prepared by dr manuel carballo - world...
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Prepared by
Dr Manuel Carballo
Report of an Evaluationof a Harvard Trauma Program Project funded by the World Bank Post
Conflict UnitIn the Canton of Travnik, Bosnia and Herzegovina (BiH)
Prepared by
Dr Manuel CarballoExecutive Director, International Centre for Migration and Health (ICMH),
Geneva, SwitzerlandProfessor of Clinical Public Health, Columbia University, New York USA
For further information please contact:
11, Route du Nant d'AvrilCH-1214 Geneva
SwitzerlandPh: + (41 22) 783 1080Fax: + (41 22) 783 1087Email: [email protected]
Copyright reserved
The contents of this material may not be reprinted, either as a whole or in part without the written consent of the International Centre for
Migration and Health.
April 2003
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TABLE OF CONTENTS
1. SUMMARY....................................................................................................... 31.1 Overview.................................................................................................... 41.2 Significance of the project ......................................................................... 5Recommendations.............................................................................................. 7
2. PEOPLE MET ................................................................................................... 8Travnik:.............................................................................................................. 8Sarajevo: ............................................................................................................ 8
3. CONTEXT....................................................................................................... 103.1 Physical trauma........................................................................................ 103.2 Psychological trauma ............................................................................... 103.3 Infrastructure............................................................................................ 113.4 Implications for health care personnel ..................................................... 113.5 War and access......................................................................................... 12
4. EMERGING RESPONSE ............................................................................... 124.1 Status of mental health problems............................................................. 124.2 Management of mental health problems.................................................. 124.3 Hospital based system.............................................................................. 134.4 Initial response ......................................................................................... 134.5 Community base response ....................................................................... 134.6 Growing awareness of need for change ................................................... 13
5. GROWING NEED FOR CHANGE ................................................................ 145.1 A system that already had problems ........................................................ 145.2 Mental health ........................................................................................... 145.3 Impact of war on the medical profession................................................. 14
6. POST-CONFLICT RECONSTRUCTION...................................................... 156.1 Reconstruction to date.............................................................................. 156.2 Barriers to reconstruction......................................................................... 15
7. HARVARD PROGRAM IN REFUGEE TRAUMA (HPRT)......................... 168. A NEW CONCEPT OF RECONSTRUCTION .............................................. 16
8.1 World Bank and HPRT............................................................................ 178.2 Flexibility as a key ................................................................................... 178.3 CBRs ........................................................................................................ 17
9. TRAVNIK....................................................................................................... 189.1 Travnik in the war.................................................................................... 189.2 Travnik after the war................................................................................ 18
10. THE HPRT PROJECT AND TRAVNIK...................................................... 1910.1 Political impact .................................................................................... 1910.2 Technical robustness............................................................................ 19
11. THE HPRT PROJECT AND PRIMARY HEALTH CARE ......................... 2011.1 PHC and health care reform................................................................. 2011.2 An expanded role of PHC staff ............................................................ 2011.3 Interest in mental health....................................................................... 21
12. THE HPRT PROJECT AND THE CBRS..................................................... 2112.1 A solidified base .................................................................................. 21
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12.2 A changed approach............................................................................. 2212.3 CBRs in the future ............................................................................... 22
13. THE HPRT PROJECT AND FAMILY MEDICINE .................................... 2213.1 Poorly explained .................................................................................. 2213.2 Origins and development ..................................................................... 2313.3 Role of family practitioners ................................................................. 23
14. PROCESS ...................................................................................................... 2314.1 Logical evolution ................................................................................. 2414.2 Indirect impacts.................................................................................... 2414.3 Flexibility and adaptability .................................................................. 2414.4 Bosnian character of project ................................................................ 2514.5 Family Medicine .................................................................................. 2514.6 Capacity to grow and lead.................................................................... 2514.7 Political process ................................................................................... 2514.8 Health care worker health .................................................................... 26
15. CONCERNS .................................................................................................. 2715.1 Referral and feedback .......................................................................... 2715.2 Paediatric mental health....................................................................... 2815.3 Occupational health ............................................................................. 2815.4 Long term commitment........................................................................ 2815.5 How specialised to become.................................................................. 2815.6 Changing epidemiology ....................................................................... 2915.7 Access .................................................................................................. 2915.8 Breadth of coverage ............................................................................. 2915.9 Experience............................................................................................ 3015.10 Standardisation..................................................................................... 3015.11 Diagnosis.............................................................................................. 3015.12 Continuing education ........................................................................... 3015.13 Chronic disease management............................................................... 31
16. CONCLUSIONS............................................................................................ 32
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1. SUMMARY
The Harvard Program in Refugee Trauma (HPRT) was funded by the World
Bank Post-Conflict Unit to pilot a culturally appropriate mental health program
within the primary health care system of one canton of Bosnia and Herzegovina
(BiH), namely Travnik Canton. The specific objectives of the three-year project
were to:
(a) provide training and technical assistance to primary care providers (PCPs)
so they can identify and treat psychiatric disorders and physical
disabilities resulting from the recent war trauma.
(b) create a network of PCPs skilled in mental health care and supporting
each other in the treatment of persons with trauma-related and other
mental health disorders.
(c) develop with the cantonal Ministry of Health an approach to the provision
of mental health services integrated into all levels of the primary health
care system, including CBRs.
(d) produce sustainable results by integrating this project into the BiH health
care reform, including BiH’s continuing medical education activities.
(e) evaluate the achievement of objectives so that lessons learned can be
disseminated to other cantons and other countries in the region.
The 2 major overarching project objectives achieved by HPRT were:
1. Improving mental health skills (diagnosis, treatment, and referral) among
primary health care providers (PCPs)
2. Creating options for organization and development of mental health
services in Travnik Canton and BiH, including the integration of mental
health in the primary health care system.
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In preparing its program of work, HPRT first undertook a primary health care
practitioner survey. It revealed a mental health system primarily focused on the
mental hospital and hospitalisation. The World Bank WVR Project developed in
coordination with a major World Bank health reform in BiH provided a unique
opportunity for a traumatized population to have access to community-based
mental health services within the new Community Based Rehabilitation Centers
(CBRs). The evidence nevertheless indicated that the CBRs were underutilized
because they were not well connected to the overall primary health care system.
