World Health Organization

World Health Organization
27 November, 2018 Building Back Better: Sustainable Mental Health Care after Emergencies It’s my pleasure to introduce you to the new World Health Organization report, Building Back Better: sustainable mental health care after emergencies. This report was produced by the Department of Mental Health and Substance Abuse at WHO headquarters in Geneva.

27 November, 2018 “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 Show this slide on the screen while the audience enters the room.

Report structure 27 November, 2018 Part 1: Seeing opportunity in crisis (Introduction) Part 2: Seizing opportunity in crisis (10 detailed cases) Part 3: Spreading opportunity in crisis (lessons learnt) The report is divided into three distinct parts: Part 1 provides the rationale for understanding emergencies as opportunities to build better mental health care. Part 2 presents 10 case examples of areas that have seized opportunities during and after emergencies to build better mental health care. They represent a wide range of emergency situations and political contexts. Part 3 summarizes overlapping practices among the 10 cases.

Part 1 – seeing opportunity in crisis
World Health Organization Part 1 – seeing opportunity in crisis 27 November, 2018 Part 1 provides the rationale for understanding emergencies as opportunities to build better mental health care.

Mental health challenges
World Health Organization Mental health challenges 27 November, 2018 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 report stands on 2 pillars: (a) the mental health situation in the world; and (b) humanitarian emergencies. With regard to (a) the mental health situation in the world: Around 450 million people are affected by mental disorders. They touch all countries, communities, and age groups. If left untreated, mental disorders create an enormous toll of suffering, disability and economic loss. Despite the potential to successfully treat mental disorders, only a small minority of those in need receive even the most basic treatment. The scant resources that are dedicated to mental health are often inappropriately deployed: most mental health resources are spent on expensive care in psychiatric hospitals rather than on community-based services.

This is not effective or humane care
World Health Organization This is not effective or humane care 27 November, 2018 These are not random images. Rather, these photos were sent to us by our case contributors from Indonesia, Kosovo, and Burundi, pictured from left to right, to demonstrate conditions before reform. This is the reality of what people with mental disorders face in many countries around the world.

It is possible to do better
World Health Organization It is possible to do better 27 November, 2018 Community-based services in action We can do better. WHO has affirmed that mental health care in all countries – including those rebuilding from emergencies – should be centred on services that are accessible in the community. These photos display community-based services in Burundi on the left, and Afghanistan on the right.

Emergencies at a glance
World Health Organization Emergencies at a glance 27 November, 2018 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 The second pillar of the report is (b) humanitarian emergencies. Humanitarian emergencies are caused by natural disasters, armed conflict, and other hazards. They affect millions of people around the world. This year the world has witnessed numerous emergency situations. Countless people have been affected, and will continue to be affected as their countries struggle to recover and rebuild. Emergency situations frequently involving large-scale injury and death, insecurity, displacement of people, malnutrition, disease outbreaks, and disrupted economic, political, health, and social institutions. In addition, rates of a wide range of mental health problems increase as the result of emergencies. And at the same time, existing mental health infrastructure may be weakened. Buildings can be damaged, electricity and water supplies can be affected, and supply lines for essential medicines can be disrupted. Health workers may themselves fall victim to the emergency situation through injury, death, or forced displacement.

Emergencies are opportunities
World Health Organization Emergencies are opportunities 27 November, 2018 Media interest Interest of decision-makers (e.g. government leaders, heads of humanitarian agencies) Decision-makers willing to consider options beyond the status quo While the challenges related to mental health care are considerable, emergencies also present unique opportunities for better care of all people with mental health needs. Following disasters, the media often focus on the plight of surviving people, including their psychological responses to the stressors they face. In some countries, government leaders and heads of nongovernmental organizations express – for the first time – serious concern about their nation’s mental health. Within this context, decision-makers often become willing to allocate resources towards mental health and to consider options beyond the status quo. Collectively, these factors create the possibility of introducing and implementing more sustainable mental health services.

Taking action helps recovery and development
World Health Organization Taking action helps recovery and development 27 November, 2018 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 Mental health reform is important because high-quality mental health care is crucial to the overall well being and functioning of individuals, societies, and countries recovering from emergencies. As described in detail in the 2010 WHO report on mental health and development, shown here on the right, good mental health has been linked to a range of priority development outcomes. These include better health status, higher educational achievement, enhanced productivity and earnings, improved interpersonal relationships, better parenting, and closer social connections. These outcomes are important for all countries, not least of all those that have recently experienced emergencies.

