|Year : 2019 | Volume
| Issue : 2 | Page : 206-211
Strategic priorities for mental health and psychosocial support services for Rohingya refugees in Bangladesh: a field report
Sarah Harrison1, Alex Ssimbwa2, Mohamed Elshazly3, Mahmuda Mahmuda4, Mohamed Zahidul Islam5, Hasna Akter Sumi6, Olga Alexandra Rebolledo7
1 Masters (Hons) Psychology with International Relations and MA (Hons) Peace and Conflict Studies, International Federation of Red Cross Red Crescent Societies Reference Centre for Psychosocial Support, Denmark
2 Masters in Social Sector Planning and Management, Danish Red Cross, Denmark
3 Masters Mental Health Services and Policy and MSC Neurology and Psychiatry, United Nations High Commissioner for Refugees, Denmark
4 MSc Educational Psychology, United Nations High Commissioner for Refugees, Denmark
5 MSc Psychology, United Nations High Commissioner for Refugees, Denmark
6 MSc Clinical Psychology, United Nations High Commissioner for Refugees, Denmark
7 MPhil Social and Developmental Psychology, International Organisation for Migration, Denmark
|Date of Submission||20-Jun-2019|
|Date of Decision||23-Sep-2019|
|Date of Acceptance||04-Oct-2019|
|Date of Web Publication||29-Nov-2019|
International Federation of Red Cross and Red Crescent Societies Reference Centre for Psychosocial Support, c/o Danish Red Cross, Blegdamsvej 27, 2100 Copenhagen, Denmark
Source of Support: None, Conflict of Interest: None
In early January 2019, a participatory workshop took place in Cox’s Bazar, Bangladesh, with the mental health and psychosocial support working group (MHPSS WG) members. The principal purpose of the workshop was to develop the top ten strategic priorities that the MHPSS WG members wished to focus on over the next two years to improve the mental health and psychosocial wellbeing of the Rohingya registered and non-registered refugee camp populations. The strategic prioritisation areas also served as key advocacy messages that can be used in discussions with policy makers, government authorities and humanitarian donor agencies regarding the mental health and psychosocial needs of Rohingya refugee males, females, boys and girls residing in Cox’s Bazar, Bangladesh. The authors believe the strategic prioritisation process contributes to the functioning and purpose of a country-level MHPSS WG and therefore advocates for the approach in other humanitarian and refugee contexts.
Keywords: advocacy, mental health and psychosocial support, MHPSS working groups, refugee, strategic prioritisation
|How to cite this article:|
Harrison S, Ssimbwa A, Elshazly M, Mahmuda M, Islam MZ, Sumi HA, Rebolledo OA. Strategic priorities for mental health and psychosocial support services for Rohingya refugees in Bangladesh: a field report. Intervention 2019;17:206-11
|How to cite this URL:|
Harrison S, Ssimbwa A, Elshazly M, Mahmuda M, Islam MZ, Sumi HA, Rebolledo OA. Strategic priorities for mental health and psychosocial support services for Rohingya refugees in Bangladesh: a field report. Intervention [serial online] 2019 [cited 2020 Jan 18];17:206-11. Available from: http://www.interventionjournal.org/text.asp?2019/17/2/206/271893
| Introduction|| |
In late January 2019, a workshop took place in Cox’s Bazar, Bangladesh, with mental health and psychosocial support working group (MHPSS WG) members. The principle purpose of the workshop was to develop the top ten strategic priorities that the MHPSS WG members believed should be their focus for the next twenty four months as part of the overall response to meeting the MHPSS needs of Rohingya registered and non-registered refugee camp populations. The strategic prioritisation process conducted in Cox’s Bazar was based upon similar services conducted by the United Nations High Commissioner for Refugees (UNHCR) and the International Federation of Red Cross Red Crescent Societies Reference Centre for Psychosocial Support (IFRC PS Centre) in Turkey in 2016 and Iraq in 2016 and 2017 (UNHCR internal communication and Harrison, 2017). The methodology on how to conduct a situational analysis, using the case example of the Cox’s Bazar response, is the subject of another article in this special edition (see Harrison et al., 2019, p. X-X).
