VZCZCXYZ2359
RR RUEHWEB

DE RUEHBE #0370/01 2791722
ZNR UUUUU ZZH
R 061722Z OCT 09
FM AMEMBASSY BELMOPAN
TO SECSTATE WASHDC 2051

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