HPRT’s patient survey (N=206) receiving health care at six primary health care
centers (Dom Zdravlja) revealed high rates of depression (44%) and low health
care seeking (10%). Patients, moreover, were not being diagnosed and treated by
primary health care doctors for mental health problems at the Dzs (2.9%) and
75% of DZ patients in Travnik were not aware of the new CBRs. HPRT’s
provider survey (116 PCPs) practicing in Travnik Canton revealed a significant
inability to identify and treat patients with mental health disorders.
The model HPRT created in response is consistent with WHO’s 2001 landmark
mental health report (Mental Health: New Understanding, New Hope) that
emphasizes the integration of mental health in primary health care. It also takes
up many of the difficulties encountered in creating culturally competent mental
health services in conflict/post-conflict societies by providing first-hand
experience with shifting from previous mental health systems that focused on the
hospital to a primary health care model based on community care.
1.1 Overview
This evaluation consisted of five components: (a) initial discussions with Dr
Richard Mollica and Mr James Lavelle in Boston; (b) a review of documentation
provided by Dr Richard Mollica, Mr James Lavelle and Dr Aida Kapetanovic; (c)
discussions with Dr Aida Kapetanovic in Sarajevo; (d) an intensive round of
meetings with a range of health care staff in Travnik and Sarajevo, during 20 to
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25 February 2003, (e) a final de-briefing with World Bank staff in Sarajevo, and
(f) the evaluator’s personal knowledge and familiarity with Bosnia and
Herzegovina (BiH) both during and after the war1. The project personnel in
Boston and Sarajevo were at all times open, frank and very helpful in answering
questions posed to them. Indeed the evaluation would not have been possible
without their full support.
1.2 Significance of the project
The Harvard Program in Refugee Trauma (HPRT) has had a number of important
direct and indirect impacts on the process of health care delivery, and in
particular the delivery of psychological services, in the Canton of Travnik.
1.2.1 First of all, it has contributed to making the overall health care system
more rational and logical in terms of the links between primary,
secondary and tertiary care of people with mental health problems and
their referral from one to another. In this regard it has highlighted the
importance of the first line of health care with respect to timely diagnosis,
treatment and referral of mental health problems.
1.2.2 Its second major impact has been its familiarization of primary health
care (PHC) non-psychiatric staff with the concept of mental health and
the need for mental health protection. This constitutes a major
achievement in a system that was not especially mental health-sensitive at
the primary level. In making PHC medical staff more comfortable with
handling mental health problems and concerns it has probably made them
more at ease with their own conflict and post-conflict-related problems.
1 Dr Carballo was based in Sarajevo 1993-95 as a Public Health Adviser for WHO with
responsibility for the whole of Bosnia and Herzegovina (BiH). Following the war he remained
adviser to the Minister of Health, Dr Lubic, and worked extensively with a number of the
Institutes of Public Health throughout the country.
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1.2.3 Its third important impact has been to demonstrate the importance of a
bottom-up approach to the logical development of projects and the value
of undertaking technically sound situation and perceived needs
assessments rather than proceeding to “introduce” new ideas and
predefined programs. In what was previously a highly centralized system
of planning, this has been a very positive contribution.
1.2.4 A fourth key impact has been to invite and encourage health staff to
participate in a process of change as stakeholders, and invite them to
“speak out” and ask questions concerning fundamental issues such as
health care reform. This has been a new and valuable addition to the
health care process in BiH where staff were more used to following top-
down directives with little opportunity to question them in open fora such
as training courses.
1.2.5 A fifth impact has been to encourage stakeholders to see the project as a
Bosnian one that has grown out of a Harvard initiative, and which now
has a national character of its own. This will enhance its sustainability,
and indeed has already been a source of encouragement for authorities in
Sarajevo to become involved in, and provide leadership to, a regional
project that builds on the thematic areas and experiences of the HPRT
project.
1.2.6 Finally the project has given high visibility and credibility to the World
Bank’s work in post-conflict reconstruction, and could open up a number
of important doors to the Bank’s work in post-conflict reconstruction
elsewhere. This is a valuable contribution given the skepticism with
which much of the international community’s work has been viewed in
BiH.
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Recommendations
The recommendations below merit immediate consideration by the World Bank.
a) The project should be quickly taken to a second phase (Phase II)
b) The World Bank should support a Phase II strongly
c) A three year Phase II should “scale-up” the Phase I experience
d) Phase II should cover the entire country
e) Phase II should visibly build on the Travnik experience and the trainees
f) Phase II should incorporate psychologists, nurses and social workers
g) Phase II should involve a more standardised curriculum
h) Phase II should attach more importance to diagnostic procedures
i) Phase II should take into account the preventive role for PHC staff
j) Phase II should involve a lifestyle approach to mental health
k) The project should be evaluated for its “social and political cohesion” role
l) The concept underlying the project should be further developed
m) The project’s implications for the World Bank should be explored
n) Greater MoH ownership and use of the model should be encouraged.
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2. PEOPLE MET
Travnik:
Dr Nurudin Strovic – Minister of Health of Middle Bosnia Canton
Dr Sakib Alibegovic – Chief of psychiatric department in Cantonal hospital
Travnik DZ
Dr Nermin Selman – Director of Mental Health Center, Travnik
Dr Mustafa Strukar – Director of Mental Health Center, Bugojno
Dr Salih Terzic – Psychiatrist in Mental Health Center, Bugojno
Dr Vlasta Kaurin – Chief of Psychiatric Department, Hospital Nova Bila
Dr Sead Karakas – Director of Institute for Public Health, Travnik DZ
Dr Franjo Tibold – Deputy Director of Institute of Public Health, Travnik DZ
Dr Edib Maglic– Travnik DZ
Dr Mirzeta Alijagic– Travnik DZ
Dr Jecic Ahmed– Travnik DZ
Dr Jivanovic Amra– Travnik DZ
Dr Peco Mirsad– Travnik DZ
Dr Mahmutovic Drita– Travnik DZ
Dr Sijan Birgita– Travnik DZ
Sarajevo:
Dr Neza Rusdic – Liason Officer, WHO
Professor Geoffrey Hodgetts, Queens University, Sarajevo
Dr Bakir Nakas – Director of General Hospital Sarajevo
Dr Aida Kapetanovic – HPRT Project Manager
Professor Slobodan Loga, Psychiatrist
Dr Lilijana Oruc, Psychiatrist
Mrs Betty Hanan – World Bank, Washington
Mrs Mirjana Karahasanovic – World Bank, Sarajevo
Dr Nedim Jaganjac, World Bank, Washington
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Dr Goran Cerkez, Federal Ministry of Health, Sarajevo
Professor Ismet Ceric, Psychiatrist, Faculty of Medicine, Sarajevo
Professor I. Simic, former Professor of Gynecology, Sarajevo
Professor Arif Smajkic, former Professor of Public Health, Sarajevo
Professor Nedjat Mulabegovic, Faculty of Medicine Sarajevo
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3. CONTEXT
The war in former Yugoslavia was one of the bloodiest and most intense in
recent times. Although it affected all parts of former Yugoslavia, there is no
doubt that BiH was the most badly and intentionally damaged region. Ethnic
wars are historically not new, but it was nevertheless the war in former
Yugoslavia that gave rise to the term “ethnic cleansing” and it was in BiH that
the practice took its most virulent form.
