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Lul1C8S :
rof. uaya Somasundaram,
ur. 1harlnl keLharanaLhan,
ur. on keLheswaran (M88S, l8AnZC8),
ur. !ananl 1hlllalnadesan (M88S)

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Date: Sunday, 18th September, 2011
Venue: Reg. Byrne Community Centre, Wentworthville, NSW AUSTRALIA


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Table of Contents
AMAFs post-Seminar announcement ..................................................................... i
ACKNOWLEDGMENTS!!!!!!!!!!!!!!!!!...!!!!!!!!.ii
ABOUT AMAF!!!!!!!!!!!!!!!!!..!!!!!!!!!!!.!iii
SEMINAR PAPER - Mental Health in North and East of Sri Lanka
1. MEMBERS OF THE EXPERT PANEL ........................................................... 1
2. MENTAL HEALTH IN NORTH EAST SRI LANKA ............................................. 2
by Prof. Daya Somasundaram
3. PRESENTATIONS BY REGION
3.1 JAFFNA .......................................................................................................... 4
3.2 KILINOCHCHI ................................................................................................ 5
3.3 MULLAITIVU .................................................................................................. 6
3.4 MANNAR ........................................................................................................ 7
3.5 VAVUNIYA ..................................................................................................... 8
3.6 TRINCOMALEE .............................................................................................. 9
3.7 BATTICALOA ............................................................................................... 10
3.8 KALMUNAI ................................................................................................... 12
4. DISCUSSION ........................................................................................................ 13
5. FUTURE DIRECTIONS ......................................................................................... 15
6. CONCLUSION ...................................................................................................... 15
!

! !


ll

ACKNOWLEDGMENTS

We take this opportunity to thank Prof. Daya Somasundaram (Seminar Convenor),
all our participants, especially our special guests who travelled from overseas and
interstate, and Dr. Tharini Ketharanathan, for the success of the seminar.

In the course of writing this paper we received invaluable feedback from a number of
experts in this field who have been relentlessly working for several years to improve
mental health in North East Sri Lanka, but were unable to attend the Seminar in
person.

Specifically we would like to thank:
Dr John Mahoney (Former Mental Health Advisor WHO Sri Lanka),
Dr Sambasivamooorthy Sivayokan, (Consultant Psychiatrist, Jaffna, Sri Lanka),
Dr Gadambanathan Thanabalasingam (Visiting Psychiatrist Teaching Hospital,
Batticaloa & District Psychiatrist, Batticaloa),
Dr Prasantha De Silva (Consultant Community Physician), and
Dr Mahesan Ganesan (Psychiatrist, Ministry of Health Sri Lanka).

We wish to extend our sincere thanks to Dr. Janani Thillainadesan, Dr. Chitra
Harinesan and Dr. Nalayini Sugirthan for organising the Seminar on behalf of the
Australian Medical Aid Foundation (AMAF).

Dr. P. Ketheswaran Dr. V. Mano Mohan
President, AMAF NSW Branch The Chairman, AMAF



lll

ABOUT AMAF

The AMAF Ltd is a registered voluntary non-profit charitable organisation and a
member of the Australian Council for International Development (ACFID). Historically,
this initiative was started in 1996 to help those civilians caught in the ravages of the
civil war in Sri Lanka. It was formally inaugurated in Sydney, Australia on 10
th
March,
2001. The AMAF has branches in Sydney, Melbourne, Canberra and Adelaide.

OUR VISION
The establishment of an excellent and sustainable healthcare system, especially in
North East Sri Lanka, by advancing the clinical, research, infrastructure and
educational aspects of medical and allied health services.

OUR MISSION
To provide medical care, rebuild healthcare infrastructure, provide external support,
generate financial aid and develop local expertise while fostering strong links with
similar institutions at national and international levels towards achieving our vision.

