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Community Care, also called Care in the Community, is the policy of deinstitutionalization, treating, caring for and supporting physically, mentally and intellectually disabled people in the society, in their own homes and neighbourhood rather than in an institution.
Institutional care was the target of widespread criticism during the 1960s and 1970s in many countries. Community mental health model projects have been evaluated and found to be successful (Harding et al, 1983; World Health Organization, 1984; Wig, 1989).
Much of the debate on community care for individuals with mental disorders has focused on issues relevant to industrialised nations.
Developing countries also have accepted the need for community care, with the World Health Organization spearheading the crusade to incorporate the mental health component into primary health care (World Health Organization, 1990). Many developing countries have set up model programmes that form the basis of national implementation strategies (Harding et al, 1983; World Health Organization, 1984; Wig, 1989). However, many programmes are not successfully implemented (Wig, 1989; Agarwal, 1991;Gureje & Alem, 2000). The issues with regard to community care for people with mental illnesses in the developing world are complex and differ from those in western societies.
The success of model projects in a number of countries did not result in mental health care being implemented on a national scale. The vast majority of the population are outside these model programmes and still lack the basic facilities suggested in the national plans. For example, in India the programme is in different stages of implementation in small pockets (22 districts, with an estimated population of 4 million in a country with a population of 1 billion). The evaluation of some of these demonstration projects also has shown a low use of government health care, with major reliance on private health providers (Chisholm et al, 2000).
Jacobs (2001) mentions a number of reasons why it is difficult transforming traditional services to community care services.
1. Absence of social welfare
The community programmes operating in industrialised societies make active use of social welfare services in delivering care and are intrinsic to mental programmes (Thornicroft et al, 1998). The complete absence of a social welfare net in most developing countries is a major obstacle to the delivery of mental health care.
2. The vertical nature of health programmes
Community health programmes in many developing countries are essentially vertical in nature and their organisation reflects the specialist nature of hospital care. Vertical programmes do not fulfil the holistic nature of primary care and tend to break it up into compartments. Even in programmes where these are apparently integrated, the assimilation is superficial, with different vertical programmes competing for the community health worker's time and expertise.
3. Scope of the programme
The enlarged scope of the mental health programmes (Director General of Health Services, 1982), with emphasis on positive and preventive mental health, is ideal but beyond the scope of the available resources and expertise. The majority of mental health professionals have been trained in diseaseoriented systems and lack the required skills. In addition, knowledge and expertise in the prevention of illness and the promotion of mental health at the community level are still in their infancy.
4. Other factors
Other factors that may interfere with community care include the high levels of civil strife and violence in some societies, political instability and corruption and gender inequality. The abuses perpetrated by psychiatry (i.e. the absence of basic human rights in some state-run mental hospitals) do not add to public confidence in seeking mental health care. Finally, a major psychosocial phenomenon, the ‘Matthew effect’, has been documented in primary health care: it has been demonstrated that populations with a poor standard of health seem to achieve only meagre improvements, whereas those with good standards seem to show substantial progress (Joseph, 1989). The Matthew effect also seems to influence the community care of people with mental illnesses. Resource allocation is biased in favour of hospital-based strategies, despite their inability to cater for the needs of rural populations. The discrimination against community care hinders the creation of alternative health strategies.
For more reading about Community care for people with mental disorders in developing countries: see Jacob K.S. (2001): http://bjp.rcpsych.org/content/178/4/296.full
last edited by Jean Pierre Wilken March 2013