3.1 Physical trauma
During the course of the four years the war lasted almost 200,000 persons were
killed and at least 180,00 were wounded, many of them gravely with severe long-
lasting repercussions. ICMH estimated that over 200,000 people had insufficient
food to sustain good health, and although gross malnutrition was not very widely
reported, weight losses of up to 14kg were not unusual among people living in
towns under siege. Although reports vary, over 30,000 people are thought to
have been tortured, and estimates of the number of women raped have been
placed as high as 40,000. Systematic ethnic cleansing uprooted over half of the
population of BiH, and many sought refuge in other parts of Europe. The other
half remained internally displaced within BiH in what were initially expected to
be safe havens, but which in many cases became heavily targeted towns.
3.2 Psychological trauma
In addition to the massive physical trauma that occurred, the nature of the war
was such that it caused even greater psychological damage to the population.
Estimates of the extent of psychological damage still remain imprecise and the
true magnitude and profundity of the psychological morbidity will probably
always remain difficult to define but BiH Ministry of Health officials have at
times referred to 75% of the population suffering from some form of
psychological trauma. A 1996 HPRT article in the Journal of the American
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Medical Association (JAMA) referred to the fact that 45% of refugees leaving
BiH were suffering from psychiatric symptoms relating to violence and that as
much as 25% of the refugees could be considered to have been "disabled" as a
result of psychiatric problems. A second HPRT article (1999 JAMA) talked of
widespread chronic disabling depression and reported that recovery was proving
slow and difficult. ICMH studies in 1995 and 1996 reported massive loss of self-
esteem and difficulties with decision-making. Although all parts of BiH were
affected in one way or another, some parts of the country were exposed to more
major events than others. In cantons such as Travnik where there was a strong
mix of "nationalities", ethnic aggression assumed an especially high intensity and
the physical and psychological shock to the population was intense.
3.3 Infrastructure
In addition to causing massive physical and psychological morbidity, the war
effectively destroyed human and material components of the healthcare system.
In 1994 the Institute of Public Health in Sarajevo and ICMH estimated that at
least 12,000 trained health workers had already been lost to death, injury or
forced flight, and that over 60% of all health facilities including hospitals, had
been damaged to such an extent that they could no longer function. In addition,
equipment in health facilities was either damaged or could not be maintained,
and it was not until well after the war ended that any extensive repair could
begin.
3.4 Implications for health care personnel
Throughout the period of the war, health care workers who remained in the
country and who were not themselves injured, worked with minimal support
while having to assume responsibility for a type and magnitude of emergency
care for which they had not been trained and which could in fact never have been
foreseen. Many were called on to manage patients who had been sexually
tortured and raped (men as well as women). A large number of them were
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themselves traumatized by what they witnessed, the physical injuries they had to
manage, the long hours they had to work, the fact that they were not paid and had
little food security for themselves or their families. Within the specific domain
of mental health, interrupted care, lack of medication, loss of staff, and lack of
available beds seriously impaired what had been a highly hospital-oriented
system just at a time when the needs of the local population and those of
incoming IDPs were growing dramatically.
3.5 War and access
In many parts of the country, including cantons such as Travnik, the health
situation was exacerbated because fighting and the breakdown in transportation
and communication made accessing health care precarious. Indeed access to
health care facilities became at times impossible. The population of Travnik, just
as with towns under siege, went through grave food and water shortages, lack of
medical supplies, and lack of contact with the outside world. These facts
contributed significantly to stress, trauma and depression.
4. EMERGING RESPONSE
4.1 Status of mental health problems
Prior to the outbreak of the war mental illness was one of the leading causes of
disability in BiH, and is estimated to have accounted for approximately 17% of
all DALYs.
4.2 Management of mental health problems
As with most other health problems in BiH, the health care system’s response
took the form of a primarily hospital-dominated approach that involved
dependence on highly specialized psychiatric care that offered little in terms of
community based support. This approach could not be maintained in a war
context where there was little opportunity for movement of people with or
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without mental health problems, and where the hospital system became fragile, if
not entirely defunct, as a result of staff and material losses and direct attacks.
4.3 Hospital based system
The fact that little had been done to develop a community-based approach to
mental health also meant that hospitalization for mental health problems (as with
all hospitalization in BiH) tended to be excessive and often unnecessarily long. It
also meant that decisions on caring for people with mental health problems had
become increasingly left to psychiatrists, most of whom were located in hospital
settings.
4.4 Initial response
An awareness of the magnitude and changing nature of mental health problems
nevertheless emerged quickly during the war, and by 1994 a more community-
based approach was already being considered and indeed developed by
Professors Ceric and Loga of the Department of Psychiatry in Sarajevo, in close
collaboration with the local emergency office of WHO.
4.5 Community base response
The result was a beginning exploration of the need for psychological as well as
physical rehabilitation, and the formulation of a community-based approach to
mental health that could gradually reduce dependency on the hospitals that were
no longer capable of responding. The war thus highlighted the difficulty of
maintaining a highly hierarchical health care system that was so hospital based,
and also brought out its limitations with respect to reaching the most in need of
care and support, such as refugees and IDPs.
4.6 Growing awareness of need for change
The devastation that came in the wake of the war also alerted national authorities
to the need for a more community or PHC-based approach to health care in
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general. It did much to highlight the fact that the pre-war health care system
might have been financially, administratively and logistically unsustainable
under any circumstances.