Some of the many projects that have been successfully undertaken since 2001
include:
! Delivery of more than $5million worth of new and used medical equipment to
Eastern and Southern Sri Lanka (2001 ongoing)
! Establishment of the only pathology lab to service a population of half a
million (cost A$85,000) Ponnambalam Memorial Hospital- Kilinochchi,
Northern Sri Lanka in 2002-2003
! Establishment of a cardiac investigation unit to service a population of 1million
Batticaloa Hospital, Eastern Sri Lanka in 2008
! In partnership with International Centre for Eye Care Education (University of
NSW) - provided free eye care and spectacles to more than 50,000 people
Eastern Sri Lanka in 2005-2007
! In partnership with Rotary Club of Geelong and Barwon Health built a primary
health care facility in Trincomalee, Eastern Sri Lanka in 2008-09


lv

Since the armed campaign ended in May 2009, AMAFs efforts have focussed on the
desperate and displaced population who were held in internment camps. Some of
the projects that have been undertaken since May 2009 include:
! Provided acute health care for the internally displaced civilians held in Menik
Farm and nutritional supplements for pregnant women and children
! Built a ward at Chavakachcheri Hospital to care for the patients in the
overcrowded hospital due to influx of IDPs
! Funded 150 above-knee and below- knee prostheses for amputees in Mannar
and employed 10 paramedics to provide physiotherapy and care of
stump/prostheses
! Funded mobile mental health services in Chavakachcheri and Jaffna Districts
! Sponsoring 30 disadvantaged and displaced medical students (released from
IDP camps) from the University of Jaffna
! Funded the installation of a centralized air-conditioning unit in the surgical ICU
at the Jaffna Teaching Hospital
! Donated 30 tricycles to amputees in Jaffna and 30 bicycles to health care
volunteers in Kilinochchi
! Employed 5 junior medical officers to serve in remote un-manned peripheral
units in Vanni
! Provided urgent medical care for the 2011 flood victims in Batticaloa and
adjoining affected districts through the Ramakrishna Mission and Rotary club




For more information:
AUSTRALIAN MEDICAL AID FOUNDATION (AMAF)
Phone: 61 1300 990 828
AMAF, P.O.Box 4440, HOMEBUSH, NSW 2140, AUSTRALIA
P.O.Box 226, Glen Iris, VIC 3146, Australia
Email: ausmedaid@gmail.com, Website: www.ausmedaid.org.au


1

SEMINAR PAPER - Mental Health in North and East of Sri Lanka

1. MEMBERS OF THE EXPERT PANEL
1. Professor Daya Somasundaram (Seminar Convenor), BA (USA), MBBS (India),
MDpsych (SL), FRCPsych (UK), FRANZCP (AUS). Based in Adelaide
2. Dr. Dan Sirunjayan Soundararajah, MBBS, PGrDip. Psychiatry. Based in Batticaloa
3. Dr. Sivasubramaniam Sivathas, MBBS, MD in Psychiatry. Based in Vavuniya
4. Dr. Sivagnanam Suthakaran, MBBS, PGrDip. Psychiatry. Based in Vavuniya
5. Dr. Judy Ramesh Jeyakumar, MBBS(SL),Dip in Psy (Col), SFMH(Canada). Kalmunai
6. Mr. Gopalakrishnan Krishnakumar, MA (Pub. Admin), B.Sc. Based in Jaffna
7. Dr. Kanagasingam Aruljothy, MBBS, PGrDip. Psychiatry. Based in Mullaitivu
8. Dr Masilamani Jeyarasa, MBBS, PGrDip. Psychiatry. Based in Kilinochchi
9. Dr. Tharini Ketharanathan, MBBS, MD in Psychiatry. Based in Melbourne
10. Dr. Rasiah Yuvarajan, MBBS,MBA, MRCPsych, FRANZCP. FPOA. Based in Sydney
11. Dr. Ramani Sivakadadchan, MBBS, FRANZCP, MMed(Psychiatry) Based Melbourne
12. Mrs. Kohila Mahendirarajah, Former Deputy Director of Education, Valigamam
Education Zone, Jaffna, Sri Lanka and a trained senior counsellor.
Seminars expert panel and a few AMAF executive members: Front row (left to right): Dr. S. Sivathas,
Dr. P. Ketheswaran, Dr. V. Mano Mohan, Professor D. Somasundaram, Mrs. K. Mahendirarajah, Dr. T.
Ketharanathan. Back row (left to right): Mr. G. Krishnakumar, Dr. K. Aruljothy, Dr M. Jeyarasa, Dr. S.
Suthakaran, Dr. J. Jeyakumar, Dr. D. Soundararajah, Dr. T. Sathiyamoorthy, Dr. R. Sivakadadchan, Dr.
N. Sugirthan.


