Building Back Better: Sustainable Mental Health Care after Emergencies

1. Building Back Better: Sustainable Mental Health Care after Emergencies

2. “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

3. Report structure • Part 1: Seeing opportunity in crisis (Introduction) • Part 2: Seizing opportunity in crisis (10 detailed cases) • Part 3: Spreading opportunity in crisis (lessons learnt)

4. Part 1 – seeing opportunity in crisis

5. Mental health challenges • Hundreds of millions affected by mental disorders • All countries • All communities • All age groups • If untreated, substantial disability and economic loss • 22.7% of global Years Lived with Disability (YLDs) • Hundreds of billions of dollars in lost productivity • 80% in low- and middle-income countries do not receive needed mental health services • Many countries spend their limited resources on ineffective and often inhumane practices

6. This is not effective or humane care

7. It is possible to do better Community-based services in action

8. 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

9. 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

10. Taking action helps recovery and development • Positive mental health is crucial for individuals, societies and countries recovering from emergencies • Positive mental health linked to higher educational attainment, enhanced productivity and earnings, better parenting, improved health and quality of life

11. Part 2 – Seizing opportunity in crisis

12. 10 emergency-affected areas • Afghanistan • Burundi • Indonesia (Aceh Province) • Iraq • Jordan • Kosovo • Somalia • Sri Lanka • Timor-Leste • West Bank and Gaza Strip

13. Afghanistan • Violence and instability for more than 30 years • Increased focus on mental health following fall of Taliban in 2001 • Integration of mental health into general health services • Initially NGO project-driven within selected areas • Increasingly coordinated by MOPH at national level

14. Afghanistan – policy milestones • 2003: Mental health included in Basic Package of Health Services (BPHS) 2nd tier • 2005: Mental health included in BPHS 1st tier • 2010: BPHS called for psychosocial counsellors in health centres and basic mental health training for medical doctors working with them • 2010: 5-year National Mental Health Strategy

15. Afghanistan – other achievements • Standardized training materials for health workers • Inclusion of mental health indicators in health information system • Inclusion of psychiatric medications in essential drugs list

16. Afghanistan - Nangarhar Province Since 2001: • > 1000 general/primary health workers trained and supervised in basic mental health care • Almost 100 000 people helped

17. Burundi • Cyclical outbreaks of violence • Hundreds of thousands killed • More than one million displaced • In 2000, no mental health policy or plan, no services other than one psychiatric hospital, only one psychiatrist in country • From 2000, mental health services provided by international NGO • From 2005, government began to takeover responsibility for mental health services

18. Burundi – service development • Introduction of psychosocial workers • Mental health clinics in provincial hospitals • Physician and nurse training in basic mental health care

19. Burundi – policy achievements • National Mental Health Strategy adopted in 2007 • Inclusion of mental health indicators in health information system • Inclusion of psychiatric medications in essential drugs list

20. Burundi – other achievements • More than 17 000 people helped by psychosocial workers, 2000 – 2008 • 10 000 people seen at mental health clinics for more than 60 000 consultations, 2006 – 2008 • Current project: integrating mental health into primary care via mhGAP

21. Indonesia (Aceh) • Decades of civil strife and tsunami of December 2004 • 165 000 killed • 400 000 displaced • Health facilities destroyed • Prior to tsunami, mental health care available only through one psychiatric hospital located in capital of Aceh

22. Indonesia (Aceh) - strategy • Recommendations for Mental Health in Aceh (2005) • Roadmap for coordinating diverse agencies • Community mental health nurses • Inpatient units in general hospitals • Psychiatric hospital reform

23. 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

24. Iraq • Decades of dictatorship, economic sanctions, war, violent insurgency • Millions displaced internally and to neighbouring countries • Pre-2004, limited mental health services in urban areas, 2 psychiatric hospitals