5. GROWING NEED FOR CHANGE
5.1 A system that already had problems
From the point of view of management of psychological morbidity, the first point
of contact within the BiH health care system, namely the ambulanta or primary
clinic, had never been particularly effective. In a highly specialized healthcare
system such as that of BiH, and in a country where the public was educated and
well informed about how the health care system functioned, people were already
bypassing the ambulanta level and going directly to the Dom Zdravjia (DZ)
(primary level) or hospital (tertiary) level for most conditions.
5.2 Mental health
Management of mental health problems had been left almost entirely to
psychiatrists and psychiatric institutions and within this system there was little
felt need among ambulanta or DZ level medical personnel to interfere. Indeed
there was a fairly widespread reluctance to deal with psychological problems in
general. Although this was and is not unique to BiH, the war and its impact on
mental health highlighted the dramatic need for this attitude and system to
change.
5.3 Impact of war on the medical profession
The war presented a number of new mental health challenges for health care
staff. Just as the rest of the population, they were at risk of death and injury, loss
of family and homes. Anecdotal reports suggest that in some locations they were
often specifically targeted together with the institutions they worked in. At the
same time the demands on them grew daily as the war progressed. As morbidity
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and mortality increased, so the physical and psychological load on them also
mounted, and they were confronted with war injuries and atrocities they were
totally unprepared for. This affected them badly.
6. POST-CONFLICT RECONSTRUCTION
Post conflict reconstruction is one of the most important and complex challenges
confronting countries and the international community today. In part this is
because the nature of conflict itself has changed and has become increasingly
characterized by military-versus-civilian aggression involving anti-personnel
arms and tactics. Ethnic hostilities designed to destroy cultures as well as people
have become increasingly common and produced broad-scale traumatization of
civilians and the destruction of civil society.
6.1 Reconstruction to date
To date, post-conflict reconstruction has tended to focus on infrastructure needs
such as the repair of buildings and communication networks. These are essential
elements of any post-conflict reconstruction phase, but in themselves are
insufficient and can easily eclipse other more important needs such as the social
and psychological welfare of the people. Reconstruction efforts that fail to give
priority to these aftermaths of war are likely to fail, especially in the wake of
hostilities that leave social cohesion and the fabric of society so destroyed that
there can be little effective socioeconomic development unless the psychological
and social needs of people are first attended to.
6.2 Barriers to reconstruction
Management of psychological and social problems linked to war is not easy.
Many of the problems call for approaches that are difficult to mount in situations
such as post-conflict BiH where the number of people psychologically injured
was in the hundreds of thousands, and where the human resources for working
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with them were limited. Another barrier is the short “shelf-life” of interventions
and the limited staying power that is often characteristic of donors and
implementing partners.
7. HARVARD PROGRAM IN REFUGEE TRAUMA (HPRT)
The Harvard group brought with it an extensive body of international experience.
It had assisted in transforming the mental health care systems of the UK and Italy
from a hospital-based approach to a more community-based delivery system.
The HPRT had also helped to pioneer services for survivors of mass violence and
torture resettled in the USA, and had also developed diagnostic and treatment
services for refugees in Cambodia, Italy, Thailand, Australia and New Zealand.
Based in Boston, the HPRT is run by Dr Richard Mollica and Mr James Lavelle
with a small administrative staff. In Sarajevo the HPRT was given an office by
Dr Nakas in the General Hospital, and is managed there by Dr Aida Kapetanovic
and an assistant.
The HPRT training program has “recruited” staff as and when needed from
within BiH, and in doing so has effectively broadened its base of operation and
given the project a Bosnian character and professional legitimacy.
8. A NEW CONCEPT OF RECONSTRUCTION
When the HPRT project began, there was an urgent need for new approaches to
reconstruction. In the absence of new approaches that stress social and
psychological reconstruction it is unlikely that countries emerging from ethnic
hostilities will attain the type of social stasis and cohesion required to move
forward.
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8.1 World Bank and HPRT
In focusing on mental health within a framework of reconstruction the Canton of
Travnik program developed by the World Bank (WB) the Harvard Program in
Refugee Trauma (HPRT) assumed a special significance. First of all it has gone
far in opening up a window of opportunity for a renewed approach to
reconstruction, and certainly to the exploration of mental health reconstruction as
a key component of the larger reconstruction effort. This is no mean feat and in
itself is already a major contribution to the international debate.
8.2 Flexibility as a key
The HPRT initially set out to test a culturally appropriate mental health program
that could fit within the overall primary healthcare system being proposed for
BiH. The HPRT proposal highlighted the need to support and strengthen the
Community Based Rehabilitation Centres being developed as part of the overall
response to the war and the health reform process. As the project developed,
however, the HPRT project assumed new dimensions and a degree of creative
flexibility that allowed it to grow. Not only did it contribute to the work of the
CBRs but it also opened up new avenues (and questions) for health
reconstruction and health care reform by strengthening the primary level of care.
This experience presents a relatively unique model that merits further conceptual
and operational development.
8.3 CBRs
The World Bank Project included the development of 38 new Community Based
Rehabilitation Centers (CBRs) but contained a number of requirements if it was
to succeed. Among these were: (a) well trained and readily available human
resources, (b) an effective management system within which the CBRs would fit,
and from which they would benefit administratively and technically, and (c) the
understanding and support of the public at large. In post-conflict BiH these
conditions were and are still difficult to meet. Vital human resources were lost
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during the war and later as a result of the brain drain to other parts of Europe and
North America; this adversely affected the potential for management. As far as
the third requirement was concerned, many health care personnel and lay people
did not, and still do not appear to fully understand the role of the CBRs.
9. TRAVNIK
The choice of Travnik Canton as a site in which to develop the project must be
seen as one of the greatest challenges HPRT took on, and it can be safely
assumed that any project successfully taken to term in Travnik will have a high
likelihood of succeeding anywhere else in BiH.
9.1 Travnik in the war
Because of its ethnic composition, Travnik was one of the Cantons most affected
by the war, and saw some of the most far-reaching hostilities between Croats and
Moslems. Hundreds of people were killed, thousands injured and uprooted.
Houses were looted and destroyed and hundreds of thousands of dollars worth of
possessions lost. The challenge the HPRT project took on was thus not only one
of training health staff in primary care and management of mental health
problems, but was also one of doing so in a setting where two “nationalities” had
been at war in a bitter way.
