building back better - who · 2 | building back better | mental health “emergency situations –...

Building Back Better | Mental health 1 |

Building Back Better:

Sustainable Mental Health Care after

Emergencies


“Emergency situations – in spite of the adversity and challenges they create – are openings to transform mental health care. These are opportunities not to be missed because mental, neurological, and substance use disorders are among the most neglected problems in public health, and because mental health is crucial to the overall well-being and productivity of individuals, communities and countries recovering from emergencies.”

Dr Margaret Chan

Director-General, World Health Organization


Report structure

Part 1: Seeing opportunity in crisis (Introduction)

Part 2: Seizing opportunity in crisis (10 detailed cases)

Part 3: Spreading opportunity in crisis (lessons learnt)


Part 1 – seeing opportunity in crisis


Mental health challenges

Hundreds of millions affected by mental disorders – All countries – All communities – All age groups

If untreated, substantial disability and economic loss – 22.7% of global Years Lived with Disability (YLDs) – Hundreds of billions of dollars in lost productivity

80% in low- and middle-income countries do not receive needed mental health services

Many countries spend their limited resources on ineffective and often inhumane practices


This is not effective or humane care


It is possible to do better

Community-based services in action


Emergencies at a glance

Caused by: natural disasters, armed conflicts, other hazards

Numerous emergencies annually around the world

Result in: large scale injury, death, displacement, destruction, disease outbreaks

Mental health problems increase – while mental health infrastructure often weakened


Emergencies are opportunities

Media interest

Interest of decision-makers (e.g. government leaders, heads of humanitarian agencies)

Decision-makers willing to consider options beyond the status quo


Taking action helps recovery and development

Positive mental health is crucial for individuals, societies and countries recovering from emergencies

Positive mental health linked to higher educational attainment, enhanced productivity and earnings, better parenting, improved health and quality of life


Part 2 – Seizing opportunity in crisis


10 emergency-affected areas

Afghanistan

Burundi

Indonesia (Aceh Province)

Iraq

Jordan

Kosovo

Somalia

Sri Lanka

Timor-Leste

West Bank and Gaza Strip


Afghanistan

Violence and instability for more than 30 years

Increased focus on mental health following fall of Taliban in 2001

Integration of mental health into general health services

– Initially NGO project-driven within selected areas

– Increasingly coordinated by MOPH at national level


Afghanistan – policy milestones

2003: Mental health included in Basic Package of Health Services (BPHS) 2nd tier

2005: Mental health included in BPHS 1st tier

2010: BPHS called for psychosocial counsellors in health centres and basic mental health training for medical doctors working with them

2010: 5-year National Mental Health Strategy


Afghanistan – other achievements

Standardized training materials for health workers

Inclusion of mental health indicators in health information system

Inclusion of psychiatric medications in essential drugs list


Afghanistan - Nangarhar Province

Since 2001:

> 1000 general/primary health workers trained and supervised in basic mental health care

Almost 100 000 people helped


Burundi

Cyclical outbreaks of violence – Hundreds of thousands killed – More than one million displaced

In 2000, no mental health policy or plan, no services other than one psychiatric hospital, only one psychiatrist in country

From 2000, mental health services provided by international NGO

From 2005, government began to takeover responsibility for mental health services


Burundi – service development

Introduction of psychosocial workers

Mental health clinics in provincial hospitals

Physician and nurse training in basic mental health care


Burundi – policy achievements

National Mental Health Strategy adopted in 2007

Inclusion of mental health indicators in health information system

Inclusion of psychiatric medications in essential drugs list


Burundi – other achievements

More than 17 000 people helped by psychosocial workers, 2000 – 2008

10 000 people seen at mental health clinics for more than 60 000 consultations, 2006 – 2008

Current project: integrating mental health into primary care via mhGAP


Indonesia (Aceh)

Decades of civil strife and tsunami of December 2004

– 165 000 killed – 400 000 displaced – Health facilities destroyed

Prior to tsunami, mental health care available only through one psychiatric hospital located in capital of Aceh


Indonesia (Aceh) - strategy

Recommendations for Mental Health in Aceh (2005)

– Roadmap for coordinating diverse agencies

Community mental health nurses

Inpatient units in general hospitals

Psychiatric hospital reform


Indonesia (Aceh) - achievements

All districts have mental health services at primary care level

13 districts have specific mental health budgets

3 districts offer secondary care

Psychiatric hospital has improved

Mental health part of health regulations (2010)

A model for other parts of the country


Iraq

Decades of dictatorship, economic sanctions, war, violent insurgency

Millions displaced internally and to neighbouring countries

Pre-2004, limited mental health services in urban areas, 2 psychiatric hospitals


Iraq – milestones

National Mental Health Council (established 2004)

