International Medical Corps South Sudan Baseline Mental Health Situational Analysis

March 2015  

 

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1.   Background 2.   Methodology

3.   Results 3.1  The Environment

3.1.1   Location and physical setting 3.1.2   Socio-economic profile 3.1.3   Socio-political environment 3.1.4   Socio-cultural attitudes towards

people with mental illness

3.2  The Health System 3.2.1   General health services 3.2.2   Mental health services

3.3  Mental Health Needs

3.3.1   Prevalence of mental health problems and psychological distress

3.3.2   Psychosocial issues

3.4  Anticipated challenges in mental health PHC integration

4.  Summary and Recommendations Appendices Appendix A: Situational Analysis

Information Framework and Data Sources

Appendix B: IMC MHPSS Situational Analysis Tool

Appendix C: IMC Mental Health Knowledge and Attitudes Questionnaire

Appendix D: IMC PHC MH Integration Checklist

Acknowledgements

The International Medical Corps South Sudan County Team as well as the Mental Health and Psychosocial Support Team have played a pivotal role in bringing this report to light. We especially wish to thank Dr Esubalew Wondimu, Gurusewak Khalsa and Erin Shedd for their invaluable assistance. Agany Majak, the national coordinator of the Global Mental Health PHC Integration Program has contributed substantially in the preparation of this report. We also wish to thank the many key informants who have shared valuable insights with us as well as International Medical Corps’ mental health specialists whose rapid assessment reports conducted earlier have contributed to much of the information included in this report.  

Contact

This report was completed by Dr. Neerja Chowdhary, International Medical Corps Global Mental Health PHC Integration Project Coordinator.

For questions regarding this report please contact: Dr. Inka Weissbecker, International Medical Corps Global Mental Health and Psychosocial Advisor (iweissbecker@InternationalmedicalCorps.org)  

Table  of  Contents  

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“South Sudan’s political turbulence is akin to the chaotic structure of a stream of water from a tap: unpredictable from moment to moment……”1 This sentence best describes the political chaos and resulting internal conflict in South Sudan since it gained independence in 2011. Fighting in Juba erupted on the December 15, 2013, causing the deaths and displacement of thousands and a wave of insecurity throughout the country, which continues today, particularly in the fragile states of Unity, Jonglei, and Upper Nile. Currently, 2.5 million people face crisis/emergency levels of food insecurity and 1.5 million people are internally displaced by conflict.2

International Medical Corps is currently operating both mobile and static health care units and nutrition interventions to highly vulnerable populations across the three states. In addition, mental health programming is deemed as being essential to address and strengthen the coping mechanisms of the populations in the current crisis, to mitigate the effects of stress and trauma on individuals and to support the social cohesion of society at large. The overall objective of this situational analysis is to review mental health needs and services in South Sudan before International Medical Corps started supporting mental health services in order to have baseline information as a comparison against follow-up and to inform International Medical Corps’ longer term Mental Health and Psychosocial Support (MHPSS) programming in the region. The sites in which this situational analysis has been conducted, therefore, are the sites in which International Medical Corps is currently implementing its MHPSS programs i.e. Juba, Maban, Malakal, Awerial and Akobo.

The situational analysis collated information collected during initial rapid assessments by International Medical Corps’ psychiatrists conducted in April and May 2013, February 2014 and October 2014 and as well as data collected subsequently by the Global and National International Medical Corps program coordinators.

The timelines of the different assessments are presented in the Gantt chart below: Assessment 2013 2014 2015

Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Rapid Mental Health Situational Analysis, International Medical Corps, Maban

Apr

Mental Health in Health Facilities, International Medical Corps South Sudan

May

Rapid Mental Health Siutuational Analysis: Awerial and Malakal

Feb

Rapid Mental health Assessment: International Medical Corps, Akobo and Juba

Aug

Field visit by Global Project Coordinator Feb Data collection methods included desktop reviews as well as semi-structured interviews and focus group discussions with key informants.  Appendix A provides the detailed situational analysis information framework and data sources that contributed to this report.  The specific tools used for data collection included (Appendices B, C, D):                                                                                                                  1  Alex de Waal. When Kleptocracy Becomes Insolvent: Brute Causes Of The Civil War In South Sudan. African Affairs, 2014, 113/452, 347–369. Downloaded from http://afraf.oxfordjournals.org/  2  The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) South Sudan: Crisis Situation Report No.78 (as of 12 March 2015).  

1. Background  

2. Methodology  

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1.   An adapted version of the WHO/UNHCR (2012) Assessing Mental Health and Psychosocial Needs and Resources - Toolkit for Humanitarian Settings, specifically, the checklist for integrating mental health in primary care in humanitarian settings and the Participatory assessment: perceptions by general community members

2.   A Knowledge and Attitudes questionnaire adapted from the following sources: a.   US Department of Health and Human Services, Substance Abuse and Mental

Health Services Administration (SAMHSA, 2010). Health Styles Population survey. Conducted annually in the United Stated by Porter Novelli and adapted from British Omnibus National Survey.

b.   Scottish Government (2008). Well? What Do You Think?: The Fourth National Scottish Survey of Public Attitudes to Mental Wellbeing and Mental Health Problems.

c.   Afghanistan Ministry of Public Health (MOPH). Basic Package of Health Services, Mental health Training attitude survey.

d.   IMC Iraq Mental Health Attitudes Survey (described in: Sadik, S., Bradley, M., Al-Hasoon, S., & Jenkins, R. (2010). Public Perception of Mental Health in Iraq. International Journal of Mental Health Systems 2010, 4:26). (adapted from Weller 1998, does contact with people with mental illness affect nurses)

e.   Questions suggested for Afghanistan by IMC Afghanistan Technical Team. 3.   Field guides for semi- structured interviews prepared based on themes to be explored

for this report.

Informed consent was obtained from all key informants who were interviewed.

Data collected was entered and analyzed using Microsoft Excel software. All qualitative data was analyzed using theme coding analysis.

3.1. The Environment 3.1.1. Location and physical setting South Sudan, officially the Republic of South Sudan, is a landlocked country in northeastern Africa that gained its independence from Sudan in 2011 following a referendum that passed with 98.83% of the vote. South Sudan is divided into ten states, which correspond to three

historical regions: Bahr el Ghazal, Equatoria, and Greater Upper Nile. It is covered in tropical forest, swamps, and grassland. The White Nile passes through the country, passing by Juba. 3.1.2 Socio-economic profile

South Sudan has a population of approximately 8 to 10 million (the exact figure is disputed) and a predominantly rural,

subsistence economy. This region has been negatively affected by war for all but 10 of the years since 1956, resulting in serious neglect, lack of infrastructure development, and major destruction and displacement. The economy of South Sudan is one of the world's most underdeveloped with South Sudan having little existing infrastructure and the highest

3. Results  

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maternal mortality and female illiteracy rates in the world as of 2011. The major ethnic groups present in South Sudan are the Dinka at more than 1 million (approximately 15 percent combined), the Nuer (approximately ten percent), the Bari, and the Azande. While inter-ethnic warfare predates the war of independence, since December 2013 up to 10,000 people are estimated to have been killed in the inter-ethnic Dinka-Nuer fighting.

3.1.3. Socio-political environment

Mental Health Policy and Legislation The policy statement on mental health as part of the South Sudan Health Policy (2006-­‐‑2011) asserts that mental health is an integral part of public health and that the Ministry of Health will work with the social and other sectors to develop a flexible integrated system of accountable, accessible, and equitable mental health care and support services particularly at the community level. It states that “a mental health strategy will be developed that will include advocacy, legislation and human rights, planning, financing and organization of services, quality, the use of psychotropic medicines and how to address the mental health of people of all ages including children and adolescents” (Government of South Sudan, 2007). To date, a draft Mental Health Strategy for South Sudan has been developed in a collaboration between WHO and the Ministry of Health (MoH, Dec, 2011) and is currently under review. It outlines six strategic components: 1. Strengthening leadership and political commitment for mental health 2. Scaling up integration of mental health in primary health care2

3. Strengthening secondary and tertiary care mental health services 4. Identifying and prioritizing vulnerable persons 5. Inter-­‐‑sectorial coordination and collaboration to promote mental health and prevent mental disorders 6. Promoting operational research. The strategy document also outlines mental health activities and levels of care from the catchment villages to Primary Health Care Units (PHCUs), Primary Health Care Centres (PHCCs) to the County Hospitals that are also specified in the South Sudan Basic Package of Health Services (BPHS) – (Table 1). Table 1: BPHS mental health activities outlined in the South Sudan MoH Strategy, 20113,4  Services  and  activities   Village   PHCU   PHCC   Hospitals  Mental health education and awareness   ü   ü   ü   ü  Case detection   ü   ü   ü   ü  Anxiety disorders (e.g. post traumatic stress; panic disorder)   refer   follow  up   ü   ü  Depression: identification and biopsychosocial management   refer   follow  up   ü   ü  Epilepsy: identification and treatment   refer   follow  up   ü   ü  Psychotic and psychiatric cases: biopsychosocial management   refer   follow  up   ü   ü  Mental retardation: identification, education to parents   ü   ü   ü   ü  Community based care and rehabilitation incl. support groups ü   ü   ü    Inpatient treatment   ü   refer   ü+  refer  Reporting ü   ü   ü   ü  Monitoring and supervision   ü   ü   ü  

                                                                                                               3  The  Basic  Package  of  Health  and  Nutrition  in  Primary  Care.  South  Sudan,  July  2011  (update)    4  Mental  Health  in  Health  Facilities,  International  Medical  Corps  South  Sudan,  May  2013  

