International Review of Psychiatry, December 2006; 18(6): 559562

Mental health model of care programmes after the tsunami in

Aceh, Indonesia
PRASETIYAWAN1, EKA VIORA2, ALBERT MARAMIS3, & BUDI ANNA KELIAT4
1

Departemen Psikiatri, RS Cipto Mangunkusumo, Jakarta, Indonesia, 2Departemen Kesehatan, Direktorat Kesehatan
Jiwa, Jakarta, Indonesia, 3World Health Organization, Indonesia Country Office, Jakarta, Indonesia, and 4RS Marzuki
Mahdi, Bogor, Indonesia
Abstract
Before the tsunami, there was no systematic training provided for General Practitioners (GPs) and nurses in issues related
to mental health and psychosocial support in times of disasters. After the tsunami, the Department of Psychiatry, Faculty of
Medicine, University of Indonesia in Jakarta was contracted to organize a special two-week intensive training programme
on basic psychiatry for 13 GPs from Banda Aceh Mental Hospital. To improve the nursing practice, a Professional Nursing
Practice Model (MPKP) has been piloted in two wards in Banda Aceh Mental Hospital. This is a model of best practice for
nursing care and management in an open ward system developed by the School of Nursing group and implemented in
several mental hospitals in Indonesia. Basic training of GPs located at the primary healthcare level is being carried out
based on the existing Ministry of Health curriculum for GPs. It covers 14 conditions listed in the International
Classification of Diseases (ICD) Primary Care classification and has been conducted in 11 tsunami-affected districts.
Currently, a total of 169 GPs have been trained. In general, there is an increasing interest among primary care doctors in
mental health. Currently, community mental healthcare is provided in 11 districts in Aceh and two districts in North
Sumatra by 277 Community Mental Health Nurses (CMHN) who have received basic training. Two thousand six hundred
and two cases of serious mental disorders (mostly chronic psychosis) have been detected and treated by the CMHN and the
doctors in Primary Health Centres (PHC). CMHN can provide a vital link between patients in the community and doctors
in PHC. Two years after the earthquake and tsunami in Aceh, psychosocial intervention should continue and mental
healthcare should be made available not only at Banda Aceh Mental Hospital, but also general health services, including
PHC services.

Introduction
Even prior to the tsunami, the Acehnese people
had already been affected psychologically by the
prolonged armed conflict between the Free Aceh
Movement (GAM) and the government of
Indonesia. The tsunami added substantially to their
psychosocial distress.
Banda Aceh Mental Hospital is the only mental
hospital for the whole province of Nanggroe Aceh
Darussalam. Prior to the tsunami this was the main
and perhaps only provider of mental health services
to the community in the province of Aceh. This
hospital has 250 beds and the bed occupancy rate is
usually more than 100%. The patients are cared for
by one psychiatrist, five psychologists, 180 nurses
and 13 General Practitioners (GPs) who do not have
any special training in mental health. Thus, the
quality of care is not always optimal.
To overcome the problem of limited human
resources for mental health in Aceh, one of the

critical tasks is to train health and other professionals

and the workers in providing basic mental healthcare.
This includes a short orientation course on mental
health and psychosocial aspect to PHC staff. Most
Primary Health Care Centre staff have limited
knowledge of mental health. The clinical and nursing
care skills need improvement to help the staff move
forward from providing merely custodial type of care
to a more comprehensive and humane model of care.

Indonesian government policy

The Indonesian government has a policy for the
management of mental health and psychosocial
problems in communities affected by disaster and
violence. There are several important aspects to the
policy:
1.

Services in mental health and psychosocial

problems for disaster and conflict- affected
communities are implemented from the earliest

Correspondence: Prasetiyawan, Departemen Psikiatri, RS Cipto Mangunkusumo, Jl Diponegoro, Indonesia. E-mail: pras_prasetiyawan@yahoo.com
ISSN 09540261 print/ISSN 13691627 online/06/0605594 2006 Informa UK Ltd.
DOI: 10.1080/09540260601039959