Part 2 – Seizing opportunity in crisis
World Health Organization Part 2 – Seizing opportunity in crisis 27 November, 2018 Part 2 presents 10 case examples of areas that have seized opportunities during and after emergencies to build better mental health care. They represent a wide range of emergency situations and political contexts.

10 emergency-affected areas
World Health Organization 27 November, 2018 Afghanistan Burundi Indonesia (Aceh Province) Iraq Jordan Kosovo Somalia Sri Lanka Timor-Leste West Bank and Gaza Strip All of these cases were initiated between 2000 and 2010 and were chosen because they succeeded in making clear improvements in access to basic mental health services. The following slides present the main findings from each of these cases.

Afghanistan 27 November, 2018 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 has experienced protracted violence and instability for the past 30 years. Following the fall of the Taliban government in 2001, attention increased on strengthening mental health services in the country. Initially, nongovernmental organizations took the lead in implementing services. From 2004, the Ministry of Public Health became increasingly involved.

Afghanistan – policy milestones
World Health Organization Afghanistan – policy milestones 27 November, 2018 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 After the fall of the Taliban, the initial version of the Basic Package of health Services (BPHS; 2003) included mental health among its seven priority areas. However, because it was a second-tier priority, funds would not be allocated to mental health services. From 2004, the MOPH took a stronger stand and the 2005 version of the BPHS included mental health in its first tier of priorities. The 2010 revision of the BPHS further strengthened mental health services in outpatient settings. It called for psychosocial counsellors to be added to health centres, and basic mental health training for medical doctors working with them. Additionally, the BPHS revision called for a mental health focal point in each district hospital. In 2010, a 5-year National Mental Health Strategy was endorsed by the MOPH.

Afghanistan – other achievements
World Health Organization Afghanistan – other achievements 27 November, 2018 Standardized training materials for health workers Inclusion of mental health indicators in health information system Inclusion of psychiatric medications in essential drugs list Other achievements have been made in Afghanistan. In 2008: A technical working group of the Ministry, WHO, and NGOs produced a full range of mental health training manuals for different health worker cadres (doctors, nurses and midwives, community health workers). As part of the 2010 BPHS revision: Eight mental health indicators became part of the national health information system. Key psychiatric medications were introduced into the Afghan essential drug list.

Afghanistan - Nangarhar Province
World Health Organization Afghanistan - Nangarhar Province 27 November, 2018 Since 2001: > 1000 general/primary health workers trained and supervised in basic mental health care Almost people helped In the eastern province of Nangarhar, staff working in basic health facilities were trained in mental health and then provided with regular supervision. In addition, district hospitals in the province began to offer outpatient services, and a mental health ward was established in the provincial hospital. In Nangarhar province alone, 334 doctors, 275 nurses and midwives, and 931 community health workers received basic mental health training. This photo depicts village health volunteers being trained in the province. The proportion of mental health consultations in general care increased in nine years from less than 1% to around 5% (almost people diagnosed and treated).

Burundi 27 November, 2018 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 is a small, densely populated country situated in the African Great Lakes region that experienced the restoration of democracy in In the prior few decades, an estimated Burundians were killed; were forced to flee to neighbouring countries; and hundreds of thousands were internally displaced. Modern mental health services were almost non-existent prior to the past decade. In 2000, the Ministry of Public Health did not have a mental health unit or a mental health policy or plan. The entire country had just one psychiatrist, and altogether lacked psychiatric nurses and psychiatric social workers. Virtually all mental health services were provided by a single psychiatric hospital with limited capacity. In 2000, the NGO HealthNet TPO initiated a psychosocial and mental health pilot project and built a network of psychosocial and mental health services in parts of the country. In 2005, a democratically elected president took office and peace returned to the country; this political change allowed HealthNet TPO to begin to advocate for the anchoring of mental health services within government-run health-care structures.

