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Table of Contents
ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 18-27

Three models of scaling up mental healthcare post-disaster: common challenges


1 Mental Health Consultant, Medical School of University of Zagreb, Croatia, Senior Member of Croatian Medical Chamber, Croatia
2 Doctor Honoris Causa, Birmingham City University, UK, Senior Fellow, University of Melbourne, Australia
3 Department of Health, Eastern Visayas Centre for Health Development, Palo, Leyte, Philippines
4 Post-graduate Student in Public Health at Frontier Institute of Medical Sciences, Abbottabad, Pakistan
5 UK, Board Certified Consultant in Public Health, Sri Lanka

Date of Submission24-Apr-2019
Date of Decision10-Jan-2020
Date of Acceptance26-Feb-2020
Date of Web Publication29-May-2020

Correspondence Address:
MD, MSc, MPH Boris Budosan
Consultant Psychiatrist, Vocarsko Naselje 22, 10000 Zagreb
Croatia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/INTV.INTV_11_19

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  Abstract 


There are number of challenges in strengthening mental healthcare services in underserved areas post-disaster. The objective of this paper is to identify common challenges by comparing and contrasting three models of scaling up mental healthcare services post-disaster. Primary and secondary data were collected before, during and after mental health programming in Sri Lanka, Haiti and the Philippines. A qualitative case study methodology including a set of narrative topics and programme indicators developed by the London School of Hygiene and Tropical Medicine was employed to document the services of the programmes. The authors added a set of outcome indicators to address the outcomes of programmes at community and individual level. We discuss challenges and conclude that sustainability of programme achievements, change of practices of trained non-specialised healthcare providers and their supervision and evidence of impact of clinical interventions are common challenges for scaling up mental health (MH) services post-disaster. We believe that more comparative evidence is needed on how MH services initiated by different actors’ post-disaster function in actual practice, especially in the longer term.
Key implications for practice

  • Mental health services can be significantly scaled up at community, primary and secondary healthcare level within a relatively short period of time post-disaster.
  • Essential principles/components to be considered as key standards in MHPSS strategies post-disaster include regular consultations with local and national government and health authorities, a clear perspective on how to continue with longer term supervision after theoretical trainings, enough programme time allocated to clinical MH consultations (including follow-up) and focus on monitoring of improvement of clinical symptoms and functionality of clients.
  • It would be useful for developers of MHPSS programming post-disaster to respect the key standards in designing an innovative service model with an optimal mix of community-based psychosocial, outpatient clinic and inpatient clinic-based interventions to improve wellbeing and resilience of clients at community level and access to PHC and SHC level including affordability of psychiatric medications.

Keywords: case study, challenges, mental healthcare, natural disasters, post-disaster


How to cite this article:
Budosan B, Mahoney J, Dorego WC, Aziz S, Ratnasabapathipillai K. Three models of scaling up mental healthcare post-disaster: common challenges. Intervention 2020;18:18-27

How to cite this URL:
Budosan B, Mahoney J, Dorego WC, Aziz S, Ratnasabapathipillai K. Three models of scaling up mental healthcare post-disaster: common challenges. Intervention [serial online] 2020 [cited 2020 Oct 29];18:18-27. Available from: https://www.interventionjournal.org/text.asp?2020/18/1/18/285311




  Introduction Top


Worldwide, disaster settings are challenged to provide appropriate access to mental healthcare. Mental health (MH) services in many low- and middle-income (LAMI) countries are often inadequate even before a disaster (Saxena, Thornicroft, Knapp, & Whiteford, 2007) and after disaster, gaps between needs and services widen (Ommeren, Saxena, & Saraceno, 2005). Still, according to the World Health Organization (World Health Organization, 2013), emergency situations − in spite of the adversity and challenges they create − are openings to strengthen and even transform mental healthcare. According to Saraceno et al. (2007), a post-disaster focus on MH, paired with professional expertise, can improve community MH services and access to MH for affected populations. However, there is a comparative lack of evidence about how MH services in low-income countries (LIC) function in actual practice (Cohen et al., 2011).