Refugees often present with inter-related and complex mental health and psychosocial needs, which require a multi-sectoral response from governments and supporting humanitarian agencies. However, the current, vertically pillared, humanitarian response system, where Humanitarian Response Plans (HRPs) and Refugee Response Plans (RRPs) are organised according to clusters or sectors, makes it challenging for cross-cutting areas of work, such as MHPSS, to find visibility and traction. Agencies providing MHPSS services must, therefore, advocate with other sectors (in the case of refugee response) or clusters (internal conflict and natural disasters) for MHPSS activities to appear within the Humanitarian Needs Overview chapters, the sector project sheets in Response Plans and their corresponding budgets, which are compiled by UNHCR for refugee based emergencies and the Office for the Coordination of Humanitarian Affairs (OCHA) for clusterised emergency contexts. The fragmented reflection of MHPSS within these documents makes it difficult to see the wider picture on what areas should be prioritised to meet the MHPSS needs of affected girls, boys, women and men. This fragmentation often leads to a poorly represented and sometimes a poorly coordinated MHPSS response, in addition to agencies struggling to find funding for multi-sectoral programmes, as funds are channelled vertically through sectors or clusters. The creation of inter-agency-endorsed strategic priorities, generated through community-level participatory processes, facilitates the work of a country-level MHPSS WG to engage with sectors, guides agencies’ future programming approaches and is a useful resource for donor agencies.
| Methodology|| |
An extended, full-day, MHPSS WG meeting took place on 24 January 2019 in Cox’s Bazar with 23 MHPSS WG members from 16 agencies (eight national NGOs, three UN agencies, Bangladesh Red Crescent Society and five international NGOs). A strategic prioritisation exercise was held in the afternoon hours following an interactive workshop format to generate the ten strategic priorities. A brief, English language, Powerpoint presentation was shown to all MHPSS WG members to stimulate the possible areas that the MHPSS WG may wish to focus on during 2019 and 2020. The presentation showed examples from the World Health Organisation’s Building Back Better (World Health Organisation, 2013) approach and highlighted some key areas or initiatives from various contexts around the world. Examples of such categories included the role of the Ministry of Health, human resources, legislation, service provision and government policies. The results from similar strategic prioritisation exercises conducted in Turkey for the Syrian refugee response (2016) and the internal conflict in Iraq (Harrison, 2017) were also presented for inspiration. The workshop participants took part in a brainstorming exercise to ascertain the broad headings that were relevant for the Rohingya refugee context. Agencies split into smaller groups (five to six persons/group) and were tasked to list key points they believe the wider MHPSS WG should focus on for the next two years. Each group listed their points on a flip chart, which they then presented to the wider group in a plenary session. Again, in a plenary format, similar topics or points were grouped, and a new list of topics was created and documented on the central whiteboard in the room. Individual agencies voted for the top ten topics they believed should be prioritised. Voting was conducted by agency and not per individual, as some agencies had many individuals in attendance. Ten points represented the most prioritised area for an agency, with one point the least prioritised area. The ten topics that received the highest number of points were then prioritised (according to the overall number of points received) from highest to lowest, using an amended version of the Delphi (Kobus & Westner, 2016) ranking approach. The points ranged from 134 for the most prioritised area to less than 20 for the least prioritised areas. The final list of topics can be found in [Table 1]. Topics that did not appear in the top-ten list were disregarded.
| Results|| |
After the workshop, the ten strategic priority areas were reviewed and complemented with the qualitative results from seven age- and gender-disaggregated focus group discussions (FGDs) conducted with camp populations and MHPSS service providers in Ukhiya and Teknaf districts, where the 34 Rohingya refugee camps are located. FGDs were held with male and female older persons (aged 50+ years), adults (18–59 years) and children (aged 7–17 years), in addition to one FGD with national NGOs providing MHPSS services. FGD questions probed how the camp population currently supports adult males and females, boys and girls with MHPSS needs; how needs may have changed over the past eighteen months; the availability of services to meet the MHPSS needs of the camp population; the type of services provided and knowledge of service providers. The methodology and specific data collection tools for the FGDs are described in detail in another article within this special edition.
The strategic prioritisation workshop and the FGDs were conducted as independent studies within the broader situational analysis framework, however, the results from these mixed-method approaches were analysed and triangulated for consistency. The qualitative data from the FGDs were thematically analysed, coded and used to complement the recommendations under each strategic priority which were generated by the workshop participants.
The results below combine the strategic prioritisation exercise and the qualitative information from the FGDs.
Family and community-led services
MHPSS WG member agencies reported that most of their interventions were focused at the individual level (i.e., individual clients or patients) or were focused at the population or group level (IASC Reference Group for Mental Health and Psychosocial Support in Emergency Settings, 2012). They identified gaps in services provided to families as a unit and reflected on how services were being implemented. Workshop participants indicated that many interventions lacked community involvement in their design, implementation, monitoring and evaluation. Qualitative data from FGDs indicated that male and female adults and older persons with MHPSS needs were primarily seeking treatment services from traditional healers and that Rohingya men, women, boys and girls will only enter the formal healthcare system (to access mental health care) if there is a physical problem associated with their condition (Tay et al., 2018). Adolescent boys and girls reported to very rarely (if ever) use the health clinics in the camp, preferring to seek MHPSS from their peers and parents.
