DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE
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COUNTRY PROJECTS on MENTAL HEALTH:
SELECTED CASES
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For more information
Department of Mental
Health and Substance
Abuse
World Health Organization
Avenue Appia 20
CH-1211 Geneva 27
Switzerland
Tel: +41 22 791 21 11
Fax: +41 22 791 41 60
E-mail: mnh@who.int
Website: www.who.int/mental_health
Addresses of WHO Regional Offices
WHO Regional Office for Africa
Cite du Djoue
PO Box 06
Brazzaville
Congo
Tel: +47 241 39100
+242 8 39100
Fax: +47 241 39501
+242 8 39501
E-mail: regafro@afro.who.int
WHO Regional Office
For the Eastern Mediterranean
WHO Post Office
PO Box 7608
Cairo 11371
Egypt
Tel: +20 2 670 2535
Fax: +20 2 670 2492
E-mail: PIO@emro.who.int
Pan American Health Organization/
WHO Regional Office for the Americas
525, 23rd Street, NW
Washington, DC 20037
USA
Tel: +1 202 974 3000
Fax: +1 202 974 3663
E-mail: postmaster@paho.org
WHO Regional Office for Europe
8, Scherfigsvej
2100 Copenhagen 0
Denmark
Tel: +45 39 17 17 17
Fax: +45 39 17 18 18
E-mail: postmaster@euro.who.int
WHO Regional Office
for South-East Asia
World Health House
Indraprastha Estate
Mahatma Gandhi Road
New Delhi 110 002
India
Tel: +91 11 2337 0804
Fax: +91 11 2337 0197
E-mail: pandeyh@whosea.org
WHO Regional Office
for the Western Pacific
PO Box 2932
1000 Manila
Philippines
Tel: +63 2 2 528 8001
Fax: +63 2 521 1036
E-mail: postmaster@who.org.ph
Acknowledgements
The Department of Mental Health and Substance Abuse would like to thank the
Governments of Belgium, Netherlands and Italy, and Caritas Ambrosiana (Milano,
Italy) and Cittadinanza (Rimini, Italy) for their generous contribution to these
projects. The support of DFID, UK is also gratefully acknowledged.
MENTAL HEALTH AND SUBSTANCE ABUSE
The proportion of the global burden of disease attributable to mental, neurological and
substance use disorders is expected to rise from 12.3% in 2000 to 16.4% by 2020.
More than 150 million persons suffer from depression at any point in time and nearly
one million commit suicide every year. Moreover, there is strong evidence that
mental disorders impose a range of consequences on the course and outcome of
comorbid chronic conditions, such as cancer, heart disease, diabetes and HIV/AIDS.
The rise in the burden of mental, neurological and substance use disorders will be
particularly sharp in developing countries, primarily because of the projected increase
in the number of individuals entering the age of risk for the onset of disorders. These
problems pose a greater burden on vulnerable groups such as people leaving in
absolute and relative poverty, those coping with chronic diseases and those exposed to
emergencies. Mental health has been raised much higher up on the international
health agenda owing to WHO's international campaign during 2001, with its
unprecedented series of events, including the World Health Day, which was
celebrated in more than 150 countries, the round tables at the Fifty-fourth World
Health Assembly, in which more than 110 ministries of health participated, and The
World Health Report 2001, which was devoted to mental health. Governments are
now much more aware of the major mental health disorders and substance abuse,
recognizing their impact on the health and well-being not only of individuals but also
of families and communities. Although effective treatments for mental and
neurological disorders exist, there is a big gap between their availability and their
implementation; even in developed countries only a few of those suffering from
serious mental illness receive treatment. Improving treatment rates for those disorders
and substance abuse problems will not only reduce the burden of disease and
disability and health care costs, but also increase the overall productivity and quality
of life.
In the year 2002, following resolutions adopted by regional committees, the Executive
Board adopted a resolution on "Strengthening mental health" (resolution EB109.R8)
and the World Health Assembly, in resolution WHA55.10, affirmed its provisions. As
a response to these issues and challenges, in 2002 WHO launched the mental health
Global Action Programme (mhGAP). This programme is WHO's major effort to
implement the recommendations of the World Health Report 2001 and projects
presented in this report are embedded in the mhGAP framework. The programme is
based on four strategies described below, that should enhance the mental health of
populations.
Strategy 1: Increasing and improving information for decision-making and
technology transfer to increase country capacity.
WHO is collecting information about the magnitude and the burden of mental
disorders around the world, and about the resources (human, financial, socio-cultural)
that are available in countries to respond to the burden generated by mental disorders.
This is pursued by the ATLAS project. The ATLAS' aim is, in fact, to provide
information on mental health from all countries. The information relates not only to
epidemiology but, more significantly, to resources and infrastructure for mental health
care within each country. The sources of this information are Ministries of Health,
government documents, WHO Collaborating Centres, professional associations and
scientific literature. Country profiles have been published making it easier for
planning, priority setting and monitoring change over time. WHO is also
disseminating mental-health-related technologies and knowledge to empower
countries in developing preventive measures and promoting appropriate treatment for
mental, neurological and substance-abuse disorders.
Strategy 2: Raising awareness about mental disorders through education and
advocacy for more respect ofhuman rights and less stigma.
The World Health Organization is maintaining constant communication and
information networks with professional NGOs, parliamentarians, family members and
service users' groups in order to sustain the groundbreaking work of the last two
years. The Global Campaign Against Epilepsy is a successful history of advocacy and
collaboration. The Global Campaign is managed by a Secretariat consisting of
representatives of three responsible organizations: WHO, International League
Against Epilepsy (ILAE) of professionals, and International Bureau for Epilepsy
(IBE) of lay persons. The Campaign tactic is to help organize demonstration projects
and to generate regional declaration on epilepsy, produce information and facilitate
the establishment of national organizations of professionals and lay persons who are
dedicated to promoting the well-being of people with epilepsy.
Strategy 3: Assisting countries in designing policies and developing
comprehensive and effective mental health services.
The World Health Report 2001 and the Atlas: Mental Health Resources in the World,
have revealed an unsatisfactory situation with regard to mental health care in many
countries, particularly in developing countries. WHO is engaged in providing
technical assistance to Ministries of Health in developing mental health policy and
services. Building national capacity is a priority to enhance the mental health of
populations. In this logic, country projects are planned and implemented with constant
support provided by the Department of Mental Health and Substance Abuse.
Strategy 4 : Building local capacity for public mental health research in poor
countries.
Besides advocacy, policy assistance and knowledge transfer, mhGAP formulates in
some detail the active role that information and research ought to play in the
multidimensional efforts required to change the current mental health gap at country
level.
The country projects reported in this document are selected cases exemplifying the
modus operandi of the Department of Mental Health and Substance Abuse in different
scenarios. The cases reported in the following sections are restricted to the area of
mental health. Country projects on Substance Abuse are also promoted and supported
by the Department, but are not included in this report.
TABLE OF CONTENTS
Albania Reform
1
India: Support to people with schizophrenia
11
Mozambique : policy project
17
Sri Lanka : technical advice
27
Sri Lanka: deinstitutionalization and reintegration in the community
33
West Bank and Gaza Strip :
improving mental health policy and service delivery
47
%
Albania Reform
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authorities, or concerning the delineation of its frontiers or boundaries.
Data Source: Country Response
Programme
Map Production
Public Health Mapping Group
Communicable Diseases (CDS)
World Health Organization
6) World Health Organization, July 2003
Project Goal
To assist in designing the necessary steps towards the implementation of the Policy
for Mental Health Services Development in Albania (endorsed by the Minister of
Health in 2003).
Project Objectives
1. Provide technical support to WHO Albania and the Ministry of Health in planning and
developing mental health services in Albania.
2. Provide technical support to the National Steering Committee for Mental Health,
WHO Albania and the Ministry of Health in the design of a very concrete operational
action plan to implement the Policy for Mental Health Services Development.
a. Collection of relevant information on Albania through the WHO Department
of Mental Health and Substance Abuse's new instrument to monitor mental
health system and services in countries;
b. Defining achievable targets (i.e. Gap Reducing Achievable National Targets)
in discussion with relevant health authorities. Key targets are in relation to
the following areas:
• Organization of comprehensive community mental health services along
with deinstitutionalization in four catchment areas of Albania (600,000
inhabitants).
• Capacity building ofmental health and primary health care professionals.
• Implementation of the Mental Health Act 1996.
1
Background
Albania is located in southeastern
Europe in the Balkan Peninsula. It is
bordered by the Federal Republic of
Yugoslavia in the north, the former
Yugoslav Republic of Macedonia in
the east and Greece in the southeast.
The country covers an area of 28,750
square kilometres and has a population
of approximately 3.2 million persons,
of which one third is under the age of
15 years and 40% under the age of 18.
The population is also largely rural
with some two thirds of persons in
1993 living in the countryside.
Albania is one of the poorest countries
in Europe with a Gross Domestic
Product per capita of $1290 in 1996.
Albania has experienced civil and
political unrest in the 1990s. First, in
1991 and then in 1992 following the
fall of communism. Opposition parties
were introduced for the first time and
there were subsequent rapid changes in
leadership.
Further unrest also
occurred in 1997 and 1998 following
the collapse of several saving schemes,
which saw an estimated loss of US$
one billion to the population. This was
further exacerbated by the influx of
refugees and the humanitarian disaster
from the war in Kosovo in 1998 and
1999.
For purposes of governance, the
country
is
divided
into
12
administrative
areas,
called
Prefectorates, each with a centrally
appointed administration.
Each
Prefectorate is made up of around 3
districts. Districts had been the main
administrative divisions in Albania for
the previous 50 years. There are 26
districts that are further divided into
rural and urban areas as follows: rural
areas are divided into communes and
have elected local authorities; urban
2
areas
are
divided
into
town
municipalities and have elected
councils. Each district has a least one
municipality and a number of
communes. In the case of Tirana, there
are also semi-urban municipalities. In
total, there are 315 communes and 42
municipalities in the country. The
Ministry of Health provides services
through
the
country’s
26
administrative districts.
Health services
In the 1960s an extensive primary
health care system was developed. In
the 1970s the emphasis shifted to the
construction of hospitals in every
district to provide basic inpatient care
and specialist outpatient care by
polyclinics. By the 1980s the Ministry
of Health provided and regulated all
health services through the district
system.
Health services were
organized and controlled from the
centre
by
means
of vertical
programmes that were administered at
the district level via separate
directorates responsible for medical
care.
Tertiary hospitals were run
directly by the Ministry of Health.
The health system was badly affected
by the civil unrest in the country. In
1991 and 1992 the violence which
accompanied
political
changes
destroyed almost one quarter of health
centres in cities and two thirds of
health posts in small villages. In 1997
and 1998 the violence also involved
the widespread looting of drugs and
equipment and some destruction of
district hospitals, health centres and
public health departments.
Despite the setbacks caused by civil
unrest, the 1990s saw two public
administration reforms that have had
an impact on health services. One is
the transfer of more administrative
authority from the centre to the
prefectorate (1993).
The other is
aimed at strengthening the role of local
government through the Local Power
Law, which regulates the election of
local authorities along with their
responsibilities and relations with the
national government. As part of this
change of responsibilities, some
responsibility for primary care has
been given to local authorities in rural
areas.
The Albanian health system can be
described as going through a period of
transition. This means that although
many of the essential elements of the
old system exist, health reforms occur.
The Ministry of Health continues to
provide and regulate all health services
in the 26 administrative districts of the
country. Most of the work of the
Ministry is therefore focused on health
care administration rather than policy
and planning.
The Ministry manages most health
services with only primary health care
being partially not under their direct
control. The 320 local rural govern
ment authorities are partly responsible
for primary health care and own the
facilities.
The funding for these
primary health care facilities comes
directly from the Ministry of Finance.
However, in the urban areas the
primary care services are administered
by the Ministry of Health’s district
offices.
In 1993, the Ministry produced a
national health policy, but work needs
to be done on updating the policy to
reflect developments in the health
sector. Some of the basic goals are
stated as:
• care at an affordable price;
• to give priority to those forms of
health care that offer the best
•
•
•
•
chance of improving health at the
lowest price;
to base the health system on a
foundation of primary health care;
to introduce market elements in
financing health care;
to give more managerial autonomy
to districts and to create health
regions.
to streamline health services.
The most important components of the
reforms can be seen as:
1) Streamlining health services
a) maintaining and rationalizing
the network of primary health
care facilities;
b) transforming rural hospitals
into outpatient health centres;
c) maintaining a network of
district hospitals offering four
basic health care services;
d) upgrading a few district
hospitals to the level of
regional hospitals offering 1012 specialized services;
e) reorganizing national level
unified
facilities
into
a
university hospital.
