|Year : 2019 | Volume
| Issue : 2 | Page : 212-216
Field-level coordination of mental health and psychosocial support (MHPSS) services for Rohingya refugees in Cox’s Bazar
Mohamed Elshazly1, A.N.M. Mahmudul Alam2, Peter Ventevogel3
1 MD, MSc, ABPsyc, IMMHPS, Public Health and Nutrition Unit, UNHCR Cox’s Bazar, Bangladesh
2 MSc, MS, Public Health and Nutrition Unit, UNHCR Cox’s Bazar, Bangladesh
3 MD, PhD, Public Health Section, High Commissioner for Refugees, Geneva, Switzerland
|Date of Submission||13-Jun-2019|
|Date of Decision||14-Aug-2019|
|Date of Acceptance||16-Oct-2019|
|Date of Web Publication||29-Nov-2019|
Public Health and Nutrition Unit, UNHCR Cox’s Bazar
Source of Support: None, Conflict of Interest: None
The areas around Ukhiya and Teknaf in Cox’s Bazar district in Bangladesh are the location of some of the world’s largest and most congested refugee settlements. The refugees have myriads of needs, and hundreds of different organisations provide assistance in an enormously complex and at times chaotic humanitarian operation. The humanitarian community in Bangladesh has identified the provision of effective mental health and psychosocial support (MHPSS) services as a priority. However, the multi-sectoral nature of MHPSS can create challenges especially when it comes to coordination of services. A central coordination mechanism, the MHPSS working group, was established in December 2017. It is a sub-working group of the health sector and it has close ties with other sectors, mainly protection. This central MHPSS working group is attended mostly by mid-level and senior staff involved in policy and programming. We found that adding ‘field-level coordination’ with actors who work in the same geographical area helped to strengthen communication, cooperation and local coordination. It assists field-based staff to stay informed of each other’s work and can promote collaboration. For example, in the elaboration of the Emergency Preparedness and Response Plan to mitigate the effect of monsoon-related events in Cox’s Bazar, the field-level coordination mechanism proved very useful. Moreover, an area-based coordination mechanism can be a suitable platform to engage the affected communities in MHPSS coordination. This field report highlights the rationale, challenges and lessons learned from field-level coordination experience and argues that in large humanitarian settings establishing such area-based coordination mechanisms can have a clear added value and should be routinely considered.
Keywords: Bangladesh, field level coordination, humanitarian response, multi-sectoral approaches
|How to cite this article:|
Elshazly M, Alam AM, Ventevogel P. Field-level coordination of mental health and psychosocial support (MHPSS) services for Rohingya refugees in Cox’s Bazar. Intervention 2019;17:212-6
| Introduction|| |
Rohingya refugees have fled to Bangladesh in consecutive waves of displacement, the last of which has started in August 2017 following mass violence in Myanmar. Most refugees reside in two major refugee settlements: Kutupalong and Nayapara. In the current emergency, the need for mental health and psychosocial support (MHPSS) services has been identified as a priority by the humanitarian community in Bangladesh. At the moment, 77 organisations provide some form of MHPSS and work in 34 different camps or locations. Proper information sharing and coordination between so many actors is not easy. An additional problem is that these organisations have various sectoral affiliations: some are health organisations who implement mental health as part of their primary care activities, others are primarily active in protection and include psychosocial support activities within their work. These factors make coordination around MHPSS challenging.
Such challenges are not unique for the Rohingya situation. Humanitarian emergencies are, almost per definition, complex situations where many different actors strive to provide assistance according to their mandates and objectives and compete for funding and media attention. Examples of how coordination of services can be extremely challenging have been described for almost all major complex humanitarian emergencies (Bennett, Bertrand, Harkin, Wickramatillake, & Samarasinghe, 2006; Farmer, 2011; Knox Clarke & Campbell, 2015). Coordination around MHPSS is often particularly complicated because of the crosscutting nature of MHPSS and the diversity of stakeholders (Eloul et al., 2013; Jones, 2017; Van Der Veen & Somasundaram, 2006). In fact, the current humanitarian architecture does not provide a clear position for MHPSS coordination. The Inter-Agency Standing Committee Guidelines on Mental Health and Psychosocial Support in Emergency Settings (Inter-Agency Standing Committee, 2007) recognise coordination of MHPSS services as an important domain in the response to humanitarian emergencies. The guidelines recommend that coordination groups for MHPSS are intersectoral and neither ‘owned’ or co-opted by the health sector/cluster nor the protection sector/cluster. MHPSS Technical Working Groups should ideally be co-chaired by representatives from health and from protection backgrounds and the members of the group should broadly represent a wide range of actors, from local NGOs to UN agencies. Coordination aims to ensure that MHPSS interventions are included in the humanitarian response and that the humanitarian response is implemented in a way that promotes the mental health and psychosocial wellbeing of affected individuals.