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According to the BPHS, service elements for mental health include “(i) awareness creation at community level on mental disorders and their manifestations in local settings (ii) support for parents of infant with mental impairment, (iii) school-­‐‑based interventions, such as teacher to pupil counseling, peer to peer counseling, identification and referral of children with poor school progress, counseling and referral of children with “new” onset deterioration in class (iv) workplace and unemployment counseling programs for youths and adults, (v) activity programs for elderly people (vi) abatement of domestic violence and street related aberrant behavior, substance abuse, home and school truancy and gender related violence (vii) interventions to develop assertiveness, self-­‐‑reliance and appropriate participation, which are in turn components of mental health e.g, ‘gender equitable rights training” as an integrated component of programs for prevention of HIV infection”. The Government of Southern Sudan (2006) “Prevention and Treatment Guidelines for Primary Health Care Centers and Hospitals Clinical book” contains sections on neurology (including epilepsy) and psychiatry (including psychosis, depression, anxiety disorders, PTSD, alcohol dependence) and it covers psychosocial and pharmacological management. The guidance is only partially consistent with the WHO (2010) mhGAP Intervention Guidelines for mental, neurological and substance use conditions in general health settings and could benefit from updating. Nevertheless, the BPHS mental health component has not been implemented in South Sudan. General health staff has not received training in mental health and psychotropic medication and those is not yet on the list of national essential medicines for PHCCs and PHCUs. In terms of mental health rights and advocacy there is no mental health Act or other mental health related legislation in South Sudan and no informed consent procedures for inpatient admission or mental health treatment. Coordination Several organisations working in South Sudan started implementing psycho-social support programmes, to address the psychological and social effects of the civil war (detailed list in Table 6). This included international and national organisations. The scale and approach to psycho-social programming varied in approach and scale. There is still limited coordination and collaboration of the on-going psycho-social programmes in all sectors, like education, protection and health. This prompted the MoH to establish a MHPSS platform at the national level with the objective of enhancing the coordination and delivery of psychosocial support services and mental health services in South Sudan. Members are drawn from Government Departments, United Nations and Non-governmental Organisations working in health, education, (child) protection and other sectors (nutrition, security etc.) and meet once a month or as and when need arises. International Medical Corps is an active member of this group. The terms of reference of this Platform (drafted in December 2013) has the following specific objectives and activities5: 1.   To reinforce the active participation of the members of the Platform while making it an

‘attractive’ platform with an additional value for its members •   Visit each potential member of the Platform, assess the motivation, expectations and

expertise •   Identify final list of active members of the Platform

                                                                                                               5  Terms of reference for psycho-social support and mental health lead organizations in South Sudan. Drafted by the Mental Health Working Group. December 2013    

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•   Finalize the mapping of actors for MH and PSS at national and State level as initiated by UNICEF (5Ws format) and translate this in a visual map (who is doing what where)

•   Drafting a common and ‘attractive’ agenda in collaboration with Platform members •   To conduct monthly platform meetings

2.   Contributing to the development of national policies, laws, planning frameworks and

practices that enhance PSS and MH care programming •   Support the MoH in its efforts to put MH as a priority on their agenda •   Ongoing lobby and Advocacy efforts for PSS and MH within relevant Ministries in

collaboration with the Advocacy Workgroup of DCR •   Link the Platform with other different Clusters and Forums ((NGO) Health,

Education) and sub clusters (Child Protection, GBV), Ministries in collaboration with the Advocacy Workgroup of the Dutch Consortium for Rehabilitation (DCR)

•   Starting up to link the Platform to similar Regional initiatives (Burundi, Tanzania, Uganda, Congo) in order to exchange best practices

3.   Enabling the stakeholders of the Platform to share their knowledge and expertise towards improved capacity and quality delivery of PS and MH interventions •   Provide each member of the Platform the opportunity to present, share strategies,

activities, results and training opportunities •   Sharing existing Best Practices for PSS and MH care •   Compile existing assessments, surveys of the different members of the platform

about PS and MH prevalence rates, priorities to be addressed etc. 4.   Ensuring that consultation takes place within the Platform in case of an emergency for the

delivery of quality and cultural appropriate PS/PFA services •   Organizing an ad-hoc meeting of the Platform in case of an emergency •   Briefing and exchanging about the results of the emergency related actions

3.1.4 Socio-cultural attitudes towards people with mental illness

The lack of a mental health policy and widespread social stigma in South Sudan has meant that mental illness is a hidden issue. People with mental illness are vulnerable to human rights violations, to physical and emotional abuse and from discrimination both from health workers and the wider community6.

Perceptions of general community members

Data in this section has been collated from the earlier rapid assessments (2013, 2014) as well as the recent field assessment done by the Global coordinator (Feb 2015). The sources are detailed in Appendix A. During the 2015 field assessment, community members were asked about their understanding of mental illness using the Participatory Assessment Questionnaire (see Appendix B). This explored how the community recognized someone with a mental illness, the perceived impact of mental illness including how the community treated people with mental illness, coping methods used by the patient and family and the pathways to care. The findings from these interviews are informing the content of International Medical Corps’ awareness raising activities in the community.

                                                                                                               6  WHO  AIMS  report  on  mental  health  system  in  South  Sudan.  2009  

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A total of 63 (39 women, 24 men) respondents were interviewed in 4 FGDs. In general, people with mental illness are identified as those who display bizarre appearance and behavior or those with ‘thinking too much’ (Table 2). The former group share common features with psychotic disorders (and called ‘Jin’) as described in Western classification systems. People who had experienced stressful life events were identified as ‘thinking too much’ and having symptoms suggestive of depression/anxiety disorders.

In addition, during the International Medical Corps rapid assessment conducted in Maban (May 2013), key informants reported that non-specific somatic complaints and somatic problems in reaction to stress are common. Depression usually occurs with somatic complaints and people tend to speak about stress in physical ways. Indeed, a local counselor may open a consultation by saying “how is the body”7.

Causes attributed to mental illness were an evil curse, punishment from God due to sins committed by him or his family (including ancestors), stress caused by the conflict, lack of support from family and close ones.

The impact of mental illness is experienced by the individual, the family and the community. The patient’s physical health may be affected, the family may be abandoned or suffer neglect and the community may be exposed to violent acts by the person with mental illness.  

 

 

Table 2: Summary of mental health problems including symptoms, impact and help-seeking (Source: FGDs with community members, Feb 2013 and International Medical Corps rapid assessment, Maban 2013)

MHPSS Problem

Signs/Symptoms Impact Ways of help-seeking

Jin (possibly psychosis)

Talking alone, saying something that people do not expect them to say, getting worried and almost mad, going and shouting as if something surprised him, person cannot be understood by people, feeling like they need to get something but cannot, fighting, being in the street, not being able to think properly, wandering naked, neglect personal hygiene, isolated, talk to themselves

On the individual: Physical illness, don’t get married. Suicide On  the  family:  abandon  the  family,  including  childrenOn  the  community:  may  be  aggressive  and  violent  with  other  people  

Nothing can be done, some people can recover, some go to the hospital. Those one with severe mental disorders are taken to prison or tied up at home to protect them from making harm to the people. Some families isolate them, don’t take care of them Some take them to the traditional healer/doctor who may advise them to slaughter/sacrifice sheep, chicken

Thinking a lot (possibly depression)

People think about what they had before and what they worked hard for (e.g. land, business, cattle that died or was left behind), they sit with their head down and are worried, they cannot complete daily tasks

There is no help, people do not have a chance to gain anything back.

Alcohol abuse On the individual: neglect of personal health and appearance, may have physical complications such as oedema, anaemia. Neglected by family On  the  family:  These people show lack of responsibility, stress in the family, violence,  

                                                                                                               7  Rapid  Mental  Health  Situational  Analysis,  Maban  Refugee  Camps,  South  Sudan,  International  Medical  Corps.  April  2013  

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Help seeking involves either doing nothing, taking the person to prison or hospital or seeking the help of religious/faith healers. Coping: A literature review article on the mental health of South Sudanese refugees in the Diaspora found that mechanisms of coping with emotional distress, including encouraging connections with others, group social support and sharing experiences, helped to ease emotional difficulties8.   Community members in the refugee camps were asked about the ways in which people cope and support each other. The results are summarized below.

Support of people in need •   Coming together to help each other •   If someone does not have something, neighbors will share

what they have or take up a collection •   Giving sick people water and porridge •   When someone in the community dies, neighbors cook for

their family

Music and art •   Dance, music and drama groups •   People coming together and playing guitar

and drums

In addition, people with mental illness are helped by family in fulfilling their practical needs such as nice clothing, good food, Shelter to sleep in and help with bathing and personal hygiene. Perceptions of healthcare providers  In order to obtain information about knowledge and attitudes towards people with mental illness among health care providers, a self-report questionnaire was administered to a cohort of 33 respondents whose work experience ranged from 2 weeks to 3.5 years. They were composed of clinical officers (n=7), nurses (n=14), midwives (n= 4), social workers (n= 2) and others (n=6). The questions were rated on a 5-point scale (5=agree, 4=agree somewhat, 3=neutral, 2=disagree somewhat, 1=disagree). Note: While social workers are not directly targeted in the mhGAP training, they have been included here since they support activities in the PHCs. Amongst the causes that health care providers attributed to mental illness, most believed that it was due to trauma/misfortune and almost half believed that mental illness may have spiritual causes or occur as a result of personal weakness. (Figure 1).

Figure 1: Healthcare providers’ perceptions of the causes of mental illness

                                                                                                               8  Tempany  M.  What  research  tells  us  about  the  mental  health  and  psychosocial  wellbeing  of  Sudanese  refugees:  a  literature  review.  Transcult  Psychiatry.  2009;  46(2):  300-­‐‑15.  

