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Reflections on capacity building in Sri Lanka

Reflections on capacity building in Sri Lanka. Dr Shamil Wanigaratne Consultant Clinical Psychologist, Adjunct Professor United Arab Emirates University, Visiting Senior Lecturer King’s College London. Scope. What is capacity building Capacity building in mental health

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Reflections on capacity building in Sri Lanka

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  1. Reflections on capacity building in Sri Lanka Dr Shamil Wanigaratne Consultant Clinical Psychologist, Adjunct Professor United Arab Emirates University, Visiting Senior Lecturer King’s College London 10th November 2012 University of East London

  2. Scope • What is capacity building • Capacity building in mental health • Sri Lankan context • Mental health services • Civil conflict and tsunami • UK-Sri Lanka trauma group • Samutthana • Some of our activity • Have we had an impact? • The future

  3. What is capacity building? • Definitions: conceptual approach to development that focuses on understanding the obstacles that inhibit people, governments, international organizations and non-governmental organizations from realising their developmental goals while enhancing the abilities that will allow them to achieve measurable and sustainable results. • Assumptions? • Giving in an unequal relationship • The giver is more developed than the other • One side has more resources than the other • One side has more technical and scientific knowledge than the other • Reciprocal or return benefits is not often identified • Donor countries may have indirectly contributed to “capacity reduction” in recipient countries • Lexicon- what does it mean? Capacity development, capacity building “give a man a fish and he will eat one meal – teach him to fish and he will eat for a lifetime” In health care and mental health care it is about knowledge, skills and competencies

  4. Capacity building Knowledge & skills Donor (HIC’s) Resources Research & development Recipient LAMIC’s Knowledge, skills and competencies Research & development

  5. Capacity building and mental health • Global rise in mental health problems • Availability of evidence based treatment but most people don’t receive it (27% and 30.5% in Europe and USA, less than 2% in Nigeria (Thornicroft, 2007, Alonso et al 2007, Thomas et al 2008). • Poor allocation of resources for mental health in LAMIC’s • The “10/90 gap” – (10% of global health research resources were used for health problems of countries which accounted for 90% of world health problems – CHRD, 1990) • ? Dealng with major disaster in such a context – has any country got the capacity?

  6. Global Mental Health • Returning the debt: how rich countries can invest in mental health capacity building (Patel, Boardman, Prince and Bhugra, 2006). (UK consultant psychiatrists – general psychiatry 26%, old age psychiatry 32%and learning disabilities 59% trained overseas). (UK 40 psychiatrist per million, Sub Saharan Africa -1, India-4). • International Journal of Mental Health Systems (2007) • The Lancet series – current mental health situation in LAMIC’s (2007) “No health without mental health” Prince, Patel and Saxena (2007) • Movement for Global Mental Health (2008) – improving services for people with mental health disorders worldwide through the coordinated action of a global network of individuals and institutions • WHO – Mental Health GAP action programme (mhGAP 2008) • Second Lancet series – 2011 • McGill initiatives • Harvard Review 2012

  7. Mental Health System Development (Minas, 2012)

  8. Generate local evidence that would inform decision makers • Developing a policy framework • Securing investment • Determining the most appropriate service model for the context • Training and supporting mental health workers • Establishing and expanding existing services • Putting in place systems for monitoring and evaluation • Strengthening leadership and governance capabilities

  9. Sri Lanka

  10. Sri Lanka Demographics • Population 20 million • Language Sinhala, Tamil & English • GDP (PPP)2005 estimate - Total$86.72 billion (61st) - Per capita$4,600 (111th) • 53rd most populated country in the world • Sinhalese 74%, Tamil 18%, Moors 7%, Burghers, Malays and Vaddas 1% • Religion:Buddhism 70%, Hinduism 15%, Christianity 8%, Islam 7% • 92% literacy rate, 83% has had secondary education, 16 Universities • WHO report ranking 76th (India 112, china 144)

  11. Sri Lankan Context • Independence from British rule in 1948 • Very good infrastructure, schools, colleges, universities, medical schools and educated elite (some educated in the UK and the West). Over inflated administrative infrastucutre • Political changes in the late 50’s and 60’s led to migration of educated classes, particularly the Burgers to Australia, West and other developing countries eg. Africa, Middle East • JVP insurgency in the 70’s and 80’s and the 30 year civil conflict also contributed to the brain drain which weakened the infrastructure in many ways • Poor economy also meant lack of investment in education as well as research and development also contributed brain drain • Migration