2) Improving the quality of health
services through rehabilitation of
its infrastructure and standardizing
medical equipment.
3) Protecting and increasing financial
resources for the health services;
protecting and increasing the
public
budget
for
health;
introducing
private
services;
introducing
health
insurance;
increasing regulation at the same
time as allowing privatization.
4) Developing human resources by:
reducing the number of students in
the faculty of medicine; reviewing
the national curriculum and
standardization of postgraduate
training; upgrading nurse training;
introducing regular in-service
training and new post graduate
3
training in family medicine;
introducing public health and
health management.
5) Decentralizing and regionalizing
health services.
6) Strengthening and
improving
statistics and health information.
The planning process that was being
undertaken in collaboration with WHO
was interrupted by the violence in
1997. Subsequently sub-sector plans
have been produced with the assistance
of international experts.
These
include:
• a policy for primary health care
(European
Union
PHARE
programme);
• plans for the development of Vlore
and Shkoder regional hospitals;
• a strategy for the Tirana regional
health system (World Bank);
• a master-plan for the development
of the Tirana University Hospital
(Assistance Publique des Hopitaux
de Paris);
• a national mental health policy
(National Steering Committee for
Mental
Health/
Albanian
Development Centre for Mental
Health).
What is now needed is integration of
these reforms and plans within the
framework of the national health
policy and a health sector plan. In the
current
situation,
day-to-day
administration takes precedence over
planning.
Planned reforms
Two parallel training initiatives have
been reported. First, the launching of
World Bank and the Ministry of Health
six-month training course in health
planning/management at the district
level after piloting six short-term
training courses, with a focus on
primary health care. This course was
4
prepared through the support of the
University of Montreal. USAID and the
Faculty of Medicine planned a second
postgraduate training course in health
management, which began in 2000,
with the assistance of New York
University. In addition, the University
of Tirana proposes to develop a new
field of study in public health
management. The Faculty of Medicine
has already started a postgraduate
training course in public health.
Mental health care
Mental health care in Albania has
traditionally been largely hospital
based, biologically oriented and
symptom focused. There are two large
psychiatric wards in general hospitals
in Tirana (120 beds) and Shkodra (110
beds) and two State hospitals at
Elbasan (400 beds) and Vlora (280
beds). Because of the location of these
facilities, they are largely inaccessible
to the majority of the population.
There is much that is needed in order
to reform the mental health system as a
whole, but in particular, to improve
mental health service provision. The
Policy Document of Mental Health in
Albania, which has been approved by
the Government in 2003, addresses
some of these priorities. In describing
the context in which service provision
is to be improved, the document states
the following:
• There are 840 psychiatric beds in
the country, most of which are used
for long-term treatment.
• There is around one psychiatrist
per 78 000 inhabitants or maybe
less considering the centralization
of psychiatrists in four districts.
• No nurses have been previously
trained in psychiatry, although
there are around 200 nurses
working in psychiatric settings
(including
hospitals
and
ambulatory care).
Again, this
•
figure is less, considering that
many nurses in
psychiatric
hospitals are not engaged directly
in
patient
care,
but
in
administrative
and
laboratory
activities.
Until recently, there were no social
workers and and psychologists
employed in
in the psychiatric
services.
In 2001, the country reports from the
WHO European Network on Mental
Health listed some additional facts
concerning the poor state of mental
health services in Albania. Included
among them are:
• The first psychologists graduated
from the university in the year
2000.
• Contemporary psychotherapy has
not been available.
• GPs have had limited knowledge
about mental disorders, although
they are consulted by many people
with mental health disorders.
• Drugs for people with mental
illness are limited.
• Professional knowledge in general
has not been up to international
standards.
With regard to outpatient treatment,
this service has been provided by
neuro-psychiatrists who are however
not present in every district. Very
often however, they cater for
neurological as well as psychiatric
consultations
although
some
neurologists have little knowledge of
the latter. Each service consists of one
doctor and one nurse only and whereas
a minority of neurologists has received
some training in psychiatry, nurses
have received none since there has
been no training for psychiatric nurses
in the country. The above situation has
been exacerbated by inter alia: the
poverty of the country, the small
percentage of GDP spent on health in
general (1.91% in 2000), the high level
of stigma against the mentally ill, and
the presence of under-resourced, oldfashioned psychiatric services.1
Mental Health Reform
As part of the Ministry’s commitment
and efforts to reform mental health
services,
a
National
Steering
Committee for Mental Health was set
up in May 2000 with the support of
WHO to decide and propose what was
needed in the mental health field. The
Committee is also assisted by the
Albanian Development Centre for
Mental Health, which was formed in
October 2000 and follows up the
implementation of the Policy in all its
aspects.
The National Steering Committee for
Mental Health was mandated to
perform four tasks:
1. To develop a mental health policy.
2. To plan the reform of psychiatric
services.
3. To follow up, support and
coordinate the implementation of
innovative activities, experiences,
and services aimed at the
development of community-based
mental health services, and
promote
and
implement
deinstitutionalization processes.
4. Monitor the deinstitutionalization
processes.
Overall, the reform process in Albania
which has been given technical
assistance by WHO and has begun to
take place at two levels, the policy
level and the field level. At the policy
level, the Mental Health Policy
produced by the National Steering
Committee for Mental Health, has
1 Mental Health in Europe, 2001.
5
been approved by the Ministry of
Health.
Mental Health Policy
The focus of the mental health policy
document has been on the re
organization of psychiatric services,
although the 14 priorities cited for
implementation in the Policy document
cover a much wider area of reform.
Included in these are: creating a
Department
for Mental
Health
Development within the Ministry of
Health; continuing the integration of
mental health services into primary
health care (which has only recently
begun with the establishment of
Community Mental Health Centres);
defining and instituting a separate
mental health budget; reviewing
mental health legislation with a view to
ensuring rights to treatment, housing,
education, employment, etc. for
persons with mental health disorders;
the deinstitutionalization of psychiatric
services; establishing community
based demonstration systems; and the
provision of continuous training of
mental health staff (within and outside
Albania).
Community Mental Health Centres
At the field level, six community
based mental health facilities have
been established. Four are under direct
WHO technical and financial support
and a further two in Vlora and Shkodra
are
supported
financially
and
technically by UNOPS in collaboration
with WHO.
WHO has been
responsible for setting up community
mental health centres in four areas of
the country. This is with the intention
of incorporating them into the
mainstream state health system. They
are located in Tirana, Elbasan, Gramsh
and Peshkopi. More recently, there
has been a decision taken for WHO to
6
concentrate relatively more on the
development of the Centres at Tirana
and Elbasan, and with UNOPS on
Vlora and Shkodra in order to achieve
wide geographical coverage.
The
intention is to develop community
based services and undertake training
of staff in these four catchment areas.
WHO in Tirana and Elbasan will
continue to provide supervision,
coordination of NGO activities in the
area of mental health, training,
evaluation and the preparation of
background material for the National
Steering Committee for Mental Health.
All these activities are done with the
support of the Albanian Development
Centre for Mental Health. The remit of
the Centre is as follows:
• Building
knowledge
and
competence on community-based
mental health practice;
• Evaluation of mental health
services from a multi-dimensional
perspective;
• Approaching
the
community
through information and education;
• Supporting
the
national
organization of the relatives of
persons with mental health
problems.
Reforming mental health in
Albania
All of the Centres have received and
continue to receive a mixture of
technical support, training and an
exchange of valuable experiences from
WHO, the Geneva Initiative on
Psychiatry, the North Birmingham
Mental Health Trust in the UK and the
Principado de Asturias, in Spain.
Financial resources, initially from the
European Commission Humanitarian
Aid Office (ECHO) and later from the
Swedish International Development
Agency (SIDA) were instrumental in
providing the foundation for the
modernization of mental health care in
Albania.2 A description of the work of
the centres follows along with an
analysis of the progress made.
Mental Health Legislation
In 1996, the Parliament approved a
Mental
Health
Law
whose
implementation status is uncertain.
One of the aims of the mental health
reform is to implement the law and
increase the provision of community
based services.
Tirana
The district of Tirana (made
up of one urban municipality
three semi-urban municipal
ities and 15 rural communes)
has been served by one
psychiatric hospital in the
past. In an effort to increase
the provision of community
care services, and as part of
the reform of mental health
services, the first community
centre for mental health was
established in Tirana in
December 2000. The team is
multidisciplinary,
provides
therapeutic care, day care and
outreach services. It has also
created a network for
collaboration
within and
outside Albania.
An analysis of the progress
made over the last three years
has shown that at the field
level the pilot community
mental health centre in Tirana
will now cease to be a
demonstration site and become
an integral part of the
community services completely
financed by the Regional
Health Authority.
Other
supporting activities such as
the exchange programme with
the Birmingham collaborating
centre have been working
successfully. A car has been
donated for carrying out home
visits.
2 Mental Health in Europe, 2001.
7
Elbasan
Another community mental health
centre has been created at
Elbasan. This town has been
traditionally served by a 40-year
old psychiatric hospital that has
also housed forensic patients.
The stigma associated with the
presence of forensic patients has
made the work of the new
community team difficult and
challenging since its inception in
the latter half of 2000. Apart
from having to deal with the
stigma of mental illness the other
challenges faced have been: lack
of community awareness about
the needs of the mentally ill, lack
of involvement of different sectors
of the community, lack of links
with other health service
facilities, and the inexperience of
community-based
work.
However, some links are being
made and there has been support
from the Public Health Office and
Municipality to look at the
problems of integration.
Over the last three years, the
community mental health centre
has been working in the
polyclinic and the staff and
running costs are being met by
the Ministry of Health.
A
rehabilitation unit close to the
hospital has been renovated. The
hospital-based team and the
community mental health teams
have both received training and
the UK and Ireland Collaborating
Centre has been successful in
changing modalities of daily
work.
8
Gramsh
The Centre in Gramsh, which
began functioning in January
2002, has received much more
support
from
the
local
authorities and the local
community, which has made its
initial work easier. The building
and the staff are funded by the
local health authorities. This
Centre also provides active
outreach work especially with
families.
Outreach
is
particularly important because
the local terrain leads to the
isolation of many villages from
services.
Personnel at the Centre have
also received training locally
and abroad and a few beds have
been identified in the General
Hospital for allocation to mental
health treatment. A car has also
been donated for outreach work.
Peshkopi
The fourth Centre, in Peshkopi
has recently become functional.
This is the only one of the four
centres that is totally financed
and administered by the State.
A car has been donated and the
team has received in-service
training with support from
Asturias WHO Collaborating
Centre. There has also been an
agreement reached over the
identification of a few beds in
the local general hospital for the
treatment of patients with
mental disorders.
Visiting Albania Community
Mental Health Resource Centres
Setting Achievable National Targets.
The Policy for Mental Health Services
Development specifically states that an
implementation strategy (operational
plan) should be developed to define
feasible and sustainable activities that
are of the highest priority.
To facilitate the development of such a
plan, the Department of Mental Health
and Substance Abuse assisted WHO
Albania in doing a comprehensive
assessment. For this assessment the
Department's new instrument to
monitor mental health systems and
services in countries was administered.
Through over 300 indicators, the 10
key components of any mental health
system (reflecting the 10 main
recommendations made in the World
Health Report 2001 on mental health)
were systematically assessed. This
assessment
provides
baseline
information for the operational plan,
which details activities to be
implemented over the coming five
years in Albania.
timeframe), the exact implementation
plan, the responsible agents for
implementation, the resources needed,
the funder, potential barriers to
implementation and specific indicators.
The writing of the plan is facilitated by
the Department of Mental Health and
Substance Abuse who assisted WHO
Albania and the Working Group of the
National Steering Committee on
Mental Health in developing the plan.
The plan is based on (a) the Policy, (b)
the results of the mental health system
monitoring exercise, (c) WHO
Albania's and the Ministry of Health's
experience in the country through
aforementioned community mental
health projects, (d) the normative
information provided in the Policy and
Guidance Package developed by the
Department in recent years, and (e) the
clear vision articulated by the WHO
Albania mental health staff.
Supporting activities to be
undertaken by the Ministry of Health
Strengthening human resources for
mental health services.
• Establishing a Unit for Mental
Health and Substance Abuse within
the Ministry of Health to coordinate
the implementation of the Policy
Document and wider reform.
• Moving resources from the hospital
to the community.
•
For each activity, detailed operational
planning has been conducted. Tailormade plans describe for each activity:
the target group, the purpose, the
current situation, the overall need, the
unmet need, the target (with
k
9
References
European Observatory on Health Care
Systems (1999), Health Care Systems
in Transition: Albania.
