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10 May 2012, Tajikhan Village, Jabalseraj District Parwan Province, Afghanistan : The Sar-e-Hause medical health clinic. The clinic is funded by the Strengthening Health Activities for Rural Poor Project (SHARP). SHARP aims to improve the health and nutrition status of Afghans, focusing especially on women and children and the underserved areas of the country. Already remarkable progress has been made in the reduction of infant and under-5 mortality as well as pregnancy related mortality. With World Bank support in 11 provinces the number of health clinics has nearly tripled from 148 to 432 and about 85% of the population now lives in districts which now have service providers to deliver a basic package of health service. The project supports Afghanistan's Health and Nutrition Sector Strategy, the government's blueprint for the health sector program for the period 2008-13.

Integration of a collaborative mental health care in primary care in Afghanistan

IntroductionMental health is a low public health priority in low-income countries, especially in post-conflict country like Afghanistan. After the fall of Taliban the country’s health care services had to be rebuilt from scratch, this provided opportunity for mental health to be included in basic health package after much advocacy. However, very little was done to implement and deliver services. We advocate that treatment of mental disorders within the health care system needs to be integrated in the primary health care accompanied by a community-based approach that focuses on psychosocial problems. Case studies from other countries show effectiveness of this policy. Although some progress has been made towards improving mental health by international NGO’s in some provinces but a lot more needs to be done, therefore investment in mental health is required in order to expand the services to all provinces and rural population. Overall, mental health in Afghanistan is a public health area that has faced negligence over decades, and little has been done to improve general awareness and treatment standards. We advocate for a mental health policy aiming to integrate a collaborative mental health care in primary care. The policy will be explained by a four stage policy process: 1. Agenda setting/Problem identification 2. Policy formulation 3. Policy implementation 4. Policy evaluation. The analysis will incorporate the policy triangle framework (Walt and Gilson, 1994) that takes account of actors and the political context of the policy making environment. The agenda section will give justification of why mental health should be public health priority and why it should be given attention by the government. In the discussion on Policy formulation, policy will be proposed and various stakeholders such as the state, International organizations and NGOs will be identified and their roles in making the health policy implementation possible in Afghanistan will be examined. The evaluation stage will further focus on the implications of policy implementation, limitations of the policy and suggest future interventions to improve mental health in the country.

1. Agenda Setting and Problem Identification

Afghanistan has faced more than 30 years of war, conflicts, political instability and large internal and external migration of millions of Afghans. The war has resulted in demolished infrastructure and majority of technical expertise have fled the country and have left the state’s health care system in poor condition. Afghanistan’s population suffers from multiple health issues, with maternal health and child mortality being one of the worst in the world, along with a high burden of communicable diseases and recent increase in HIV/AIDS. Since the collapse of Taliban regime, there have been great improvements in the health care system of Afghanistan where the Ministry of Public Health, through the help of the World Bank, World Health Organization (WHO) and other Non-Profit Organizations created the Basic Package of Health services (BPHS) trying to address  priority health issues. While many healthcare challenges have been prioritized, and some addressed, very little attention has been paid to the issue of mental health, especially to Post Traumatic Stress Disorder (PTSD), anxiety, and depression.  As consequences of conflicts and lack of social services, these mental health issues are exacerbated by the continuous negligence. According to the WHO representative for Afghanistan, more than 60 percent of Afghans suffer from psychosocial problems and mental disorders [Salehi, 2010]. These issues are significant as they could also lead to more violence in the community and severe lack of social cohesion. More women suffer from mental illnesses (WHO, 2006) due to marriages at an early age and high fertility rate. It is important to note that women, who are already marginalized, have a tougher time accessing mental health services, as there is taboo and stigma associated with this [Baig, 2013]. Although much advocacy for mental health in Afghanistan has been included in BPHS, very little has been done to implement the national strategies. The mental health care system is hospital based and is in a very bad condition.  There is only one hospital in capital Kabul where most of the mental health budget of MOPH is spent (Sayed, 2011). Two other cities, Nangarhar and Shabarghan, are highly understaffed, have no available drugs and have a few beds in their medical faculty. The country is facing an acute shortage of professionally trained psychiatrists, specialist mental health nurses and psychologists (Ventevogel, 2002). It is also reported that majority of primary health care workers and nurses have not received even the basic mental health care training in the last 5 years (WHO, 2011). By examining the evidence, it becomes evident that mental health has remained a neglected underserved public health area that needs urgent attention. Therefore, we  promote mental health problem into the policy agenda using the Kingdon model, which consists of three streams, the Problem, Policy and the Political stream. According to Kingdon the window of policy opens when the three streams flow together (Buse, Mays and Walt, 2012).