Burundi – service development
World Health Organization Burundi – service development 27 November, 2018 Introduction of psychosocial workers Mental health clinics in provincial hospitals Physician and nurse training in basic mental health care Several important service developments took place: A new health worker cadre, the psychosocial worker, was introduced and salaried by the initial pilot project. They developed the necessary basic skills to manage a wide range of mental health issues. The photo shows a psychosocial worker attending to a boy and his father. More specialized psychiatric services, including medication and psycho-education, were provided through monthly mental health clinics in provincial hospitals. A team consisting of an expatriate psychiatrist and Burundian nurses employed by the NGO ran these clinics. They saw people referred by the psychosocial workers or health-care professionals, and those who self-referred. Four government nurses from each provincial hospital received mental health training, which was provided by an expatriate psychiatrist and a Burundian nurse. The physicians working at the provincial hospitals also received training and follow-up.

Burundi – policy achievements
World Health Organization Burundi – policy achievements 27 November, 2018 National Mental Health Strategy adopted in 2007 Inclusion of mental health indicators in health information system Inclusion of psychiatric medications in essential drugs list National level policy developments also have happened in Burundi: A national mental health strategy was drafted and signed by the Minister of Public Health, and a national mental health policy was drafted in 2007 by a multidisciplinary team with representatives of the MOPH, WHO, and HealthNet TPO. Monitoring and reporting tools have been elaborated by the project, and six psychiatric diagnoses have been incorporated into the government’s health information system. The National List of Essential Drugs has been revised and now includes all basic psychotropic and anti-epileptic drugs from the model List of Essential Drugs by WHO, with the exception of long-acting depot medication, which was deemed too costly.

Burundi – other achievements
World Health Organization Burundi – other achievements 27 November, 2018 More than people helped by psychosocial workers, 2000 – 2008 people seen at mental health clinics for more than consultations, 2006 – 2008 Current project: integrating mental health into primary care via mhGAP Other achievements of the project: The project has maintained a database recording the number of people who have requested assistance from psychosocial workers. In total, more than people have been assisted. From 2006 to 2008, the mental health clinics in the provincial hospitals registered almost people, who received more than consultations. The photo illustrates people queuing for one such clinic in Burundi. In 2011, new funding enabled HealthNet TPO and the Burundian government to initiate a 5-year project aimed at strengthening health systems. One of the project’s components is the integration of mental health care into primary care. The project is using the WHO mhGAP Intervention Guide for treating mental disorders in non-specialist health settings.

Indonesia (Aceh) 27 November, 2018 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 of Aceh The province of Aceh in Indonesia suffered from decades of civil strife before it was struck by the devastating tsunami of Hundreds of thousands of people were killed or displaced and numerous health facilities were destroyed. Before the tsunami struck, mental health care was available only through the province’s sole mental hospital, located in the capital city of Banda Aceh. This mental hospital was institutional in nature.

Indonesia (Aceh) - strategy
World Health Organization Indonesia (Aceh) - strategy 27 November, 2018 Recommendations for Mental Health in Aceh (2005) Roadmap for coordinating diverse agencies Community mental health nurses Inpatient units in general hospitals Psychiatric hospital reform In the aftermath of the tsunami, more than 100 Indonesian and international agencies arrived in Aceh to offer a wide range of mental health services. The vast majority of agencies, however, planned to stay only for the initial emergency period. After they left, their services and supports would no longer be available, and most had nothing planned to ensure that care would continue in the longer term. As a result of this expected service gap, Indonesia’s Ministry of Health (MOH) WHO agreed to move forward based on WHO’s (2005) Recommendations for Mental Health in Aceh, which included a specific recommendation on building a comprehensive mental health system. The programme would rely on community mental health nurses to deliver mental health care – as shown in the photo on this slide. Within this model, nurses would conduct home visits, ensure that people with mental disorders received appropriate medication, and provide support to families. When needed, they would refer people to acute inpatient care. Psychiatric acute care units in district general hospitals were established. They deliver short-term care for people with severe mental disorders, who cannot be treated in the community due to the severity of their symptoms. The goal is to stabilize them and then refer them back to their primary health centre. Meanwhile, reform was undertaken at the Banda Aceh Mental Hospital, including establishing open wards in place of locked wards.