25. Iraq – milestones • National Mental Health Council (established 2004) • National strategy and action plan (current 2009-2013) • Integration of mental health care into PHC (2009-2011) • Health worker training • 80-85% of psychiatrists • > 50% of general practitioners • 20-30% of nurses, psychologists, social workers • National formulary of psychiatric medications

26. Iraq – service development

27. Jordan • Periodic influxes of refugees from neighbouring countries • Since 2003, continuous waves of displaced Iraqis • Scattered throughout country • High rates of mental health problems • Mental health system hospital-based, urban – no PHC integration

28. Jordan • 3 pilot community mental health centres (2008-2009) • Biopsychosocial approach • Multidisciplinary teams • Individualized treatment plans • Wide range of services • Successes built support and momentum for further change

29. Jordan – further achievements • National Steering Committee for Mental Health • National mental health policy and plan • Mental health unit in MOH • Service developments • Short-stay inpatient units • PHC: WHO Mental Health Gap Action Programme • Service user training and empowerment

30. Kosovo • Conflict came to a head in 1998-1999 • Rapid political change • Mental health services hospital focused, biological, no PHC integration

31. Kosovo • Mental Health Task Force • Mental Health Strategic Plan (2001) • Roadmap for coordinating actions

32. Kosovo – service development

33. Somalia • Internal discord, violence, humanitarian emergencies since 1991 • Millions internally displaced • Food crises • Collapse of public health system • Mental health services • 3 psychiatric institutions with poor conditions • Severe shortage of mental health workers • No PHC services

34. Somalia • Full reform not possible • Progress through different initiatives • Mental health situation analyses • Chain-free initiative • Health worker training

35. Somalia - achievements • Chains removed from >1700 people (2007-2010) • Now expanded to all regions • 55 health workers trained • 2 mental health coordinators • 3 new mental health facilities • Situation analyses attracted donor attention

36. Sri Lanka • Areas of protracted civil conflict • Tsunami of December 2004 • More than 35 000 killed • 1 million displaced • Extensive damage • Mental health services through tertiary-level hospitals near capital

37. Sri Lanka – policy milestones • National mental health policy (2005 - 2015) • decentralized, comprehensive, community-based services • roadmap for coordinated efforts • National Mental Health Advisory Council (2008)

38. Sri Lanka – service development

39. Timor-Leste • 1980s – 1990s: military conflict, mass displacement, human rights violations • 1999: humanitarian emergency • 2002: political independence • Pre-reform: no mental health specialist services or professionals in the country

40. Timor-Leste • PRADET formed and begins developing mental health services (2000) • priority to community-based services and those with severe problems • Mental health worker training and supervision (2000 – 2005) • Progressive integration with MOH

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

42. West Bank and Gaza Strip • Two geographically separated areas • Decades of occupation, conflict, unrest • Pre-reform: 90% of resources for tertiary psychiatric care, few community mental health clinics, no PHC integration

43. West Bank and Gaza Strip – milestones • WHO technical assistance initiated (2001) • Agreement between MOH and Consulates of France and Italy (2003) • 5-year strategic operational plan (2004) • 3-year European Commission project contract (2008 and 2012)

44. West Bank and Gaza Strip – service development Number managed in community mental health centres Number of inpatient beds, Bethlehem Hospital

45. Part 3 – Spreading opportunity in crisis

46. Key Actions • 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

47. 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

48. The future

49. Key messages • Major gaps remain worldwide in the realization of comprehensive, community-based mental health care. • It is possible to take meaningful action after emergencies to accelerate the development of mental health systems. • Global progress will happen more quickly if, in every crisis, strategic efforts are made to convert short-term interest in mental health problems into momentum for mental health reform. • This would benefit not only people’s mental health, but also the functioning, stability and resilience of societies recovering from emergencies.

50. What you can do • Read the report and supplementary information • Incorporate relevant slides into presentations • Disseminate the report’s website (below) • Use the report to guide technical advice http://www.who.int/mental_health/emergencies/building_back_better/en/index.html