Problem Stream:

Mental health problem is important for many reasons; it represents potential problems that are politically sensitive. PTSD often causes domestic violence. Many cases where women have been abused by their husbands have been reported. National surveys have found that 52% of Afghan women have experienced physical violence (Gazan, 2012). Moreover, it has been argued that mental health issues will affect other millennium development goals such as promoting gender equality, reducing child mortality and combating HIV malaria and other diseases (Skeen et al, 2010).The existence of mental health issues is well recognized by health professionals and the general populations in Afghanistan. Help seeking patterns for mental disorders by general population are based on traditional believes, where they resort to shrines and some even believe that chaining for certain number of days can cure the illness (Salehi, 2010).

Policy Stream:

Many studies have been carried out which gives statistical data on the number of people suffering from mental health as well strategy papers have been formulated. The debate in these studies also highlights the causes of mental illness, how they are perceived in the society, talks about gender, age group, ethnicity and other characteristics of the target population. More importantly, these studies suggest policies and solutions of how mental health illness can be included in the government ‘policy agenda’, how treatment can be provided at primary healthcare level and how the underlying causes of the issue can be addressed. Furthermore, the policies are in tandem with the social values of a society like Afghanistan. For instance they may insist on the training and inclusion of more female mental healthcare workers, as this will improve accessibility to the target population, majority of which are females.

Political Stream:

Female politicians can be important players to be persuaded to generate government’s interest regarding mental health issue, since there are increasing numbers of female who suffer from mental illnesses. They can expose the social discrimination and inequality that is embedded in the health care system and demand an equal access to mental health services. Their voice can also get attention internationally, which might attract foreign donors.  Also, the opposition can raise a voice and highlight the government’s failure to include mental healthcare in its national health agenda. This criticism from the oppositions might be taken seriously by the current government and a window of opportunity can be opened. It is reported that advocacy for mental health has been low because people with mental illnesses and their families are often invisible (Saraceno et al, 2007) hence it is very important to get people’s attention about the issue. Since Afghanistan is starting to develop a culture of having an independent and vibrant media, it would be possible to raise awareness through media among public and this in return will get interest groups’ attention such as women’s organizations and human rights lobbyists.

2. Policy Formulations and Stakeholder Analysis Policy Formulation:

The development of policy in Afghanistan is the role of Ministry of Public Health. Although the national health authority did define mental health as a priority but little has been done to implement interventions, mainly due to low funds, as the health care system is normally reliant on donor funding. However, donors have been very hesitant to fund mental health services due to unclear studies and doubts about cost-effectiveness of the interventions (Saraceno et al, 2007). For the development of mental health services, I would propose the policy below which includes different components. Collaborative Integration of mental health into primary health care

  • Training of staff/community workers in primary care
  • Availability of psychotropic medication in primary care facilities
  • Creating awareness of mental illnesses in the community to reduce sigma
  • Creating community based psychosocial programs to help prevent and solve psychosocial problems, especially for women.

Integration of mental health into primary care has been discussed for many years now, but its effectiveness is questionable in developing countries. World Health Organisation (WHO, 2008) have suggested integration of mental health into primary care and have also provided case studies of many countries that have successfully done this, Iran being one such country. Islamic Republic of Iran has fully integrated mental health in its general health care at national level. Moreover longitudinal data from Pakistan have also shown that integrating mental health might provide better services and improve the health care system.