Indonesia (Aceh) - achievements
World Health Organization Indonesia (Aceh) - achievements 27 November, 2018 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 Significant progress has been made since the devastating tsunami struck Aceh in 2004. All districts in the province have at least some capacity to deliver mental health services at primary care level. For 2011, 13 out of 23 districts/municipalities had specific mental health budgets (up from 0/23 before the tsunami). At the secondary or district level, three district general hospitals are providing short-term hospitalization for acute exacerbations of symptoms of severe mental disorders, as well as outpatient services. At the tertiary or provincial level, the existing Banda Aceh Mental Hospital has improved its quality of care, although progress is still needed to improve its overall conditions. In 2010, Aceh further demonstrated its commitment to improving services through the inclusion of mental health within its Provincial Regulations on Health. Aceh is now viewed as a model for other provinces in Indonesia that are seeking to improve their mental health services.

Iraq 27 November, 2018 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’s governmental and social infrastructure was devastated by decades of dictatorship, the Iran–Iraq war, economic sanctions, the Gulf wars, the invasion in 2003, and the subsequent violent insurgency. Health-care delivery suffered greatly. By the end of 2007, about 1.6 million people were internally displaced and an estimated 2.5 million were living as refugees in neighbouring countries. Many Iraqis suffered from intense psychological distress. Before 2004, mental health services were provided by fewer than 100 psychiatrists, who were providing (mostly outpatient) psychiatric services in a few general and university hospitals. In addition, there were two psychiatric hospitals in Baghdad (Al-Rashad, with 1325 beds, and Ibn Rushid, with 76 beds) and private clinics in the main cities for those who could afford them.

Iraq – milestones 27 November, 2018 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 In 2004, the Iraq National Mental Health Council (NMHC) was formed and a series of action-planning conferences were held. One of the most important recommendations to come from these meetings was to create a mental health system that was radically different from the country’s previous one. This included transforming the institutional, biomedically based model of mental health care to an integrated, community-based approach. Iraq’s mental health policy was first revised in 2004, and the current strategy and action plan cover the period 2009–2013. Priorities include developing community mental health services, downsizing institutional psychiatric hospitals, developing acute care units in general hospitals, and integrating mental health care into primary health care. A range of courses, workshops, and resource materials for health workers on mental health issues have been developed and implemented. Around 80–85% of psychiatrists, more than 50% of general practitioners, and 20–30% of nurses, psychologists, and social workers in Iraq have received this training. To complement this effort, a national formulary of psychotropic drugs was approved for use.

Iraq – service development
World Health Organization Iraq – service development 27 November, 2018 Substantial progress was made from 2003 to 2011. Efforts were made to reform the psychiatric institutions that dominated mental health care in Iraq. In particular, Al-Rashad hospital decreased its average number of residents by around 45 people, while taking steps to reinforce the number of health workers and improve the quality of its services. A total of 25 new community-based units in general hospitals were established, as were new inpatient beds for children and adolescents. An additional 34 outpatient-only mental health facilities were also established. These units are found mainly in general hospitals and primary health centres. Since 2009, steps were taken to integrate mental health services within the primary health care system.

Jordan 27 November, 2018 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 Over the past decades, Jordan has periodically received influxes of refugees fleeing neighbouring countries. Specific to this case, continuous waves of displaced Iraqis flowed into the country starting in 2003. The influx of Iraqis in Jordan differs from other refugee situations because they do not live in defined camps; rather, they are scattered throughout the country, especially in major cities. Consequently, they are difficult to identify and reach with psychosocial and other services. This is important because there are high rates of depressive symptoms, fatigue, insomnia, and anxiety among this group. Prior to the reform described in this case, Jordan’s mental health system was highly centralized and mainly based on psychiatric hospitals. Some outpatient services were available, but predominantly restricted to large cities and overall insufficient.

Jordan 27 November, 2018 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 The first action phase of the reform focused on developing community mental health centres in existing Ministry of Health (MOH) facilities. From 2008 to 2009, the MOH and WHO developed three pilot centres, each located in a geographical area with a high concentration of displaced Iraqis. The community mental health centres (CMHCs) were designed to provide biopsychosocial services using a multidisciplinary team. This photo is of the first multidisciplinary team established in Jordan. The CMHCs provide a wide range of services, including medical treatment, psychological interventions, social assistance, rehabilitation services, psycho-education for people with mental disorders and their families, home visits, and awareness-raising activities in the community. Patients received individualized treatment plans tailored to their needs and preferences. The project’s many achievements built momentum for further change.