2

2. MENTAL HEALTH IN NORTH EAST SRI LANKA
by Prof. Daya Somasundaram
The North and East of Sri Lanka currently consists of Jaffna, Kilinochchi, Mullaitivu, Mannar,
Vavuniya, Trincomalee, Batticaloa and Amparai Districts. Kalmunai is a municipality within
Amparai. These areas have been adversely affected by decades of civil war beginning in the
1980s. The population in these districts have faced deaths in their families, relatives, friends
and communities, injuries, disappearances, arrests, detention, torture; military, paramilitary
and militant violence; bombings, shellings, destruction of home, property and belongings;
and multiple displacements with life in Internally Displaced (IDP) camps for lengthy periods.
In addition, the coastal areas were exposed to the massive Tsunami in 2004 while the
Eastern District faced two large floods in December 2010 and February 2011. The final
phase of the war started in the Eastern Province in 2004 and extended to the North in 2006,
culminating in the displacement of 300,000 people from the Vanni region in 2009. Currently
people are returning to their homes, resettling in former villages and trying to rebuild their
lives. But they have undergone severe trauma, lost everything and are struggling to find
sources of livelihood. There is now an opportunity for the outside world to play an important
role in the rebuilding process, particularly those who have managed to escape from these
terrible situations to find refuge in safer havens.

Psychiatric services in the North and East were started in 1966 by the pioneering efforts of
Dr. Thamotheram Arulambalam at Mandihai Hospital, Point Pedro. His illustrious picture still
hangs at the hospital psychiatric unit which is unchanged from that period. He later
expanded the services to Kankesanthurai (KKS), and later moved to Tellipallai. It is to be
noted that Tellipallai Hospital was displaced in 1990 and has still not been able to return to
its old premises. In a very progressive move for the time, Dr. Arulambalam initiated the
Friends of the Psychiatric Unit in 1966, a community and carer society looking after the
welfare of psychiatric patients and their families. Dr. Arulambalam was followed by a series
of eminent psychiatrists, Drs Kathirkamasekaran, Sathananthan, Gnanasingham,
Ganesvaran, Selvaratnam, Mahadevan and, now Sivayokan. Like Sivayokan, several
graduates of the University of Jaffna Medical Faculty, such as Sivathas and Gadambanathan
have become psychiatrists and are continuing to serve in the North and East regions.
Medical Officers like Sooriyabalan and Kathiravetpillai stand out in having done yeoman
service to mental health. Dr. Kathiravetpillai in particular, went on serving the psychiatric
patients as the District Medical Officer at Point Pedro till his retirement just last year. Some
nurses, Mr. and Mrs. Canagarathanam in particular, have been a central part of the
psychiatric unit, mental health services and programmes from the onset. More recently,
3

Jaffna graduates, including Mullai, Suthakaran, Kalaichelvan, Aruljothy, Judy Jeyakumar and
Dan Sounthararajah, are serving as Mental Officers of Mental Health (MOMH) throughout
the North and East.

The 2004 Tsunami saw an influx of generous help from all over the world. This goodwill and
recognition of the mental effects of the Tsunami on the survivors gave the opportunity to
develop mental health services in Sri Lanka, particularly in the North and East. Sri Lanka
adopted a Mental Health Policy in 2005 which envisioned a community based mental health
service with decentralization of services to the districts. It was planned to appoint a
psychiatrist to each district with a MOMH for each division. Several other categories of staff
such as psychiatric nurses, psychiatric social workers (PSW), clinical psychologists,
occupational therapists (OT) and community mental health nurses were to be appointed.
Acute inpatient units and intermediate care facilities were to be established in each district.
To some extent, some of these goals have been achieved. There is now at least one MOMH
in each district with most of them having a Diploma in Psychiatry. Most districts have a
functioning acute inpatient unit, intermediate care units, and multidisciplinary teams (MDT)
with psychiatric social workers and community level workers. However, many of the districts
still lack a psychiatrist and other staff. The state is still to recognize the concept of
psychosocial needs. Most of the MDT and community level workers are not in the state
cadre and have to be supported by various external means. Transport, equipment, drugs
and other facilities are in short supply. The younger generation of mental health
professionals and workers have responded to the variety of needs of the region through
commitment, hard work, organisation and innovative measures in an attempt to rectify the
shortages. Dr. Judy Jeyakumar and his team were recently recognized for their untiring
efforts by being awarded the Asian Leadership Award for Excellence in Mental Health at the
3rd World Congress of Asian Psychiatry held in Melbourne on the 2nd of August, 2011. Dr.
Sivayokan was awarded the Oration for the 2011 Annual Sessions of Sri Lanka College of
Psychiatrists for his research, Waiting in limbo: Psychological impact of disappearance". He
has also been responsible for the production of several outstanding psychological dramas, in
addition to several books written in Tamil. Dr. Sivathas has also produced several books
and photographic exhibitions with his rich artistic talent.