WHO Regional Office for Europe
(2001), Mental Health in Europe:
Country reports from the WHO
European Network on Mental
Health. WHO Regional Office for
Europe.
National Steering Committee for
Mental Health (2003). Policy for
Mental Health Services Development
in Albania. Republic of Albania,
Ministry of Health.
Albanian Development Centre for
Mental Health (2003), Information
material on the State of Art of the
Mental Health Development in
Albania.
World Health Organization Tirana
Office (2003). Implementation of the
Community Mental Health System
in the frame of the Health Care
System and Social Welfare System.
WHO Tirana Office.
10
J
INDIA
SUPPORT TO PEOPLE
WITH SCHIZOPHRENIA
Country project of support to people with schizophrenia
Ludhiana
.hmcdabad'.
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311 Cxt’Jar Deuelcvnenl
U» Prodickn:
Mile He4hU*phl 7»3n
Canmirteaile DUesei'CtlCi'
Vtold HeJIiOnierCaHi
The presentation of material on the maps contained herein does notimplythe expression of any opinion whatsoever on the part of the
World Health Organization concerning the legal status of any country, territory, city or areas or of ite authorities, or concerning
th^ delineation of its frontiers or boundaries
Project Activities / Outcomes
1. Development, in local languages, of a manual for family intervention.
2. Training of the local health workers to both raise awareness about mental health
problems and their appropriate identification, management and referral, and
implement actual interventions.
3. Immediate care to some 1500 families, in terms of brief psychoeducational
intervention sessions, whose content covers basic information about the diseases and
basic training in daily living, problem-solving and communication skills, and of
pharmacological treatment to patients. The opening of day centres for people with
mental disorders is a central aspect of this care model.
4. Contacts with relevant NGOs in order to get them mobilized and actively involved
in the project, particularly for awareness-raising events and information
dissemination about mental health problems and their management. Particular
attention is given to the establishment of creating /strengthening of existing NGOs of
relatives and friends ofpeople with mental disorders.
11
Background
Schizophrenia is a severe mental
disorder which accounts for much
suffering of those affected and their
families, in addition to a cost to society
estimated as 1.1% of the total burden
of disease (in terms of DALYs disability adjusted life-years) and 2.8%
of the total YLDs (years lived with
disability).
The ultimate goals of the treatment of
people with schizophrenia is the
productive
reintegration
into
mainstream society. There is enough
evidence that care of persons with
schizophrenia can be provided at
community level through:
(i)
medications
to
relieve
symptoms and prevent relapse;
(ii)
education and psychosocial
interventions to help patients and
families cope with the illness and its
complications, and also to prevent
relapses; and
(iii)
rehabilitation that helps patients
reintegrate the community and regain
educational or occupational function
ingThe
goals
of
psychosocial
rehabilitation
for
people
with
schizophrenia encompass a variety of
measures that go from improving
social competence and social support
networking, to family support.
Central
to
this
is
consumer
empowerment and the reduction of
stigma and discrimination, through
improvement of both public opinion
and pertinent legislation. The respect
for human rights is a presiding
principle to this strategy.
The incidence of schizophrenia is
largely similar in developed and
developing countries; there are,
however, indications pointing to the
12
fact that the outcome of this disorder is
strongly influenced by social factors,
of which the family appears to be a key
element.
Awareness-raising activity (theatre) in a rural
area.
The state of mental health
In India, for a population of nearly one
billion people, there are an estimated
four million people with schizophrenia,
with different degrees of impact on
some 25 million family members.
India has a national mental health
programme, which was formulated in
1982 and adopted as the mental health
policy. More recently, the IO111 FiveYear Plan of India for the Years 20022007 emphasized some strategies for
the
National
Mental
Health
Programme as saying ".... and to shift
the focus from the present custodial
model to a community-based approach
with extension of basic mental health
care through outreach facilities."
The objectives of the national mental
health programme are:
i)
to ensure availability and
accessibility of minimum mental
health care for all in the foreseeable
future, particularly to the most
vulnerable
and
under-privileged
sections of the population;
ii) to encourage application of mental
health knowledge in general health
care and in social development; and
iii)
to
promote
community
participation in mental health service
development and to stimulate efforts
towards self help in the community.
The approaches
programme are:
adopted
by
the
i) integration of basic mental health
care into general mental health care
services;
ii) training of primary health care
personnel in the aspects of mental
health care;
iii)
provision
of
adequate
neuropsychiatric drugs in peripheral
health care institutions;
iv) support and supervision of trained
primary health care personnel;
v) establishment of a psychiatric unit at
the district level; and
vi)
encouraging
participation.
community
The proportion of health budget to
GDP is 5.2%. The country spends
0.83% of the total health budget on
mental health (WHO, 2001)3.
9CAHF I
Mental health services
Mental health care is a part of the
primary health care system. Mental
health care in primary care is available
in certain designated project areas but
not all over the country. Community
care facilities for patients with mental
disorders are available in some
designated districts. In addition,
various nongovernmental organiz
ations provide different types of
services.
The District Mental Health Programme
which is being operated in 22 districts
in the country attempts to take mental
health care to the rural and
underprivileged sections of the society.
There are about 40 mental hospitals
operating in India with a varying
amount of bed strength. They still have
a large proportion of long-stay
patients. Funding is poor and staffing
is inadequate. All this adds to the
problem of stigma against mental
disorders.
There is a total of 0.25 psychiatric beds
per 10,000 population and 0.4
psychiatrists per 100,000 population.
Yet, there are no more than 40
psychiatric hospitals, some 26,000
psychiatric beds in total and some
4000 psychiatrists in the whole
country; in other words, approximately
one psychiatrist per 1000 persons with
schizophrenia.
This clearly indicates:
Meeting with relatives ofpeople with mental
disorders in a suburban area.
3 World Health Organization (2001). Atlas:
Country profiles on mental health resources.
Geneva, WHO.
(a)
the importance of developing
innovative programmes to help these
people and their families in their daily
confrontation with schizophrenia, and
(b) that these programmes must be
strongly anchored in the community
and also be strongly family-based and
family-oriented.
13
With the financial support of
Associazione
Cittadinanzza
and
Caritas, WHO has launched a project
of support to people with schizo
phrenia with the ultimate goal of
emphasizing the empowerment of
families.
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Example of information leaflet in local
language (Hindi).
are not accessible in terms of the costs
involved in consulting mental health
professionals and the expenditure for
medicines. Besides these, outreach
programmes provide other benefits by
reducing stigma and spreading the
message that these illnesses can be
kept under control, if appropriate
professional help is given in time.
These efforts of treating the mentally
ill within the society makes the
reintegration of such persons back to
the mainstream of society easier, since
they are not separated from the society
at any given time of the treatment. The
modern concept of Community-Based
Rehabilitation is the order of the day in
the treatment of the mentally ill. Given
the support of adequate resources,
appropriate NGOs can augment these
services in the existing clinics and
further initiate such clinics in several
new places.
Project description
This project has two main lines of
action:
(a) support for families, basically
through
interventions
such
as
psychoeducational programmes, and
social and emotional support, and
(b) development / strengthening of
associations of families affected by
schizophrenia.
Information being provided to school children
in a rural area.
The strategic approach involves
establishing mental health extension
services in the community, particularly
in some which never had this kind of
services. It builds up on already
In order to do that, a manual for family
intervention has been developed,
translated into local languages and
used to train health workers who see
people with schizophrenia.
The training of those local health
workers covered both awareness
raising about mental health problems
and their appropriate identification,
management and referral techniques,
as well as the actual implementation of
those interventions.
existing resources in the community,
like
buildings
and
eventual
community health workers of Primary
Health Care Centres.
In practical terms, the Project initiates
community-based and outreach mental
health programmes in areas wherein
these services have not yet reached or
14
■I
A
variety
of conscientization
programmes and student mental health
orientation programmes were initiated
to propagate the existence of mental
health services available at their
doorsteps besides making them
conscious that there exist various types
of mental health problems in varying
severity in children and adults and that
these can be managed with appropriate
interventions if given at the onset of
the illness.
Training and orientation programmes
are imparted to the village health
workers and teachers of the schools in
the community, nursing trainees,
psychology students posted from both
undergraduate
and
postgraduate
colleges. They are given a detailed
orientation
on
psychosocial
rehabilitation by the Project’s teams.
gradual results, as there is an increase
in the number of clients attending these
new clinics.
Those who require further in-patient
care or any other general medical care
are referred to the nearest general
hospital
psychiatric
unit
of
Government Hospital.
This co
ordination
helps
the
actively
symptomatic clients obtain the in
patient care until they stabilize
medically and later can be followed up
in the community by the local mental
health team. Those with problems of
co-morbid substance abuse and
alcoholism are referred to de-addiction
centres for detoxification.
So far, approximately 1500 families
have benefited from these activities, in
terms of brief psychoeducational
intervention sessions. The scope of
these interventions covers basic
information about the diseases and
basic training in daily living, problem
solving and communication skills, and
pharmacological treatment to patients.
To all of those in need, appropriate
psychiatric and other medication is
provided free of charge, as is the case
with all other interventions.
Relatives ofpeople with schizophrenia
attending an information/support session.
The teams visit the villages and slum
areas near Delhi, especially local
schools,
grocery
shops,
local
physicians and the clinics run by them,
STD booths and distribute leaflets on
mental illness. In addition, they request
the shop owners and the school
authorities to distribute the copies of
these to the children at schools and the
public who visit the shops. They
advise them to refer or send people
who suffer from any of the mentioned
problems to the newly opened clinics
for free treatment and counselling.
These efforts have started showing
Hand in hand with the care model is
the opening of day centres for people
with mental disorders, with active
outreach programmes both in rural
areas in South India and in different
slum areas.
The Project’s teams are in a position to
bring about a substantial change in
people’s attitudes by way of multiple
activities aimed at conscientization
about the mental illness and the
treatment available. This has resulted
in gradual attraction of the clients with
mental health problems towards the
clinics running in different suburban
and rural areas in both Central and
South India. The team consists of a
dedicated staff who make regular
15
periodic visits to the identified centres.
After the initial screening by members
of the team, a psychiatrist further
reviews the patient in detail to confirm
the
diagnosis
before
further
professional assistance is given along
with free medication. The patients are
reviewed periodically and kept on a
maintenance dosage. Those who
require inpatient care are referred to
the
nearby
General
Hospital
Psychiatric Units (GHPUs) and once
discharged from the GHPUs the team
follows them up in the community and
continues to provide counselling and
medication free of cost.
Contacts are also established and
maintained with relevant NGOs in
order to get them mobilized and
actively involved in the project,
particularly for awareness-raising
events and information dissemination
about mental health problems and their
management.
A particular attention is given to the
establishment of new /strengthening of
existing NGOs of relatives and friends
of people with mental disorders.
Regular family support groups are
organized with family members/carers
of people suffering from mental health
problems with the purpose to psycho
educate and to strengthen the services
offered by this society for the needy.
Family therapy sessions are being
taken for the patients’ families,
especially wherever family pathology
exists, as usual.
16
Mozambique: policy project
Country Response Programme-MSD*
United Republic
of Tanzania
Indian Ocean
Zambia
MSD projects
Administrative
boundaries
Madagascar
Zimbabwe
South Africa
\
\
* Department of Mental Health
and Substance Dependence
Swazilanr
Data Source: Country Response
Programme
Map Production:
Public Health Mapping Group
The presentation of material on the maps contained herein does not imply the expression of any opinion whatsoever
Communicable Diseases (CDS)
on the part of the World Health Organization concerning the legal status of any country, territory, city or areas or of its
World Health Organization
authorities, or concerning the delineation of its frontiers or boundaries.
©World Health Organization, November2003
Project objectives
• To increase the technical capacity of Mozambique in mental health policy-making
and planning.
• To assist the Ministry of Health of Mozambique to draft a mental health policy and update and
improve its mental health programme.
• To build the capacity ofmental health professionals to provide community-based care.
Project strategies
• Ensuring the harmonization of the mental health plan with the overall health plan.
• Strengthening the technical expertise and skills of local mental health professionals especially
in the area of community care.
• Paying particular attention to the development of community-based services in the planning
process.
• Ensuring the involvement of non-governmental organizations, especially traditional healers, in
the area of training.
• Actively encouraging the involvement of a range of ministries, other than the Ministry of
Health, in the policy-making process.
Implementing institutions
• Ministry ofHealth, Maputo
• Pro vincial Health A uthorities
17
Background
Provisional results of the national
census conducted in 1997 put the
population of Mozambique at nearly
15.7 million inhabitants.
This is
approximately 15% lower than earlier
estimates of 18 million. Primary care
remains the basis for the public health
system in this country. The National
Health Service is the major provider of
all health services.