Jordan – further achievements
World Health Organization Jordan – further achievements 27 November, 2018 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 As a result of the effective community mental health centre field project, a National Steering Committee for Mental Health was formed by the MOH. The Committee’s 36 members represented the main mental health stakeholders in Jordan, including service users and community representatives. The Committee was tasked with developing a national mental health policy and plan for Jordan. The policy and plan were launched in They call for bio psychosocial and multidisciplinary services. The newly launched policy led to the formation of a new Mental Health Unit in the MOH. The unit functions as a national mental health authority and coordinates the multiple entities within and outside the MOH that are involved in mental health. Various recent efforts, including the establishment of the community mental health centre described above, have helped reform services. A key achievement was the establishment of a new short-stay inpatient unit in the psychiatric hospital. Subsequently, it was agreed to open three new inpatient units within general and teaching hospitals. Progress has been made to integrate mental health services within PHC. Jordan is implementing the WHO Mental Health Gap Action Programme (mhGAP). Efforts also have ben made to empower service users. A total of 120 service users were trained on human rights and the first national users’ association, Our Step, was established.

Kosovo 27 November, 2018 Conflict came to a head in Rapid political change Mental health services hospital focused, biological, no PHC integration Kosovo has endured substantial violence and conflict, which culminated in international intervention and transition of governance to the United Nations (UN) in 1999. This rapid change and interest in mental health created an opportunity to reform Kosovo’s mental health system, which until that time had been hospital-focused and biologically oriented. PHC services for mental disorders were virtually non-existent.

Kosovo 27 November, 2018 Mental Health Task Force Mental Health Strategic Plan (2001) Roadmap for coordinating actions A Mental Health Task Force (MHTF), which consisted of psychiatrists from different regions and representatives of WHO’s mental health unit, was formed and charged with developing a mental health reform strategy. Following extensive consultations, the strategic plan was finalized in 2000 and officially approved in Mental health became one of five priority health areas within the new health policy. Numerous mental health and psychosocial organizations and government donors were present in Kosovo at that time; the strategic plan served as the roadmap, through which all actions could be coordinated. The strategic plan emphasized the strengthening of community-based mental health services at the same time as closing Kosovo’s notorious asylum. The photos on this slide show a patient, referred to as Lady M, before and after mental health reform. In the top photo, she was still a patient in the asylum. The bottom photo shows her after she had transitioned to community-based services.

Kosovo – service development
World Health Organization Kosovo – service development 27 November, 2018 Community-based mental health services were developed to provide a continuum of care for people with mental health needs. This table displays progress from 2000 to 2010. Community-based mental health centres are staffed by multidisciplinary teams, and offer a range of outpatient services, as well as support to PHC centres; Inpatient wards in general hospitals provide acute care for those in need of inpatient services; Residential facilities offer a limited number of beds to those with severe mental disorders. Residents are usually former patients of Kosovo’s asylum. Children and adolescents were given special consideration as part of the reform. Some progress has been made in developing services for this age group. Kosovo’s asylum was transformed into the Centre for Integration and Rehabilitation for long-term patients. It is now part of the community-based mental health service and is managed by the mental health unit of the MOH.

Somalia 27 November, 2018 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’s governance structure has been in turmoil for more than 20 years, and during most of that time the country has been riddled with humanitarian emergencies caused by conflict. The Somali people have suffered greatly as a result, with internal displacement, food crises, and general collapse of the public health system. Mental health services consisted mainly of institutional care in three psychiatric facilities. In these facilities, living conditions were dismal, basic hygiene poor, and psychotropic drugs almost non-existent. Many people with mental disorders were routinely chained. More generally, the country suffered from a severe shortage of mental health workers: only five trained psychiatrists, insufficient and poorly trained nursing staff, and no clinical psychologists or psychiatrist social workers. Mental health services were not available through primary health care (PHC) or otherwise available in the community.