Stakeholder Analysis:

There are various stakeholders that can be involved in advocacy and in making the implementation of this policy a reality. These include people experiencing mental health issues and their family members, governmental and non-governmental organizations, international organizations (WHO, World bank, USAID), health care professionals, leaders in mental health from non-governmental organizations, academics, and ministries of Public Health, Education, Women’s Affairs and Religious Affairs.

Key Stakeholders:

Ministry of Public Health is the main body that deals with matters concerning the health of Afghan population. They are involved in developing policies, forming strategies and implementing health services. All the expenses for health services within Afghanistan are provided by the ministry of Public Health. Therefore, the ministry will also be providing a budget for mental health. World Health Organization (WHO) is a key stakeholder, which is a global agency that sets standards and general encouragement for countries. It has a mental health division that has been conducting research and formulating documents regarding mental health in both low and middle income countries.  WHO has been providing technical support to the mental health department within the Ministry of Public Health. It is important to note WHO’s main job is not to act as donors therefore for the implementation of policy, funds needs to be attracted from elsewhere. The World Bank is a key investor in the health sector including reproductive health, infectious diseases and millennium development goals. Although mental health is not included in one of their priorities, but they have some funds dedicated to mental health projects, especially for post-conflict development (Jenkins et al, 2011) Afghanistan well fits this set of criteria. Strong and effective lobbying is required to increase awareness among these donors about the grave situation of mental health in Afghanistan and to convince them to allocate separate and specific financial packages for mental healthcare. Other key donors like The European Union (EU) and the USAID have been investing in mental health in Afghanistan by financing training of staff and development of mental health guideline materials. The general population is one of the key stakeholders; they can be people with mental health illnesses or family members of the affected people who would want to seek help or people in the community who live with the people in question who would want to offer direct services voluntarily. In addition, in Afghanistan, the community leaders can play an important role. Community leaders are respected people in the society and are people who others listen to, especially those residing in the rural areas. They play an important role and should be involved in policymaking process. Moreover, due to very little knowledge about mental health by general population, it is paramount to raise awareness, and this can be done through media. The media can spread awareness among the public about the social threats and consequences of mental illnesses, its causes and the methods of prevention. In the past both locally based and international NGOs were involved in delivering mental health services. International NGOs, such as HealthNet-TPO, had started a pilot project in three districts of Nangarhar. The project was successful and based on their data these services were expanded to 12 other provinces. It is very important for these NGOs to be in contact with the Mental Health department within MoPH as these NGOs can be used as mid-actors who could work to attract more funds and implement mental health services in primary care at national levels.  Such projects seemed to have worked in Bangladesh where mid-level actors developed nutrition strategies and advocated these strategies to higher level actors and gained political attention (Pelletier et al 2012).

3. Policy Implementation:

The implementation process is turning policy into practice. It is important to consider implementation strategies at the policy formulation stage to avoid “implementation gaps”, when the outcome of policy in reality isn’t what is expected of the policy (Buse, Mays and Walt, 2012). Implementation approaches, either top-down or bottom-up can affect the final result of policy and will involve three key activities: interpretation of policy into administration, forming different administrative methods to put interventions into effect and routine examination of the services.  The top-down approach has been criticized for giving too much importance to the decision maker who are involved in the initial policy formulation and neglecting the role of other actors, those who are involved in implementing the policy.  Such policy, if imposed, can face resistance from low-level bureaucrats (Walker and Gilson, 2004). It is important to be realistic about implementing the policy having the context in mind, and factors such as infrastructure, workforce, and financial resources can influence policy implementation (Pelletier et al 2012). Moreover, to implement policy successfully, it is vital to involve the local actors, understand different learning and working styles and more importantly, to ensure the policy is culture-specific, especially when implementing a mental health policy. Improving mental health in Afghanistan will therefore require strengthening four main areas: education/training, resource allocation and awareness to reduce stigma in collaboration with strengthening community care.