There are four levels of care in
Mozambique’s 10 provinces. At the
primary level, there are health posts,
mobile services, and rural health
centres that carry out preventive and
basic curative activities. Health posts
are staffed by semi-skilled or unskilled
personnel. The large health centres
have basic inpatient facilities and are
staffed by nurses.
Mental health care
At the secondary level, there are rural
and general hospitals. The general
hospitals
provide
services
in
paediatrics,
obstetrics
and
gynaecology, general surgery and
medicine. Few rural hospitals provide
surgical services.
A rural hospital in the north
At the tertiary level, there are
provincial
hospitals
offer
that
18
diagnostic
facilities
and
some
specialist services.
The quaternary level includes the three
central hospitals in Maputo, Beira and
Nampula.
The mental health care system in
Mozambique can be broadly divided
into three sectors:
1) Services found in primary care
facilities
Primary health care facilities are an
important source of mental health care
delivery.
There are currently 34
psychiatric technicians located in
health
centres
throughout
Mozambique’s 10 provinces. Their
main roles are to prescribe and
administer psychiatric medication to
patients attending the health centres
and
to
provide
psychosocial
rehabilitation. The health centres also
engage in mental health awareness and
educational programmes in an attempt
to reduce the stigma associated with
mental illness and to highlight the risks
associated with alcohol consumption.
Medication can also be administered
by staff in health posts. These are
generally smaller than health centres.
2) Mental hospital services and
psychiatric beds provided by general
hospitals where outpatient services are
also available
Psychiatric facilities within general
hospitals are very limited. They are
available in Maputo from the Central
Hospital and in the province of Sofala
where there is a small unit in the local
rural hospital. There are currently two
psychiatric hospitals in Mozambique.
They cater primarily to inpatients with
severe mental health problems who
have been referred by primary care
psychiatric technicians. One is based
in the city of Maputo and the other in
the northern province of Nampula.
3) Traditional healing
The Ministry of Health has looked
positively upon traditional medicine
because it recognizes its importance to
the people of Mozambique. Given that
only 60% of the population has access
to formal health care services,
particularly in rural areas, healers are
most often the preferred port-of-call
for individuals who suffer from health
and mental health problems.
In November 1996, a national mental
health programme was outlined for the
first time. This programme identified
several areas of importance for
Mozambique that needed to be
addressed to improve mental health
facilities. These included:
Since many patients who suffer from
chronic mental illness are prone to
relapses, one of the most important
priorities for the Ministry of Health has
been to monitor patients’ access to
health and social care services once
they have been discharged from the
hospital. There is evidence to suggest
that the psychiatric hospital in Maputo
has been a victim of the same
“revolving door” phenomenon that
bedevils hospital services in many
developed mental health care systems.
Nevertheless, it is evident that some
arrangements have been made with
local health centres to monitor patients
on discharge and provide general
assistance to them and their families in
the process of re-integration into the
community.
• The failure to prioritize mental
health services.
• The dominance of a custodial
system of psychiatric care, which
perpetuates stigma against persons
with mental health problems.
• The lack of epidemiological
information on mental illness.
Within the ministerial hierarchy,
mental health is one of six sections that
together make up the Division of
Family Health.
The Division of
Family Health comes under the
Department of Community Health,
which has its own National Deputy
Director.
A National Programme
Coordinator for Mental Health is
responsible for planning and policy
decisions. In each province, there is a
coordinator for the local mental health
programme.
The coordinator is
usually a psychiatric technician, except
in two provinces where the work is
carried out by psychiatrists. A twoyear strategic plan for mental health
was drawn up but has only been
partially implemented. It is related to
the
National
Integrated
Plan/Community Health 2001.
• The lack of human and financial
resources and facilities.
• The lack of awareness among
health staff and the community as a
whole about mental health
problems.
• The lack of systematic knowledge
about the influence of social and
cultural factors on Mozambique’s
mental health problems.
• The absence of an agency to
organize, promote, coordinate and
supervise action in the mental
health sphere.
• The lack of continuity in action
undertaken. This can be attributed
to lack of resources and heavy
reliance on international cooperat
ion.
• A highly centralized structure and a
lack of intersectoral collaboration.
There is a need to incorporate mental health
care into general health care.
19
Each issue is discussed in turn, below.
The low priority given to mental health
services
This continues to be the case in
Mozambique largely because of
limited financial resources and the
pressing needs created by communic
able diseases.
The dominance of a custodial system of
psychiatric care, which perpetuates
stigma against persons with mental
health problems
There has been a noticeable
improvement in the conditions of
patients in the psychiatric hospital and
in their management.
Therapeutic
work, in the form of agricultural
projects, has been developed on land
surrounding the hospital in conjunction
with members of the local community.
WHO is encouragingjoint-working between mental
health workers and traditional healers
Owing to the work of Italian
Cooperation, the management of the
hospital has been improved and work
in the community has been encouraged
and promoted. Italian Cooperation has
also had an input into the training of
psychologists, nurses and psychiatric
technicians through the Central
Hospital in Maputo. A new project to
further develop community activities
will shortly begin.
Community
projects have also been developed and
implemented by the Italians in Manica
and Sofala anxhby WHO in Niassa.
• 'fV.
20
The lack of epidemiological information
on mental illness
For the first time as part of this
project, WHO has funded the
undertaking of a pilot epidemiological
study to provide an evidence base for
the mental health policy.
The Ministry of Health has outlined
the
benefits
of
the
pilot
epidemiological study as follows:
• Increase the availability of reliable
epidemiological information on
mental health in Mozambique.
• Begin the integration of mental
health epidemiological information
into the general health information
system (statistics).
• Improve, monitor and supervise the
effectiveness of mental health
interventions on the basis of the
initial evidence.
• Monitor the changes and trends in
mental and neurological disorders.
These are a major cause of disability
in
Mozambique,
a
country
undergoing rapid and severe social,
political and economic changes with
serious impacts on the population.
• Work
towards
reducing
the
incidence and prevalence of mental
and neurological disturbances with
better information systems.
The lack of human and financial
resources and facilities
These continue to be a big challenge to
the provision of mental health service
particularly in the community. Until
2002 there were only five psychiatrists
in Mozambique, (none of whom are
Mozambican).
Three Mozambican
doctors have been trained as
psychiatrists, but their location and the
duration of their stay in Mozambique
in the future cannot be predicted with
any degree of certainty. In addition,
because of the shrinking pool from
which to draw nurses for training as
psychiatric technicians, no new
psychiatric technicians were being
trained.
Most of the psychiatric
technicians who provide the bulk of
psychosocial rehabilitation and are
trained to administer medication, are
due to retire shortly (two-thirds) or are
planning to change careers. Training
of new technicians was not envisaged
because of the lack of financial
resources in the Ministry of Health to
absorb staff at this level. The issue of
training is therefore a crucial one and
is addressed in the mental health
policy.
The lack of awareness about mental
health problems among health staff
and the community as a whole
The first training sessions given to
mental health personnel in June 2000,
have been continued in a limited way
with general health staff at some health
centres, in particular in Cuamba where
there was another WHO community
based mental health project.
The lack of systematic knowledge
about the influence of social and
cultural factors on Mozambique s
mental health problems
While anecdotal knowledge exists, no
systematic research has been carried
out on a national scale. However, a
study was carried out as part of the
preparation of another WHO-funded
project in the province of Niassa in the
north of the country. Beliefs about the
causes, the types of treatment and
where treatment is sought, were
recorded.
The study also gathered
information about local names given to
mental health problems. As part of an
epidemiological study, a comparison
was made between these and ICD-9
classifications.
The absence of an agency to organize,
promote, coordinate and supervise
action in the mental health sphere
This has been overcome to some extent
by the appointment of a National
Programme Coordinator for mental
health based in the Ministry of Health.
However, this programme is only
managed by two people and the
Coordinator
also
has
clinical
responsibilities. Some progress has
been made to coordinate action in the
mental health sphere by giving people
in the province (mainly psychiatric
technicians) responsibilities for mental
health. However, whether or not a
mental
health
programme
is
implemented remains the responsibility
of the provincial director of health.
The lack of continuity in action
undertaken, attributable to the lack of
resources and heavy reliance on
international cooperation
This continues to be the case except in
a few provinces where community
services have been established.
A highly centralized structure and lack
of intersectoral collaboration
At the regional and provincial levels,
there has been some decentralization of
services, and regional and provincial
officials responsible for mental health
have been appointed.
Project description
Mozambique faces many problems and
challenges due to the lack of human
and financial resources in the field of
mental health. There is a need to
address all of these issues in a
systematic and practical manner.
Because of the scale of communicable
diseases in Mozambique, that are
exacerbated by periods of flooding and
drought, the health sector in general is
under considerable pressure.
The
project therefore set out to address the
objectives spelt out at the beginning of
this document.
ro,
v(
A
A1*'*
)
t>°c
21
Increasing the technical capacity
of Mozambique in mental health
policy making and planning
'll J'1
I
International training seminar for health
professionals in Maputo, June 2000
WHO has assisted the government of
Mozambique to develop and write a
mental health policy. The policy has
addressed inter alia, a number of key
areas. Among them areas such as: the
organization of mental health services;
human resource development; the
provision of psychopharmacological
drugs at all levels of the health system;
intersectoral collaboration; the role of
the traditional practitioners; and, the
need for adequate epidemiological
information to support the planning
process.
The policy-making process was
achieved through joint collaboration
and planning between officers
responsible for mental health in the
Ministry and consultants hired by
WHO to collaborate with the Ministry
and guide it through the process.
As previously mentioned, a; pilot
epidemiological study has been
undertaken and has provided a base for
policy-making and planning. It was
conducted in one rural and one urban
province and included a sample of
people in the community, as well as
22
people in primary care and general
hospitals.
The training given by WHO as part of
the pilot epidemiological study has
been part of a capacity-building
exercise to enable the Department of
Epidemiology within the Ministry of
Health to begin to integrate some
information into its routine statistics
and for record-keeping purposes.
Strengthening the technical
expertise and skills of local
mental health professionals
especially in the area of
community care
In June 2000, approximately 90 mental
health
professionals
and
representatives of non-governmental
organizations from all 10 provinces of
Mozambique were trained in best
practices in community mental health.
The training also included persons
from the statutory and non-statutory
sectors.
Participants at the international meeting in
Maputo, June 2000
An international meeting of experts
and local mental health policy-makers
and practitioners was also convened in
June 2000.
The following received training as
part of the project:
•
•
•
•
•
•
•
•
•
•
•
•
•
Clinical psychologists
Psychiatric technicians
General practitioners
Psychiatrists
Traditional healers
Technicians
in
preventive
medicine
Nurses
Nursing tutors
Heads/representatives of nine
NGOs
Chiefs of provincial community
mental health services
Senior primary health care staff
National
Programme
Co
ordinator for Mental Health
Psychiatric technician based in
the Ministry ofHealth
Paying attention to the
development of community
based services within the policy
and planning process
It has already been recognized that this
is a fundamental part of the process of
strengthening the role of mental health
in primary health care. Discussions with
Ministry and clinical staff indicated a
high rate of re-admission.
It was
recognized that there is a need for
greater follow-up in the community.
This is a problem because of the
insufficient numbers of trained staff.
Given the size of the country and
logistical
problems
in
servicing
communities with poor infrastructure,
the provision of mental health services is
greatly limited.
There are however
successes in a few provinces where
international aid is being injected into
the community by Italian Cooperation.
Overall however, the issue of staff
training, support and retention is one
that runs across the whole of the health
sector and affects the provision of
community services.
Existing community services were
visited and discussions held with
workers and international NGOs, where
they existed, in order to evaluate the
impact on community service provision.
Actively encouraging the
involvement of a range of
ministries other than the
Ministry of Health in the policymaking process
This process of building intersectoral
collaboration where none has previously
existed was initiated with the Ministry of
Social Action and the Ministry of
Labour. It was then extended to cover a
range of other ministries who were
consulted to contribute recommend
ations on the way forward.
Other areas that need to be addressed as part
of the policy-making process affecting
community care include:
• Integrating mental health into existing community
health programmes within the Ministry of Health
(such as the Infant and Maternal Health
Programme (UNFPA), and the Integrated
Management of Childhood Illnesses Programme
(WHO/UNICEF)).
• Introducing/strengthening the training and use of
primary health care staff such as health agents and
social agents. This is aimed at improving care in
the community as part of a national programme of
training by the Ministry of Health.
• Ensuring
the
adequate
provision
of
psychopharmaceutical drugs at each of the four
levels of distribution and ensuring the introduction
of the necessary psychopharmaceutical drugs into
the "kit system ” at the PHC level.