76

45 4236

18

0

20

40

60

80

Mental  illness  is  caused  by  bad  things  happening  to  youI  think  mental  disorders    have  mainly  spiritual  causesMental  illness  is  caused  by  a  personal  weaknessMost  people  with  convulsions  are  faking  (pretending)Mental  illness  is  God's  punishment   for  having  done  something  wrong

%  of  respondents  who  agreed  or  somewhat  agreed

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Healthcare providers tended to underestimate the abilities of people with mental illness, the majority believed that they were less intelligent and less likely to succeed at work as compared to others (Table 3). They also believed that people with mental illness were difficult to speak with and incapable of true friendships. The majority of the respondents believed that people with mental illness were dangerous and unpredictable but believed that their rights should be respected. Self stigma (i.e. avoidance of disclosure about one’s mental illness due to anticipation of negative attitudes) was not a major consideration amongst health care providers and the majority demonstrated positive attitudes towards treatment of people with mental illness. These findings have important implications when planning training modules for healthcare providers.

Table 3: Perceptions of health care providers towards people with mental illness

ATTITUDE TOWARD PEOPLE WITH MENTAL ILLNESS

% Agreement (agree and agree somewhat)

ABILITIES OF PEOPLE WITH MENTAL ILLNESS

Most people with mental illness are less intelligent than the average person 55

People with mental illness can work 67

People with mental illness can be as successful at work as others 39

People with mental illness cannot speak for themselves 30

People with mental illness need others to make decisions for them 76

People with mental illness are not capable of true friendships 61

People with mental illness are hard to talk with 64

RISKS POSED BY PEOPLE WITH MENTAL ILLNESS

People with mental illness are dangerous to others 64

People with mental illness are unpredictable 61

RIGHTS OF PEOPLE WITH MENTAL ILLNESS

People wih mental illness should be prevented from having children. 42

People with mental illness should not get married 33

People with mental illness should have the same rights as anyone else. 76

People with mental illness do not need privacy 45

STIGMA OF MENTAL ILLNESS

One should avoid all social contact with people with people with mental illness 27

One can always tell a person with mental illness by his or her physical appearance 79

Anyone can suffer from a mental illness 85 I would be ashamed if people knew that someone in my family had been diagnosed with a mental illness 30

If I was suffering from a mental illness, I would not want people to know about it 30

CARE OF PEOPLE WITH MENTAL ILLNESS

People are generally caring and sympathetic to people with mental health problems 76 If a patient is asked if they have suicidal thoughts they are more likely to commit suicide 33

It is not important to take the preferences of the person with mental illness into consideration when choosing treatment 42

People with mental illness who receive treatment and support can lead normal lives 94

Most people with mental illness will improve if given treatment and support 94 I believe that keeping people with mental illness in the hospital makes the community a safer place 76

People with mental illness should not be told about possible adverse side effects of their medications 48

People receiving mental health care are weak 42

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People with mental illness can receive good care from a traditional healer 12

3.2 The Health System

3.2.1 General health services

South Sudan is acknowledged to have some of the worst health indicators in the world. The under-five infant mortality rate is 135.3 per 1,000, whilst maternal mortality is the highest in the world at 2,053.9 per 100,000 live births (Table 4). The epidemiology of HIV/AIDS in South Sudan is poorly documented but the prevalence is believed around 3.1%. South Sudan probably has the highest malaria burden in sub-Saharan Africa" and is one of the few countries where dracunculiasis (guinea worm disease) still occurs Table 4: Basic Health Data   Health  week  10   Cumulative*  Number  of  medical  interventions  (whole  country)   76,780   713,578  Number  of  people  in  need  (whole  country)     6,400,000  Number  of  people  targetted  (whole  country)     3,400,000  Outpatient  consultations  conducted   74,018   615,094  Vaccination.  Children  0-­‐‑5  years  protected  against  polio  in  round  3  SAID  in  3  conflict  affected  areas  

  844,483  

Reproductive  health  –  women  provided  ANC  services   2,452   27,343  Reproductive  health  –  women  with  caesarian  sections   31   411  People  reached  with  GBV  prevention  messages      Cholera  suspected  cases   9   52  Leishmaniasis  cases   6   1025  Hepatitis  E  cases   2   6  Health  Cluster  as  of  12th  March  2015  *Cumulative  figures  are  of  29  December  2014   South Sudan has 3 teaching hospitals, 7 state hospitals and 27 county hospitals. There are 792 Primary Health Care Units (PHCUs) and 284 Primary Health Care Centres (PHCCs) out of which 20% are not functional because of lack of skilled medical and health personnel. In addition, there are 10 private health facilities, 14 specialised facilities and 10 police/military health facilities International Medical Corps Sit analysis May 2013). On average, in rural areas, there are about 14,000 people per health unit and 75,000 per health center. There are about 400,000 people per hospital; a recent inventory of hospitals in South Sudan describes a heavy, largely derelict infrastructure9. Since the December 2013 conflict, a number of International organisations have begun providing health services to meet the growing need (Figure 2). Figure 2: Health Cluster Mapping in South Sudan (July 2014)

                                                                                                               9  The  Basic  Package  of  Health  and  Nutrition  in  Primary  Care.  South  Sudan,  July  2011  (update)  

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3.2.2 Mental health services

In South Sudan, a country of some 11 million people, there are only two trained psychiatrists. "The scale of the problem is huge," says Dr Atong, one of those two, and the new head of mental health care in South Sudan. There is no psychiatric hospital in the country. There is one psychiatric inpatient and one outpatient department as part of the Juba Teaching Hospital. The capacity of the psychiatric department is 12 beds (Table 5). The Military Hospital in Juba provides counselling services to some patients with mental illness. People who suffer from mental illness are also put in in jail. From mid-2011 to mid-2012, 90 South Sudanese were in prison only because they appeared to have mental illness.10 The psychiatrist and psychiatric assistants from Juba teaching hospital conduct regular ‘ward reounds’ in the prison where patients may stay upto one month, ususally 1-2 weeks. This has been cited as a source of concern to human rights organisations.11 Table 5: Mental health facilites and resources in Juba (Source: International Medical Corps MH Situational Analysis May 2013) Staffing Psychiatrist Psychologists Social workers Other Juba Teaching Hospital Psychiatry ward, Juba

2 1 0 3 psychiatry medical assistants 2 counsellors 2 nurses (2 OPD, 6 IPD)

Training Trained in Tanzania and Kenya

Trained in Khartoum (MA in clinical psychology)

Specialist psychiatric medical assistant training in Khartoum. Occassional in-service training

Juba Military Hospital, Juba

0 3 counsellors 0

Training Training in psychology

                                                                                                               10  Solomon  Ehiemua.  Mental  Disorder:  Mental  Health  remains  an  invisible  problem  in  Africa.  European  Journal  of  Research  and  Reflection  in  Educational  Sciences  Vol.  2  No.  4,  2014    11  http://www.hrw.org/news/2012/06/21/south-­‐‑sudan-­‐‑arbitrary-­‐‑detentions-­‐‑dire-­‐‑prison-­‐‑conditions  

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While the MoH has begun mapping the mental health service providers in the country since early 2015, this information is not available to date. International Medical Corps mapping conducted during the rapid situational analysis (2013, 2014) and updated during the recent field visit (February 2015) are shown in Table 6, below. Table 6: Select NGOs involved in psychosocial activities in International Medical Corps field sites

Who What Where Handicap International Psychosocial sessions for persons with disability

Juba POC (Persons of Concern camps)

Oxfam Food security and livelihood Juba POCs UNMISS Provides inpatient support and medication for patients referred from

International Medical Corps PHC. Coordinates referral to MoH specialist in Malakal regional hospital

Malakal (Level 2 hospital)

ACTED (Agency for Technical Cooperation and Development)

WASH, SGBV in camps, Food Security and Livelihoods & Camp management

Juba POC Akobo Maban – Kaya, Gendrassa

IOM (International Organisation for Migration)

Registration/Verification of the affected populations; • Stand by teams to register new spontaneous and organized arrivals; • Information sharing

Juba POC Malakal

World Vision General food and blanket distribution & supplementary feeding

Juba POCs Malakal

MSF Inpatient hospital – medical - in Maban. Earlier providing MHPSS services in Gendrassa camp – the patients have now been handed over to International Medical Corps Inpatient hospital in Malakal with 1 psychologist and 2 counsellors – psychosocial activities for women and children admitted in the hospital. Community awareness about mental health

Maban – Batil, Malakal. Earlier, Awerial

Samaritan’s Purse Bunj County Hospital, Inpatient facility. Receives some patients with MI, Epilepsy. Has essential psychotropics

Maban, Bunj

DRC (Dutch Consortium for Rehabilitation)

Psychosocial support including child friendly spaces and women centers Works closely with ACTED. Prepared SOP for SGBV to which IMC will be a signatory

Maban, Malakal

LFW (Lutheran World federation)

Protection (women and children)

Maban

Relief International PHC and mobile units Maban – for the host population

Health Link (S. Sudan NGO)

Runs 2 inpatient health facilities handed over by MSF. Some basic psychosocial services. May have some meds – diazepam, amitriptyline

Awerial

International Red Cross GBV: Case Management and referral • Women and adolescent girls have safe access to psychosocial support activity, women empowerment activities, women’s network built to support each other and access important information and freely voice their concerns through the IRC women’s center. • Protection monitoring – Through out reach activities and risk assessments • Referral – Of people with specific needs (PSNs) to proper agencies • Case Management – Identification, referral/support, follow up • Information sharing - Provision of information about the services available in the camp

Awerial

CCM (Comitao Collaborative Medica)

Runs the PHC with MoH. Offer basic counseling to people in distress Awerial

Save the Children Education, Identification, registration, follow-up and tracing/reunification of separated or unaccompanied children • Child Protection Center (Child Friendly Space)

Akobo Awerial

Plan International (Supported by WFP)

Food distribution Psychosocial support integrated at the child friendly spaces

Akobo Awerial

Psychotropic medication availability: The South Sudan essential medicine list includes drugs for epilepsy and mental illness. However, only a limited number of psychotropic medications are available in the health facilites and their supply is inconsistent. Private pharmacies in Juba stock psychotropic

  13  

medication but this is expensive and beyond the reach of most people. The MoH too depends on donations from WHO and OVCI (Organismo di Volontariato per la Cooperazione Internazionale) to obtain psychotropics but this is provided only to Juba Teaching hospital and not in other parts of the country. This means that continuation of maintenance medicines is often not possible for patients from outside Juba. Currently, the MoH is trying to negotiate the price of drugs with the private pharmacies by reducing taxes. Specialist training: Opportunities for training in mental health are limited in South Sudan with no specialised training available in psychiatry, psychiatric nursing or psychology. Some health staff such as clinical officers at the Juba Teaching Hospital complete one month placements in the psychiatric department. There are plans to develop new course material in psychiatry to train medical doctors at the Juba Teaching Hospital.