9.2 Travnik after the war
There is a feeling among health care staff in Travnik (and possibly elsewhere in
the country), that BiH has become a “post-trauma” society. In Travnik many of
the people interviewed referred to the more than 50% of the population still
suffering from war-related psychological problems, of which at least 25% are
reportedly of a somatoform presentation with serious implications for day-to-day
functioning and participation in the process of personal and social development.
The poor economic situation in Travnik (and Middle Bosnia as a whole) is
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exacerbating many of these problems, and having a serious impact on mental
health in general. Senior health staff in Travnik referred to the high and still
growing rate of suicide attempts per year (more then 1000), and the fact that a
large proportion of them involve war veterans, many of whom remain
unemployed and have lost much of their dignity and self-esteem. Aggravating
the overall health situation was the fact that after the war, the canton had two
health insurance schemes, one Zagreb-based and the other Sarajevo based. It
also had two health surveillance and reporting systems, and two informally
perceived sources of technical direction and guidance.
10. THE HPRT PROJECT AND TRAVNIK
The HPRT initiative initially set out to build on the World Bank’s program to
assist the national authorities develop a community based mental health system
that could be integrated into the healthcare reform process. Its demonstrated
flexibility nevetheless gave it a capacity to adapt to other emerging realities and
needs in BiH.
10.1 Political impact
Senior officials in Travnik repeatedly mentioned the fact that the project had met
a major political as well as technical need, and had done so at an opportune time
in the course of the reconstruction process. There was also a feeling among
senior officials that the project had gone far in demonstrating how health can
become a vehicle for social reconstruction and reunification of otherwise
opposing parties.
10.2 Technical robustness
There was unanimous praise for the HPRT project in terms of its demonstration
of the importance of undertaking needs assessments and using the results of these
assessments as a basis for designing and refining projects. In this sense, the
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HPRT project was able to add to its originally defined goals and respond more
directly to the needs of healthcare practitioners without whom the CBR strategy
could not have functioned in Travnik. This theme emerged repeatedly and was
clearly one of the more impressive demonstrated outcomes.
11. THE HPRT PROJECT AND PRIMARY HEALTH CARE
The health reform process in BiH has been slow and even now remains under-
funded and poorly explained. It is not clear whether everyone in a decision-
making capacity has understood or fully accepted the need for an intensified PHC
approach, and there have been serious misunderstandings about its possible
impact on career structure within the medical profession.
11.1 PHC and health care reform
The HPRT project has gone far in helping to overcome some of the problems
associated with the reform process, and has served to demonstrate how an
expanded role (in this case mental health) for health staff at the primary level can
contribute to health care and the health care system in general. This was evident
in the comments of staff in both Travnik and Sarajevo. While this was not one of
the initial objectives of the project, it deserves to be especially highlighted
because it is one of the few “living” examples of what a reformed primary care
system in BiH could look like.
11.2 An expanded role of PHC staff
In both Travnik and Sarajevo senior health staff mentioned that they and others
had had serious concerns about the load any mental health component might
place on the PHC system and on the health staff at the primary level. The HPRT
project apparently satisfied these concerns and may have gone much further by
demonstrating how a greater awareness of, and involvement by, primary health
21
staff in mental health can make other health interventions more acceptable and
the provision of health care in general more rational and cost-effective.
11.3 Interest in mental health
Not only has the improved and expanded role of primary care physicians been
welcomed but there is now a perception that clinicians in Travnik have become
more interested in mental health and are more willing to deal with problems than
ever before. They are also seen as having become more proficient and
increasingly willing to enter into co-operation with psychiatrists on “shared”
cases. Whereas many physicians were previously reluctant and possibly afraid of
dealing with psychiatric problems, they seem to be much more confident
diagnosing and prescribing treatment as well as referring patients in a technically
sound way.
12. THE HPRT PROJECT AND THE CBRS
In Travnik there was (and in some quarters still is) a feeling that CBRs had not
been created with a long-term or technically sound vision, and were unlikely to
attract continued funding. The impact of the HPRT project on the CBRs has
been multi-faceted.
12.1 A solidified base
The HPRT project appears to have given a much more solid base to mental health
at the primary level and in so doing has provided a window of opportunity for a
“long-term vision” to emerge with respect to the role of the CBRs. This became
evident in discussions with the Cantonal Health officials in Travnik and in
discussions with DZ staff.
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12.2 A changed approach
There was a fairly unanimous feeling that the HPRT project has provided of
logistical support to the CBRs, and more importantly has helped to rationalise the
mental health care system in Travnik. For example, prior to the war in Travnik
where at least 120 hospital beds were allocated to mental health problems the
number has been reduced to 20. The duration of hospitalisation has also been
brought down, and is now estimated to be on average 20 days shorter than it used
to be. To what extent the HPRT training project has been instrumental in this is
not clear, but most people this was discussed with felt it had contributed
significantly.
12.3 CBRs in the future
To what extent CBRs will be needed in the future still remains unclear, but it is
evident that if the CBRs are to be further developed and strengthened, an HPRT-
like component will be required as an integral and even determining part of any
future expansion of them.
13. THE HPRT PROJECT AND FAMILY MEDICINE
Much of the health care reform in BiH has revolved around the idea of family
medicine. The decision by the MoH to emphasise family based care began to
emerge towards the end of the war and took better form after 1995. It has not
been an easy evolution, however, and in some quarters remains unclear at best
and controversial at worst.
13.1 Poorly explained
Even though it was seen as a key part of the overall health reform process family
medicine has suffered because of the manner it was presented and explained to
medical staff. Today, there are still many health practitioners and medical
students who say they remain unclear how a family medicine approach will
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function, what their role in it will be, and how it will relate to what is still seen by
many as a hospital-based healthcare system. Nor is it clear to them how a family
medicine policy will affect their careers, and if and how a specialisation in family
medicine can be institutionalised within the existing national healthcare system.
13.2 Origins and development
Family medicine training was started by Professor Arif Smajkic in Sarajevo at
the end of the war. Since then it has attracted support from other areas and has
been increasingly complemented by the Queens University initiative under the
guidance of Professor Hodgetts, and to a much lesser extent by Project Hope and
the University of Geneva. In discussions with Professor Hodgetts and Dr Nakas
in Sarajevo, there was a strong feeling that the HPRT training had done much,
albeit indirectly and in a relatively unplanned way, to provide family medicine
with a renewed technical content and expanded role.