• Rationalizing the work of psychiatric technicians
with the roles of health agents, recently trained
psychiatrists and social action agents from the
Ministry of Social Action, with particular reference
to roles and responsibilities, and career structures.
23
As far as future collaboration is
concerned, the involvement of the
Department of Mental Health in the
training of “social agents” who work in
the community has been discussed
with the Ministry of Social Action as
part of this project. This is seen as a
fruitful area for cooperation. Future
collaboration also includes further
work with the Directorate for Women
within the Ministry of Social Action.
This is because domestic violence is an
area of concern.
For the Ministry of Labour, recent
labour legislation has been drawn up
but still needs to be implemented
through various regulations.
Input
from the Department of Mental Health
in drawing up regulations for workers
who have mental health problems has
been welcomed.
A series of consultations were held
with other Ministries during the course
of the project. These are outlined
below. Consultations and visits covered
all of the 10 provinces.
Some of the chief aims of the
activities that have taken place
included:
• understanding the problems and
issues ofmental health;
• understanding how health/mental
health services were organized at
all levels;
• discussing recommendations on the
key areas that need to be addressed
in the policy document and
suggestions on how to address the
current problems in mental health;
• getting a better idea of the role and
contribution of the traditional
sector;
• agreeing on the nature and scope
of collaboration with other
ministries in order to optimize
limited human and financial
resources.
24
The following consultations and
visits have been made:
Ministry of Health
• Deputy Minister of Health
• National Director of Community Health
• Head of School and Adolescent Health
• National Director of Human Resources
and Training
• Deputy National Director of Medical
Assistance
• Head ofPharmaceutical Department
• Meeting with Restricted Consultative
Group (a Maputo-based group with
representatives from the Ministry of
Health, the Military Hospital, the
psychiatric hospital, the central
(General) hospital and NGOs).
Psychiatric Hospital - Infulene
• Meeting with the Psychiatric Hospital
Director followed by a tour of the
hospital.
Ministry of Social Action
• National Director of Women and Social
Action
• National Director of the Institute of
Social Action (INAS)
• Chief ofProgrammes - INAS
Ministry of Labour
• Permanent Secretary
• Head of “Gabinete de Estudos ” (Study
Cabinet)
NGOs
• Italian Cooperation
• Executive Director of Reconstruindo
Esperanca (Reconstructing Hope) children and adolescents
• Mahotas (adults)
Focal points for mental health in all of
the provinces
• Relevant local health personnel
• Provincial authorities
• International NGOs
• Local NGOs
• Traditional healers
• Ministry of Education
• Ministry of Youth and Sports
• Ministry ofJustice
• Ministry ofInternal Affairs
• Ministry ofFinance
• The City Health Board
Key results
The formulation ofa national mental health policy.
This was achieved through a process of:
• Political commitment and collaboration with senior personnel in the Ministry of
Health.
• Training ofmental health professionals in the area of community mental health.
• Undertaking an initial situational analysis ofmental health issues and problems.
• Drawing up a clear and costedplan-of-action.
• Engaging in widespread consultations and discussions at the central and
provincial levels (75 meetings involving over 250persons).
• Ensuring consensus on areas to be included in the policy through a national
meeting.
• Underpinning the policy with an evidence base by undertaking a pilot
epidemiological study.
• Building in-country capacity for undertaking epidemiological research.
• Disseminating the final policy document for comments.
• Holding a final meeting before submission for formal adoption by the Council of
Ministers.
25
SRI LANKA:
technical advice
Country Response Programme-MSD‘
India
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Comm iiteabte Diseases (CDS)
WorM Heartt OrgaiEattoi
O W or kl He a Itb 0 rga i EaMo i. Nov ember 2003
Provision of Technical Advice to Sri Lanka
A country visit was undertaken for the purpose of a mental health needs assessment in
Northeast Sri Lanka. Consequently, a comprehensive five-year mental health plan
was developed in close collaboration with local mental health expertise.
Country Visit
Participants in the one-week mission were:
Ministry of Health (including the Director ofMental Health Services)
Ministry of Rehabilitation, Resettlement, and Refugees
WHO Sri Lanka
WHO Geneva
We gratefully acknowledge Dr M. Ganesan (Ministry ofHealth, Batticaloa) and
Dr Daya Somasundaram (District Hospital Tellipallai, Jaffna) for their excellent
input and constructive feedback during the development of this plan.
27
Background to technical
advice
the world, the prevalence of
schizophrenia is between 0.5% and
1%.
The WHO Department of Mental
Health and Substance Abuse visited
Sri Lanka at the request of Professor
Jayalath Jayawardena, MP, Minister of
Rehabilitation,
Resettlement
&
Refugees. Dr Jayawardena had prior
discussions concerning the visit with
the Department of Mental Health and
Substance Abuse in Geneva in 2002
and 2003. The Minister’s specific
request was to conduct a mental health
needs assessment in Northeast
Sri Lanka.
The suicide rate in Sri Lanka ranks
among the ten highest in the world,
and the most recent official figures of
1991 put it at 31 per 100,000. The
rates for men however are more than
double that of women (44.6 compared
to 16.8). Both the actual suicide rates
as well as those for attempted suicide
in Northeast Sri Lanka may be
particularly high, especially among
displaced persons as in Vavuniya,
where an epidemic rate of 103/100,000
was observed5.
In June 2003 a needs assessment
mission in Northeast Sri Lanka was
undertaken
(Jaffna,
Batticaloa,
Killinochi, Vavunia). The mission
involved technical staff from WHO
Geneva, WHO Sri Lanka, the Ministry
of Rehabilitation, Resettlement and
Refugees, and the Ministry of Health.
Mental health services
The state of mental health
A 1994 community survey of the
effects of war in the North found 25%
depression, 27% anxiety disorder and
14% post-traumatic stress disorder.
These rates were higher in a study of
outpatient attendees at a general
hospital in Jaffna. Schizophrenia has
been, is, and will continue to be the
major mental health problem for the
mental health services, because it is
common (affecting up to an estimated
1% of the population), highly
disabling, striking at a young,
productive age and running a chronic
course. There is some evidence that
schizophrenia may have a relatively
high
incidence among Tamils
(Somasundaram et al., 1993)4. Around
4 Somasundaram DJ, Yoganathan S, Ganesvaran T.
Schizophrenia in northern Sri Lanka. Ceylon
Medical Journal 1993 Sep;38 (3): 131-5.
28
In the Northeast as in other parts of Sri
Lanka, many administrators and health
staff consider mental health to be a
separate and unimportant area.
However, the WHO Global Burden of
Disease 2000 study suggests that
mental and neurological disorders
account for more than 12% of loss of
disability-adjusted life years across the
globe.
Several meetings with top-level policy
makers to highlight the urgent need to
establish mental health in the Northeast
have taken place involving the
Ministry of Health.
i
1
Inpatient accommodation
5
Lancet, 2002 Apr 27;359:1517-1518.
Although the Ministry of Health is
known to have given mental health top
priority in the Northeast, concrete steps
still have to be taken to implement
these priorities. The circumstances in
the Northeast (i.e. a post-conflict area)
would need to be recognized to make a
special case temporarily.
Because of 20 years of violence,
service development for persons with
severe mental disorders has been
severely impaired or destroyed,
resulting in the under-provision and
fragmentation of mental health
services.
War-torn hospital
In June 2003, there were only two
Tamil psychiatrists who, with limited
resources, were providing community
mental health care in and near the
districts of the two largest cities in the
Northeast (Batticaloa and Jaffna). In
addition, a variety of NGOs run
programmes targeted at trauma-related
mental and social problems in a variety
of locations. Different mental health
stakeholders in the Northeast advocate
for different mental health activities.
In the absence of a comprehensive
mental health plan, new activities
appear to develop in an uncoordinated
fashion, with the implementation of
lower order activities before higher
order needs are met.
In seven of the nine districts there is no
acute inpatient care. There is some
follow-up care (through outreach
clinics) for patients with severe mental
disorder in some divisions, but not in
divisions far away from both Jaffna
and Batticaloa. Although there have
been some efforts to train family health
workers (i.e. primary care staff), the
majority of primary care staff are still
not sufficiently competent to reliably
identify mental problems, manage
common mental disorders, refer
patients when necessary, and provide
follow-up mental health care for those
with severe problems.
The lack of services in parts of the
province
is
coupled
with
a
concentration of staff (and beds) in a
few cities and a lack of staff in more
rural districts. In these districts, the
government has created limited posts
and only small numbers of health staff
are expected to seek work. Although
good acute inpatient care exists in two
districts, the Northeast does not have
any appropriate inpatient facilities of
intermediate duration (up to six
months) to provide psychosocial
rehabilitation for those who do not
recover sufficiently during acute
inpatient care.
4
Mental health unit
Without such facilities, chronic
patients with schizophrenia do not
receive the care they require. They are
at risk of neglect or becoming long
term residents in the Colombo-based
custodial psychiatric hospitals, where
29
treatment is inadequate and patients
tend to deteriorate in the absence of
psychosocial rehabilitation or family
social support.
Mental health workshop
Recommendations
Rehabilitation unit-gardening
Overall, the mental health problems
that need to be addressed by services
include both (a) mental health
problems found in normal times, and
(b) common mental disorders and other
mental health problems due to the
adverse effects of conflict. The burden
of these problems is both on the mental
health system and on the general health
system, where most people tend to
seek help for mental health problems
(typically presented in the form of
somatic complaints).
In the aftermath of the conflict, an
increasing number of patients who
suffer from disabling mental health
problems need and seek treatment. The
rehabilitation,
development
and
reconstruction of the Northeast needs
to include a social and mental health
component in an integrated approach
to improve the mental health of a
people affected by war.
. .
visit-
i . So
;
% ■
: i
30
In recognition of the fact that the
services and people in Northeast
Sri Lanka are seriously affected by the
conflict, the following recommend
ations were put forward:
•
•
•
Giving priority to the development
of normal community-based mental
health services in Northeast
Sri Lanka. The normal mental
health system can and should
address both severe mental illness
and common mental disorders and
problems, including trauma-related
mental problems.
Increasing efforts to draw relevant
mental health professionals to the
Northeast, and to identify creative
solutions to ensure that trained
informal mental health human
resources will not be lost.
Ensuring that there are functioning
acute inpatient psychiatry units in
general hospitals in each district.
This activity includes (a) either
building or repairing/refurbishing
units in seven districts and (b)
hiring ward nurses and auxiliary
staff where needed. (This activity
also includes a telephone hotline at
each unit).
Organizing monthly follow-up
outpatient clinics of severe
mentally ill persons in each
division of the Northeast.
• Organizing care in the community
for those with common mental
disorders and problems (incl.
trauma-related problems), and
heavy alcohol and drug use. This
activity involves training and
supervision by two groups of
psychosocial
trainers.
The
community resources to be trained
include: primary health care-staff,
teachers, village leaders, and
traditional healers.
•
A detailed five-year mental health plan
has been written with a budget to
estimate the amount of external
resources required to implement
priority activities. It is envisioned that
further fund raising for this plan will
continue to be based on a rank order of
priorities, which are therein defined.
WHO/Headquarters in collaboration
with the WHO regional and country
offices continues to commit itself to
search for resources to implement the
plan.
K H - 10^
08453\
31
Sri Lanka
Mental Health Policy and Service Development (MPS) Projects
Sri Lanka
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Project goal
To encourage a process of deinstitutionalization of psychiatric patients and promote
reintegration in the community.
Project objectives
• To reduce the number of admissions and re-admissions to the Angoda/Mulleriyawa/
Hendala Hospital complex.
• To establish a supportive infrastructure, including follow-up care, based on the existing
primary health care infrastructure and with the involvement of NGOs active in the field of
mental health and well-being.
Implementing institutions
• Ministry ofHealth, Colombo
• Angoda (Teaching) Mental Hospital, Colombo, Western Province
• Nivahana Society ofKandy (NGO), Central Province
33
Background
Sri Lanka is an island nation with a
population of 18.5 million. The
population is made up of mostly
Sinhalese (74%), Sri Lankan Tamils,
(12.6%) Indian Tamils (5.5%) and
Muslims (7%), as well as other
minorities such as Moors, Malays and
Burghers. The country is divided into
eight provinces. Each province has an
elected Provincial Council. There are
around 300 Local Councils across the
island. For the last 20 years, there has
been political unrest and an ongoing
civil war in the north and east of the
island between Tamil separatists and
the Government. Therefore, there has
been substantial migration of Tamils
from the north and northeast to the
south as well as from Sri Lanka itself.
Each
province
consists
of
approximately three districts and 30
divisions. Each district has a Deputy
Director of Health Services. At the
divisional level, a group of Divisional
Directors of Health Services (DDHS)
has been created. These Directors
have been appointed by the Central
Ministry of Health.