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Prasetiyawan et al.
stage, and in an integrative way to the other
health services and utilize the existing infrastructure and resources.
The prevention and management of mental
health and psychosocial problems are executed
in collaboration with partners including the
international community across programmes
and sectors to strengthen the network.
Every district/city that is affected by or vulnerable to disaster and conflict has the obligation
to prepare people who are capable of handling
mental health and psychosocial problems in
their area by involving all resources (the
government, private sectors and community
elements).
Prevention and management of mental health
and psychosocial problems in communities
affected by disaster and conflict must take into
account local culture and vulnerable groups,
e.g. children, adolescents, women, the elderly
and the disabled.
Services for mental health and psychosocial
problems are executed in three stages: (1) Preimpact phase for all communities, (2) Impact
phase for most of the population, and (3) Postimpact phase for those with mental health and
psychosocial problems and vulnerable groups.
The provision of services is done in tiers from
community level to the highest referral level.
The service levels are:
a. Community-based service. This is a service
performed by trained volunteers who join
an institution or community/religious
organization or by cadres or government
agencies in village or at county level. The
activities done at community level are
information giving, basic guidance, counselling, and assistance.
b. Service at the level of Public Health Centre
(Puskesmas) and District General Hospital.
These services deliver basic psychiatric
drug therapy, basic guidance and counselling, and community empowerment.
c. Specialist service (province general hospital or
mental hospital). This service receives
referral of mental and psychosocial
problems from primary health centres,
district/city general hospitals or directly
from the community. The patient will be
treated by trained personnel in psychiatric
medicine (psychiatrists, psychologists,
social workers, etc.). Patients will then be
referred back for maintenance treatment
to PHCs or district/city general hospitals.
Besides those services, technical assistance
is given to health personnel in PHCs

7.

or district/city general hospitals on

prevention and management of mental
health and psychosocial problems.
The government co-ordinates and facilitates the
implementation of the programme and activities on prevention and management of mental
health and psychosocial problems.

In terms of capacity building, there are training

programmes mentioned in the document, such as:
. Central government has programmes to give
training at various levels on early detection and
management of mental health and psychosocial
problems for communities affected by disaster and
conflict.
. Provinces have programmes to give training to
personnel in provinces and district/citiy health
offices, programme managers, health personnel in
hospitals and PHCs, and in the communities.
. Community mental health services with programmes to train potential staff in the community
to educate and help with prevention and management of mental health and psychosocial problems
for communities affected by disaster and conflict,
and to involve them in the supervision, monitoring
and evaluation of the programmes.
The document also mentions some recommendations on basic mental health service programmes to
be done:
. To organize a team for prevention and management of mental health and psychosocial problems
in PHCs and district/city hospitals. This team
should be ready to take action in the community.
. To train personnel from PHCs and district/city
hospitals in early detection and management of
mental health and psychosocial problems in communities affected by disaster and conflict.
. To train personnel from PHCs and district/city
hospitals to do counselling and psycho-education.
. To prepare a list of drugs that are needed by PHCs
and district/city hospitals.
. To refer patients that can not be handled by PHCs
and district/city hospitals.
. To train personnel from PHCs to do supervision
and evaluation of prevention and management of
mental health and psychosocial problems for
communities affected by disaster and conflict.

Development of a programme for Aceh

The mental health programme for Aceh was developed with input from the World Health
Organization, recommendations of the inter-country

Mental health model of care programmess after the tsunami in Aceh, Indonesia
expert meeting on psychosocial and mental health
response after disaster, and taking into consideration
the policy document (Chandra, 2006).
It was decided that the Primary Health Care
system would be the fundamental system of the new
mental healthcare policy for the tsunami-affected
population in Aceh. The community mental health
providers would provide outreach and clinical
services to the residents and families and the IDP
camps and barracks, as well as for the whole
community (Maramis, 2006).
The backbone of the system would be the nurses
working in public health centres who would work
together with the doctors (WHO, 2005; Saxena,
2006). Special training would be provided to make
them able to deliver psychiatric nursing care for
patients in the community.
Doctors would be given a refresher course in
primary care psychiatry to update them with practical
information and skill to treat patients in PHCs and in
the community.
Community mental health nurse (CMHN)
A curriculum and syllabus for the CMHN course
was developed by a group of mental health nursing
teachers from the Faculty of Nursing, University of
Indonesia. The CMHN course consists of three
levels: Basic, Intermediate and Advanced. The
CMHN Basic Course is a ten-day course covering
the role of nurses in diagnosing mental health
problems and nursing interventions that involve
working with patients and families. The
Intermediate Course is a thirty-day course. It comprises the diagnosis and management of common
mental disorders, psychosocial issues, including the
implementation of a healthy village concept of mental
health. The CMHN Advanced Course, focusing
more on mental health promotion and prevention,
will be developed later.
The basic course has been developed and nurses
have been trained in tsunami-affected districts in
Aceh and also in Nias and Nias Selatan in North
Sumatra. The course requires that classroom teaching be followed by a three-month monitoring and
supervision period by the trainers, the District Health
Office and Provincial Head Office. It is expected that
through this mechanism the capacity of the CMHN
nurses will be further improved to enable them to
become the backbone of the system.
The content of the module about concept and
theories of CMHN includes nursing care for
children, adults and the elderly with mental disorders; recording and reporting; monitoring and
evaluation. The candidates are nurses who currently
work in the health centre. The head of the health