Recommendations to address this strategic priority included supporting whole families when conducting outreach activities within individual tents and shelters and adjusting the timing of shelter visits according to when the whole family is likely to be present. Involving the camp population, including traditional healers and religious leaders, in the design and delivery of MHPSS services through the recruitment of community volunteers (Rohingyas) and the sensitisation of Imams so they can conduct outreach activities within the camps and shelters (see human resources section). Other recommended community-led activities included peer to peer support (including child to child support), community workshops on specific topics or themes and support groups.
Standardised training packages
Capacity-building initiatives are conducted on an almost weekly basis in the humanitarian hub of Cox’s Bazar or in one of the 34 camps for the registered and non-registered Rohingya refugees. Despite the volume of capacity-building initiatives and the overlap of trainings on specific topics, workshop participants stated that there was only minimal standardisation of training content, supervision approaches and facilitation skills across agencies.
The workshop participants’ recommendations focused on the following key training packages: psychological first aid (PFA) (World Health Organization, War Trauma Foundation and World Vision International, 2011), detection and referral for persons with mental health conditions, referrals (Inter-Agency Standing Committee Reference Group for Mental Health and Psychosocial Support, 2016), a basic training package for community-level workers, integration of mental health into health care services (World Health Organisation (WHO) and United Nations High Commissioner for Refugees (UNHCR), 2015) and support to caregivers of persons with mental health conditions. MHPSS WG member agencies stated that trainings should be delivered in the Rohingya language with written materials in Burmese for community participants, and the Bangla language used for capacity-building initiatives focusing on Bangladeshi professionals. They also wished all training packages to focus on implementation (the how to or operationalisation behind programming) and less on theoretical concepts.
Integration of services
To increase the access to services and support for individuals and families with MHPSS concerns, the MHPSS WG members highlighted the importance of integrating MHPSS into other sectors or services. The pervasive stigma (Tay et al., 2018), ignorance, myths and discriminatory practices associated with MHPSS by both the Bangladeshi host population and Rohingya camp population indicate the need to embed and integrate MHPSS into other sectors and services. The provision of stand-alone MHPSS services runs contrary to the guidance within the Inter-Agency Standing Committee (IASC) Guidelines on Mental Health and Psychosocial Support in Emergency Settings (Inter-Agency Standing Committee, 2007).
Recommendations included integrating topics related to MHPSS into community centres/spaces and into the role of protection case managers, social workers and (health) outreach workers. The following topics were offered as examples: peer support, stress management techniques, active listening, communication skills, PFA, good sleep hygiene, relaxation techniques and providing support to caregivers of persons with disabilities and/or mental health conditions, managing conflicts, anger management, life-skills and mental health and care practices in relation to infants and young children. Child-focused, MHPSS WG member agencies advocated for the training and mentoring of staff and volunteers working in such centres on child development, child psychology and trauma-informed care so that approaches and activities were age appropriate and context specific too.
Child-focused mental health and psychosocial support services
All countries around the world have persons living with mental health conditions, irrespective of whether they have been exposed to a traumatic event, displacement or an emergency. Within the 34 Rohingya refugee camps, there are boys and girls living with chronic mental health conditions, such as developmental delays, autism spectrum disorders and epilepsy, in addition to children with emergency-induced conditions such as acute stress and anxiety (Inter-Agency Standing Committee, 2007). There are multiple, child protection agencies listed as providing psychosocial support for children and caregivers within the overall humanitarian response, with their interventions primarily focused at levels two and three of the IASC intervention pyramid (Inter-Agency Standing Committee, 2007, p. 18). It was noted that there is a chronic lack of child psychologists, child psychiatrists and child development professionals overall in Bangladesh. This is amplified by the overall low number of these professionals in the Cox’s Bazar area, equating to an absence of specialised child-focused mental health services.
Initiatives to address the above concerns include the creation of a child mental health taskforce within the MHPSS WG, and the pilot roll out of an innovative, child-led, psycho-educational group activity for children, which is described in a case study article within this special issue. Health, protection and nutrition agencies also advocated for prioritising the following interventions moving forward: support for the caregivers of children living with mental health conditions through specific parenting programmes, maternal and new-born child health care and focusing on key skills such as communicating with your child, managing daily routines and tasks, taking care of oneself (self-care for caregivers) and helping caregivers to focus on her/his child’s abilities rather than functional impairments. Supporting the creation of service user organisations for persons with mental health conditions and their caregivers was also discussed.