They are
responsible for coordinating all
curative and preventive health
activities as well as for the
management of facilities, including
district hospitals. This has further
helped to devolve power to divisional
levels.
Health Services
The state of mental health
The Central Ministry of Health is
responsible for funding public health
services
through
provincial
departments of health and divisional
health services. Preventive health
services are provided through primary
care facilities, by public health
midwives and nurses, and public health
inspectors. The Central Ministry of
Health remains responsible for human
resource development,
personnel
posting and discipline, bulk purchasing
of drugs and allocation of capital
expenditure.
Between 5% and 10% per cent of
people in Sri Lanka are known to
suffer from mental disorders that
require clinical intervention. Nearly
70% of patients seen in clinical
practice are diagnosed with psychosis
or mood disorders. Among the most
common conditions seen in clinical
practice are psychosis, mood disorders,
dementia,
anxiety
disorders,
somatoform
disorders,
substance
abuse, stress disorders, and adjustment
disorders. Psychiatric practice tends to
be based on the biomedical approach
and relies mainly on the use of drugs
and
electro-convulsive
therapy.
Patients who need or seek other
treatments are referred to non-medical
mental health professionals (Paper
given at WHO Expert Committee
Meeting, SEARO, 2000).
Each province has a department of
health led by a Provincial Director of
Health Services who reports to the
Provincial Minister of Health and the
Central Ministry.
The Provincial
Director is responsible for hospitals as
well as primary and secondary health
care facilities. The provincial Ministry
of Health is responsible for policy-
34
making,
planning,
monitoring,
coordination of provincial health
activities, procurement of supplies and
managerial and technical supervision
of divisional health teams.
An estimated 70,000 Sri Lankans
suffer from schizophrenia. This figure
is expected to rise with the increase in
the number of young adults. It is
estimated that 5-10% of the population
over 65 years of age suffers from
dementia. The most recent figures
show that the suicide rate in Sri Lanka
is 44.6 for men and 16.8 for women.
However these figures date back to
1991 (please see WHO website figures
at:
http://www.who.int/mental health/media/en/3
63.pdf
and
http://www.who.int/mental health/prevention/
suicide/suiciderates/en/
Mental health services
At the time of writing there are an
estimated 38 psychiatrists for the
whole country (not all of whom are
with the Ministry of Health). There
are also 17 occupational therapists
medical assistants and others, 410
psychiatric nurses, and 9 social
workers attached to the inpatient units
(ATLAS project, Department of
Mental
Health
and
Substance
Dependence, 2001, WHO).
who have been transferred from
Angoda. In addition, a few provincial
“Base” (general) hospitals provide
outpatient services.
The Central,
Northern and Southern Provinces have
psychiatric units or “Teaching Units”
with beds in general hospital settings
as well as effective outpatient services.
The three psychiatric hospitals as well
as the Teaching Units are under the
control of the Central Ministry of
Health in Colombo.
General hospital units are only
permitted by law to admit voluntary
(informal) patients. However, there is
some question about whether this does
in fact happen in all cases. To admit
patients to Angoda and Mulleriyawa
requires an order from a Magistrate. If
this is by-passed, and patients are
admitted involuntarily, they have no
legally enforceable rights.
In Colombo and its environs, there are
three large mental health hospitals.
Community mental health team members
in Angoda hospital
Psychiatric hospital, Western province
These include, Angoda, which takes
new admissions from any part of the
country; Mulleriyawa, which is
primarily for long-stay female patients;
and the mental health hospital at
Hendala, for long-stay male patients
Outpatient clinics are run in most Base
hospitals when psychiatrists are
available.
In order to strengthen
mental health services around the
country a total of District Medical
Officers have been trained and
assigned to Base hospitals across the
country to run psychiatric clinics.
However, not all of these Medical
Officers have remained in their posts.
There are also plans afoot by the
Ministry of Health to relocate patients
requiring
long-term
care
to
community-based facilities.
35
Ayurvedic services
Doctors are being trained to provide care
at Base hospitals
The private sector
There are several private practices in
the capital run by psychiatrists who are
employed by the statutory services but
work part-time in private hospitals.
District Medical Officers at Base
hospitals also sometimes see private
patients.
Numerous
general
practitioners see patients privately
since general practice is not part of the
Government’s free health service. A
few consultant psychiatrists are
believed to run large practices in
Colombo.
Counselling services for people with
suicidal
behaviour,
interpersonal
problems,
stress-related
health
problems and psychosocial problems
are provided by non-medical mental
health professionals in the non
governmental sector.
Some non
medical mental health professionals
also provide psychological services
that are based on cognitive behaviour
therapy and other psychological
models.
Rehabilitation services in hospital
36
Throughout South Asia, religious
healing and forms of indigenous
medicine such as Ayurveda have
traditionally dealt with mental health
problems.
There is a large
Government Ayurvedic hospital with
an Ayurvedic college and research
centre that trains physicians. However
little is known about their work among
mental
health
professionals.
Administratively, Ayurvedic medicine
does not come under the Ministry of
Health, but under the Ministry of
Indigenous Medicine. There is also a
Buddhist temple some 20 miles from
Colombo that has been using
Ayurvedic treatment for unmada
(equivalent to mental illness) for many
years.
Non-governmental organizations
There are at least five NGOs working
in the field of mental health. The
oldest started in 1987 as a befriending
scheme for patients in one of the three
mental hospitals (Mulleriyawa). Three
of these organizations now run
rehabilitation programmes for people
with mental health problems. One is a
community-based programme and the
other two take the form of residential
programmes where services are
provided for the long-term mentally ill.
Generally speaking, the current range
of mental health services, service
delivery models, facilities, personnel,
funding organization of services and
priority-setting processes are totally
inadequate to meet the present and
emerging mental health needs of the
community. Services are not evenly
distributed and there are problems with
access, particularly to community
based care. Most of the available
services are concentrated in Colombo
and other urban areas, leaving the rest
of the country largely devoid of
services. Hopefully, the situation will
improve as medical health officers are
trained to work in the Base hospitals.
As the project becomes more
established, there will be a network of
primary care services in some areas;
however, much needs to be done
across the country as a whole.
individuals, with a shared interest in
mental health issues, came together to
advocate for improved mental health
services within the Province. The
director of this NGO is also a
consultant psychiatrist at the teaching
hospital in the Province. He has been
able to engage the Central Provincial
Ministry of Health and the Department
of Psychiatry of the University of
Peradeniya in pursuing the aims of this
project.
Project description
Central Province
The aims of the project were the same
in both the Gampaha district of the
Western Province and in the Central
Province. The main objectives of the
project were to reduce the number of
admissions and re-admissions to
psychiatric hospitals in Colombo, and
to establish an infrastructure of
support, including follow-up care,
based on the existing primary health
care infrastructure.
However, the
approach has differed somewhat in the
two project areas. This has largely
been because of the differing mental
health services available (or lacking) in
the two areas, as well as the
availability of human resources in
each.
State psychiatric services in the Central
Province are provided by general and
specialist psychiatric clinics in the two
main teaching hospitals in Kandy and
Peradeniya, as well as by a 20-bed
medium-stay unit in one of the
districts. During the period of the
project, there were no other formally
recognized state-funded psychiatric
services.
Work in the Western Province has
been carried out by a team of social
workers attached to one of the main
mental hospitals in the capital
(Angoda). This has been done in
collaboration with one of the few
psychiatrists to conduct clinics in the
community.
In the Central Province, work has been
carried out by an NGO active in the
field of mental health and well-being
(Nivahana Society of Kandy (NSK)),
based in the capital town of the Central
Province. This NGO was established
in 1985 when a group of concerned
The main thrust of the project in the
Central province was to supplement
current mental health services by
providing care in the community to
those patients recognized as suffering
from mental health problems as well as
to their families. The idea was that this
would eventually be incorporated into
mainstream services. The philosophy
of the project was to work with
patients to maximize their ability to
live independently and to facilitate and
promote the development of cost
effective, accessible, and quality
mental health services. This was being
implemented through the various
activities described below.
Raising awareness among policymakers and planners about the need
for more sensitive community mental
health systems
In order to ensure support for the
project and to facilitate links with
37
current services, the project staff have
organized meetings both within the
Central Province and with senior
personnel from the Central Ministry of
Health in Colombo. In the Central
Province, project staff have met with
local policy-makers and now take part
in Provincial community health
meetings, which are chaired by the
Provincial Director of Health. This has
meant that the project is now seen as
integral to the development of mental
health services for the Province and it
has therefore secured the support of the
Provincial Department of Health.
Project staff now take part in regular
mental health divisional meetings with
the Director General of Health.
Establishing
community
mental
health resource centres
As part of the project, there is a plan to
set up three community mental health
resource centres in each of the districts
of the Province. The first centre was
established during the second year of
the project and training manuals and
journals on mental health and
addictions have now been purchased.
It is located within the grounds of the
district hospital. The main roles of the
current centre are to:
• Coordinate service delivery between
the specialist services, supporting
hospitals, community staff, and other
centres and community workers.
• Monitor and evaluate service
delivery effectiveness/efficiency and
revise as appropriate to improve
them.
• Act as a resource centre to provide
workers with information on mental
health issues, house up-to-date
journals and books, and provide
internet services.
38
Katugastota Mental Health Resource
Centre
Relocating people discharged from
mental hospitals in Colombo to the
Central Province
A register of all patients from the
Central Province who were eligible for
discharge from mental hospitals was
compiled and attempts were made to
contact their respective families.
Assessments were done with patients,
and relatives who could be found were
questioned about their willingness to
take in family members who had been
recently discharged from hospital.
Based on the responses from relatives,
it emerged that because of the length of
stay of some persons in mental
hospitals in Colombo, and the loss or
weakening of family ties, of the
original 150-200 persons who could be
relocated, only an estimated 15% could
be reintegrated in their families. It
became clear that different types of
accommodation would need to be
established to house patients following
their discharge from hospital.
The project has therefore worked to
establish medium and long-term
accommodation for patients within the
community. To this end, 20 beds were
added to a medium-stay psychiatric
unit in the district of Deltota to
accommodate 40 people (roughly
equal numbers of men and women).
The average length of stay has been
approximately 18 months.
The
Provincial Department of Health has
provided extra staff to cater for the
increased number of patients. In turn,
the staff has been trained by the project
to undertake psychosocial rehab
ilitation with patients who have been
discharged from the Angoda mental
hospital in Colombo. As part of this
process of rehabilitation, the female
residents have been engaged in
craftwork (batik, needlework, soft toys,
embroidery and making utensils out of
local materials such as coconut shells),
while the men are employed in animal
husbandry and gardening. The plan is
to make products that can be sold at
the local market.
The project also planned to convert an
old hospital site, owned by the
Provincial Department of Health, into
a long-stay unit. This unit will house
patients who have been discharged
from the Angoda hospital complex in
Colombo and who have little chance of
returning to their families in the
Central Province.
The provincial
government has given its approval and
support for the establishment of this
long-term rehabilitative facility. Funds
are currently being sought to undertake
refurbishment. The facility will offer
different
levels
of
sheltered
accommodation, according to the
different needs of individuals.
Establishing
effective
systems,
policies and procedures to support the
emerging community mental health
care services
A number of activities have been
undertaken to fulfil this objective.
These include training different
categories of staff, establishing clinics
where none previously existed,
ensuring adequate drug distribution,
and establishing effective methods of
recording, storing and analysing
services’ data.
As far as training is concerned, five
groups of professionals have been
targeted: Base hospital doctors (in five
Base hospitals), Divisional Directors of
Health Services (DDKS), public health
nursing sisters (PHNS), public health
midwives (PHM) and public health
inspectors (PHI). A training manual
has been compiled for teaching public
health midwives. The manual covers
basic information on mental illness,
medication and communication skills.
In the second year of the project,
weekly psychiatric clinics were
introduced in two of the five Base
hospitals. These clinics act as a
gateway to the main psychiatric clinics
in the two local hospitals. The DDHSs
currently specialize in child and
maternal health and are responsible for
community and preventative services.
With training, their role has been
extended to incorporate mental health.
They will in turn support the public
health nursing sisters by providing care
to people living in the community and
suffering from mental health problems.
A link has also been made between
trainee doctors at the University of
Peradeniya and doctors at the Base
hospitals in order to offer training in
mental health as part of training in
community medicine.
All of the 800 public health midwives
and public health inspectors in the 33
divisions of the Central district who
offer community preventive services,
have been trained.