13.3 Role of family practitioners
In both Sarajevo and Travnik senior health officials referred to the fact that the
HPRT training project had demonstrated how and to what extent family medicine
practitioners could begin to play a role in mental health system that is rapidly
changing as part of the overall health care reform process. Both Professors
Hodgetts and Smajkic (now retired) acknowledged the important role the HPRT
project has played and must continue to play in the future development of family
medicine.
14. PROCESS
BiH, like many other countries in the Balkan region and indeed East and Central
Europe, has traditionally followed a top-down planning process. There has rarely
been any attempt to encourage participatory planning in health, or indeed in any
other area. As a result of this, when the war ended one of the difficulties many
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people in BiH encountered was the hesitation in taking policy decisions and
indeed even becoming involved in decision-making. Nor had there been much
exposure to evidence-based planning in clinical or public health.
14.1 Logical evolution
In this regard the HPRT project has been particularly prominent and especially
well received. It is seen as having an orientation that is non-institutional but
which has been technically prepared and logically developed. The fact that an
initial needs assessment was done with indicators and evaluation measures, and
that the program was formulated on and around the results of this has impressed
staff and made them feel they have participated in a scientifically derived
initiative. This has gone far to legitimate not only the HPRT project but the
health care reform process as a whole.
14.2 Indirect impacts
Some key components of the HPRT training, such as that provided by Dr Nakas
(Director of the General Hospital in Sarajevo) have been seen as more
informative on the health care reform process and its significance than any other
information provided by government. It has also provided a forum in which this
could be discussed.
14.3 Flexibility and adaptability
The demonstrated capacity of the project to respond to changing or emerging
needs, and not remain limited to a predefined framework has impressed many
people and has gone far to provide BiH with a model of health planning and
development. This is especially important given the lack of experience many
people within the health care system have had with evidence-based planning and
decision-making.
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14.4 Bosnian character of project
Another theme that has emerged in support of the HPRT project is the fact that
although the Harvard name and staff brought credibility to the initiative, most
people said the project had become increasingly Bosnian. This is important for
identification with the project, and it will contribute greatly to its sustainability
over time (even though it is unlikely that it can continue without strong HPRT
involvement).
14.5 Family Medicine
In Sarajevo a number of senior officials said the HPRT project had much to offer
the family medicine initiative being developed by Queens University. This was
confirmed by Professor Hodgetts and is an issue that will need to be taken up in
the near future, especially since the HPRT component presents an approach to
primary care that is currently not included in the family medicine training.
14.6 Capacity to grow and lead
With regard to the training, a number of people in Travnik and Sarajevo referred
to the fact that in the first cycle of training many of the lectures had tended to be
“old-fashioned”, but that by the second cycle this had changed and lectures had
become more open and inviting of debate. This must be seen as an important
contribution to a system that has traditionally not given priority to participatory
learning. The project is also seen by Sarajevo senior health staff as having
become a leader in team work, and as having been able to force a type of
communication between different levels that had not been seen before.
14.7 Political process
A consistent theme to emerge from the discussions with senior officials in
Travnik was that the HPRT project has helped to create a political and social
“space” in which the two ethnic entities could come together around a common
objective, namely to improve the capacity of the healthcare system to respond to
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the mental health needs of a highly traumatised population. Although many
organisations, including WHO have referred to the role that health can play in
bringing about reconciliation between warring parties, the HPRT Project stands
out as a real example of this process and outcome.
14.8 Health care worker health
The training on mental health using an increasingly open and participatory model
has “defused” some of the traditional hesitation surrounding mental health and
allowed healthcare workers to come to terms with their own concerns and
problems. It has apparently gone far to make them understand how generalised
the impact of the war has been on all groups in society.
14.9 Specific indicator outputs (a) Needs of patients, community and providers: the HPRT initiative was
systematic in addressing this issue and has provided some of the best data in BiH
on the mental health situation and needs of both patients and providers; reports
are available and technical papers have been published; the Bosnian version of
the Harvard Trauma Questionnaire was validated together within the Hopkins
Symptom Checklist.
(b) PCPs are trained in MNH care and trauma treatment: the HPRT
initiative has provided a total of 120 hours of training to 103 of the 120 primary
health care providers in Middle Bosnia Canton. It has also evaluated these
trainees and the impact of the course has also been systematically evaluated. My
own evaluation is referred to throughout this report.
(c) Dissemination of MH information and policy recommendations through
newsletters and website: HPRT created an official website in June 2001. This
provides detailed information on all the materials, training courses, screening
instruments and other instruments developed and used as part of the program. In
addition three newsletters (3,000 copies in total) were published in English and
27
Bosnian and give wide dissemination, including to academic institutions and
policy makers.
(d) PCPs receive on-site supervision, consultation, and evaluation regarding
MH skills: throughout the initiative HPRT provided 40 on site consultations
involving local and international consultants. Each of the 19 Dzs in Middle
Bosnia Canton received 4 visits.
15. CONCERNS
Despite the very obvious and significant success of the HPRT project a number
of concerns emerged that will need to be addressed in Phase II. Some of these
concerns are more health care system and health care reform related than they are
HPRT related. This is perhaps indicative of the role the project has played in
generating questions and a felt capacity to raise questions concerning the larger
picture of health development in Travnik and BiH in general.
15.1 Referral and feedback
Although the training has been universally seen as successful and well tailored to
the needs of BiH at this time in its reconstruction history, the practice of primary
care medicine may not have been able to change fast enough to keep up with the
training. In Travnik concerns were repeatedly expressed with respect to patient
management and how the referral system and feedback could be improved. The
problem appears to be poor (perceived and real) feedback linkage between the
primary care (DZ) level and specialists in the Mental Health Center who
apparently do not send information back to the PHC level unless specifically
asked to do so.
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15.2 Paediatric mental health
There was a concern in Travnik that paediatric mental health problems are not
being sufficiently addressed in the HPRT course and will deserve more attention
in the future. Given the high (and apparently increasing) incidence of adolescent
psychosocial problems in BiH, this is a concern that should be addressed in the
future iterations of the course.