Baseline Mental Health PHC Integration: survey results

A survey was conducted in 11 health facilities to assess mental health capacity and integration using the IMC MH PHC Integration checklist. The survey was conducted prior to the onset of training to reflect baseline information. Table 7 below provides details on the number of health facilities surveyed with the corresponding catchment population per facility type. All of these facilities shown in Figure 3 are supported by International Medical Corps in the current MHPSS program. Figure 3: International Medical Corps supported health facilites in 5 sites in South Sudan (marked with pink arrows)

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Table 7. Details of health facilities surveyed

Site Health Facility Total Catchment Population

Average No. of Patients

Seen per Day

Staff details

Doctor Clinical

officer Nurse/

Nurse asst Midwife Social

worker/Psy-chologist

CHW Others

Juba POC

Inpatient facility 20,000 150 1 5 10 3 0? 6 4

PHC1 20,000 80 1 2 5 0 29

PHC2 2500 45 0 1 1 0 15

PHC3 20,000 220 1 1 0 2 11

Maban refugee camps

Kaya PHC 21,000 150 1 6 3 2 64

Gendrasa PHC 18,000 250 1 5 3 2

Malakal IDP camp

PHC1 17,000 70 1 2 5 1

PHC2 17,000 150 1 3 4

Awerial IDP camp

PHC1 12,743 80 1 2 3 2 3

PHC2 33,300 70 1 1 3

Akobo County Hospital 185,000 100 3 3 33 5 59 5

The average catchment population of the facilities is 33,322 (range: 2500-185,000) with an average of 124 (range: 45-250) patients visiting the outpatient clinics per day. Staff details: The number of staff in the health facilities varied. Table 7 shows the number of staff per type of health facility. Psychotropic medication availability: Table 8 below illustrates the availability of psychotropic medications Table 8. Availability of psychotropic medication (by site) in 11 International Medical Corps health facilities (10 PHCs and 1 County Hospital).

Basic Pharmacy Data Psychotropic Medications Facilities with available psychotropic medication in the

PHC clinic or nearby pharmacy in the previous week (by site) Juba Maban Malakal Aweria

l  Akobo  (county  hospital)  

Generic antidepressant medication (amitriptyline, fluoxetine)

Never Never Never Never Usually

Generic anti-anxiety medication (diazepam) Usually Never Usually Never Usually Generic anti-psychotic medication (haloperidol tab and injection, chlorpromazine, Thioridazine)

Never Never Never Never Usually

Generic anti-epileptic medication (phenobarbital carbamazepine, diazepam inj, valproic acid)

Never Never Usually Never Usually

Generic bipolar disorder medication (valproic acid, carbamazepine)

Never Never Never Never Never

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Medication as part of substance use programs (nicotine replacement therapy)

Never Never Never Never Never

Generic antiparkinsonian medicine for the management of side effects from antipsychotic medication (biperiden)

Never Never Never Never Usually

Basic laboratory services: Laboratory services to support initiation and monitoring of some psychotropic medications are largely unavailable in the International Medical Corps supported health facilities (Table 9) Table 9: Laboratory services (by site) in 11 International Medical Corps primary health facilities. Laboratory services Juba Maban Malakal* Awerial** Akobo Complete blood count Referred to the Juba

Teaching Hospital or private lab outside the camp

X ✓ ✓ X

Liver Function test Referred to Juba Teaching Hospital

X ✓ X X

Thyroid Function test Referred to Juba Teaching Hospital

X X X X

Rapid blood glucose ✓ ✓ ✓ ✓ ✓ Toxicology screening test (urine) Referred to Juba Teaching

Hospital X ✓ X X

Creatinine clearance test Referred to Juba Teaching Hospital

X ✓ X X

Serum Lithium X X X X X *Laboratory services available at the UN hospital *Laboratory services available at the hospital run by Health Link Staff training and skills: Table 10 shows the number of staff who were provided in-service MH training. No PHC staff received in service mental health training and/or support supervision in all PHCs in Juba and Akobo County Hospital. None of the staff had heard of the mhGAP program and the guidelines. Several Doctors and Clinical Officers in camp clinics had completed their studies in neighboring countries such as Uganda, Ethiopia and Kenya. Several of them had received theoretical training on mental health and some have also completed clinical placements of one to three months in psychiatric facilities (e.g. Butabika mental hospital in Uganda, psychiatric unit at Juba teaching hospital). At the level of community response the community volunteers recruited by various agencies can be an important resource to strengthen the overall coping of the community with mental health issues and to provide assistance and emotional support. Community health workers working in Juba and Akobo did not receive any training related to MHPSS including psychological first aid (PFA). The exceptions to this are two counselors who had been working with MSF-B in Juba PoCs (Persons of Concern camps). The two counselors received training on basics of counseling by MSF?. In Malakal UNHCR and DRC recently began training of community mobilisers. International Medical Corps had trained community members in basic counseling skills and psychosocial support for its Nutrition and GBV program. In Maban, some staff had received prior training from MSF in PFA. Table 10. Staff training (by site) in 11 International Medical Corps health facilities (10 PHCs and 1 county hospital) prior to initiation of the MHPSS program Staff Training Indicators

Staff What % of this staff was trained? How many sessions of on the job supervision were provided?

% of staff trained No. of sites (N=5) % of supervisions No. of sites (N=5)

Doctor ⓪None (0%) ①Some (1-50%) ②Most (>50%)

2 3

⓪None  (0)    ①Some  (1-­‐‑2)  ②Several(>3)

5

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Clinical officer ⓪None (0%) ①Some (1-50%) ②Most (>50%)

2 3

⓪None  (0)    ①Some  (1-­‐‑2)  ②Several(>3)

5

Nurse/nurse asst ⓪None (0%) ①Some (1-50%) ②Most (>50%)

3 2

⓪None  (0)    ①Some  (1-­‐‑2)  ②Several(>3)

5

Midwife ⓪None (0%) ①Some (1-50%) ②Most (>50%)

5 ⓪None  (0)    ①Some  (1-­‐‑2)  ②Several(>3)

5

Social Worker/psychologist

(Not applicable)

⓪None (0%) ①Some (1-50%) ②Most (>50%)

⓪None  (0)    ①Some  (1-­‐‑2)  ②Several(>3)

CHW ⓪None (0%) ①Some (1-50%) ②Most (>50%)

4 1

⓪None  (0)    ①Some  (1-­‐‑2)  ②Several(>3)

5

During the rapid assessment in Maban (May 2013), a questionnaire was administered on current practices in identifying and addressing priority mental and neurological problems among general health staff in International Medical Corps PHCC/PHCU facilities (5 Clinical Officers, two nurses, one midwife). Data showed that the staff were making efforts to address mental health problems encountered in clinical practice, especially non-specific somatic complaints. General health staff were already identifying and managing some people with mental illness. Staff at general health facilities in the camps and the referral hospital were asked how they identified and managed mental health cases. Their responses are presented in Table 11, below.   Table 11: Ways of managing mental health problems at health facilities among general health care providers (PHCU, PHCC, hospital)      

Medically unexplained somatic complaints/depression were most common and providers could not distinguish between both. Other mental disorders were detected only rarely and there was a wide variation across camps (which could be due to different diagnostic skills of healthcare providers) and over time. General health staff at PHCU clinics reported that they

Mental health related problem

Reported Signs Psychosocial Intervention Pharmacological Intervention

Unexplained somatic complaints and depression with somatic elements

Somatic complaints such as not being able to sleep, dizziness, headache, general body pain, leg pain, patients say they have fever (but do not), joint pain (many come two days later with another problem)

Giving advice (e.g. explaining that medication is not the solution, that there is no physical problem), talking about stressors (e.g. lost property)

Antihistamine (for sleep/side effect), pain medication (e.g. paracetamol), folic acid (if indicated)

Depression Insomnia, loss of appetite, signs of stress General counseling Treat with diazepam and multi-vitamins

Insomnia Being unable to sleep Asking about current stressors (e.g. problems with husband), providing re-assurance, advising to “take it easy”

None

Psychotic disorders Talking alone, shouting, running off PHCC/PHCU: Talking to them, giving needed items such as mosquito net, piece of clothing (and refer)

Regional hospital: inpatient admission, giving drugs (diazepam) to calm down

Epilepsy Convulsions None Treat with Phenobarbitol (if available)

Inpatient admission and diazepam

Developmental disorders

Slow development Giving nutrition advice N/A

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do not see people with psychotic disorders at health facilities but that they do see them in the market and around the clinic. Pharmacological management for mental health problems was often not consistent with global guidelines. Some psychosocial management such as addressing current psychosocial stressors is consistent with mhGAP. However, staff could benefit from learning about the range of psychosocial (and pharmacological if appropriate) brief interventions in the mhGAP guide (especially for non-specific somatic complaints, depression and intellectual disabilities). General health staff with previous mental health training reported using their skills when counseling patients but also noted that patients with mental disorders are often not identified or not accessing health facilities. They noted that community awareness raising and a referral system would be needed. In terms of staff roles and team work, in none of the 11 facilities did the staff have defined roles in identification, management and referral of mental disorders nor did discussion of MH cases take place. Referral from general health care to mental health services: General health clinics within the camps in Maban reported referring people with severe mental health problems to the Bunj Hospital where some psychotropic medication is available and patients are kept for a short time as inpatients. In the Juba camps, referrals were made to the Juba teaching hospital and in Malakal to the UN hospital. None of the other sites had referral options for patients with mental illness. Referral from general health care to other services: Referrals are made by general health care providers for GBV, general protection, child protection to International NGOs ie. IRC, DRC, and UNHCR. Only very few health care providers reported having referral links with other agencies. Children with intellectual disabilities and people in need of physical rehabilitation are at times referred to Handicap International. Health Information System (HIS) reporting: HIS reporting to UNHCR occurs at all camp health facilities. UNHCR has one category for mental health and neurological conditions, which is broken down into seven sub-categories and which are used globally by UNHCR and other agencies. Some health facilities including International Medical Corps were reporting under one category of “mental illness or distress” but this was done in an inconsistent manner.