The provision of quality MHPSS services relies upon a well-trained and supervised MHPSS workforce. Unfortunately, the Ukihya and Teknaf districts in Bangladesh are short of social workers, psychologists and psychiatrists to support the host Bangladeshi population, in addition to the multi-faceted and complex needs of 900,000 refugees residing in this part of the country. Language barriers, restrictions on work permits and livelihoods for the Rohingya refugees, coupled with a poor recognition of qualifications and a lack of previous experience, all inhibit the scale-up of an effective workforce to meet the needs of Bangladeshis and Rohingya refugees.
Recommendations included shifting priorities towards building the capacity of the Rohingya camp inhabitants to design and run services for their community, given that they are permanently based in the camp, speak the same language, are unlikely to move to other agencies and are unable to move to other locations in Bangladesh to seek work. In terms of mental health care provision, a greater number of Bangladeshi psychiatrists are not only required to see more complex patients but also to supervise the general healthcare doctors who have been trained on the theoretical part of integrating mental health into the primary health care system (WHO and UNHCR, 2015). Child-focused MHPSS professionals, including social workers, are also required in Cox’s Bazar (see point ‘Child-focused mental health and psychosocial support services’ above) to support child-friendly spaces, non-formal education activities and to conduct outreach to families and households.
Coordination (national, Cox’s Bazar and camp levels)
To bridge the gap between discussions happening at Cox’s Bazar city level and the staff (and agencies) providing services in the camp, UNHCR and IOM as co-chairing agencies of the MHPSS WG began convening camp-level coordination meetings with service providers working in defined geographical areas (e.g., in four to five camps that are geographically proximate). This initiative arose through the emergency preparedness and response (EPRP) planning discussions to address concerns that many service providing agencies and organisations had not met each other, nor had the opportunity to interact and coordinate service provision. The MHPSS WG agencies advocated to continue and scale up this approach through 2019 and 2020.
Monitoring and evaluation
MHPSS WG members identified the need for common indicators to be developed for core MHPSS activities that could be used and tracked across agencies (see standardised training packages under point ‘Standardised training packages’ above). MHPSS WG members also indicated their wish to receive additional support on data collection tools that can be administered by frontline staff, to support indicator measurement for individuals (clients/ patients), families and large population groups such as women and men attending community centre activities or children attending child-friendly spaces. Workshop participants linked monitoring and evaluation to advocacy, (see point ‘Advocacy/awareness’ below), stating that the stronger their data collection and measurement methodologies, the more secure the MHPSS WG can be in terms of the collective (positive) impact of their interventions and programmes. Agencies referred to the importance of Bangla language versions of the Common Monitoring and Evaluation Framework for Mental Health and Psychosocial Support Programmes in Emergency Settings (IASC Reference Group for Mental Health and Psychosocial Support, 2017), the IASC MHPSS Guidelines (Inter-Agency Standing Committee, 2007) and the Referral Guidance Note and Form (IASC Mental Health and Psychosocial Support in Emergency Settings, 2017) to support their data collection and analysis moving forward.
The concept of MHPSS is not well known within the Rohingya community (Tay et al., 2018) and nor is it much known in the Bangladeshi host population community. The mysticism and stigmatisation around mental health are relatively high among both the Rohingya and Bangladeshi populations, but this also corresponds to a relatively low literacy or awareness of MHPSS problems. This is compounded by the cross-cutting nature of MHPSS work, which makes it difficult to advocate for its relevance and importance within a sector-based coordination system, which views an affected individual in terms of a single issue (e.g., health/food/shelter) rather than a person presenting with multiple complex needs. The structural positioning of the MHPSS WG under the health sector was raised as a challenge by the co-lead working group agencies, as it creates a perception that psychosocial activities conducted by protection and nutrition agencies are not included in the wider understanding of MHPSS services. They also reflected that this subsuming under the health sector made it very challenging to mainstream and promote psychosocial wellbeing (a level one intervention) (Inter-Agency Standing Committee, 2007) across the humanitarian response.
Workshop participants recommended better outreach activities to families and communities (see point ‘Family and community-led services’), coupled with continuous community-level awareness-raising activities in open areas, market places, community centres, women centres, health clinics, mosques and within tents/shelters. Qualitative data from the FGDs indicated the importance of jointly developing messages and activities with community leaders (including female community leaders), traditional healers and religious leaders. MHPSS WG members also identified key agencies to attend other sectoral meetings and tasked them with the responsibility to act as an advocate and conduit for MHPSS within these meetings including how other sectors can mainstream psychosocial wellbeing within their work.