National strategy and action plan (current 2009-2013)

Integration of mental health care into PHC (2009-2011)

Health worker training – 80-85% of psychiatrists – > 50% of general practitioners – 20-30% of nurses, psychologists, social workers

National formulary of psychiatric medications


Iraq – service development


Jordan

Periodic influxes of refugees from neighbouring countries

Since 2003, continuous waves of displaced Iraqis

– Scattered throughout country – High rates of mental health

problems

Mental health system hospital-based, urban – no PHC integration


Jordan

3 pilot community mental health centres (2008-2009)

– Biopsychosocial approach – Multidisciplinary teams – Individualized treatment

plans – Wide range of services

Successes built support and momentum for further change


Jordan – further achievements

National Steering Committee for Mental Health

National mental health policy and plan

Mental health unit in MOH

Service developments – Short-stay inpatient units – PHC: WHO Mental Health Gap

Action Programme – Service user training and

empowerment


Kosovo

Conflict came to a head in 1998-1999

Rapid political change

Mental health services hospital focused, biological, no PHC integration


Kosovo

Mental Health Task Force

Mental Health Strategic Plan (2001)

– Roadmap for coordinating actions


Kosovo – service development


Somalia

Internal discord, violence, humanitarian emergencies since 1991

– Millions internally displaced – Food crises – Collapse of public health system

Mental health services – 3 psychiatric institutions with poor

conditions – Severe shortage of mental health

workers – No PHC services


Somalia

Full reform not possible

Progress through different initiatives

– Mental health situation analyses

– Chain-free initiative – Health worker training


Somalia - achievements

Chains removed from >1700 people (2007-2010)

– Now expanded to all regions

55 health workers trained – 2 mental health coordinators – 3 new mental health facilities

Situation analyses attracted donor attention


Sri Lanka

Areas of protracted civil conflict

Tsunami of December 2004 – More than 35 000 killed – 1 million displaced – Extensive damage

Mental health services through tertiary-level hospitals near capital


Sri Lanka – policy milestones

National mental health policy (2005 - 2015)

– decentralized, comprehensive, community-based services

– roadmap for coordinated efforts

National Mental Health Advisory Council (2008)


Sri Lanka – service development


Timor-Leste

1980s – 1990s: military conflict, mass displacement, human rights violations

1999: humanitarian emergency

2002: political independence

Pre-reform: no mental health specialist services or professionals in the country


Timor-Leste

PRADET formed and begins developing mental health services (2000)

– priority to community-based services and those with severe problems

Mental health worker training and supervision (2000 – 2005)

Progressive integration with MOH


Timor-Leste

Mental health-trained general nurses are available in around one quarter of the country’s 65 community health centres, compared with none before the emergency.


West Bank and Gaza Strip

Two geographically separated areas

Decades of occupation, conflict, unrest

Pre-reform: 90% of resources for tertiary psychiatric care, few community mental health clinics, no PHC integration


West Bank and Gaza Strip – milestones

WHO technical assistance initiated (2001)

Agreement between MOH and Consulates of France and Italy (2003)

5-year strategic operational plan (2004)

3-year European Commission project contract (2008 and 2012)


West Bank and Gaza Strip – service development

Number managed in community mental health centres

Number of inpatient beds, Bethlehem Hospital


Part 3 – Spreading opportunity in crisis


Key Actions

1. Mental health reform was supported through planning for long-term sustainability from the outset

2. The broad mental health needs of the emergency-affected population were addressed

3. The government’s central role was respected

4. National professionals played a key role

5. Coordination across agencies was crucial


Key Actions

6. Mental health reform involved review and revision of national policies and plans

7. The mental health system was considered and strengthened as a whole

8. Health workers were reorganized and trained

9. Demonstration projects offered proof of concept and attracted further support and funds for mental health reform

10. Advocacy maintained momentum for change


The future


Key messages

Major gaps remain worldwide in the realization of comprehensive, community-based mental health care.

It is possible to take meaningful action after emergencies to accelerate the development of mental health systems.

Global progress will happen more quickly if, in every crisis, strategic efforts are made to convert short-term interest in mental health problems into momentum for mental health reform.

This would benefit not only people’s mental health, but also the functioning, stability and resilience of societies recovering from emergencies.


What you can do

Read the report and supplementary information

Incorporate relevant slides into presentations

Disseminate the report’s website (below)

Use the report to guide technical advice

http://www.who.int/mental_health/emergencies/building_back_better/en/index.html##

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