  12. Health indices

  13. Prevalence estimates • National survey of mental health in Sri Lanka (IRD, 2007) • (n = 6120, 16-65, 86% Sinhalese, 7.7% Tamil, 6% Muslims and 1% from Burgher and Malay) • Prevalence estimates: Major depression 2.1%, other depression minor, bipolar, dysthymaia 7.1%, somatoform disorder 3%, PTSD 1.7%, alcohol abuse 7%, psychosis 3.6% • Helplesness 6.3%; hopelessness 4.4%, passive suicidal ideation 4.2%, active suicidal ideation 1.6% • 6000 commits suicide, 100,000 attempts suicide (Silva, 2010) • Husain et al (2011) Prevalence of war-related mental health conditions and association with displacement status in post-war Jaffna district, Sri Lanka (JAMA) • (n = 1448, 30% recently resettled, 2% currently displaced, 86% long term residents) • PTSD 7%, anxiety 33%, Depression 22%

  14. Historical context of trauma • Communal riots in the 1950’ • JVP insurrections in the 70’s • Civil Conflict since the 80’s • Riots and displacement of Tamils 1983 • Tsunami 2004 • Final phase of the war and end 2009 Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

  15. Estimation of need Who is traumatised? Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

  16. Mental health services • Asylum • Psychiatry in general hospitals • General practice • Private practice • Community psychiatry? • Voluntary sector

  17. Workforce • Psychiatrists • MOMH • Psychologists • Psychiatric nurses • Social workers • PHI’s • Counselors • Volunteers

  18. Capacity building • Volunteers • NGO workers • Nurses • Teachers • PHI & Midwifes • CSO • MOMHS • Psychologists • Psychiatrists Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

  19. UKSLTG and History Context during the formation of the group • Leading figures in Sri Lanka • Expats from UK and other countries as well as non Sri Lankans made individual contributions with mixed reception

  20. UK-Sri Lanka Trauma GroupTHE UK WORKING GROUP TO FACILITATE WORK TO MINIMISE PSYCHOLOGICAL IMPACT OF TRAUMA IN SRI LANKAUK Charity Registration Number 1074746 Why was it formed ? • To do some thing about the psychological impact of the civil conflict in Sri Lanka • Co-ordinate efforts to maximise impact How were we going to do this? • By working towards increasing awareness • By influencing policy development • By helping to increase the skills of front-line workers in Sri Lanka • Helping develop mental health infrastructure

  21. Formed in 1996 (Dr Athula Sumathipala and Dr Shamil Wanigaratne) • First conference on Psychological aspects of Trauma in Colombo 1996 • Registered as an UK Charity in 1999 • Numerous conferences and training workshops in Sri Lanka between 1996 and 2005 on civil conflict related trauma • Involvement in early post tsunami work

  22. History Continued • 2005 lobbied for grant to establish a resource centre in Sri Lanka for skills training in mental health • With the help of King’s College and South London and Maudsley NHS Trust obtained a Grant from CAFOD (6 -8 months negotiations and revised applications) • Established Samutthānawith UK and Sri Lankan partners (Forum for Research and Development, Mangrove, BasicNeeds)

  23. Objectives UKSLTG • Working towards increasing awareness • Influencing policy development • Helping to increase the skills of front-line workers in Sri Lanka • Helping develop mental health infrastructure • Raise funds to help achieve the above

  24. Samutthāna the King’s College London Resource Centre for Trauma, Displacement and Mental Health Samutthāna meaning “renewal” or “regeneration” in Sanskrit has the following objectives: Objectives • Training and skills development • Creating a supervision infrastructure • Providing a resource on mental health books and information • Research • Conflict resolution (peace building) & policy development

  25. The structure of SamutthānaThe King’s College London Resource Centre for Trauma, Displacement and Mental Health Jaffna Outpost In partnership with Shanthium Resource Person: Mr Radnam Jegananthan Colombo Resource Centre Batticaloa Outpost In partnership with Mangrove Network Resource Person: Mrs Selvika Sahathevan 3/2 Kynsey Road Colombo 8 Centre Manager: Ms Shikanthini Varma-Atthanayake + 2 staff Hambantota Outpost Resource Person: Mr Duminda Wanigasekare

  26. Summary of Samutthana Activities

  27. Samutthana • New strategy • Work-streams • Restructure and move Strategy • Develop and maintain an organisational identity as a provider of training and ongoing support. • This will be achieved by networking, developing partnerships and working with organisations within state and voluntary sectors including religious organisations, in all areas of the country

  28. Work-streams I Mental health work with children and adolescents Mental health work with those with disabilities including ex-combatants Work relating to misuse of alcohol and other substances Work targeted at war widows Work that would benefit internally displaced who would not come under the above categories

  29. Work-streams II General mental health capacity building that includes contributions to psychiatry training, clinical psychology training (M.Phil) and mental health nurse training. Research including evaluation work and needs assessment Work that could specifically contribute to peace and reconciliation