A coordination mechanism for MHPSS in the Rohingya situation was established in fall 2017 in the midst of the influx of Rohingya refugees. Structurally, it lies under the health sector but the members of this working group (WG) are affiliated to different humanitarian sectors. The MHPSS WG has important roles such as information sharing, advocacy for MHPSS within other sectors, and mapping of resources. Despite the increasing importance of the MHPSS WG, the co-chairs felt the need to add another level of coordination, field-level coordination, which is meant to strengthen coordination in smaller geographical areas and make it more practice oriented.
In this paper, we will first describe how MHPSS coordination in emergencies is organised and then describe what we mean by field-level coordination. We argue that local coordination mechanisms are necessary to record and address field needs and challenges and are a suitable platform for engaging affected communities in MHPSS coordination and creating supportive networks within communities for persons with severe mental health problems.
| Coordination of MHPSS services for Rohingya refugees in Bangladesh|| |
The MHPSS WG in Cox’s Bazar was officially created in December 2017 through collaborative efforts of the Government of Bangladesh, UN agencies, INGOs and local NGOs. It lies structurally under the health sector, but it has close ties to all other sectors and sub-sectors, for example, protection, child protection and gender-based violence (GBV).
The MHPSS WG has been progressively reaching out to organisations providing MHPSS services in different sectors to strengthen the communication and coordination of services at different levels and has been involved in comprehensive mapping of MHPSS services which is an essential (and cumbersome) element of MHPSS coordination (O’Connell, Poudyal, Streel, Bahgat, Tol, & Ventevogel, 2013). At the moment, a total of 47 organisations (out of an estimated 77) participate in the MHPSS WG. They operate in a total of 34 camps and other refugee locations in Cox’s Bazar district.
Four taskforces were established by the MHPSS WG around: 1) integration of mental health into general health care services, 2) tools translation and adaptation, 3) emergency preparedness and response planning (EPRP) and 4) child mental health and psychosocial support.
While this coordination mechanism is essential, we observed various shortcomings to conventional MHPSS WGs in such a large emergency. One important shortcoming is that such coordination platforms usually include mid- and senior-level management and rarely field staff who are directly providing services for refugees. The channels of communication among organisations are not always functioning and therefore information and decisions in the coordination groups are not communicated consistently and timely to field-level service providers. Moreover, the discussions in the central coordination group are not always informed by practical issues and challenges faced in the field.
Additionally, MHPSS working groups are often forced to be part of one of the existing sectors/clusters. In Cox’s Bazar, MHPSS WG is a sub-group of the health sector which tend to limit the engagement of actors who primarily work in the protection sector which has its own sub-groups for child protection or gender based violence (GBV), who then may feel compelled to organise ‘sub-sub WGs’ such as a ‘child psychosocial support WG’ under the child protection sub-sector and an ‘adolescent girl psychosocial support WG’ under the GBV sub-sector. This overfragmentation made communication, coordination and service provision challenging and risked to make MHPSS actors losing a people-centred comprehensive approach. The scope of the MHPSS WG was usually limited to overarching and generic issues like development of guidance notes and position statements, MHPSS assessments and service mapping and doing joint capacity-building activities. Location-specific needs and challenges may easily be overlooked and this was certainly the case in the huge humanitarian operation in Bangladesh with 34 different refugee camps/locations. The meetings of the MHPSS WGs take place in the district capital of Cox’s Bazar which is the hub of humanitarian and governmental activities. This is one and half to three hours drive from where refugees reside. Coordination meetings therefore usually do not involve communities and local authorities (e.g. camp management).