3.3 Mental Health Needs

3.3.1 Prevalence of mental health problems and psychological distress

The World Health Organization estimates that in humanitarian emergencies, the percentage of people with common mental disorders such as depression or anxiety disorders can double from a baseline of 10% to about 20%, while severe mental disorders such as psychotic disorders, which are more rare, can increase by 1% over the baseline of 2–3%.12 In addition, persons who are marginalized and with various disabilities (people with hearing, visual and movement disabilities, with intellectual impairment and with epilepsy) are often neglected or have no caregivers, and/or lack access to services. The Health Cluster Bulletin (December 2014) while identifying the need for mental health services states that 30% to 50% of total outpatient consultations in the Malakal PoC and Mingkaman IDP camp consist of people with mental health problems. There are also concerns that there may be under-reporting of people with mental illness either due to lack of

                                                                                                               12 World Health Organization & United Nations High Commissioner for Refugees (2012). Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Major Humanitarian Settings. Geneva: WHO, 2012.

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identification by health facility staff or failure to seek help by patients/families13. This is illustrated in the following observation made by one of the International NGO staff in Awerial; “Mental health is the Hippopotamus in the water” - what is seen is only a small part of what is really there. For e.g. one woman committed suicide and only after that did people say she had a mental problem. People don’t recognize that such people need medical attention.

While mental health data from South Sudan is limited, one post-conflict study from Juba found that 36% of the sampled population (n=1242) met criteria for post-traumatic stress disorder (PTSD) and 50% for depression14. The multivariate logistic regression analysis showed strong associations of gender, marital status, forced displacement, and trauma exposure with outcomes of PTSD and depression. Men, IDPs, and refugees and persons displaced more than once were all significantly more likely to have experienced eight or more traumatic events. A study, conducted in northern Uganda and South Sudan, found the prevalence of PTSD was 46% among South Sudanese refugees and 48% among South Sudanese who stayed in the country15. Another study that combined data from rural and urban settings and used diagnostic interviews (rather than only symptom rating scales) PTSD only was found in 331 (28%) and depression only in 75 (6.4%) of the study population. One hundred and twelve (9.5%) of the participants had PTSD-depression comorbid diagnosis. Exposure to traumatic events and socioeconomic disadvantage were significantly associated with having PTSD or PTSD-depression comorbidity but not with depression. Participants with a comorbid condition were more likely to be socioeconomic disadvantaged, have experienced more traumatic events, and showed higher level of psychological distress (PD) than participants with PTSD or depression alone.16 The estimated rates of generalized anxiety disorder (GAD)-only and PD-only (without comorbidity with PTSD) were 5.5% and 3.1%, respectively. Exposure to traumatic events and socio-economic disadvantage were significantly associated with having one or more anxiety diagnoses. After controlling for age, sex, rural/urban setting, and socio-economic disadvantage, exposure to trauma was independently associated with anxiety diagnosis. There were gender differences in the pattern of risk factors for having PTSD, GAD or PD17. Anxiety, substance abuse, and substance abuse-related complications such as alcohol withdrawal are also frequently seen in post-conflict settings18. Alcohol and drug abuse is a growing concern in South Sudan as increasing social freedom and access to alcohol and drugs bring increased risk for excessive use and harmful consequences19. These studies indicate a high prevalence of mental illness in South Sudan as well as the potential for an increase in psychiatric disease as more refugees and internally displaced persons return home20.  

3.3.2 Psychosocial issues

                                                                                                               13  South  Sudan  Cluster  Bulletin  #34.  21st  December  2014  14 Roberts B, Damundu EY, Lomoro O, Sondorp E. Post-conflict mental health needs: a cross-sectional survey of trauma, depression and associated factors in Juba, Southern Sudan. BMC Psychiatry. 2009; 9: 7.  15 Karunakara UK, Neuner F, Schauer M, Singh K, Hill K, Elbert T, et al. Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. Afr Health Sci. 2004; 4(2): 83-93. 16 Ayazi et al. What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? a cross-sectional community study in South Sudan BMC Psychiatry 2012, 12:175 17 Ayazi et al. Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community study in South Sudan BMC Psychiatry 2014, 14:6 18 de Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet. 2003; 361(9375): 2128-30. 19 King. Alcohol a Growing Problem in South Sudan. Voice of America. 2006. 20 Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders. Maithri Ameresekere, MD, MSca and David C. Henderson, Mda. This document was originally published in two parts the South Sudan Medical Journal in volume 5 number 1 and number 2.

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On collation of information that was reported in the International Medical Corps rapid assessments (Maban, 2013, Awerial and Malakal 2014) and collected during the field visit (February 2015; interviews with 13 PHC staff in Juba, Maban, Malakal, Awerial; 1 FGD with 13 community health workers in Malakal), the following stressful circumstances were cited as most common and can increase the risk of developing mental health problems:

•   Loss of loved ones: Having family members killed as a result of the violence or death of family members due to physical illness.

•   Conflict and violence: domestic violence, cattle raiding, tribal conflict, past experience of violence or armed conflict, killing or torture of children

•   Protection issues: kidnapping of children, orphaned children due to violence, early marriage

•   Health/GBV issues: spread of STDs •   Environmental issues: Overcrowding, food insecurity, risk of floods

In addition, refugees reported a range of problems in their daily lives that impact their mental health (Table 12): Table 12: Psychosocial problems identified by people residing in the refugee/IDP camps21

•   Physical  health  (e.g.  Sickness,  Diarrhea,  Eye  problems,  dizziness  from  heat,  back  pain  from  grinding)  

•   Available  Medical  treatment  (e.g.  People  at  the  health  center  give  tablets  without  examining  what  the  problem  is,  at  home  injections  and  syrup  for  children  were  available  but  not  here  (children  throw  up  pills))  

•   Food  and  Nutrition  (e.g.  lack  of  tea,  coffee  sugar,  salt,  and  milk,  green  vegetables,  only  sorghum  and  lentils  available,  no  balanced  diet,  supplementary  food  only  available  for  children  under  5,  low  quality  supplementary  food)  

•   Food  preparation  (e.g.  Sorghum  available  but  nothing  to  grind  it  (only  few  grinding  machines  are  available),  would  need  seeds  for  vegetables  (before  rainy  season),  no  place  to  dig  and  plant)  

•   Shelter  (e.g.  tents  are  hot  and  wearing  out,  grass  houses  would  be  better  but  they  have  to  pay  to  cut  the  grass  or  the  host  community  chases  them  off  the  land)  

•   Weather  (e.g.  heat  (different  from  what  they  are  used  to,  tents  are  hot  inside),  changes  in  weather)  

•   Insects  (e.g.  too  many  flies,  not  enough  mosquito  nets)  

•   Education  (e.g.  Education  for  children  is  not  up  to  date,  both  children  and  adults  need  education,  not  enough  teachers,  teachers  are  not  qualified  enough)  

•   Economic  (e.g.  no  employment  available)  •   WASH  (e.g.  It  takes  time  to  get  to  water  points,  water  

tables  are  low,  not  enough  soap  available  (only  2  pieces  per  person  per  month))  

•   NFIs  (e.g.  no  flashlights  (only  torch  at  night,  can  be  dangerous  and  burn  tent),  no  clothes  (some  people  have  to  walk  around  without  clothes),  no  utensils  for  cooking,  no  saucepans  and  cups  for  tea,  lack  of  clothes  (often  people  can  not  go  out,  they  have  to  wait  for  someone  else  to  come  back  to  wear  their  clothes),  host  community  does  not  allow  to  collect  firewood  

Psychosocial  Related  Concerns  •   Child  Development  (e.g.  Delayed  development  among  

children)  •   Lack  of  engagement  in  meaning  ful  activties  (e.g.  many  

refugees  are  skilled  and  educated  but  they  are  idle)  •   Problems  with  the  host  community  (e.g.  lack  of  

cooperation  with  the  host  community,  refugees  are  blamed  for  robberies  by  host  community  leading  to  frequent  violent  confrontations)  