The purpose of this Seminar was to raise awareness among the Diaspora and other
humanitarian organisations of the mental health status in the North and East of Sri Lanka, to
stimulate discussion, recommend initiatives and ultimately translate these proposals into
action to improve mental health services in North and East Sri Lanka.

4

3. PRESENTATIONS BY REGION
Guest representatives from each of the areas, namely Jaffna, Kilinochchi, Mullaitivu,
Vavuniya, Batticaloa and Kalmunai made presentations at the Seminar conveying
information about their existing mental health facilities, current needs and potential areas for
development. Though not physically present at the Seminar, the presentations from Mannar
and Trincomalee were received and included. The information is summarised below.

3.1 JAFFNA (presented by Mr Gopalakrishnan Krishnakumar)
Jaffna has a catchment population of 650,000. In relative terms, they have a well developed
mental health care system. The districts mental health care service is comprised of:
! Inpatient units in Tellipalai and Point-Pedro
! Outpatient clinics at the Jaffna Teaching Hospital, Tellipalai Base Hospital, Point
Pedro Base Hospital, Chavakachcheri Base Hospital, Velanai Divisional Hospital,
and Maruthankerny Divisional Hospital
! An outpatient Childrens Clinic at the Jaffna Teaching Hospital
! Community mobile mental health services with assertive follow up facilities
! Rehabilitation services including Intermediate Care Units in Kudil, group houses in
Manthikai (Point Pedro) for males and in Mallakam (Tellipalai) for females, and an
outpatient rehabilitation setting in Chavakachcheri

Other specific activities include:
! Treatment of substance abuse issues through the Regional Addiction Rehabilitation
Centre established at the Tellipalai Base Hospital
! Addressing gender based violence (GBV) through the Gender based violence desk
established at the Jaffna Teaching Hospital
! Training of teacher counselors as part of school based mental health activities

The Jaffna districts mental health care system is centered around the multidisciplinary team
(MDT) approach. The MDT comprises psychiatric social workers (PSW), occupational
therapists (OT), community mental health educators, and counselors (e.g. alcohol
counselors), who function as the backbone of service delivery and also as intermediaries in
the mental health referral system. The medical team consists of a consultant psychiatrist, a
medical officer of mental health (MOMH), and 3 medical officers.

The major mental health need raised, was financial assistance to stabilize the current
workforce as it has been a challenge to employ the necessary skilled staff. For example, at
present the estimated cost to employ a skilled mental health worker for one year is LKR
3

18,000. Thus, a 15 member MDT team costs LKR 3,240,000 annually (monthly allowances
for the MDT staff - 15 staff x 18,000 x 12 months = LKR 3,240,000).

3.2 KILINOCHCHI (presented by Dr. Masilamani Jeyarasa)
The mental health services in Kilinochchi cater to a population of almost 120,000; most of
them have been affected by the civil war. The major services are outreach clinics (up to 8)
and psychosocial activities such as mental health awareness programs, school visits, and
bereavement services. The clinical team consists of a medical officer (MO)/medical officer
of mental health (MOMH) under a visiting psychiatrist, PSWs, counselors and volunteers.

At present mental health provision in Kilinochchi relies on grass root services such as
community support workers (CSW) who play a major role in service delivery. Service
providers have also recognised the pervading psychosocial issues. The post-war era has
seen the emergence of new psychosocial problems manifesting as self-harm and suicide,
unwanted pregnancies, substance related problems, child abuse/neglect, physically
challenged/handicapped community members, increased number of widows, unemployment,
and increasing family conflicts, all of which have contributed to the burden on the areas
psychiatric services.

