Building Back Better: Sustainable Mental Health Care after Emergencies Mark van Ommeren, PhD JoAnne Epping-Jordan, PhD April 2014 On behalf of the World Health Organization © WHO, All rights reserved. Permission has been granted to University of Pittsburgh to use and disseminate this presentation for non-commercial purposes.

Objectives of Lecture 1.To describe why emergencies are opportunities for mental health reform 2.To summarize how 10 diverse emergency- affected areas were able to make sustainable improvements in mental health care 3.To review key actions that facilitated reform within most or all of these cases

Lecture Based on WHO Global Report (click link for more information--in Slide Show mode only) Building Back Better: Sustainable Mental Health Care after Emergencies Part 1: Seeing opportunity in crisis (Introduction) Part 2: Seizing opportunity in crisis (10 detailed cases) Part 3: Spreading opportunity in crisis (lessons learnt)

Why was the Report Needed? Hundreds of millions of people facing natural disasters, armed conflict, and other hazards around the world could be helped more effectively through transforming mental health care, which in turn would improve the well-being, functioning, and resilience of individuals, societies, and countries recovering from emergencies.

Mental Health Challenges Mental disorders touch everyone – 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 (Click book cover for more information--in Slide Show mode only) 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

10 Emergency-Affected Areas Afghanistan Burundi Indonesia (Aceh Province) Iraq Jordan Kosovo occupied Palestinian territory Somalia Sri Lanka Timor-Leste

Afghanistan – Progress Despite Protracted Violence and Fragile Context Violence and instability for more than 30 years Increased focus on mental health following fall of Taliban in 2001

Afghanistan - Achievements 2003: Mental health included in Basic Package of Health Services (BPHS) 2 nd tier 2005: Mental health included in BPHS 1 st tier 2008: Standardized training materials for health workers 2010: Psychosocial counsellors in health centres and basic mental health training for medical doctors working with them 2010: Inclusion of mental health indicators in health information system 2010: Inclusion of psychiatric medications in essential drugs list 2010: 5-year National Mental Health Strategy

Afghanistan - Nangarhar Province Since 2001: > 1000 general/primary health workers trained and supervised in basic mental health care Almost people helped

Burundi – NGO Initiative is Basis for more Comprehensive Services 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 assume responsibility for mental health services

Burundi – Achievements Introduction of psychosocial workers Mental health clinics in provincial hospitals Physician and nurse training in basic mental health care 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 people helped by psychosocial workers, 2000 – people seen at mental health clinics for more than consultations, 2006 – 2008 Current project: integrating mental health into primary care via mhGAP mhGAP

Indonesia (Aceh) – Influx of Emergency Resources Used to Strengthen Mental Health System Decades of civil strife and tsunami of December 2004 – killed – displaced – Health facilities destroyed Prior to tsunami, mental health care available only through one psychiatric hospital located in capital

Indonesia (Aceh) - Strategy 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 – National Mental Health Council Drives Progressive Service Developm ent Decades of dictatorship, economic sanctions, war, violent insurgency Millions displaced 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 ) Integration of mental health care into PHC ( ) 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 – Small-Scale Pilot Project Leads to Broader Reform Periodic influxes of refugees from neighboring countries Starting in 2003, continuous waves of displaced Iraqis – Scattered throughout country – High rates of mental health problems Mental health system hospital-based, urban – no primary health care integration

Jordan – Early Achievements 3 pilot community mental health centres ( ) – Biopsychosocial approach – Multidisciplinary teams – Individualized treatment plans – Wide range of services Successes built support and momentum for further change

Jordan –Further Reform 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 mhGAP – Service user training and empowerment

Kosovo – Mental Health Strategic Plan Helps Coordinate Diverse Stakeholders Conflict came to a head in Rapid political change Mental health services hospital focused, biological, no primary health care integration

Kosovo Mental Health Task Force Mental Health Strategic Plan (2001) – Roadmap for coordinating actions

Kosovo – Service Development

Occupied Palestinian Territory Two geographically separated areas Decades of occupation, conflict, unrest Pre-reform: 90% of resources for tertiary psychiatric care, few community mental health clinics, no primary health care integration

Occupied Palestinian Territory – Milestones WHO technical assistance initiated (2001) Agreement between Ministry of Health and Consulates of France and Italy (2003) 5-year strategic operational plan (2004) 3-year European Commission project contract (2008 and 2012)

Occupied Palestinian Territory – Service Development Number managed in community mental health centres Number of inpatient beds, Bethlehem Hospital

Somalia – Improvements while Full Reform not Possible 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 primary health care services

Somalia - Initiatives 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 ( ) – 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 - Policy Framework Guides Action; New Mental Health Worker Cadres Fill Service Gaps Areas of protracted civil conflict Tsunami of December 2004 – More than killed – 1 million displaced – Extensive damage

Sri Lanka – Policy Milestones National mental health policy ( ) – decentralized, comprehensive, community-based services – roadmap for coordinated efforts National Mental Health Advisory Council (2008)

Sri Lanka – service development

Timor-Leste – Building a Mental Health Service from Scratch 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 –Development Milestones 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 Ministry of Health

Timor-Leste - Achievements 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

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. 10 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. 10 Key Actions

The Future

Summary Major gaps worldwide in realization of comprehensive, community-based mental health care. Meaningful action can be taken after emergencies to accelerate 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 to 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 WHO report and related informationWHO reportrelated information Disseminate the report to stakeholders (summaries available in multiple languages) Use the report to guide technical advice