Programme interventions for adult males
There are very few agencies supporting the Rohingya adult male camp population. This was acknowledged by agencies in the strategic prioritisation exercise and was confirmed by the qualitative date from FGDs, with male adults and adolescents who reported a lack of services focusing on their needs. The overall response has prioritised activities and services for women and children (boys and girls), through the provision of women’s centres, women’s groups, mother–baby groups and sexual and reproductive health services at clinics. There is evidence of women’s empowerment and awareness raising on women’s and girls’ rights within the camps, but little noticeable activities for adult males. Adult males were also reportedly a difficult population to reach as they are often outside of their shelters during the day looking for work or directly working. Males stated they rarely access health services (unless to accompany a female member) and reported not feeling welcomed at many of the community centres or other spaces that appear reserved for women and girls. Males are also under-represented within the staff and volunteers of MHPSS service providers − making it even harder to reach this population group, given the general gender segregation outside of the family home. Agencies providing MHPSS services reported striving to achieve a 50–50 split between males and females when recruiting Rohingya community volunteers.
Workshop participants shared successful activities or approaches to reach adult males including having specific times scheduled for males in community centres, working with Imams and traditional healers and conducting listening groups − where men get together to read the newspapers, listen to a podcast or the BBC Myanmar service − which stimulates social interaction and peer support.
Mental health law and the national mental health strategy
The Bangladesh Government is committed to updating the Mental Health Law and Act with a new version intended for release during 2019. The law will refer to all persons residing in Bangladesh, leading agencies within the MHPSS WG to advocate for its dissemination within the humanitarian community in Cox’s Bazar during 2020 and to link it to the overall protection and assistance for refugees living with mental health and psychosocial concerns.
| Limitations|| |
There are limitations to the above methodological approach of identifying the strategic priorities. Firstly, the workshop took place during an extended MHPSS WG meeting to which all members were invited. Despite sending open invitations, the profile and representation of participants and organisations attending the workshop may have influenced the selection of strategic priorities. For example, there was no representation from the Bangladeshi Ministry of Health, the National Institute of Mental Health nor Dhaka University, but there were a high number of agencies providing child-focused MHPSS services and good participation from national NGOs. The MHPSS WG co-chairing agencies did subsequently reach out bilaterally to the Bangladeshi Department of Health seeking their inputs, but this occurred outside of the formal data collection period. Organisations attending the MHPSS WG are those who self-identify as agencies providing MHPSS services − which due to the cross-cutting nature of MHPSS work does not necessarily equate to all agencies providing MHPSS services. For example, agencies offering restoring family links (RFL), legal protection, addressing gender-based violence, agencies responding to malnutrition and non-formal education actors may not self-identify as MHPSS actors. Their views are likely to be under-represented in the current Cox’s Bazar MHPSS WG membership.
Secondly, the lack of service users in the Cox’s Bazar workshop limited the participation of affected men, women, boys and girls and closed the community feedback loop too early. Rohingya refugees are not permitted to leave the camps in Ukhiya and Teknaf districts and were therefore unable to attend the workshop which took place with Cox’s Bazar-based staff who, whilst senior staff, are located two hours away from the camps. The perspectives of service users and their recommendations were gathered via FGDs prior to the workshop and then reviewed and triangulated against the ten priority areas. The authors recommend conducting the same prioritisation exercise with service users in the camps and then reviewing both sets of recommendations (one from the humanitarian community and one from service users) to produce the final strategic priorities.
Finally, strategic prioritisation workshops tend to focus on what priorities the MHPSS WG members wish to focus on, rather than the operational how to conduct programming or how to achieve a desired MHPSS outcome. The presentation at the beginning of the workshop to stimulate MHPSS WG members into thinking of categories may have narrowed their thoughts to focus on easier areas (what) and prevented a truly bottom-up participatory process that is closer to the more difficult reality of addressing the ‘how to’ questions.
| Conclusion|| |
The strategic prioritisation workshop provided the opportunity for the Cox’s Bazar MHPSS WG to form a consensus around which areas to collectively prioritise in their programming moving forward. The process of creating the top ten strategic priorities also provided the MHPSS WG with a renewed purpose, function and the opportunity to build their workplan for 2019 and 2020, as well as identifying key advocacy messages on the mental health and psychosocial needs of Rohingya refugee males, females, boys and girls residing in Cox’s Bazar. Finally, the creation of inter-agency endorsed strategic priorities, generated through community-level participatory processes, facilitates the functioning of a country-level MHPSS WG and their engagement with other sectors, so that they can better meet the needs of affected refugee populations and begin to build longer term response strategies.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
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