on treating mentally-ill patients, and to reduce the number of referrals to mental hospitals. • Services to patients and their families must be provided with empathy, awareness and sincerity, as the recipients are vulnerable, often disadvantaged and marginalised. • Poverty can be eradicated if efforts are made to empower the recipients of assistance, as opposed to merely providing handouts. • Initiatives are far more likely to achieve sustainable results if they partner with local communities and different stakeholders. • To obtain maximum community support, evidence-based results must show success on a small scale first, before being implemented more widely. • Changing people’s long-held, culturally-based views is hard; such efforts take time, tenacity and tremendous commitment. • Educating local communities is more effective if carried out informally and in accordance with local cultural norms, to ensure people do not feel patronized or disparaged. • Chatting (or gossiping) can be used for something positive. Information that was passed by word of mouth about the treatment and recovery of patients with mental illness spread far beyond Puskesmas Tongas’ catchment area, ensuring that all such cases within the area were detected and treated.