The immediate mental health needs that were identified included:
! Continuing financial support to keep community support workers for at least another
two years and absorbing them into the health system
! Livelihood support for families of patients with serious mental illnesses
! Creating self employment opportunities for widows from impoverished families

Medium term to long term (up to 3 years) needs that were identified included:
! A secure 10 bed inpatient psychiatry unit with a common room area and dining area
! An intermediate care psychiatry unit with vocational training facilities
! A safe home for socially disadvantaged women
! A special school for children with intellectual disabilities


6

3.3 MULLAITIVU (presented by Dr. Kanagasingam Aruljothy)
Mullaitivus population of just over 220,000, was totally displaced during the last stages of
the war in 2009. The catchment now consists of a population of 65,000, all of whom were
resettled in 2010. An increase in the population is expected as displaced persons return to
the area. From a mental health perspective, there are 2 main population groups, those with
mental illnesses and those with psychosocial issues. The impact of the war and its
devastating consequences of death, displacement, missing family members, separation and
injuries are clearly visible in Mullaitivu, with newly emerging conditions such as post
traumatic stress disorder (PTSD), abnormal grief and substance use disorders. There are
also special populations with unique needs such as ex-combatants.

Currently, due to limited medical staff resources (e.g. restricted to one MOMH) and the lack
of a MDT, the mental health system in Mullaitivu relies on its community support workers
who play a key role in the delivery of psychiatric services. Outreach clinics which are run in 3
peripheral hospitals are the major means of psychiatric service provision in the area. Similar
to other war affected areas with resettlement, the communities are undergoing considerable
change with newly arising psychosociocultural issues such as prolonged grief, increased
numbers of widows, widowers, single parents and orphans, relapse of preexisting mental
illness, poverty, poor shelter and sanitary facilities, lack of transport facilities, interruption in
education, unemployment, teenage mothers and pregnancies, abortions, substance abuse,
domestic violence, child neglect, and family conflicts.

Local initiatives have been undertaken to promote community awareness of mental health
issues; for example through local drama performances, at religious celebrations, and by
school awareness programs. The mental health unit has also released a video documentary
on child abuse. Social activities such as youth clubs have also been revived to help build a
healthy cohesive community.

The needs that were identified to enable better delivery of mental health services included:
! Provision of support, salary and transport for community support officers to visit
remote areas specifically 10 mopeds (small motorbikes) estimated to cost LKR
70,000 each
! Support for continuing community based awareness programs and social initiatives
e.g. further documentaries (an education video on domestic violence has already
been planned), resources to build a meditation hut (estimated to cost LKR 60,000),
sports equipment for youth sports clubs, and instruments for musical and other
cultural groups
7

! Establishment of caregiver support societies
! Equipment for community support centers e.g. books for the library
! Microcredit and livelihood support for mentally affected patients through provision of
skills training and equipment provision e.g. sewing machines, water pumps
! Financial resources to fund the employment of a clinical staff assistant who can
report, audit and co-ordinate activities; employment of one assistant is estimated to
cost LKR15,000/month
! Building of an acute psychiatric unit (a long term objective)

3.4 MANNAR (information provided by Dr. Suganthy Kalaichelvan)
The psychiatric services in Mannar consist of an acute inpatient unit at the General Hospital
in Mannar, outpatient clinics including 8 outreach clinics, a Centre for Rehabilitation for
Alcohol and Drug Addicts, and a rehabilitation service. Visits are also undertaken to elder
homes and schools for children with special needs. Services also play a role in gender
based violence prevention and raising mental health awareness in the community. The
clinical workforce is comprised of MOMHs, a PSW, an OT, counselors, CSOs and GBV desk
staff.

The recognized needs in Mannar included:
! Transportation facility for the PSWs
! A microcredit system to help rehabilitate patient communities


8

3.5 VAVUNIYA (presented by Dr. Sivagnanam Suthakaran)
The Vavuniya district covers an area of 1967 Sq.km and a population of around 200,000. In
recent times, a significant proportion of work has involved addressing the mental health
needs of internally displaced people. The recently established acute care units services also
extend to Mullaitivu and Kilinochchi districts where such facilities are currently absent.