Vulnerable  groups  •   People  with  disabilities  (e.g.  visually  impaired,  amputated)  •   Separated  children  •   People  who  have  no  relatives  or  others  to  support  them.  E.g.  Women  who  do  not  have  husbands  (they  may  have  died  or  

have  left  the  family  to  join  the  rebellion)   3.4 Anticipated challenges in mental health PHC integration  General health care staff at health facilities (n=13) and program managers (n=9) were asked about anticipated needs and challenges for mental health PHC integration during the field visit (February 2015). These results along with data presented in the earlier rapid assessment (Maban 2013) are summarized below. Challenges were mainly in the areas of limited human and material (medication, laboratory facilities, etc) resources, lack of community awareness

                                                                                                               21 Rapid Mental Health Situational Analysis, International Medical Corps , Maban, 2013

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and absence of national legal frameworks. Needs identified were that of comprehensive services including inpatient care and follow up services as well as referral pathways.  Psychotropic  Medication:  

•   Availability  of  psychotropic  medication  that  is  affordable  and  ensuring  continued  supply  

•   Availability  of  better  drugs  (that  are  not  part  of  WHO  essential  drug  list)    

 Laboratory  services  

•   Availability  of  lab  services  to  monitor  psychotropic  medication  including  materials  as  well  as  trained  personel  

Case  Finding:  

•   Increased  awareness  in  the  community  about  mental  health      

•   Stigma  prevents  help  seeking  for  people  with  mental  illness      

Overall  system/law  

•   Need  to  find  out  how  to  work  within  law  of  South  Sudan  (e.g.  involuntary  admission,  protection),  no  structures  in  place    

•    Community  beliefs  and  practices  

•   People  go  to  traditional  healer  instead  of  health  facility  

•   Community  believes  in  injectable  drugs  (and  syrups  for  children),  not  in  counseling  

•   Social/community  support  for  people  with  mental  illness  very  limited    

Staff  well  being  

•   Staff  well  being  /MHPSS  services  for  staff  are  needed  

 Security  concerns  

•   This  limits  staff  and  patient  mobility    

Coordination  •   Many  different  organisations  involved  in  

psychosocial  services  with  poor  coordination  between  them  

Follow  up  at  community  level  

•   Needed  to  make  sure  no  danger    •   Needed  to  make  sure  that  family  and  

community  accepts  them  •   Stigma  attached  to  mental  illness,  need  to  

ensure  community  acceptance    •   MH  patients  need  social  structure  (medication  

alone  is  not  enough)  •   Needed  to  ensure  drug  compliance    •   Need  to  make  sure  person  comes  back  

Staff  capacity/training  

•   Limited  capacity  and  large  turnover  of  staff.    •   No/minimal  prior  training  in  mental  health  •   Training  of  individuals  whose  contracts  are  short    

 Staffing/time  

•   Staffing  might  not  be  enough  for  the  amount  of  people  in  the  camp    

•   Community  health  workers  have  multiple  responsibilities  in  addition  to  mental  health  

Inpatient  services  

•   Patients  may  need  inpatient  admission.  These  resources  are  limited    

Referral  

•   Referral  forms  are  needed  for  partners  •   Need  to  establish  referral  mechanism  with  

community    •   Need  to  identify  people  within  community    •   There  could  be  referral  links  to  schools  and  

teachers  could  be  trained  to  identify  and  refer    •   Population  movement  means  people  need  to  be  

referred  to  services  at  their  place  of  return    Sustainability  of  services  

•   Depends  on  donor  funds  and  these  are  mainly  given  for  short  periods  

•   Lack  of  government  health  services  to  sustain  programs  

 

This situational analysis provides important guidance for project implementation and expansion including local concepts of mental illness, coping and help seeking behaviors and available mental health services. Based on this, recommendations for International Medical Corps’ MHPSS program which began in August 2014 are outlined below:

Coordination and advocacy

International Medical Corps’ is an active member of the MHPSS platform organized by the MoH to bring together the different organisations involved in MHPSS activities at the national level. Further recommendations:

4.  Summary  and  Recommendations  

  21  

•   It is important to explore strategies that can be implemented to strengthen collaboration with MoH and government care providers to build local capacity. This may include application to alternate sources of funding to support collaborative training programs. International Medical Corps will need to also coordinate and communicate with other national and global stakeholders and national authorities in developing the curriculum for training general health workers in mental health and share experiences and results from its own mhGAP training program.

•   Continued involvement with the MHPSS cluster to advocate for improving mental health care in the region and strengthen referral mechanisms.

•   Support PHC teams to collect and report clinical data in standardized forms including patient outcome data, details of referrals, etc.

•   Take steps to identify and overcome the challenges in medication supply. This may include support to PHC teams to record and report psychotropic drug use in order to access medication through international procurement well in advance. Also, close follow up by the IMC Juba team is crucial to ensure medicines are delivered to the field in a timely manner, anticipating the various logistical challenges this may encounter. Explore alternate sources to cover medication supply in the interim such as the MoH and WHO to obtain essential medicines and other partner organisations (for example, the MSF inpatient facility in Malakal has stock of some psychotropic medicines which they do not use. A formal request for donation of this stock could be made to cover any shortfall in International Medical Corps stocks).

Mental health training and supervision

International Medical Corps’ MHPSS program has been providing training in assessment and management of priority mental health conditions to health facility service providers (PHCUs, PHCCs) based on the mhGAP IG adapted to the region. Based on this situational analysis, the following points need emphasis:

•   Staff at health facilities are currently able to identify a very small number of people with mental illness. Staff (doctors, clinical officers, nurses, midwifes) could benefit from learning a few basic screening questions for mental health related problems. This would also facilitate better-targeted referrals for mental health problems and more accurate reporting for UNHCR HIS mental health categories. International Medical Corps can focus on health facility staff in International Medical Corps clinics first and could consider expansion to other health facility staff as a second step if resources are available such as health facility staff from the regional hospital (e.g. Bunj).

•   In view of the rapid staff turnover, it is important to schedule frequent training workshops in all sites to ensure a critical number of trained staff are present in all the health facilities.

•   The unstable security situation may mean that all staff cannot travel to a common training venue. This will require planning for additional resources to support multiple training programs in different sites. Gradually building the capacity of select trained staff who can then facilitate training of other/new staff may be one method of doing this.

•   Program trainers will need to ensure close on-the-job supervision of the PHC staff. This is best done in person, however, if this is difficult, they can plan regular supervision of trained PHC teams through mechanisms such as skype/telephone calls. Regular (weekly/fortnightly) case discussions/short online training sessions with PHC staff can also be planned.

•   Training of community health workers in conducting awareness programs and providing psychological first aid can be initially done by the program trainers/specialists using the mhGAP material. In due course, the CHWs can be supported by a trained PHC staff.

  22  

Mental health service provision

International Medical Corps has begun to integrate MHPSS services within its general health care programs in all 5 program sites – Juba POC, Maban, Malakal, Awerial and Akobo. This will be described in the subsequent case study, however, based on this baseline situational analysis, it is recommended that:

•   Interventions should address access to other services and supports (e.g. medical, protection), promote social inclusion and facilitate patients taking on daily tasks and family roles as they recover. Patients with acute mental health symptoms (e.g. acute psychosis) should be managed within their family environment and visited by a health service provider on a daily basis for at least the first 1-2 weeks as appropriate.

•   Local community mental health workers (from refugee and host communities) have the capacity to play an important role in community outreach, following up with patients (e.g. ensuring medication compliance), psycho-education and mental health promotion and messaging. They can also assist in providing several of the recommended psychosocial interventions in the WHO mhGAP and can engage in basic mental health case management functions such as helping link people to service providers and community supports. A structured plan for involvement of CHWs including awareness activities, group psychosocial activities etc will be useful and ensure uniformity of activities across the different program sites.

Referral

•   Build cross referral networks with various other formal and informal service providers. Referral networks for people with mental illness should be broadened from general health facilities and some community leaders to also include a higher number of implementing agencies and facilities and community providers. Community leaders also play important roles in the camps. The community structure among refugees is structured around sheiks who are village leaders and typically responsible for about 500 to 700 people. They can play an especially important role in identifying people with severe mental disorders in their communities. Other agencies and implementing partners in the camps provide important services, which are also relevant for people with mental disorders and their families (e.g. protection, shelter, rehabilitation, etc.) and links to such services should be strengthened. IMC could consider strengthening mental health case coordination by supporting the development and use of common referral forms and the mapping of MHPSS and protection services

•   Improve case identification and access for people with severe mental disorders such as psychosis and neurological disorders (epilepsy). Persons with severe or chronic mental illness and their families may seek out traditional healers rather than the health facilities Potentially effective strategies include engaging community leaders such as sheiks, and building links with traditional healers. IMC can work through CHWs and mental health community outreach workers on awareness raising.

Mental health promotion

•   Engage people in the camp (especially those experiencing psychological distress and mental health problems) in meaningful structured psychosocial activities. Community discussions showed that loss of resources and belongings are a significant stressor for many refugees, which can increase the risk for common mental disorders such as depression (possibly referring to the local concept of “thinking too much”). IMC can consider structured social, educational and recreational activities for youth and adults in the camp. Other International Medical Corps psychosocial programs for refugees have included activities led by refugee instructors such as cooking together, weaving baskets and mats, sharing daycare responsibilities, sports activities, music and dance. Those

  23  

activities should include and prioritize people experiencing mental health problems and psychological distress.

•   Engage refugees and people from the host community in joint purposeful activities •   Tensions with the host community contribute to limited access to resources (e.g. grass,

firewood) and psychological distress. Research suggests that resource conflicts and tensions can be addressed by having people from different groups work on common goals that can benefit all (e.g. building something that benefits both communities). Other International Medical Corps psychosocial programs have engaged refugee and host population youth for example in working together on joint community projects and learning about life skills.