Training Health Care Professionals (Doctors, Nurses, Midwives)

There are some international NGOs that have initiated training to health care professionals and also developed some training tools. However, a lot more needs to be done in order to fully and successfully integrate mental health into primary care. Health professionals should be trained to provide mental health assessment as well as screening for mental health problems. There is a large number of patients who resort to the traditional method of healing. Therefore, it will be essential for primary workers to collaborate with traditional healers to get referrals from them.

Awareness to Reduce Stigma

Due to a huge stigma and taboo associated with mental health illnesses, it is important to raise awareness about mental health among general population, Afghanistan in recent years have had great development in media, which can be used for experts to have talk shows on TV to raise awareness about mental health and the ways of seeking treatment.

Resource Allocation

Adequate resources should be available for mental health programmers, thus the budget allocated for mental health by MoPH should be increased. Essential psychotropic drugs should be made available in primary care at affordable prices. It is important that all health professionals receive enough supervision so the focus is not solely on prescribing drugs and this discourse should only be used when necessary.

Community Psychosocial Support

Mental health in primary care is unlikely to be sustained without the development of community mental health services (Saraceno et al, 2007). Not only is the community based health approach effective, but will also lower the workload for primary and secondary healthcare workers. Education workshops about basic mental health issues can be given to village volunteers, as well as self-help groups can be established, especially for women, as they are the ones with limited access to health care services. This would encourage women who are isolated to come forward and share their problems and learn from others experiences and get support.  

4. Evaluation:

Evaluation is the process of assessing the intended outcome and seeing if aims and objectives of policy have been met. The evaluation stages should be continuous and embedded in each section of the policy process for it to be more useful. Evaluation can be done in two phases, the process evaluation and outcome evaluation. Process evaluation explores the process of policy from its initiation stages, exploring the interest of stakeholders and how they influence the final policy to implementation of the policy, by monitoring the kind and resources provided and the strategic plan for implementation. If implementation is not according to plan, then the causes will be assessed. Monitoring is important as to see if evaluation is based on the real plan rather than what was intended of implementation (WHO, 2007). Evaluation of policy should be prepared and can take place even before the implementation. However in regards to mental health policy and its usefulness, it is vital for the policy to be responsive to new changes.  These changes could be economic, governmental or social in nature. The outcome evaluation is the long-term evaluation. It assesses if the policy has sustained after its implementation. The evaluation doesn’t necessary have to be limited to measuring mental health outcomes. For example in context of a country like Afghanistan where there is high stigma associated with mental health and low access to mental health services, measurements of seeing awareness of people and improved availability of services can be a positive result of policy. Conducting research is necessary for evaluation, as the results and evidence can be used for improvements in future. While evaluating this proposed policy, low budget and expertise can be a limitation. The regulatory body should allocate enough budget and staff with the necessary skills for policy implementation and effective evaluation. Moreover, expenses related to the development and implementation of services should be monitored properly to allow cost analysis.

Conclusion

We discussed the potential of collaborative integration of mental health in primary care in Afghanistan, which included ways to include mental health in government’s priority agenda and the role of different international key stakeholders that play a major role in investment in mental health policy. These are various vital factors that can affect policy making. It is the government’s job to ensure that well integrated mental health policy in general health with proper strategies is developed and this should be clearly discussed with different donors. Due to high stigma and taboo associated with identifying females with mental health illness, providing them with the right services was a key challenge of this service. To overcome this, it will be important to improve training of community female health workers and to increase awareness raising campaigns of the available services. Furthermore, primary health professionals (doctors, nurses) play a major role in implementing the proposed policy. However, for proper integration of mental health in primary care, basic mental health training should be included in medical school curriculum as well as formal psychiatrist academic trainings of doctors at postgraduate level. Moreover, nurses who are on general nursing programs should be trained on basic mental health issues.

 

References:

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