In addition to the acute psychiatric service, other services in Vavuniya include:
! Outreach clinics - established in three peripheral hospitals and in the IDP camps
! Mobile clinics in homes for elders in view of the high prevalence of mental illness in
this population
! Mobile clinics for children with learning difficulties and mental illness
! Clinics at the long-term/intermediate care unit - currently managed by non-
governmental organisations (NGOs)
! Undertaking mental health camps with the cooperation of NGOs
! Visits to schools for children with special needs to undertake screening and
appropriate referrals
! Home visits

In addition to service provision, several awareness and education activities are also
undertaken including:
! Public awareness programmes on various topics such as mental wellbeing, mental
illnesses, substance/alcohol abuse, suicide, child development, child abuse
! School workshops on basic life skills and student specific mental health issues
! Training of staff and psychosocial workers in the government and NGO sector
! Forums - Psychosocial forums on community awareness and Gender based violence
! Coordinating and assisting the District Child Protection Committee (a branch of the
National Child Protection Authority). The MH unit addresses issues of child right
violations

The key needs that were identified included:
! An electroconvulsive therapy (ECT) machine
! Resources to help build a child well being unit (regional) and a rehabilitation unit
! Support to establish a microcredit system to rehabilitate the mentally ill and their
families
! Funding for publication (in 3 languages) of Dr. Sivathas book of drawings and poems
of child soldiers

9

3.6 TRINCOMALEE (information provided by Dr. Prabath Wickrama)
The Trincomalee district in the Eastern Province of Sri Lanka consists of a population of
around 400,000. It has an area of approximately 2700 square kilometres. The population
consists of three main ethnic groups - 45% Muslims, 29% Tamils and 25% Sinhalese.
Trincomalee is rated as one of the poorest districts in the country, with 40% of families
receiving government welfare payments.

According to the Mental Health Policy of Sri Lanka there are around 8000- 12,000 patients
with severe mental illnesses in this district. The burden of common mental illnesses is said to
be great considering the catastrophic events which have affected the district, namely the
Tsunami, civil war, the recent floods, and the geographical isolation of some areas such as
Echchilampaththu, Sampur, Serunuwera and Gomerankadawala.

Health provision is through the Provincial Director of Health Eastern Province and the
Regional Director of Health Services (RDHS) for the district. Treatment services are mainly
provided through the District General Hospital Trincomalee, three Base Hospitals in
Kanthale, Mutur and Kinniya, and several lower level hospitals throughout the district.
Preventive services are rendered through eleven Medical Officers of Health regions. Mental
Health services are provided by a psychiatrist form the General Hospital Trincomalee and
three Medical Officers of Mental Health (MOMH) attached to the General Hospital and Base
Hospitals in Kanthale and Kinniya. The General Hospital has a 13 bed inpatient unit. Ten
outreach clinics have also been established to improve services in the context of limited
human resources. Yet, there remains an unfulfilled gap between those patients requiring and
receiving services.

The specific needs identified to improve the provision of and access to mental health
services in Trincomalee included:
! Resources to recruit and train Community Support Officers
! Resources to recruit and train community workers who will work at the community
level under the Divisional Secretaries
! Resources to sustain a financial incentive for Community Support Officers ideally
for at least one year and then aim to absorb them into the main stream service
through discussions with the Regional Director of Health Services (RDHS)
! Resources to facilitate the development of an innovative and flexible training
programme using existing manuals and in liaison with the current staff


10

3.7 BATTICALOA (presented by Dr. Dan Sirunjayan Soundararajah)
Caring for a population of 600,000, the Batticaloas mental health system is broad and
structurally centres around:
! The mental health unit (MHU) of the Regional Director of Health Services (RDHS)
office
! Acute inpatient units in Teaching Hospital, Batticaloa and Valaichenai Base
Hospital
! Outpatient mental health clinics including weekly child and adolescent support
clinics, and weekly family support clinics
! A rehabilitation centre in Mavaivembu which provides vocational training
opportunities and microcredit loans to patients
! A psychosocial centre (Kallady) with a hotline
! Separate hotlines for Teaching Hospital, Batticaloa and Valaichenai Base Hospital
! Consumer forums

There are special population targeted programs such as the geriatric psychiatric clinic,
outreach clinic visits to elders homes, homes for handicapped children and to schools.
Activities include school health education on life skills, alcohol abuse, gender based violence
prevention (in collaboration with the GBV desk and local police force), and conducting
community awareness programs. The current clinical workforce consists of the district
psychiatrist, 3 health professional with a Diploma in Psychiatry, 4 medical officer
(MO)/medical officer of mental health (MOMH), 2 Psychiatric Social Workers, 11 nursing
officers, 3 OT, and 14 Psychiatric social assistants. At present, the Batticaloa Mental Health
service is shifting towards becoming a community based service.