•   Development of IEC material that is contextually relevant will be useful in awareness raising as well as self help techniques to deal with stress. This can be adapted from International Medical Corps IEC material being used in other MHPSS programs

  24  

Appendix  A

Situational Analysis Information Framework and Data Sources

1. The

Environment

1.1 Location and

physical setting

Desk top review

•   Alex de Waal. When Kleptocracy Becomes Insolvent: Brute Causes Of The Civil War In South Sudan. African Affairs, 2014, 113/452, 347–369. Downloaded from http://afraf.oxfordjournals.org/  

•   Wikipedia: http://en.wikipedia.org/wiki/South_Sudan •   Mental Health in Health Facilities, International Medical Corps

South Sudan, May 2013

1.2

Socioeconomic profile

Desk top review

•   The United Nations Office for the Coordination of Humanitarian Affairs (OCHA) South Sudan: Crisis Situation Report No.78 (as of 12 March 2015).

1.3

Socio-Political environment

Desk top review

•   The Basic Package of Health and Nutrition in Primary Care. South Sudan, July 2011 (update)

•   Mental Health in Health Facilities, International Medical Corps South Sudan, May 2013

•   Terms of reference for psycho-social support and mental health lead organizations in South Sudan. Drafted by the Mental Health Working Group. December 2013

1.4 Socio-cultural

attitudes towards

mentally ill

1.41 Perception of community members

•   WHO AIMS report on mental health system in South Sudan. 2009 •   Four FGDs with 63 respondents in International Medical Corps

field sites •   Rapid Mental Health Situational Analysis, Maban Refugee Camps,

South Sudan, International Medical Corps. April 2013 •   Tempany M. What research tells us about the mental health and

psychosocial wellbeing of Sudanese refugees: a literature review. Transcult Psychiatry. 2009; 46(2): 300-15.

1.42 Perception of healthcare providers

•   Knowledge and Attitude survey with 33 respondents from International Medical Corps supported PHCs

2. The Health System

2.1 General health

services

Desk top review

•   Health Cluster report. March 2015 •   The Basic Package of Health and Nutrition in Primary Care. South

Sudan, July 2011 (update)

2.2 Mental health

services

Desk top reviews

•   Solomon Ehiemua. Mental Disorder: Mental Health remains an invisible problem in Africa. European Journal of Research and Reflection in Educational Sciences Vol. 2 No. 4, 2014

•   http://www.hrw.org/news/2012/06/21/south‐sudan‐arbitrary‐detentions‐dire‐prison‐conditions

•   International Medical Corps MH Situational Analysis May 2013 •   Rapid Mental Health Situational Analysis, Maban Refugee Camps,

South Sudan, International Medical Corps. April 2013 •   Rapid Mental health Assessment: Akobo and Juba, International

Medical Corps, August 2014 •   Rapid Mental Health Siutuational Analysis: Awerial and Malakal,

Feb 2014

Interviews

•   Baseline PHC Integration checklist administered in 11 health facilities

•   Interviews with MoH Psychiatrist, program staff in field sites, representatives from partner NGOs

3. Mental

Health Needs

Desk top reviews

•   World Health Organization & United Nations High Commissioner for Refugees (2012). Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Major Humanitarian Settings. Geneva: WHO, 2012.

•   South Sudan Cluster Bulletin #34. 21st December 2014 •   International Medical Corps MH Situational Analysis May 2013 •   Rapid Mental Health Situational Analysis, Maban Refugee Camps,

South Sudan, International Medical Corps. April 2013

  25  

•   Rapid Mental health Assessment: Akobo and Juba, International Medical Corps, August 2014

•   Rapid Mental Health Siutuational Analysis: Awerial and Malakal, Feb 2014

•   Roberts B, Damundu EY, Lomoro O, Sondorp E. Post-conflict mental health needs: a cross-sectional survey of trauma, depression and associated factors in Juba, Southern Sudan. BMC Psychiatry. 2009; 9: 7.

•   Karunakara UK, Neuner F, Schauer M, Singh K, Hill K, Elbert T, et al. Traumatic events and symptoms of post-traumatic stress disorder amongst Sudanese nationals, refugees and Ugandans in the West Nile. Afr Health Sci. 2004; 4(2): 83-93

•   Ayazi et al. What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? a cross-sectional community study in South Sudan BMC Psychiatry 2012, 12:175

•   Ayazi et al. Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community study in South Sudan BMC Psychiatry 2014, 14:6

•   de Jong JT, Komproe IH, Van Ommeren M. Common mental disorders in postconflict settings. Lancet. 2003; 361(9375): 2128-30.

•   King. Alcohol a Growing Problem in South Sudan. Voice of America. 2006.

•   Post-Conflict Mental Health in South Sudan: Overview of Common Psychiatric Disorders. Maithri Ameresekere, MD, MSca and David C. Henderson, Mda. (This document was originally published in two parts the South Sudan Medical Journal in volume 5 number 1 and number 2).

Interviews •   Interviews with program staff, community members,

representatives from MoH and partner NGOs

 

 

 

 

 

  26  

 

Appendix  B  

International Medical Corps MHPSS Situational Analysis Tool Informed consent obtained: Yes/No Name of interviewer: Date: Interviewee Name: Interviewee No: Key informant type (e.g. religious leader etc.): Gender of participant: O Male O Female Age: 1) Local concepts of mental health and psychosocial problems 1.1.How would I as an outsider recognize a person with mental health problems?

1.2.How would I as an outsider recognize a person who is emotionally upset?

2. Impact of mental illness Type of mental health or psychosocial problem

Impact

 

 

3. Coping and support Type of mental health or psychosocial problem

Coping method Helpful?

Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

4. Local attitudes and practices towards people with mental illness 4.1) What do people in the community think about those with mental illness?

  27  

4.2) How do people in the community treat people with mental illness? 5. Local help seeking behaviours Where do people with mental health problems seek help? 6. Knowledge of referral pathways If you knew someone with mental illness in this community, where will you send them?  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  28  

 

Appendix  C  

IMC  Mental  Health  Knowledge  and  Attitudes  Questionnaire  Sources  

Questions for this survey were adapted from the following sources (indicated for each question): 1.   US Department of Health and Human Services, Substance Abuse and Mental Health Services

Administration (SAMHSA, 2010). HealthStyles Population survey. Conducted annually in the United Stated by Porter Novelli and adapted from British Omnibus National Survey.

2.   Scottish Government (2008). Well? What Do You Think?: The Fourth National Scottish Survey of Public Attitudes to Mental Wellbeing and Mental Health Problems.

3.   Afghanistan Ministry of Public Health (MOPH). Basic Package of Health Services, Mental health Training attitude survey.

4.   IMC Iraq Mental Health Attitudes Survey (described in: Sadik, S., Bradley, M., Al-Hasoon, S., & Jenkins, R. (2010). Public Perception of Mental Health in Iraq. International Journal of Mental Health Systems 2010, 4:26). (adapted from Weller 1998, does contact with people with mental illness affect nurses)

5.   Questions suggested for Afghanistan by IMC Afghanistan Technical Team Please indicate the following about yourself: Male Female O Doctor O Nurse O Psychologist O Social worker O Occupational Therapy How many years have you worked in your present position?____ years Please take a few minutes to fill in this questionnaire. Your answers will be confidential and any results will be de-identified. Please tick one option for each of the statements below.  

CAUSE OF MENTAL ILLNESS

Agr

ee

Agr

ee

Som

ewha

t

Neu

tral

Dis

agre

e So

mew

hat

D

isag

ree

Mental illness is caused by bad things happening to you.

I think mental disorders have mainly spiritual causes Mental illness is God's punishment for having done something wrong

Mental illness is caused by a personal weakness Most people with convulsions are faking (pretending)

ATTITUDE TOWARD PEOPLE WITH MENTAL

ILLNESS

Agr

ee

Agr

ee

Som

ewha

t

Neu

tral

Dis

agre

e So

mew

hat

Dis

agre

e

  29  

People with mental health problems are largely to blame for their own condition.

One can always tell a mentally ill person by his or her physical appearance.

Mentally ill persons are not capable of true friendships.

Most mentally ill persons are less intelligent than the average person.

Mentally ill people do not need privacy.

Mentally ill persons can work.

People with mental illness are dangerous to others

People with mental illness are unpredictable People with mental illness are hard to talk with

Anyone can suffer from a mental illness. People are generally caring and sympathetic to people with mental health problems

Mentally ill persons should be prevented from having children.

Mentally ill persons should not get married.

One should avoid all social contact with people with mental illness persons

Mentally ill people cannot speak for themselves People with mental illness should have the same rights as anyone else

People with mental illness need others to make decisions for them

People with mental illness should not be told about possible adverse side effects of their medications

It is not important to take the preferences of the person with mental disorder into consideration when choosing treatment

If a patient is asked if they have suicidal thoughts they are more likely to commit suicide

I would be ashamed if people knew that someone in my family had been diagnosed with a mental illness.

If I was suffering from a mental illness, I would not want people to know about it.

People with mental illness who receive treatment and support can lead normal lives

People with mental illness be as successful at work as others

Most people with mental illness will improve if given treatment and support.