| Field-level coordination of mental health and psychosocial support services|| |
Field-level MHPSS coordination started initially in the context of the emergency preparedness and response plan (EPRP) in 2018 to mitigate the impact of monsoon-related events. A major challenge at that time was the lack of clear and effective referral pathways among actors working in the field and linking those MHPSS actors with frontline workers who provided the first line response during and after the monsoon. UNHCR (the refugee agency of the United Nations) and the International Organization for Migration (IOM) facilitated location-specific ‘MHPSS referral workshops’ where organisations providing MHPSS services were invited to nominate focal points for their organisations in different locations (usually a programme manager or senior staff in the field) to participate. Focal points from outreach teams (in both health, protection and field site management) and camp authorities were invited for these workshops as well. These referral workshops were one-day events that aimed to link various actors. They started with brief discussions about the potential consequences of exposure to monsoon-related events on mental health and wellbeing of individuals, families and communities at large. This was followed by a refresher session on psychological first aid and the role of outreach workforce. Participants were then divided into smaller groups, and different case scenarios were introduced to stimulate discussions about possible actions and referral to various actors working in the same location.
Interestingly, those workshops were in many cases the first time for field staff working in different organisations in the same camp to meet each other and to jointly discuss issues related to their work. They had been working in the same location for almost ten months following the influx of Rohingya refugees in August, 2017, but hardly knew each other and often were not aware of the scope of work of the other organisations.
Those referral workshops were concluded with assigning an EPRP focal person in each camp to be responsible for receiving/guiding referrals from other sectors and from frontline workers / first responders (during emergency) and linking MHPSS services providers in the same location. The workshop participants suggested to hold local coordination meetings on a regular basis to discuss challenges related to coordination and referral and provide practical solutions for practical, field-related issues. In that time, the idea to establish MHPSS field coordination groups was born.
| Objectives of field-level coordination|| |
The objectives of these groups are manifold. The first objective is to link the MHPSS WG in Cox’s Bazar better with field staff. This helps informing discussions at the WG level with field needs and challenges and also helps to communicate decisions made at the WG to the field staff. It will also help overcoming the fragmentation of discussions about MHPSS across different WGs and coordination platforms by bringing them together within one geographical area. It provides opportunities to connect staff working in health, protection, child protection, SGBV and field units and discuss location-specific issues and challenges overcoming the sectorial architecture which fragments MHPSS.
The second objective is to improve the referral process at field-specific locations (camp level) through linking partners in the field who provide different MHPSS services (especially if they work under different sectors). Also, different partners can discuss the referral pathways, the use of referral forms and the follow up of cases after referral.
The third objective, quite specific for the situation in Bangladesh, is to support the EPRP. The EPRP includes measures taken by different sectors to mitigate the impact of monsoon-related events, for example, heavy rainfall, landslides and cyclones. An important element of the EPRP is to link the frontline staff (e.g. community health workers, community outreach members and safety unit volunteers) with services providers in their respective locations. This referral process can be complicated − especially during the emergency − and leads to drop out of cases and lack of follow up. The EPRP focal point in the camp (who is leading the local coordination meeting) is responsible to receive referral from different frontline workers and re-direct them to different service providers according to age, gender and diversity.
The fourth objective is to engage local humanitarian actors who are not usually involved in discussion around MHPSS, such as camp coordinators and camp managers. Involvement of such stakeholders has proven to be very useful in other settings (Schininá, Nunes, Birot, Giardinelli, & Kios, 2016).
The final objective of field-level coordination meetings is to engage the affected populations in coordination of MHPSS services. Community involvement is easily overlooked in large-scale emergencies which leads to gaps between service providers and expectations of affected communities. Community members can have an active input to the design of activities and filling the gaps in service provision, and moreover can create a supportive network within the camp for persons with severe mental health problems and can help to overcome the stigma of mental illness.