Several needs were identified to help improve service delivery and expand the services.
These included:
! Transport for Psychiatric Social Workers and Assistants i.e. a small field motorcycle
is estimated to cost $A1,500. Better transport will enhance the efficiency of their
services including mental health promotion, child and women protection, and alcohol
abuse and suicide prevention
! Provision of support, salary and transport for Psychiatric social assistants
! An electroconvulsive therapy machine (ECT) particularly for use in new mothers
with severe postpartum depression/psychosis. Early effective treatment can
minimise the period of separation between mother and child and in turn, potentially
minimise detrimental long-term effects. Estimated to cost A$2,500
11

! Establishment of a safe home with rehabilitation and vocational training facilities for
women a location has already been identified but funding is needed to employ the
necessary staff
! Resources to fund skills and job training programs for example, a tailoring course
for 15 persons is estimated to cost A$2000/6 months; Poultry farming estimated to
cost LKR 50,000/6 months; Palmyra leaves weaving for 15 persons estimated to
cost A$500/6 months
! Funding to purchase monitors and other equipment to support detox programs as
substance abuse specific beds are to be established at Valaichenai Base Hospital
! Resources to help establish a district centre of excellence for sub
specialities such as substance abuse and child and adolescent mental health
! Development of horticultural facilities at Valaichenai Hospital
! Assistance to staff in terms of career development to help sustain the
multidisciplinary workforce
! Support to improve coordination between workforce from Central and Provincial
ministry


12

3.8 KALMUNAI (presented by Dr. Judy Ramesh Jeyakumar)
The town of Kalmunai sits on a coastal belt. Kalmunai consists of a population of around
430,000.
The Kalmunai psychiatric service is comprised of:
! An acute care unit
! Outreach Clinics
! Special services/clinics such as monthly clinic for children with special needs,
Torture and Trauma Survivors Group, Gender based violence network, substance
abuse clinics, and self help groups for terminally ill patients
! Consumer welfare clinic with microcredit provision
! A vocational training unit e.g. carpentry and needlework
! Community mental health programs such as school programs, alcohol awareness
programs, women empowerment programs, Deliberate Self Harm (DSH) prevention
programs, GBV prevention program, HIV and Mental health awareness, yoga and
relaxation classes
! Rehabilitation facilities to homeless patients and ex-combatants

Several needs were identified which included:
! Funding training programs for nurses, PSW and volunteers (approx cost A$1000) as
part of a continuing professional development program
! Transport for community mobile team (6 motorbikes estimated to cost A$6000)
! Developing and maintaining an information system
! Funding monthly allowance for volunteer workers
! Funding training programmes for village based mental health task team
! Skilled resource development in Rehabilitation, OT, CPN, Geriatric care
! Infrastructure development resources to build a long stay unit in Kalmunai,
community support centers in 3 divisional secretariat areas (Kalmunai, Navithanveli
and Thirukovil), a shelter for homeless patients, a safe house for women, and a
forensic unit in Kalmunai Base Hospital
! Resources for expanding community programs such as the establishment of school
based mental health programs, life skill training, yoga relaxation training, and a
sports/recreational hub


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4. DISCUSSION
The presentations were followed by a discussion chaired by Prof. Daya Somasundaram, and
involved the expert panel and Seminar attendees. The objective of this discussion was to
review the needs that had been highlighted by the guest presenters, prioritise these needs
and to make recommendations on how NGOs such as AMAF could help meet these needs
in a pragmatic way. Several recommendations were made.