15.3 Occupational health
Many of the same concerns were expressed with respect to occupational health,
where again the staff in Travnik said they are now seeing considerable and
growing psychiatric/psychological morbidity. The HPRT training was seen as
very good and relevant to occupational health, but there was a feeling that the
relationship between the DZ level and the Centers for Mental Health is far from
perfect and that feedback to DZ staff remains poor. Primary care physicians are
concerned that they do not know enough about what happens to the patients once
they refer them to the Centers for Mental Health.
15.4 Long term commitment
Concern was expressed about the long-term commitment of the World Bank and
national authorities to the HPRT project and what it could imply for the reform
process. There is a fear that unless the commitment of the WB is not made
evident many people will feel that their time and energy has been ill-spent and
that they have been used as guinea pigs. This should be seen as a constructive
and positive concern, namely that it demonstrates the desire among health care
staff to see the project continue and grow. It is also indicative of their desire to
be part of a new approach that they can contribute to.
15.5 How specialised to become
A number of people alluded to the fact that the HPRT project has created or
awakened a new interest in mental health. In so doing it has also raised questions
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about specialised PHC staff should become in mental health. This too is a
positive sign in the sense that it is indicative of the degree of interest being
shown in mental health and is a question that will need to be addressed soon.
15.6 Changing epidemiology
There is a feeling that the nature of mental health problems being confronted in
Travnik and elsewhere in BiH is beginning to change from trauma-related
presentations to more of a chronic depression related to the loss of self esteem,
unemployment and lack of hope in social development. In this regard there was
a suggestion that the HPRT project should focus in the future on a lifestyle
approach.
15.7 Access
Access to mental health care remains a conceptual and logitical concern. Not
only do some people in need not have easy physical access to services, but in
some instances many of them are still lacking “psychosocial” access as well. In
other words, some people are still unaware of available services or are reluctant
to use them. Many people, moreover, are still not insured and thus remain
outside the framework of access that is called for if equity is to be assured.
15.8 Breadth of coverage
To date the HPRT program has focused on medical practitioners. In Travnik
there was a strong feeling that more attention must be given to the PHC team of
tomorrow and which will ideally be made up of a family physician, a neuro-
psychologist, a nurse and a social worker. Phase II should thus be adapted to this
reality and possibly become a promoter of such a PHC team in mental health.
Professors Ceric and Loga were also of the opinion that the range of participants
deserves to be expanded to include psychologists, nurses and social workers.
These health workers constitute a key part of the primary healthcare team and in
many of the smaller towns are at the front line of primary health care. In order to
30
cover the needs of psychologists, social workers and nurses, it may be necessary
to modify the curriculum, taking into account the different basic training they
have had, and the different roles they play within the BiH healthcare system. In
Travnik reference was also made to other categories such as teachers and
religious staff benefiting from the course.
15.9 Experience
Longer-term PHC physicians appear to be doing better with the course than
shorter-term staff. This highlighted the problem of the frequent staff turn-over in
BiH, and the fact that many people going through the course are moved or
choose to move on to different tasks and positions soon after their training. This
is not a new problem in BiH and reflects the fact that PHC was never seen as a
high status profession.
15.10 Standardisation
To date the training course has been made up of lectures that, while individually
sound, have sometimes lacked obvious continuity. The organisation and content
structure of the lectures and their presentation has also varied. A number of
people referred to the need for lectures to be standardised in terms of structure
and presentation.
15.11 Diagnosis
Although there was widespread commendation of the course content, there was
also frequent reference to the need for more workshops on diagnostic procedures
and standards, and for more case studies to be presented. This again is indicative
of the growing interest that has been inspired by the course.
15.12 Continuing education
Some staff questioned the duration of the training and suggested that if the
project is to make an even stronger impact on the reconstruction effort there will
31
be a need for continuing education. If this were possible, it could create a truly
important model for medical education in general in BiH and the region.
15.13 Chronic disease management
The HPRT project has helped highlight the fact that there is currently no
community-based mechanism for taking care of chronically ill people and this
will hopefully be taken up by national and international authorities in the future.
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Project Design Summary: Community-Based Mental HealthServices in Middle Bosnia Canton (Travnik Canton)
NarrativeSummary
Indicators Monitoring &Evaluation
CriticalAssumptions
EvaluationComments
Sector Goal:1. Reduction inpsychiatric morbidityand mortality inTravnik Canton.
2. Improvedintegration andparticipation insociety by traumatizedpersons.
1. Suicide ratesdecline.
2. Increases inemployment,income-generatingactivities, and civicparticipation.
1. Cantonal healthstatistics.
2. Employmentrecords and polling.
1. No recurrenceof inter-ethnicviolence.
2. Financing forMH systemcontinues fromfederal, cantonal,and internationalaid sources.
1. Suicide may beincreasing because ofworsening economicsituation. Otherpsychiatric morbidityis clearly being betterattended andprevented.
2. Participation insocial functions hasimproved and peoplewith MH problemsare clearly betterintegrated than everbefore.
Project Objectives:1. Improved mentalhealth clinical skillsamong PCPs(diagnosis, treatment,and referral).
2. Options developedfor the organizationand development ofMH services inTravnik Canton andthroughout BiH(including integrationof MH into the PHCsystem).
1. Increasedutilization ofCBRs; patientsatisfaction isincreased;increased diagnosisof MH conditions.
2. Advisory boardpresents options topolicy makers atFederal Ministry ofHealth.
1. FC, CBR, andDZ patientutilization data;patient satisfactionsurveys; medicalrecords.
1. Healthprofessionalsaccept new modeland apply trainingknowledge.
2. Populationaccepts concept ofintegratedcommunityservices.
3. Economygrows.
1. HPRT provided120 hours of traiing to103 PCPs.Understanding of andclinical skills in MHvastly improved.
2. A number of newoptions have emergedas a result of trainingand greaterparticipation of staffin decision making.Also better linkagebetween all levels ofhealth system whichis also opened newoptions.
Outputs:1. Needs of patients,community, andproviders aroundmental health aredocumented.