I believe that keeping people with mental illness in the hospital makes the community a safer place

People receiving mental health care are weak People with mental illness can receive good care from a traditional healer

If I was concerned about a mental health issue with a

  30  

 

 

member of my family I would feel comfortable sending them to _____________________________

  31  

 

Appendix  D  

International  Medical  Corps  PHC  MH  Integration  Checklist  Adapted  from  WHO  MHPSS  Assessment  Toolkit  (Draft  Feb  2012)  

 Appendix D. BASELINE DATA collected from PHC Manager of each clinic participating in

training. Name of Interviewer: Date: Duration: Name of PHC clinic: Affiliation (e.g. MoH): Name & Title of Contact: Address: I. Basic Clinic Information Location: □ [Name of Area 1] □ [Name of Area 2] □ [Name of Area 3] □ [Name of Area 4] Catchment Population: Average number of patients visiting per day (past month): Staff Providing initial consultation: O Nurse O GP OOther:______________ II. Clinic Indicators Indicator Scoring: ⓪ Indicator not met ① Indicator partially met ② Indicator met 1. Clinic Staff Number and type of staff

Male Fem Average clinical

hours/day

Average # of patients seen/day

Average time (minutes) spent with patient

GPs ⓪ <5 ② 5-20 ②>20 Nurses ⓪ <5 ② 5-20 ②>20

Midwives ⓪ <5 ② 5-20 ②>20 Social Worker ⓪ <5 ② 5-20 ②>20 Psychologist ⓪ <5 ② 5-20 ②>20 CHWs ⓪ <5 ② 5-20 ②>20 Other (if involved in clinical services:)

⓪ <5 ② 5-20 ②>20

1. Average Score (sum/total # scored) ( )

2. Basic Pharmacy Data

  32  

Medication (please circle types available) Availability in the PHC clinic or nearby pharmacy in the previous week

Generic antidepressant medication (amitriptyline, fluoxetine)

⓪Never or rarely ①Sometimes ②Usually or always

Generic anti-anxiety medication (diazepam) ⓪Never ①Sometimes ②Usually Generic anti-psychotic medication (haloperidol tab and inj, chlorpromazine, Thioridazine)

⓪Never ①Sometimes ②Usually

Generic anti-epileptic medication (phenobarbital carbamazepine, diazepam inj, valproic acid)

⓪Never ①Sometimes ②Usually

Generic bipolar disorder medication (valproic acid, carbamazepine)

⓪Never ①Sometimes ②Usually

Medication as part of substance use programs (nicotine replacement therapy)

⓪Never ①Sometimes ②Usually

Generic antiparkinsonian medicine for the management of side effects from antipsychotic medication (biperiden)

⓪Never ①Sometimes ②Usually

2. Average Score (sum/total # scored) ( ) 3. Staff Training Indicators Training conducted

Staff

What % of this staff was trained?

How many hours of training was provided?

How many sessions of on the job supervision were provided?

Prior to IMC training, the following staff received in-service mental health training

GPs ⓪None (0%) ①Some (1-50%) ②Most (>50%)

⓪None ①Some (1-2) ②Several (>3)

Nurses ⓪None (0%) ①Some (1-50%) ②Most (>50%)

⓪None ①Some (1-2) ②Several (>3)

Midwife ⓪None (0%) ①Some (1-50%) ②Most (>50%)

⓪None ①Some (1-2) ②Several (>3)

Social Worker

⓪None (0%) ①Some (1-50%) ②Most (>50%)

⓪None ①Some (1-2) ②Several (>3)

Psychologist

⓪None (0%) ①Some (1-50%) ②Most (>50%)

⓪None ①Some (1-2) ②Several (>3)

CHW ⓪None (0%) ①Some (1-50%) ②Most (>50%)

⓪None ①Some (1-2) ②Several (>3)

3. Average Score (sum/total # scored)

3a ( ) 3b ( )

4. Staff Skills Indicators

  33  

At least one health care provider in the clinic is trained in…

If yes, specify how often trained staff uses skills:

⓪ Rarely/Never ① Sometimes ② Frequently

Assessment and management of mental disorders

Assessment of people with mental health problems ⓪ No

② Yes Clinical history taking Mental Status Exam

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of depression ⓪ No ② Yes

Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of psychosis ⓪ No ② Yes

Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of bipolar disorder ⓪ No ② Yes

Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of epilepsy/seizures ⓪ No

② Yes Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of developmental disorders (intellectual disability) ⓪ No

② Yes Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of child behavioral disorders (ADHD, conduct)

⓪ No ② Yes

Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of Dementia ⓪ No ② Yes

Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of alcohol and drug use disorders ⓪ No

② Yes Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Assessment & management of self-harm/suicide ⓪ No

② Yes Risk Assessment Management

⓪ R/N ① S ② F ⓪ R/N ① S ② F

Management of anxiety / stress related disorders (e.g. PTSD) ⓪ No

② Yes Pharmacological Non-pharmacological

⓪ R/N ① S ② F ⓪ R/N ① S ② F

4. Average Score =(sum/total # scored)

4a ( ) 4b ( )

  34  

Most (50%) health stay are trained in… Communication skills specific to mental illness (e.g. active listening, respectful attitude)

⓪ No ② Yes

Communicating with angry, very anxious, or withdrawn patients ⓪ No ② Yes

The different ways in which people in the area express psychological distress

⓪ No ② Yes

Non-pharmacological management of medically unexplained somatic complaints

⓪ No ② Yes

Giving bad news in a supportive way ⓪ No ② Yes

Responding appropriately to the sharing of extremely private or emotional events (e.g. rape, abuse)

⓪ No ② Yes

Psychological first aid (PFA) ⓪ No ② Yes

Psycho-education (Client and family education about MH) ⓪ No ② Yes

Problem-solving counseling ⓪ No ② Yes

Teaching relaxation techniques ⓪ No ② Yes

Ethics and rights of people with mental illness ⓪ No ② Yes

4. Average Score (sum/total # scored) 4c ( ) 5. Staff roles and team work

Staff Roles Yes/No Specifics Staff have defined roles in identification, management and referral of mental disorders

⓪ No ① Yes, but roles not followed ② Yes and roles are followed

If yes, specify how:

Discussion about MH cases takes place

⓪ No ① Yes, informally ② Yes in regular (weekly or bi-weekly) meetings

If yes, specify who participates:

5. Average Score (sum/total # scored)

( )

6. Service Provision Indicators

Type of Case

# of cases (if known)

In the past month, the following was provided for this diagnostic category…

According to the clinic’s health information system in the last month, service was

provided for:

Identified at the PHC

level

Treated at the PCH level

Referred to specialized care

(MH)

Depression ⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Psychotic disorder ⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Epilepsy ⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

  35  

Bipolar disorder ⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Developmental disorders (intellectual disability)

⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Behavioral disorders (ADHD, conduct)

⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Dementia ⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Alcohol and drug use disorders

⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Medically unexplained somatic complaints

⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Anxiety / stress related disorders (e.g. PTSD)

⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

Other (specify):

⓪ No ② Yes

⓪ No ② Yes

⓪ No ② Yes

6 Average Score (sum/total # scored)

SUM ( )

6a ( ) 6b ( ) 6c ( )

7. Health Information System Indicators Mental disorders are documented in clinical charts ⓪ No

② Yes Mental disorders are documented in weekly or monthly morbidity report

⓪ No ② Yes

If yes, the reports are also separated by gender and age for analysis

⓪ No ② Yes

To Interviewer: If report is available please attach to the checklist

7. Average Score (sum/total # scored) ( )

8. Social Indicators The PHC has the following characteristics: The health care facilities is in safe walking distance of affected/target communities

⓪ No ② Yes

There is at least 1 female health care provider ⓪ No ② Yes

At least 1 staff member per clinic speaks the local dialects

⓪ No ② Yes O N/A

Documented procedures are in place to ensure that patients provide consent before medical procedures

⓪ No ② Yes

Health care provision is organized in a way that respects privacy (e.g. curtain around consultancy area, private room)

⓪ No ② Yes

Information related to the health status of people, especially those related to human rights violations (e.g. rape, torture) is treated confidentially

⓪ No ② Yes

Services are provided: O free of charge $ per consultation:____ What is the percentage of people living in this area who cannot afford services?

②<10 ① 11-50% ⓪ 51-100

  36  

8. Average Score (sum/total # scored) ( ) 9. Referral indicators Health staff know: Referral options to the mental health system (e.g. staff know the location, contact, costs and referral procedures for nearby mental health services)

⓪ No ② Yes Contacts:

How to link with protection agencies/ social services to address physical and sexual abuse

⓪ No ② Yes Contacts:

How to link with at least 2 social services or support systems in the community ( location, contact -e.g. social worker, social agency, community center, educational/vocational opportunities)

⓪ No ② Yes Contacts:

9. Average Score (sum/total # scored) 9a ( ) In the last 2 weeks mental health-related referrals occurred to PHC from: Mental health specialist care (secondary, tertiary or private care)

②Frequently ① Sometimes ⓪ Rarely/ Never

Community Health Workers (CHWs) ②Frequently ① Sometimes ⓪ Rarely/ Never

Other community workers schools, social services and other community social supports, traditional /religious healers

②Frequently ① Sometimes ⓪ Rarely/ Never

In the last 2 weeks mental health-related referrals occurred from PHC to:

Mental health specialist care (secondary, tertiary or private care)

②Frequently ① Sometimes ⓪ Rarely/ Never

Community Health Workers (CHWs) ②Frequently ① Sometimes ⓪ Rarely/ Never

Other community workers schools, social services and other community social supports, traditional /religious healers

②Frequently ① Sometimes ⓪ Rarely/ Never

9. Average Score (sum/total # scored) 9b ( )

III. Scoring Summary

Please fill scores from above in table below (under matching scoring field and multiplied by 10)

  37  

Category Actual Score Notes

0-3 4-7 8-11 12-15 16-20

1. Clinic Staff

2. Basic Pharmacy Data

3a. Staff Training Indicators-Theoretical Training

3a. Staff Training Indicators -Supervision

4a. Staff Skills Indicators-management of mental disorders

4b. Staff Skills Indicators-use of management of mental disorders

4c. Staff Skills Indicators-general skills

5. Staff roles and team work

6a. Service Provision Indicators-Identification

6b Service Provision Indicators-Management

6c. Service Provision Indicators-Referral

7. Health Information System Indicators

8. Social Indicators

9a. Referral indicator-knowledge

9b. Referral indicators-to and from PHCs

Total Frequency Scores

Notes:

 

 

 

 

 

 

  38