  30. Samutthana Activity Supervision & support work Work by visiting resource persons Research work Samutthana Training by staff and local resource persons Provision of resources Liaison work with other organisations

  31. Training and support • 3 levels of training • Level I – volunteers, NGO workers • Level II – NGO workers, volunteers and counsellors with some experience • Level III – Professionals (Psychiatrists, doctors, psychologists, Nurses) • Supervision (support) • Skype supervision – substance misuse • Repeat attendance at workshops • CBT supervision – Stella Wragg

  32. Samutthana networking for capacity building Government Bodies Corporate Sector Key individuals and organisations CHA King’s College UEL

  33. Government Ministries • Ministry of Health • Ministry of Education • Ministry of Rehabilitation

  34. Government Bodies • National Institute for Mental Health (NIMH) • National Institute of Education

  35. NGO’s • Basic needs • Survivors Basic Needs • Consortium of Humanitarian Agencies (CHA) • Survivors • VSO – Sri Lanka • Aaruthal • Shantiham • Family Rehabilitatation Centre (FRC) • Sunera Foundation • Caritas / SEDEC

  36. Consortium of Humanitarian Agencies • Psychosocial Forum

  37. Education establishments • University of Colombo – FGS • University of Kalaniya – (Dept of Psychiatry) • University of Jaffna

  38. Resources • Translation of childrens manual into Sinhala and Tamil • Library

  39. CBT Manual dedicated to Padmal De Silva

  40. Research capacity building • The 3 PhD’s • Through input to M.Phil course

  41. The cost (visible and invisible) • Early stages minimum cost (airfares for British experts – not UKSLTG members), Sri Lanka costs some covered by the SLMA, some donations) • Following CAFOD grant – infrastructure, wages, management • Invisible cost – donation of time by experts and volunteers

  42. Funding picture

  43. Funding (1996 -2012) • Personal donations – 10K • Fund raising – 25K • South Asia Forum for Mental Health – 5K • CAFOD – 139K + 55K • King’s – 36K (PhD fees) • Lupina Foundation – 45K • South London and Maudsley Trustees – 74K • Amateurs Trust – 5K • Bromley Trust – 10K Total = 404K

  44. SLaM/IOP contributions towards Sri Lanka SLaM Trustees • Contribution to support staff member who was coordinating psychosocial response in the immediate aftermath of the tsunami (Prof Martin Prince, Prof Bill Yule) • Grant to rescue Samutthana and develop fundraising strategy SLaM • Study leave and support for staff doing voluntary work in Sri Lanka (Dr Anula Nikapota, Dr Shamil Wanigaratne and staff visiting to teach on the M.Phil course in clinical psychology • Formal Board approval to be linked to Samutthana as a partner • Support of the communications department • Engagement and support for the VSO scheme IOP/King’s • Study leave and support for staff doing voluntary work in Sri Lanka (Padmal De Silva, Prof Bill Yule, Prof Philippa Garety, Prof Paul Salkovskis et al) • Address and PO Box for the Charity • Providing venues for meetings and lectures • Services of Development Office and staff for grant writing and fundraising • Support with reporting back to CAFOD • Lending King’s College name to the Resource Centre in Sri Lanka

  45. Measurement of Outcome: tangibles and intangibles • Counting attendance – over 6,000 attendance • Counting network (social capital) • Feedback and satisfaction surveying • Improvement of survey template • Qualitative feedback “statements and quotes” • Formal research

  46. Tangibles • Conferences 4 • Attendance at workshops = 6 – 8,000 • People trained in child manual = 30 ++ • M.Phil in Clinical Psychology = 13 • Training of academics at Jaffna University = 30 • PhD’s = 3 • Psychiatrists • Nurses • Volunteers

  47. Centre for International Mental Health (Melbourne) Project in Sri Lanka

  48. Contributing to UK’s capacity • Kuhan Satkunanayagam • 4 clinical psychologists • Nurses • SL Volunteers • Seminar programme

  49. Evaluation • Progress reports to CAFOD • Formal evaluation by Sidartha Prakash • Ongoing evaluations and reviews • Internal evaluation funded by the Bromley Trust

  50. Siddhartha Prakash recommendations • Use local resources and experts • Develop a pro-active Steering Committee • Organize frequent activities • Cover more topics • Regular supervision required • Review staffing needs • Promote regional networking • Pilot distance learning coursesDevelop a business model • Translate resources into local languages • Conduct outreach and promotion • Review the PhD Program • Develop certified courses • Develop monitoring and evaluation systems • Conduct staff training and performance evaluations

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