With 361 suicide deaths between 2009 -2013 suicide has become a major issue in Bhutan. To address the issue the Ministry of Health supported by other stakeholders has come up with a Suicide Prevention Plan to be implemented over the next three years at a cost of Nu 29 mn.
A three year suicide prevention action is proposed to address the growing problem of suicide in the country as the first phase of response. The plan says that suicide is a preventable public health problem to a large extent when appropriate prevention strategies are employed.
It says suicide prevention requires a combination of universal strategies, selective strategies and indicated strategies.
Universal strategies like mass media, public advocacy, religious and cultural advocacy, suicide prevention in schools and institutions, mental health services and restricting means of suicide will target the entire population.
Selective strategies like Pyschosocial support for vulnerable for women and children, alcohol and druk de-addiction abuse, other groups with psychosocial needs, community resilience building and counseling are for for subgroups that may be at increased risk for suicidal behaviors.
Indicated strategies like access to services and care for individuals at risk, survivors, referral linkages, medico legal forensic investigation, suicide investigation by RBP and data and research on suicide are designed for individuals identified as having a high risk for suicidal behaviors, including having made a suicide attempt.
To date there has been no stand alone comprehensive suicide prevention program in Bhutan so this is the first comprehensive national suicide prevention plan of the country.
The overarching purpose of the national suicide prevention action plan is to promote, coordinate and support appropriate inter-sectoral action plans and programs for the prevention of suicidal behaviors at national, dzongkhags, gewogs and community levels.
Given the fiscal realities and governmental resource constraints, it says the action plan needs to be realistic and implemented through a financially sustainable model in order to accomplish the goals. This has been attempted by designing the interventions through a consultative process of the stakeholders bearing ground realities in mind.
Existing structure of services have been reviewed and opportunities for suicide prevention interventions have been identified. Easily adaptable services that have the potential to bear immediate suicide prevention outcomes have been listed and proposed for prioritization by stakeholders.
Six objectives of plan
The action plan has six key objectives. One is to improve leadership, multi-sectoral engagement and partnerships for suicide prevention in the communities. Second is to strengthen governance and institutional arrangements to effectively implement comprehensive suicide prevention plans. Third is to improve access to suicide prevention services and support for individuals in psychosocial crisis and those most at risk for suicide (including those with suicidal ideation, history of self harm or non-fatal suicide attempt). Fourth is to improve the capacity of health services and gate keepers to provide suicide prevention services. Fifth is to improve community resilience and societal support for suicide prevention in communities including schools and institutions and the sixth objective is to improve data, evidence and information for suicide prevention planning, and programming.
These objectives will be supported by a range of actions which will be implemented by multiagency stakeholders for a three year period. It says the relatively short term plan can drive actions as compared to a long term plan which often leads to loss of momentum and suffer from loss of accountability on the way.
The action plan is purposely designed for a short term implementation of three years beginning from July 2015 through June 2018. The progress and the fidelity to the plan will be assessed yearly. The full plan evaluation will be conducted towards the latter half of 2018. Based on the experience of this implementation, the next phase of the action in suicide prevention will be launched.
The plan will be implemented under the guidance of a national steering committee based at the Ministry of Health. The National Suicide Prevention Program (NSPP) to be instituted at the Ministry of Health will provide the secretarial role to the committee. The other agencies will integrate the plans in their sectors.
Activities in the action plan can be categorized into three subgroups of funding needs which are integrated funding, where activities are implemented as a part of ongoing approved plans, and do not require separate funds, minimal funding where activities require minimal budget to implement the activities, and full funding where new activities requiring total fund support.
The plan addresses overall systems strengthening in schools, health services, communities through realistic programs. Capacity improvement for service delivery in suicide prevention by key gatekeepers addressing drug use, addiction, and violence are included as the core approach. Forensic and medico-legal services which are necessary but inadequate will be addressed by this plan. Similarly, data and information system, and evidence generation will be strengthened. Overall, additional professionals required for suicide prevention services will be trained by the academic institutions in the country. Obviously, launching the plan will require resources, man, money and organizational system.
The tentative cost to implement the three year comprehensive action plan is Nu.29 million or a yearly budget of Nu 9.6 million. The activities will be implemented by various sectors such as Education, Health, RBP, KGUMS, BNCA, Local Governments and NGOs through three levels of strategies Universal, Selective and Indicated interventions reaching grass root communities and individuals exposed to suicidal risk factors.
On an average, yearly budget per agency will be approximately Nu 800,000 to Nu.900,000. This the plan says is a modest spending in addressing a national social priority to prevent many deaths and potential suicide attempts and will improve the capability of health sector, education sector, community based organizations, and police and legal systems for long term suicide prevention and response.
The Cabinet on February 16, 2014 issued a directive to Ministry of Home and Cultural Affairs (MoHCA) to form a national taskforce to conduct a nationwide retrospective suicide survey to document the burden and understand the root causes of suicide.
The suicide assessment was conducted from May 15-June 30, 2014 by a national team led by the National Statistics Bureau. The survey report presentation to Lhengye Zhungtshog on November 25, 2014 during which the Cabinet Members became informed on the problem. The Lhengye Zhungtshog then directed Taskforce Members through MoHCA to develop Suicide Prevention Action Plan.
The MoH with the support of other stakeholders led the development of the Action Plan from February through April 2015 during which stakeholders were consulted and actions were identified. The action plan was finalized following the presentation to the stakeholder teams of technical committee and the national taskforce chaired by the Home Secretary.
In Bhutan, suicide deaths ranks among the top six leading causes of deaths after alcoholic liver disease, other circulatory diseases, cancers, respiratory diseases, and transport deaths. Suicide deaths outnumber the combined deaths due to TB, malaria and HIV. For some reason, the rates have been increasing particularly in the past two years.