As far as drug distribution is
concerned, the project manager was
involved in writing a paper, which was
submitted to the Director General of
Health Services, and proposed that key
psychiatric medications be made
available in the district. Historically,
patients requiring psychiatric treatment
travel to Kandy General Hospital. This
39
involves long journeys at a time when
patients are unwell. This may be one
of the reasons why large numbers of
patients who do not attend outpatient
clinics, and therefore cease to take
their medication, subsequently suffer a
relapse. A ward survey in the teaching
hospital showed that 50% of all
admissions to the wards were people
who had discontinued their medication.
Long waiting times at psychiatric clinics
The project therefore proposed that
psychiatric medication be made
available in all Base hospitals, in all
district hospitals and to all Divisional
Directors of Health. The introduction
of Medical Officers at the Base
Hospitals
has
facilitated
the
achievement of this objective.
A data collection system and a system
of psychiatric referral has been piloted.
In addition to patient records held in
Base hospitals, these include: referral
forms to and from the divisional
psychiatric service; home visit forms;
two monthly psychiatric forms
completed by public health nurses and
doctors; quarterly forms from the
medical health officers to consultant
community physicians.
Western Province, Gampaha
District
The
Angoda/Mulleriyawa/Hendala
mental hospital complex houses
40
approximately 2800 inpatients.
Of
those, around 1500 are long-stay
patients with little access to
psychosocial rehabilitation or specialist
nursing care. The only provision of
statutory community care is through a
team of 6-8 psychiatric social workers
(the numbers have varied over time)
attached to the Angoda hospital, and
one active consultant community
psychiatrist (who is one of the project
managers).
A lack of infrastructure for follow-up
and family support has led to frequent
re-admissions and a heightened risk of
rejection by the family, as well as
burnout. The project aims to address
these issues by locating families and
preparing and supporting them to
receive their relatives. It also plans to
train primary health care workers to
identify individuals in need of help and
carry out basic follow-up in the
community.
The main efforts so far to reduce the
number of admissions and re
admissions to hospital, have been
through the provision of targeted
ongoing support in the community. In
addition, building a wider network for
support through the primary health
care teams who were equipped to both
identify cases and provide follow-up
care. Unlike the Central province,
most of the patients discharged to the
community have been sent back to
their families.
The emphasis on
reintegration therefore has focused on
working not only with patients in the
community but also with their families.
A small number of people have been
referred
to
non-governmental
community facilities because there
were no statutory facilities in the
district.
To establish a supportive
infrastructure, including follow
up care, based on the existing
primary health care
infrastructure
Reducing re-admissions to mental
hospitals and establishing effective
support systems in the community
The project has sought to achieve these
objectives by increasing the level of
support in the community to persons
discharged from hospital. This has
been done through training different
categories of staff to identify cases and
conduct follow-up and placing patients
who have been discharged but who
cannot be returned to their families in
community-based
rehabilitation
facilities.
As a starting point, the project
identified all the patients who lived in
the five divisions of the Gampaha
district and who had been admitted to
hospital more than two or three times
in the preceding two years. A range of
demographic and diagnostic data was
collected on all patients discharged
from the Angoda and Mulleriyawa
hospitals. Patients were then assessed
in terms of the degree to which they
were deemed to be at a minimum, low
or high risk of relapse after discharge.
Diagnosis, family situation, previous
number of admissions, history of
violence at home, suicide attempts and
other factors were taken into
consideration in these assessments.
This in turn determined the frequency
with which community visits were
organized not only by project staff, but
also with the participation of newly
trained primary health care staff.
Follow-up visits were then undertaken
by the project team.
The team
consisted of psychiatric social workers
and
a
consultant
community
psychiatrist who runs three to four
clinics a week within a 75-kilometre
radius of the hospital, as well as the
follow-up visits carried out as part of
this project. It was found that visits by
the psychiatric social worker helped
family members to better understand
persons
suffering
from
mental
disorders and helped them to rebuild
their personal social connections.
The
psychosocial
intervention
provided by the project included not
only counselling and supervision of
medication, but also other types of
support such as assistance in finding
employment. If patients were unable
to find employment, they are
encouraged to become self-employed
by making handicraft items for sale in
local markets.
As in the Central Province, the
emphasis in staff training has been on
training
primary
health
care
professionals such as medical officers
of health (MOH), public health
midwives, public health nursing sisters
and public health inspectors.
The
project team has conducted training
sessions in all five divisions of the
Gampaha district and has trained all
Training ofprimary health care professionals
167 primary care staff (14 medical
officers of health and 153 public health
nursing sisters, public health midwives
and public health inspectors). Ongoing
41
support is provided to primary health
care staff through monthly case
conferences.
Although at the beginning of the
project referral systems are not as
advanced as in the Central District, as
part of the training, primary health care
staff were made aware of the need to
fill out basic referral forms used by the
Ministry of Health (MOH). There is
also a system in place whereby patients
picked up in the community are
referred to the MOH. Only in cases
were the MOH does not feel able to
offer the scope of assistance needed,
will the patient be referred to the
psychiatric social worker responsible
in that particular division.
The establishment of carer support
meetings in each of the five divisions
initially has spread to cover 11 DDHS
areas.
Meetings are held in the
building in which the medical officers
of health and their teams are housed.
Transport is provided by the project to
encourage as many relatives as
possible to attend. In addition,
meetings are held on Saturday
mornings to enable those relatives who
work during the week to attend.
All meetings continue to be organized
and attended by the social worker
responsible for the division, the senior
psychiatric social worker (also one of
the project managers) and the project
psychiatrist. An officer from the social
security office has always been invited
to attend to hear the problems of
relatives first hand and to facilitate the
offers of social assistance to those
relatives in need.
Some of the main areas of concern
voiced by relatives were the following:
42
• The negative side effects of
medication which affect individuals’
ability to function normally.
• Fears for personal safety due to
aggressive behaviour of discharged
patients (leading to relatives asking
for the patient to be kept in hospital).
• Non-compliance with medication
(leading to relapses and sometimes
aggressive behaviour) and concerns
about how to respond to this.
• Worries about their sons’/daughters’
not finding marriage partners
because of the illness and what can
be done to reassure prospective
spouses.
• Queries about whether mental illness
is hereditary.
• Queries about their own mental
health (signs and symptoms).
• Queries about the relationship
between smoking and mental illness.
Mental health education in schools
Psychiatric social workers have been
visiting schools to provide information
about nature of mental illnesses and
how they can be identified and what
help is available.
Having ‘Open Days' helps to open minds
Providing social service
assistance by using a
discretionary fund
The project has established a small
fund to offer social support to needy
families since many of the persons
discharged from hospital and their
families are very poor. This fund is
therefore used to offer support for
housing and employment when
patients are discharged from hospital.
Raising awareness in the community
The project considered it important to
combine medical, social and spiritual
services for patient’s full recovery by
maximizing the existing potential in
the community.
Seminars have
therefore been organized involving 53
members of the various social welfare
organizations in three of the five
divisions.
They were aimed at
examining the welfare requirements of
people with mental health problems
more closely so that the relatives can
link up with these social welfare
organizations and obtain more support.
Key Results
• Strengthening the network ofpsychiatric services in the Central and Western Provinces by
the establishment ofnew clinics and by the extension of the range of community-based care
and support.
• Training of primary health care workers, medical health officers and divisional directors
of health services to provide community-based care thus strengthening the integration of
mental health in primary and secondary health care.
• Raising the level of awareness in the community and among policy-makers and securing
their support.
• Decreasing the number of re-admissions to psychiatric hospitals (approximately 70% of
patients in the Gampaha district).
• Intensifying the level ofsupport to reduce re-admissions to hospital.
• Establishing forums for carer groups to express their needs and concerns.
• Establishing medium term rehabilitation facilities in the community.
• Mainstreaming mental health services in the province (Central Province)
• Strengthening formal referral systems between primary health care workers and
tertiary services through designing and testing various types of referral forms.
43
Rehabilitation in the community:
Some success stories
Raj has a history of mental illness that has led to several admissions to
psychiatric hospital. He was diagnosed as
suffering from schizophrenia and prescribed
medication. Although he had been
discharged back to his family, he found it
difficult to both find and maintain
employment because of recurrent bouts of
illness. As part of the project for the
reintegration of people back into the
community, Raj was able to benefit from a
programme of support which included help
with finding employment. Through
negotiation with the manager of the local garment
factory where his wife worked, Raj was also able to find gainful employment. In
addition, he was given support through home visits that provided both counselling
and help in understanding the importance of staying on his medication. At times of
crisis, his social worker liaised with his employer and provided additional support.
As a result, Raj was able to save money and buy a small house and a plot of land so
move his wife and daughter out of the dilapidated house, which they formerly
inhabited. He is now able to help support his family financially as well as cultivate a
small plot that helps to supplement their basic food supplies. The whole family has
benefited from Raj’s improved situation. This is a Prime example of how
rehabilitation within the community can improve both the quality of life and future
prospects not only for individuals, but for their families as well.
44
Rehabilitation in the community:
some success stories
■;rJ
o
A-*
’Ml
r;
o-
L-l
5
I
*1
One of the most important ways of helping people in the community after
Discharge is to provide a means of employment. By the use of simple technology,
such as a weaving machine, items such as rugs and rope can be made for sale in small
local markets and thereby supplement the family income. The ability to earn money
and be seen as a useful member of the community is an important feature of
rehabilitation, especially in low-income countries.
_______________________
All these people have been helped
upon their discharge into the
community be means of employment.
They are engaged in weaving or
growing ofplants for sale in the local
market.
>'
;*^**d3
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45
WEST BANK and GAZA
STRIP: improving mental
health policy and service
delivery
Country Response Programme-MSD*
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Project objectives
•
•
To strengthen the expertise of local mental health professionals through training activities and to
facilitate international exchange and networking to sensitize local authorities and mental health
professionals about international mental health best practices.
To collaborate with the Palestinian Authorities and other significant international cooperation to
revise the National Mental Health Plan to ensure the development of coordinated communityoriented services.
47
Background
The occupied Palestinian territory
(oPt) includes the two geographically
separate areas of the West Bank and
Gaza. These areas are located between
the Mediterranean Coast and the
Jordan River. The areas feature several
famous cities including Jerusalem,
Bethlehem, Hebron, Jericho, Nablus
and Gaza.
The West Bank lies within an area of
5800 sq. km west of the River Jordan.
It has been under Israeli military
control since 1967. Many areas of the
West
Bank
have
diversified
communities. There are observable
differences in the lifestyles and living
conditions of the different socio
economic groups, religious affiliations,
urban, rural and refugee communities.
The population of West Bank is 1.6
million persons (47% urban, 47%
rural, and 6% in refugee camps).
The Gaza strip is a narrow piece of
land with an area of 360 sq. km, on the
coast of the Mediterranean Sea. The
area has a dense population mainly
concentrated in cities and refugee
camps. The main source of income for
the Gaza population is employment in
Israel, in addition to the export of
agricultural products via Israel. The
population of Gaza is slightly over one
million persons (63% urban, 6% rural,
and 31% in refugee camps).
The Palestinian population has lived
through several consecutive wars
(1948, 1956, 1967), occupation and
long periods of unrest. The second of
the two Intifadas (Uprising of the
Palestinian
people)
started
in
September 2000. Violence, destruction
of agricultural resources, roadblocks
and curfews have led to deteriorating
economic conditions in the West Bank
48
and Gaza. There are severe restrictions
on travel and movement with more
than 100 checkpoints throughout the
West Bank and Gaza, making travel
between many towns and cities
extremely difficult. This has had an
impact on the ability of people to
access health and mental health
services.
The state of mental health
In 1997, between the two Intifadas, a
population-based study (z7=585 adults),
involving fully structured diagnostic
interviews, was carried out among
adults in Gaza. Data were collected by
the Gaza Community Mental Health
Programme (an NGO) and analyzed by
a WHO Collaborating Centre. The data
show that in the previous 12 months
before the interview 10.6% of the adult
population met the criteria for the
Diagnostic and Statistical Manual of
Mental Disorders, 4th edition (DSMIV) Post traumatic stress disorder
(PTSD), 12.3% met criteria for another
DSM-IV anxiety disorder, 4.8% met
criteria for DSM-IV mood disorder,
and 4.8% met criteria for DSM-IV
somatoform disorder. (Ivan Komproe,
PhD, written communications, 2003).
Trauma, loss, and humiliation experiences that are part of the conflict
- are risk factors for mental disorders,
and it is thus to be expected that the
prevalence of mental disorder has
increased since the start of the Intifada.
The mental health of Palestinian
children and adolescents is of
particular concern. Children living in
war zones are at high risk of
developing emotional problems. In a
study conducted during the present
Intifada, the majority of children
exposed to bombardment and home
demolition, reported many emotional
symptoms (Thabet et al, 2002)1.