Somalia 27 November, 2018 Full reform not possible Progress through different initiatives Mental health situation analyses Chain-free initiative Health worker training Due to the ongoing crisis and weak governance structures, full reform of the mental health system has not been possible. Nonetheless, progress has been made through various intiitaives. Assessments of the mental health system in Somalia, one concerning Mogadishu and the south/central zone, and the other covering the Somaliland region, were published in 2006 and 2009, respectively. The WHO country office undertook an additional situation analysis in 2010, to better understand the mental health situation as a whole, and to raise the profile of mental health within the health agenda. The Chain-free Initiative – developed by WHO – was launched in Mogadishu in 2006, and later expanded to other parts of the country. The first phase of the initiative has involved creating chain-free hospitals by removing chains and, more generally, through the aim of reforming hospitals into humane facilities with minimum restraints. The second phase has focused on private residences and the final phase involves removing the “invisible chains” of societal stigma and human rights restrictions. Several international organizations have been active in training health workers to deliver mental health services.

Somalia - achievements
World Health Organization Somalia - achievements 27 November, 2018 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 As a result of the chain-free initiative, chains were removed from more than 1700 people between 2007 and Strong political commitment by the Minister of Health has drawn attention to the issue (he is depicted in the photo removing the chains from a patient). Public awareness has been strengthened through media coverage of the topic. The chain-free initiative has now expanded to all regions of the country. WHO’s training courses built the capacity of 55 health workers from the three zones of Somalia. In addition, the training identified people who have the ability to take this work forward: two participants are now mental health coordinators/focal points, and three newly established mental health facilities are managed by participants. The mental health situation analyses raised awareness among national and local partners and helped attract the attention of donors. New projects have been funded as a result. Overall, these achievements demonstrate that important improvements in mental health services can happen in contexts where full-scale national mental health reform is not possible.

Sri Lanka 27 November, 2018 Areas of protracted civil conflict Tsunami of December 2004 More than killed 1 million displaced Extensive damage Mental health services through tertiary-level hospitals near capital The 2004 tsunami was the worst natural disaster in Sri Lanka’s recorded history, and occurred in the midst of an already complex political and social environment: some of the devastated areas had been affected by protracted civil conflict. In addition to the immediate loss of more than lives, the tsunami caused extensive damage to schools, hospitals, businesses, and other infrastructure. Around one million people were displaced across the tsunami-affected districts. Prior to the tsunami, most mental health services were provided through tertiary-level hospitals in major cities, mainly near the capital, Colombo. Trained mental health workers were scarce in other parts of the country. This meant that most people with mental health needs failed to receive any sort of treatment.

Sri Lanka – policy milestones
World Health Organization Sri Lanka – policy milestones 27 November, 2018 National mental health policy ( ) decentralized, comprehensive, community-based services roadmap for coordinated efforts National Mental Health Advisory Council (2008) Following the tsunami, Sri Lanka’s head of state recognized the need to address the acute psychological distress of survivors. Mental health became a prominent part of the political agenda. After intense negotiations among Sri Lankan stakeholders with technical support from WHO, a new national mental health policy was agreed. The Sri Lankan government approved it only ten months after the disaster. The new policy, effective from 2005 to 2015, emphasizes comprehensive, decentralized, and community-based care. A National Mental Health Advisory Council was formed in 2008 to oversee implementation of the mental health policy in Sri Lanka. The council is chaired by the Secretary of the MOH and its members are MOH officials and representatives from other relevant ministries, professional bodies, WHO, NGOs, and of service users and carers.

Sri Lanka – service development
World Health Organization Sri Lanka – service development 27 November, 2018 Sri Lanka has made significant strides towards the development of efficient, comprehensive, and integrated community-based mental health services. As of 2011, 20 out of 26 health districts (77%) had functioning acute inpatient units within general hospital settings, compared with 10 out of 26 (38%) before the tsunami. In addition, the country had 16 fully functional intermediate stay rehabilitation units, compared with five units in 2004. Nearly 30 community support centres have been established, promoting community involvement and education.

Timor-Leste 27 November, 2018 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 was under Indonesian rule for 24 years, prior to achieving independence in 2002. The 1980s and 1990s were marked by extensive human rights violations, military conflict, and mass displacement of populations, which deteriorated into a humanitarian emergency in 1999 following a vote on independence. Prior to 1999, there were no mental health professionals or mental health specialist services in the country. On top of this, many primary health care clinics were destroyed during the conflict. Although this meant that the Timorese did not have appropriate access to any form of mental health service, it also created an opportunity to establish a modern mental health care system.