561

centre is involved in the recruitment process to create

local ownership of the programme. The trained
nurses will also be required to go out into the
community when informed about a patient, and to
follow up on patients. It is reported that when nurses
visit the community, patients often come to them
voluntarily. A card describing the important signs
and symptoms of mental illness is also distributed to
community members with the instruction that if they
know of such patients, these should be brought to the
attention of the nurse.
In Addition, in each district some trainees were
selected to become local supervisors with some
additional training. Currently, Aceh community
mental health providers consist of 277 CMHN with
basic training in 11 districts in Aceh and two districts
in North Sumatra. Two thousand six hundred and
two cases of serious mental disorders (mostly chronic
psychosis) have been detected and treated by the
CMHN and the doctors in PHCs. CMHN can
provide a vital link between patients in the community and doctors in PHCs.
The CMHN Intermediate Course has been developed and tested in the District of Bireuen. Fourteen
community mental health nurses trained in the Basic
Course were involved and 78 community leaders
have been trained. As part of the course, the Village
of Mental Health Alert was piloted in four villages.
Refresher course for GPs in PHC (GP1)
A refresher course for GPs located at the primary
healthcare level is important. The term GP refers to
those GPs who have been trained about mental
health (The trained GPs termed as GP). The
training was based on the existing Ministry of Health
curriculum for GPs that covers 14 conditions listed
in the ICD Primary Care classification.
Mental health professionals were deployed to train
GPs during a four-day training course, three days in
class and one day of field practice The course
focused on the diagnosis and management of
common mental disorders in primary care.
Training is conducted locally at the district level.
Such training has been conducted in 11 tsunamiaffected districts and a total of 169 GPs have been
trained. In general, there is an increasing interest
among primary care doctors in mental health.
Banda Aceh Mental Hospital nurses
Banda Aceh Mental Hospital is the only mental
hospital for the whole province of Nanggroe Aceh
Darussalam. It has 250 beds with a bed occupancy
rate of more than 100%. The medical staff includes
one psychiatrist, 13 General Practitioners (GPs), five

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Prasetiyawan et al.

psychologists, and 180 nurses. The care provided to

those psychiatric patients is more of acustodial type;
therefore there is a need to improve the capacity and
change the daily practice of care.
To improve the nursing practice, a Professional
Nursing Practice Model (MPKP) has been piloted in
two wards. This is a model of best practice for
nursing care and management in an open ward
system developed by the School of Nursing group
and implemented in several mental hospitals in
Indonesia. The process started by selecting 28
personnel who will be involved as heads of wards,
team leaders and nurses of the two pilot wards. Then
the selected personnel were trained in the new
system and after that they implemented the model
with supervision in an open ward policy.
Banda Aceh Mental Hospital GPs
For the 13 GPs there is no systematic training
provided before they enter their posts in the mental
hospital or during placement. The only psychiatric
knowledge they have comes from their rotation in
psychiatry at medical school. Some of them have only
attended short courses.
The Department of Psychiatry, Faculty of
Medicine, University of Indonesia in Jakarta was
contracted to organize a special two-week intensive
training programme on basic psychiatry. The topics
covered included psychiatric interview and diagnostic procedure, basic psychotherapy, basic psychopharmaco
therapy
and
management
of
schizophrenia, acute psychosis, depression, anxiety
and psychiatric emergency. After training, there were
two follow-ups within two months in Banda Aceh by
the teachers.
This kind of training programme for GPs working
in mental hospitals should be continued and
expanded to other provinces in Indonesia.

Conclusions
The experience of dealing with the tsunami disaster
highlighted the fact that a national disaster preparedness plan must be developed and that mental health
and psychosocial aspects should be included in the
plan. A quick response to a disaster depends on the
existing mental health policy structure and mental
health care system.
Because of its geographic location, Indonesia is
particularly prone to natural disasters. In addition,
the risk of man-made disaster is also increasing. This
condition puts the Indonesian population at high risk
of exposure to extreme stressors that might result in
psychosocial problems.
Mental health has been neglected for many years
across Indonesia, including Aceh, and advocacy and
consensus development among policy-makers are
part of the needed overall intervention. Capacity
building of human resources is a must and training
modules should be developed accordingly to be used
for the training of nurses and GPs in all provinces of
Indonesia.

References
1. Chandra, V., Pandav, R., & Bhugra, D. (2006). Mental health
and psychosocial support after the tsunami: Observation across
affected nations. International Review of Psychiatry, 18,
205211.
2. Maramis, A. (2006). After the tsunami, building back
for better mental health in Aceh. ASEAN Journal of
Psychiatry, 7, 4548.
3. Mental Health and Psychosocial Relief Efforts after the Tsunami in
South-East Asia (2005). World Health Organization, New
Delhi, India.
4. Saxena, S., van Ommeren, M., & Saraceno, B. (2006). Mental
Health assistance to population affected by disaster: World
Health Organizations role. International Review of Psychiatry,
18, 199204.