1. Needsassessment reportcompleted.
1. Tests andevaluations (duringtraining) and site-visits after training.
1. Facilities referpatients accordingto guidelinesdeveloped intrainings.
1. Systematic surveysof needs undertaken.New data has becomeavailable andmethodologiesadapted to needs ofBosnia.
33
NarrativeSummary
Indicators Monitoring &Evaluation
CriticalAssumptions
EvaluationComments
2. PCPs are trained inMH care and traumatreatment.
3. Dissemination ofMH information andpolicyrecommendationsthrough newslettersand website.
4. PCPs receive on-site supervision,consultation, andevaluation regardingMH skills.
2. 120 PCPs attendtraining and passexam.
3. Five newsletterssent to healthprovidersthroughout BiH;web pages devotedto project.
4. Thirty-six (36)site visits are made.
2. Project reportsand test results.
3. Printing records,project-mailingrecords.
4. Project site-visitreports.
2. Facilitiesreceive budget forstaff, training,supplies, andmedications.
3. Cantonsprovide staff forthe CBRs.
2. HPRT provided120 hours of traiing to103 PCPs.
3. HPRT createdwebsite that is beingused extensively byall levels of healthsystem.
4. 40 onsiteconsultationsachieved. All 19 Dzsreceived at least 4visits.
Activities:1. PHC and MH needsassessment conducted.
2.1 Curriculumadapted to needs ofTravnik providers andcommunity.
2.2 PCPs and facultyare recruited.
2.3 PCPs are trained.
1. Interviews with30-40 PCPs; focusgroups with 5-1hospital providers;interviews with 90-100 patients.
2.1 Curriculumcompleted inEnglish andBosnian/Croatian.
2.2 120 PCPs, 2internationalfaculty, and 4national faculty areidentified.
2.3 120 PCPsreceive 9 days ofmental health andtrauma training.
1. Needs assessmentreport.
2.1 Curriculumbook.
2.2 Project records.
2.3 Attendancerecords and exams.
1. Cantonalofficials cooperatewith needsassessment.
2. Cantonalofficials releasehealth staff toattend training.
1. All assessmentsconducted and uniqueand new body ofinformation generatedand fed into system.
2.1 Project hasdemonstratedflexibility forcurriculumdevelopment but someadaptation still neededto meet needs of nonMD staff.
2.2 PCP and facultyrecruited as part oftraining & shouldcontinue with morestandardised format ofpresentation.
2.3 HPRT provided120 hours of traiing to103 PCPs.
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NarrativeSummary
Indicators Monitoring &Evaluation
CriticalAssumptions
EvaluationComments
Activities cont.3.1 Advisory board isformed and meets.
3.2 Newsletter ofproject and relevantMH information isdisseminated.
3.3 HPRT websiteincludes newslettersand other relevant MHinformation forTravnik.
4. Consultation,supervision, andevaluation of PCPs.
5. Project evaluated.
3.1 Advisory boardof 10 nationalhealth leaders andexperts meets fourtimes.
3.2 Fivenewsletters writtenand 1000 copiesdisseminated.
3.3 Website isoperational.
4. Thirty-six (36)primary carefacilities visited.
5. 95% passing rateon training;increased diagnosisand satisfaction;appropriate use ofMH skills inprovider practices.
3.1 Advisory boardminutes.
3.2 Newsletters andpostage records.
3.3 Website pages.
4. Evaluationreports and projectrecords.
5. Evaluation report.
3. Cantonsprovide staff forCBRs.
3.1 Advisory boardhas met and provedvery involved,constructively criticaland enjoyed newparticipatoryexperience.
3.2 Three newsletters& 3,000 copiesdisseminated.
3.3 Achieved.
4. 40 onsiteconsultations, all 19Dzs received at leastfour visits.
5. Evaluationconducted by DrCarballo.
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16. CONCLUSIONS
The HPRT project came to BiH at a very timely moment. First of all it met an
urgent need within the post-conflict reconstruction process, and provided a
momentum that was clearly not forthcoming from any other source, either in BiH
or indeed anywhere else where post-conflict reconstruction is underway. It also
came at a very appropriate time in terms of the healthcare reform process that
was getting underway in BiH and which must now be accelerated. The project
has served to highlight a number of questions concerning this reform process
while at the same time opening up new opportunities for it.
The fact that the project was Harvard-linked brought a sense of credibility to the
initiative, but during the course of the life of the project in BiH it has generated
its own credibility. The non-institutionalised character of the project, that is to
say a university (Harvard) based project, undertaken in collaboration with the
Canton of Travnik, also helped to reduce misgivings and possible stigma that
might have been attached to it had it come directly from within government
and/or a UN agency.
The project has met all its objectives within the allocated time, and indeed has
gone much further by generating a new and unique interest in mental health at the
primary care level. In doing so, it has opened a window of opportunity for the
care and protection of people with mental health problems and has opened up the
possibility of a strengthened mental health prevention/promotion orientation
within the PHC system.
Its location in Travnik, which was among the worst effected cantons it the war,
and where economic development after the war has been slow, has helped meet a
growing “post-trauma” need within middle BiH and possibly elsewhere in the
country. This is not to be under-estimated. The capacity of BiH to reconstruct
will depend in great part on the psychosocial condition of its people.
36
There is evidence that the project has helped to create a political and social
“space” in the Canton of Travnik that has helped the process of reconciliation.
This bodes well for the future role of the health care system and psychosocial
interventions in general. Careful management of a scaled up HPRT project
might contribute enormously to a broader reconciliation process.
Within the overall health care system and the different initiatives that have
emerged in BiH over the past eight years, the HPRT project has, despite its
relatively small size, become a leader and demonstrated the importance of well
planned, but flexible, projects that are able to adapt to evolving needs while
retaining technical precision.
A scaled up Phase II is now essential. Unless this takes place credibility will be
lost and there is a danger that morale among health care staff will be eroded. The
World Bank has gained prominence through this project and stands to gain even
more through an improved Phase II that takes into account the concerns and
recommendations highlighted above in this evaluation report.
Finally, the staff of the Harvard Program in Refugee Trauma should be
congratulated on conceptualising and taking forward such an important initiative
in such a difficult setting. Special credit should also go to the HPRT staff in
Sarajevo who managed, with great sensitivity, the delicate process of creating
and administering the project in what were often difficult professional
circumstances. None of this, of course, would have been possible without the
support of the World Bank Post Conflict Unit, and it should be clearly
understood that credit to the World Bank goes not simply for its financial
support, but also for the technical insight and vision it has brought to post-
conflict reconstruction in BiH in general.