Timor-Leste 27 November, 2018 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 In 2000, a consortium of Australian agencies began developing the first ever mental health services in Timor-Leste. The resultant agency, PRADET, adopted the following principles for building the mental health care system: The service would be community-based, with a strong emphasis on outreach and support for families; But the service would be organizationally independent of PHC facilities, which had been severely damaged and were struggling to provide even the most rudimentary care. Nevertheless, opportunities would be sought to integrate mental health with primary care services over time. People would be treated for a range of mental disorders and manifestations of psychological distress, but priority attention would be given to those with severe mental health problems. A multidisciplinary team of mental health professionals from Australia and other countries provided extensive input into training and supervision of mental health workers from 2000 to In addition to classroom-based training, psychiatrists and other mental health professionals spent extensive time in the field working side-by-side with Timorese colleagues. As capacity developed, mental health services integrated progressively into primary care settings.

Timor-Leste 27 November, 2018 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. Today, mental health-trained general nurses are available in around one quarter of the country’s 65 community health centres. They are tasked with assessing and treating most cases. They are supported by district mental health workers (positioned in all of the country’s 13 districts), who provide specialist consultation as needed. One psychiatrist is responsible for the most complex clinical situations and provides overall clinical leadership. The goal is to achieve 100% coverage of mental health nurses in community health centres by 2030.

West Bank and Gaza Strip
World Health Organization West Bank and Gaza Strip 27 November, 2018 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 The occupied Palestinian territory comprises two geographically separate areas, the West Bank and the Gaza Strip, which have experienced numerous decades of occupation and intermittent conflict and unrest. The Palestinian population’s mental health needs are considerable and are exacerbated by the continued conflict and violence. Prior to reform, in 2000, the MOH’s mental health resources were concentrated in tertiary psychiatric care at mental hospitals. There were few community mental health clinics in the West Bank and Gaza Strip, and primary health workers had little to no training in managing mental disorders.

West Bank and Gaza Strip – milestones
World Health Organization West Bank and Gaza Strip – milestones 27 November, 2018 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) Following the start of the second intifada in 2000, renewed international attention was focused on mental health in the West Bank and Gaza Strip. In 2001, WHO conducted an initial assessment and soon thereafter started working with the MOH to provide assistance on mental health reform. Meanwhile, the Governments of France and Italy also made major commitments to strengthen community mental health care in the territory. To address the risk of duplication and fragmentation between these agencies, WHO initiated development of a technical agreement, which was signed by the MOH, the Consulates of France and Italy, and WHO. You can see here in the photo the signing event. Following this agreement, a steering committee on mental health was appointed by the MOH to develop the mental health plan. And in early 2004, the MOH adopted the committee’s 5-year Strategic Operational Plan. The plan emphasized: establishment of geographical area-based mental health service systems, with each defined area having a community mental health service consisting of a community mental health team and centre, acute inpatient beds, day care services, rehabilitation, and continuing care accommodation, and means to respond to the mental health needs of children and older people; redistribution of mental health service resources, particularly from psychiatric hospitals, across the territory; collaboration with other sectors, including the NGO sector. The work of the MOH and WHO towards implementing the plan was not funded continuously but major project contracts were awarded by the European Commission in 2008 and again in This funding has enabled significant progress to be made.

West Bank and Gaza Strip – service development
World Health Organization West Bank and Gaza Strip – service development 27 November, 2018 Number managed in community mental health centres Number of inpatient beds, Bethlehem Hospital The chart on the left shows that across the West Bank and Gaza Strip, the number of people managed in community mental health centres has clearly risen from 2007 to In the West Bank 10 new community-based centres have opened since 2004; in the Gaza Strip, 6 community mental health centres are operational. Psychiatric hospitals are also being reformed. The chart on the right shows how Bethlehem’s psychiatric hospital in the West Bank has been slowly reducing the number of long-stay inpatient beds. It has developed outpatient services, occupational therapy, and support to a family association. In addition, the hospital is developing a vocational rehabilitation programme.

Part 3 – Spreading opportunity in crisis
World Health Organization Part 3 – Spreading opportunity in crisis 27 November, 2018 Part 3 summarizes 10 overlapping practices that were identified from the 10 cases.