Recommendations that could be implemented across the North East region include:
! Providing transport for Community Support Workers and Psychiatric Social Worker
assistants this is an URGENT need in most regions
! Providing salary to support current staff, in particular CSO and PSWs
! Providing funding to train existing staff personnel in specific areas of need e.g. child
psychiatry
! Establishing telepsychiatry (Telemedicine) facilities to help improve the accessibility
of services in regional areas, save on travel expenses, enable peripheral community
workers to communicate easily with psychiatrists/MOMHs, and to also serve as a
mode of education. However, a potential barrier was the lack of electricity in
peripheral regions.
! Establishment of a hotline across the North East region (already established in
Batticaloa and Valaichenai)
! Providing resources to promote mental health education this is a key primary
prevention strategy to raise community awareness and reduce stigma. Currently
certain regions such as Batticaloa, Mullaitivu, and Vavuniya have local dramas as
part of their health education efforts. By working with talented and creative
psychiatrists, including Dr Sivayokan and Dr Sivathas, a regional health education
program can be established, for example, a travelling drama troupe. Rather than the
conventional prevention strategies, initiatives such as local dramas enable a more
effective education campaign that draws on the regions people, history and culture.
! Re-establishing the master counsellor training program which was previously
spearheaded by Prof. Daya Somasundaram, Dr Sivayokan and Mrs. Kohila
Mahendirarajah. Through this program school teachers could be trained to counsel
children, in particular those who have suffered war-related trauma, loss of parent/s
and those who have been adversely affected by recent natural disasters including the
Tsunami.



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Other recommendations which may be implemented in specific regions include:
! Funding to hire extra staff including new roles such as clinical staff assistants
! Providing ECT machines to regions without one to save on the costs involved in
transferring patients and to attempt to reduce the length of hospitalisation. However,
prior to the provision of an ECT machine, an assessment needs to be undertaken on
its benefits and the availability of qualified professionals to undertake ECT
! Infrastructure development e.g. vocational training centres and acute wards in
regions such as Kilinochchi and Mullaitivu
! Providing resources to help meet the mental health needs of specific target
populations that are currently neglected, such as establishing a regional child mental
health unit
! Improving the microcredit system


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5. FUTURE DIRECTIONS
Continue our dialogue through meetings (via Skype, in person)
Maintain internet and email group as an ongoing mode of communication
Publish updated reports detailing our progress and new projects/initiatives

6. CONCLUSION
This Seminar on Mental Health in North and East of Sri Lanka was the first of its kind in
Australia. It represented a major step forward in enabling the global community to recognise
and propose necessary projects to improve mental health care services in North East Sri
Lanka.

In light of the scale of unprecedented need outlined in this report, the Governments (Ministry
of Health) priority has to be:
The appointment of a full cadre of mental health workers in the North and East,
including one Medical Officer of Mental Health (MOMH) per Medical Officer of Health
area, as a matter of urgency and a continuation of the Diploma in Psychiatry course
for MOMHs
The continuation (and expansion) of the role of Community Support Officers and the
undertaking of a formal evaluation of their role. If this role proves to be valuable
(which we believe it will) a case should be made to the Minister of Health for the
establishment of a permanent cadre
Mental health service development in the North and East ought to be a high (and
urgent) priority for other Government Aid Agencies and Donors

Given the extent and complexity of the psychosocial issues prevalent in North and East Sri
Lanka, the task at hand is even more challenging. Mental health professionals are arguably
in a better position to address the psychosocial issues, however, understandably their major
role is the treatment of mentally ill patients. Thus, as well as supporting and rebuilding the
local mental health care system to provide specialist care, NGOs need to concomitantly
support grass root projects to improve psychosocial care.

In the context of limited resources, the projects will be prioritised on a needs basis. The aim
will be to deliver the greatest benefit to the community. For example, the provision of an ECT
machine may help in the management of a minority of individuals, whereas the provision of
salary and transport for the community workers will enable delivery of mental health services
to a wider population. Priority should also be given to the regions of Kilinochchi and
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Mullaitivu, which are facing the greatest challenges post war. Projects may be a regional
initiative, or could be specific to a hospital or centre. Whether it be a regional or provincial
project, it would be vital to work together. This report will be distributed to NGOs, which work
in the medical and health sectors in North and East of Sri Lanka. The NGOs can select
project/s. The Australian Medical Aid Foundation (AMAF) will oversee the overall allocation
of the projects.


Please send any suggestions or comments to the editor/s via:
Phone: 61 1300 990 828
Email: ausmedaid@gmail.com,
Post: AMAF, P.O.Box 4440, HOMEBUSH, NSW 2140, AUSTRALIA, or
P.O.Box 226, Glen Iris, VIC 3146, Australia