Field-level coordination meetings were piloted in some locations where focal points from two or three camps gathered in one meeting. Initially, it proved challenging to organise separate meetings for each camp due to limited supportive human resources at the MHPSS WG. Initial meetings were mainly focused on emergency preparedness and response, but later expanded to include discussions about gaps in services and challenges in the referral process. For instance, the field coordination pointed to shortages of clinical mental health services for children and adolescents, limited capacity to support persons with disabilities and lack of psychotropic medications in many locations. One staff member from UNHCR or IOM co-facilitated these meetings which guaranteed a conistent link with the MHPSS WG in Cox’s Bazar. The minutes of such meetings were discussed in the MHPSS WG so that the members were briefed about the local discussions and received feedback from field staff.
Experiences till now
Initially, representatives from some organisations had concerns about launching of these field-level meetings fearing they could be time consuming without much useful outcome. There were also concerns about involving field staff in information sharing, with worries that this might lead to breach of confidentiality when talking about clients. However, people soon realised the additional practical value of creating a platform to reduce the gaps between field staff and the MHPSS WG and to improve practical coordination around case management and referral among agencies.
In some field-level meetings, several gaps were highlighted, for example, a lack of child-focused mental health services in most camps and lack of consistency in referral processes among different actors. When these challenges were brought to the MHPSS WG, clear decisions could be made about mobilising actors to cover certain locations even through mobile teams, and more thorough discussions took place to make the process of referral practically possible and feasible at the field level.
Challenges and limitations
While we believe that field-level coordination groups are an important addition to MHPSS coordination, we also see challenges and limitations. For example, it was sometimes difficult to keep close ties with the central MHPSS WG in Cox’s Bazar: a representative from the MHPSS WG must be involved in the field coordination meetings to ensure bi-directional communication, convey information between the two levels and moreover to build the capacity of field staff on how to facilitate these coordination meetings. This can be time consuming when many field coordination meetings are taking place. We are now trying now to link MHPSS field coordination with the larger health field coordination platforms, and this may help to overcome the challenge of resources, yet we are trying carefully to make sure that MHPSS is not perceived as a part of the health sector alone and being segregated from other humanitarian sectors.
Another limitation is that some organisations are reluctant to participate in additional meetings. This is understandable given the workload and the shortage of human resources. However, we feel that once the field coordination structure is in place, the actors will see the added value. Also, the field coordination meetings are spaced (i.e. monthly basis), brief (usually do not exceed one hour) and the agenda is informed by practical issue from the field.
Community participation is still limited. Community leaders, traditional healers and religious leaders showed interest in participating in coordination meetings and in supporting persons with mental health problems, but in practice this rarely happened and more efforts need to be taken to involve them. Also, despite the valuable contribution of community members in field coordination meetings, their overall engagement was not strong and more advocacy is needed at both the camp management and the community levels to strengthen the role of the community in these meetings.
The way forward
The linkages between the field-level coordination mechanism and the central coordination mechanisms should be improved. Currently members of the central WG attend the field coordination meetings. A different approach could be to invite focal persons of each field-level WG to participate in the central MHPSS WG meeting. This will ensure that the voices from the field are heard in the central meetings.
Understanding the structure and the culture of community leadership is important to avoid undermining local social structures and arrangements in place. The links with local authorities (e.g. camp management) and different sectors (e.g. site management and community-based protection) are important here. Also, it is important to ensure that the participation of local actors such as traditional and religious leader in these coordination mechanisms does not lead legitimizing all their practices (including potentially harmful practices that violate human rights principles).
| Conclusion|| |
Field-level coordination proved to be a useful additional tool to improve coordination and cooperation of MHPSS actors in the field. In large and complex humanitarian emergencies, the establishment of such groups should be considered. Our experience in Cox’s Bazar suggests that field-level coordination can be successfully introduced and is particularly useful to increase the support for MHPSS among non-MHPSS actors and to improve community engagement. Field coordination meetings offer a great opportunity to involve communities in the discussions about mental health and psychosocial support services in their locations and exploring their views about mental health, mental illness and mental health services. The accumulated experience from these discussions with the community can inform better service delivery that is in line with community expectations. Field coordination meetings helped in bridging the different sectors at the camp level and mend the unfortunate territorial fragmentation of MHPSS services across the humanitarian response.
Financial support and sponsorship
Conflicts of interest
The views expressed in these papers are from the authors and do not necessarily reflect the opinions of the institutions they serve.
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