Mental health services
The Ministry of Health (MoH) of the
Palestinian National Authority is the
main statutory health provider
responsible for supervision, regulation,
licensing and control of all health
services. Other health providers
include the United Nations Relief and
Works Agency for Palestine Refugees
in the Near East (UNRWA), military
medical services, health services
belonging to national and international
non-governmental
organizations
(NGOs) including the Palestinian Red
Crescent Society and some private
health sector (for profit) organizations.
Overall,
service
provision
is
fragmented. The territory has neither a
mental health
policy nor a
comprehensive plan that addresses
both ongoing care for the severe
mentally ill and services for those
affected by the traumas and losses of
the conflict. There is no mental health
legislation, and no separate budget line
for mental health in the Ministry of
Health’s budget.
Fifteen community mental health
clinics are run as part of primary health
care services at a frequency of two to
six times per week by psychiatrists and
nurses without specialist training.
There is one mental health clinic for
children. Referrals can be made from
these clinics to hospitals. Outreach
services in most areas are minimal or
non-existent.
1 Thabet AA, Abed Y, Vostanis P. Emotional
problems in Palestinian children living in a war
zone: a cross-sectional study. Lancet.
2002;359:1801-4.
Gaza
The NGO Gaza Community Mental
Health
Programme
runs
four
community mental health centres in
Gaza. Many organizations in the
voluntary sector offer counselling as a
part of other (non-mental health)
services. There is no formal system of
referral between the NGO and
Government sectors. The Guidance
and Training Centre for the Child and
the Family (Bethlehem) NGO, runs
psychiatric services with a focus on
children.
UNRWA Gaza started a prevention
programme to respond to the needs of
the refugees during the second Intifada
in May/June 2002. It involves 66
counsellors working in schools,
medical centres and community
centres in the camps. Activities are at
the level of prevention and patients are
referred to professionals in mental
health when needed. A link with
resources in the community has been
developed. Counsellors are mainly
involved in group counselling with
parents, teachers, children and
adolescents.
UNICEF provides educational and
promotion services and materials for
playing, reading, learning and self
expression to children. NGOs and UN
agencies (particularly UNICEF) in
collaboration with many ministries run
short- and long-term courses on
counselling, crisis intervention, nursing
and social-work in relation to mental
health for health professionals,
teachers, parents, adolescents, and law
enforcement officers.
West Bank
There is a large custodial psychiatric
hospital in Bethlehem in the West
Bank. It has an occupancy rate of 5065% partly explained by problems of
accessibility due to restrictions on
49
mobility. The average stay for non
chronic patients is 5-8 months. About
100 out of 180 patients are chronic,
long-stay patients, and their well-being
in the hospital is of human rights
concern. The hospital in Bethlehem
absorbs the majority of resources
dedicated to mental health.
Overall, the mental health services in
the West Bank and Gaza are
fragmented. Donors and NGOs spend
millions of dollars every year on
psychosocial/mental health activities.
However, the mental health system in
most areas is not able to provide: (a)
rational treatment in primary health
care of common mental problems
(mood and anxiety disorders, including
trauma-induced problems); (b) care in
the community for chronic patients
with severe mental disorders, and; (c)
quality psychological support in the
school system for children and
adolescents who are faced with trauma
and other loss during the conflict.
Trainees
acquired
meaningful
knowledge and experience on the
organization of services and on the
practical functioning of a fully
community-based
mental
health
system.
Each
trainee
had
a
professional, personal tutor. Regular
meetings were held to have theoretical
discussions, and in collaboration with
the Training Programs Office, to
evaluate the needs for further training.
To date various, interlinked activities
have been undertaken as indicated
below.
The clinical knowledge provided
included; (a) the ability to manage
cases, taking into account the specific
contextual background of each service
user; (b) crisis management skills, and;
(c) the ability to create comprehensive,
personalised treatment programmes for
the
service
user
(biological,
psychological and
social inter
ventions). Trainees were exposed to
all activities of the mental health
service, including housing for people
with severe psychiatric disability,
vocational training, and employment
generation. Trainees also participated
in special programmes focusing on
subpopulations at risk and were
involved in ongoing work with general
hospitals, primary care settings and
prisons.
Training in Trieste for Palestinian
mental health professionals
WHO organized a five-month training
course of five Palestinian mental health
professionals in Trieste, Italy, which
ended in February 2003.
The
Palestinian
mental
health
professionals all had the opportunity to
become familiar with the operational
aspects of different structures of the
Trieste Mental Health Department.
They were also able to better
To address these and other issues, the
WHO has initiated a project aimed at
improving mental health policy and
services organization planning in the
West Bank and Gaza. The project was
conceptualised on the basis of a May
2001 fact-finding mission by the
Director of the Department of Mental
Health and Substance Abuse.
Project description
50
The provision of mental health care in
Trieste is organized and delivered
through
different
services
and
structures, each of which constituted a
basis for the training. The central point
for service delivery is the mental
health centre, which is open 24 hours a
day, seven days per week and
responsible for a catchment area
covering 60,000 persons.
persons with pre-existing disorders and
that exposure to extreme stressors and
losses is a risk factor for subsequent
social and mental health problems,
including common disorders. A range
of principles and
intervention
strategies that have wide support from
experts, can be tailored to apply to the
local context, needs and resources.
WHO has prepared a brief document
outlining advice on principles and
intervention strategies for populations
exposed to extreme stressors. This
document has become the basis for the
first-time inclusion of a mental and
social health section in the l2004
Sphere Handbook’. Because of the
relevance of the document to the
Palestinian context, and on specific
request of local organizations, WHO
translated, printed, and disseminated
an Arabic version of the document.
This publication shows how needed
social and mental health interventions
in and after emergencies can be
integrated in one framework that is
consistent with the development of
normal community mental health
services. Indeed, access to mental
health care in general health services is
a key mental health provision strategy
both in times of peace and during war.
understand the importance of different
professional roles in multidisciplinary
teams and had the opportunity to
experiment through collaboration with
their tutors and other Trieste staff.
This was done through training in case
management and by means of direct
contact with users, their network and
the general system of social support.
During 12 seminars organized for the
trainees, they had also the chance to
learn the theoretical aspects of the
transformation from a hospital-centred
organization to a community-based
system.
In addition to the aforementioned
training, a second group of Palestinians
visited Trieste in January 2004. This
was a one-week visit by senior
Palestinian mental health decision
makers. The visit helped these senior
officials become aware of alternative
ways of managing the severe mentally
ill.
The Trieste model (a fully
community-based model) is a good
example of how a cost-effective, high
quality, psychiatric service can be
successfully provided after a process of
deinstitutionalization of a custodial
psychiatric hospital.
It has been
WHO’s experience that one of the
most effective ways to convince
decision-makers about the value of and
need to develop community mental
health care, is to introduce them in vivo
to a high quality community service,
such as the one in Trieste.
Mapping of mental health resources
for the West Bank and Gaza
There are numerous NGOs and people
in Gaza and the West Bank involved in
the provision of mental health and
psychosocial services. Many of them
provide a vertical service for a narrow
target group of beneficiaries. These
organizations exist in the absence of an
adequate general mental health care
system to refer cases that are beyond
their mandate or capacity. NGOs
typically employ staff who can
potentially contribute to a general
mental health care system, especially
in the area of training. Capable NGOs
are also able to accept referrals from
An Arabic translation of the WHO
document,
Mental Health in
Emergencies: Mental and Social
Aspects of Health of Populations
Exposed to Extreme Stressorsf
WHO receives frequent requests to
advise on strategies to assist
populations exposed to emergencies.
There is broad consensus that
emergencies can severely disrupt
ongoing formal or informal care for
\ VO
08454
51
the general mental health care system
and can therefore be regarded as a
valuable resource.
It is WHO’s experience that it is
important to make a map of available
services. Such mapping can then
inform service organization plans. The
Institute for Community and Public
Health, Birzeit University has
conducted
the study
‘PsychoSocial/Mental Health Care in the West
Bank: the Embryonic System’. This
study is a careful mapping of mental
health resources in the West Bank.
WHO has contracted the University to
replicate the study in Gaza and to
publish the results of the studies in
Gaza and the West Bank.
The
resulting report (expected in May
2004) will greatly facilitate the use of
valuable NGO resources in the
development of general mental health
services.
Stakeholder meetings
To build a good mental health plan, it
was crucial to engage and listen to a
wide range of stakeholders that have a
role to play in the implementation of
the plan.
To this end, two stakeholder meetings
were organized in July by staff of the
WHO
Jerusalem
Office
in
collaboration
with
the
WHO
Department of Mental Health and
Substance Abuse. The Department
both funded the meetings and chose a
number of international consultants to
participate and give guidance.
A mental health plan for the West
Bank and Gaza
The Department has supported the
development of a Palestinian mental
health plan (endorsed by the Minister
of Health in February 2004).
Meeting in Gaza
The first meeting was held in Gaza and
the second in the West Bank
(Ramallah). These meetings - under
the slogan 'Mental health for all' were attended by a wide range of
Palestinian mental health and public
health
employees
and
by
representatives of the UN and NGO
communities. Despite severe problems
in freedom of movement (roadblocks,
curfews, etc), attendance was very
good. There were 60 participants in
Gaza and 85
Meeting in Gaza
52
in the West Bank,
representing:
• Mental hospitals in Bethlehem
and Gaza City;
• Ministry
of
Health-run
Community Mental Health
Centres throughout the West
Bank and Gaza;
•
•
•
•
Ministry of Health primary
health care system;
UN
organizations-UNICEF,
UNRWA;
Officials from the Ministry of
Health, the Ministry of Social
Affairs and the Ministry of
Planning;
Key local and international
NGOs.
During the meetings, international
experts ran intensive group-work
sessions with the participants to gather
as much input from the field as
possible on service organization needs.
■L
Ji
Meeting in Ramallah
Substantial and concrete feedback
from the various stakeholders informed
the first draft of the mental health plan
(see next section).
Appointment of a steering committee
The mental health plan was developed
by a Palestinian Steering Committee
for Mental Health.
The Steering
Committee was appointed in early
2003 by the Ministry of Health, in
consultation with WHO. Members of
the Steering Committee include
Directors of Primary Health Care in
the Ministry of Health (West Bank and
Gaza), the Directors of Community
Mental Health in the Ministry of
Health (West Bank and Gaza),
representatives of key NGOs, as well
as representatives of the French and
Italian Cooperation, WHO functions as
Secretariat.
As requested by the health authorities,
WHO facilitated the development of a
plan describing the (re) organization of
mental health services in the West
Bank and Gaza. The plan provides
guidance to the Ministry of Health on
how to advise national and
international organizations, as well as
donors, in building a well-coordinated
community-based
mental
health
system. In addition to providing a
practical strategy for psychiatric
reform, one of the benefits of such a
plan is that it substantially reduces
fragmentation, duplication of projects
and wastage of resources. WHO
therefore made a technical agreement
with the Ministry of Health, the
Consulate General of France - French
Cooperation, and the Consulate
General of Italy - Italian Cooperation
to ensure that there will be ongoing
consultation
and
institutional
collaboration
throughout
the
development and implementation
phases of the plan. This is important
because the French and Italian
governments as well as WHO
Jerusalem have generated substantial
resources (circa 3.5 million dollars) to
establish community mental health
services and the three projects are
being coordinated and run jointly.
WHO has supported the Steering
Committee in developing the mental
health plan as follows:
• providing scientific justification to
reshape services;
• guiding the planning process;
• providing guidelines, protocols and
standards;
• supporting the collection and
analysis of information on existing
services (see above);
53
contracting consultants/temporary
advisers to provide technical
assistance in the field;
• convening meetings.
•
With respect to the latter, the
organization
of meetings was
challenging. Because of road blocks,
curfews, and travel authorizations,
Palestinians from the West Bank and
Gaza were unable to meet each other.
These obstacles were overcome
through
videoconferencing
and
meeting abroad.
Meeting in Ramallah
I..
The final version of the plan was
submitted to the Minister of Health in
January 2004. The Minister signed and
approved the plan in February 2004
during a ceremony at the Ministry of
Health. Representatives of the Italian
and French Cooperation and the WHO
Office in Jerusalem also signed the
plan.
The project demonstrates that despite
the
ongoing
emergency
and
fragmented situation in the area, it is
possible to plan community mental
health services for the severe mentally
ill as well as primary health care for
those with common mental disorders,
including problems induced by trauma.
The plan provides the framework for
the development of services by
national
and
international
organizations that are present in the
West Bank and Gaza. The Ministry of
Health, the WHO Office in Jerusalem,
and the
Italian and
French
Cooperation, and major Palestinian
NGOs are presently working together
to implement the plan.
54
Signing of the Mental Health Plan for the West
Bank and Gaza by the Palestinian Minister of
Health
- Media
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