Key Actions 27 November, 2018 Mental health reform was supported through planning for long-term sustainability from the outset The broad mental health needs of the emergency-affected population were addressed The government’s central role was respected National professionals played a key role Coordination across agencies was crucial Most cases demonstrated how early commitment to mental health reform by key individuals played a role in creating long-term sustainability. Although emergency funding was often short-term (e.g. serial one-year contracts), some key donors were prepared to fund longer-term mental health reform through repeated contracts for development activities. Reforms concerned a wide range of mental health problems, as opposed to only one disorder (e.g. post-traumatic stress disorder). Not a single case profiled in this paper established stand-alone, vertical services while ignoring other mental disorders. During and following some of the emergencies described in this report, government structures were adversely affected, but humanitarian aid helped subsequently to strengthen them. Governments were not bypassed by aid agencies. In several cases (e.g. Iraq, Kosovo, Somalia), local professionals were powerful champions in promoting and shaping mental health reform. Coordination of diverse mental health actors was typically crucial when working towards mental health reform. In several cases, proactive efforts facilitated consensus among diverse partners, who then worked from an agreed framework.

27 November, 2018 Key Actions Mental health reform involved review and revision of national policies and plans The mental health system was considered and strengthened as a whole Health workers were reorganized and trained Demonstration projects offered proof of concept and attracted further support and funds for mental health reform Advocacy maintained momentum for change Most cases described a process that involved policy reform, usually at national level. In the context of disaster, when political will for mental health was high, the policy reform process was accelerated in some cases. In many cases, the mental health system was reviewed and assessed as a whole, from community level to tertiary care level. Doing so provided an understanding of the overall system and where improvements were needed. Decentralization of mental health resources towards community-based care was a key strategy in all cases. Opportunities frequently arose post-emergency to reorganize, train, and provide ongoing supervision to health workers so that they were better equipped to manage mental health problems. New health worker cadres were introduced in some cases. Notably, investments like these -- in people and services -- outweighed investments in constructing or refurbishing buildings. Demonstration projects, many of which were completed using short-term emergency funding - provided proof of concept in several cases and helped ensure momentum for longer-term funding. In almost all cases, key individuals or groups played crucial roles in advocating for broader mental health reform. They helped maintain momentum for change after the acute emergency.

The future 27 November, 2018 We do not know where the next major emergencies will be in the world, but we do know that those affected will have the opportunity to build back better mental health care for the long term. By publishing this report, WHO aims to ensure that the next people faced with emergencies do not miss the opportunity for mental health reform. The 10 cases described in the report provide proof of concept that it is possible to build back better, no matter how weak the existing mental health system or how challenging the emergency situation.

Key messages 27 November, 2018 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. We are reaching the end of my presentation. But before closing, I would like to review the key messages of the report. Mental disorders remain among the most prevalent, burdensome, and undertreated health conditions globally. They affect all communities and age groups. Yet major gaps remain worldwide in the realization of comprehensive, community-based mental health care. This is especially true in low- and middle-income countries, where around 80% of people in need do not receive appropriate services. This report has made the case that emergencies, in spite of their tragic nature and adverse effects on mental health, are unparalleled opportunities to build better mental health systems for all people in need. The report describes in detail how this was done in 10 diverse emergency-affected areas. Global progress will happen more quickly if, in every crisis, strategic efforts are made to convert short-term interest in the mental health needs of survivors into momentum for mental health reform. This would benefit people’s mental health, which is important in its own right and also because mental health is crucial to the overall well-being, functioning, and resilience of individuals, societies, and countries recovering from emergencies.

What you can do 27 November, 2018 Read the report and supplementary information Incorporate relevant slides into presentations Disseminate the report’s website (below) Use the report to guide technical advice This concludes my presentation on the new WHO report. I will leave you with some comments from early reviewers of the report, as well as a web address, where you can download the full report in English, and executive summaries in French and Spanish. There also is a link on this same web page for ordering a hard copy. Thank you for your attention.

World Health Organization

Similar presentations

Presentation on theme: "World Health Organization"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

World Health Organization

Similar presentations

Presentation on theme: "World Health Organization"— Presentation transcript:

Similar presentations

About project

Feedback