According to Ventevogel, Perez-Sales, Fernandez-Liria, & Baingana (2011), mental health and psychosocial support (MHPSS) interventions in emergencies should begin with a clear vision for the long-term advancement of community MH services. Taking steps to develop a sustainable MH system during early recovery planning and protracted crises is one of the key actions to attain the minimum standard of MH response in emergencies (Sphere Association, 2018). According to the Inter-Agency Standing Committee (2007), the effects of disaster on MH are best addressed by existing services, that is, through capacity building rather than by establishing parallel systems. MHPSS interventions in post-disaster settings can develop service capacity and community access through non-specialist health practitioners and community-level workers (O’Hanlon & Budosan, 2015). Ideally in the longer term, the minimum response actions should serve as an opportunity to transform MH services post-disaster. A set of far reaching recommendations on how to strengthen and transform MH care was provided by the WHO (World Health Organization, 2001). These recommendations can be adapted by every country according to its needs and its resources. The socio-political and cultural context of every emergency varies widely and details of a health and MH system in a disaster affected area and/or country are important for the actors on the ground (World Health Organization, 2013). Context-specific methods should be emphasised and local approaches should be respected.

The objective of this paper is to compare and contrast three models of scaling up MH services post-disaster and identify common challenges to this process. The first model was implemented by the international non-governmental organisation (INGO), International Medical Corps (IMC); the second one by the INGO Cordaid and the third one by WHO. The importance of addressing common challenges that can impact strengthening of MH services post-disaster has been highlighted. While there are case examples on building sustainable mental healthcare after emergencies (World Health Organization, 2013) and a number of publications which provide detailed descriptions of building MH services after disasters and in fragile contexts (Epping-Jordan et al., 2015; Jones et al., 2007; Budosan et al., 2007; Ventevogel, van de Put, Faiz, van Mierlo, Siddiqi, & Komproe, 2012; Budosan, O’Hanlon, & Aziz, 2014; Budosan O’Hanlon, Mahoney, Aziz, Kesavan, & Beluso, 2016), to the best of our knowledge there is no prior publication from the perspective of practitioners which provides such detailed comparative and empirical evidence of different service models implemented in post-disaster settings.


  Methods Top


Settings

The four programmes which represent three models of scaling up MH services post-disaster are the foci of this paper:
  1. Tsunami relief: Expansion of a community support and social rehabilitation intervention to address the emotional and psychological needs of local tsunami-affected communities in Sri Lanka; Ampara (Kalmunai) and Hambantota (the first model)
  2. A community-based integrated MHPSS programme in the earthquake affected areas and areas of displacement of the earthquake affected population in Haiti (the second model)
  3. Psychosocial support in the mass casualty context of Typhoon Haiyan in Eastern Visayas, the Philippines (the third model)


The programmes that were to be the subjects of the case studies were selected by the main author because of the availability of extensive documentary evidence due to his direct involvement in programme implementation. The programmes were funded by the Netherlands Refugee Foundation (Sri Lanka), European Community Humanitarian Office (ECHO), Cordaid and Trocaire (Haiti) and United Kingdom’s Department for International Development (DFID) (the Philippines).

Design

A qualitative case study methodology developed by the London School of Hygiene and Tropical Medicine (LSHTM) (Cohen et al., 2011) was employed to document the services of programmes. The qualitative case study is an approach to research that facilitates exploration of a phenomenon within its context using a variety of data sources. The guiding research question in this study was ‘What challenges were common to all selected programmes in scaling up mental healthcare post-disaster?’ A set of narrative topics and programme indicators was employed to document the context and the services of programmes. A set of outcome indicators was employed to document their outcomes (see [Table 1]). The major component of this descriptive study was an extensive review of the relevant documentary evidence (primary data) collected during direct programme implementation. The secondary data relevant to all programmes were utilised to confirm and/or augment the information collected during the review of primary data.
Table 1 Narrative topics, programme-level and outcome indicators

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Data collection

The documents from four programmes were reviewed in detail to collect data relevant for the purpose of this study. The time period reviewed was May 2005–January 2007 for programmes in Sri Lanka, March 2010–June 2012 for the programme in Haiti and January 2014–March 2015 for the programme in the Philippines. Information was also derived from documents such as brochures, materials on the Internet and peer-reviewed papers related to programmes (see [Table 2]). After the limitation of available documentation was noted, especially in relation to programme sustainability, e-mail requests for up-to-date information on programmes were sent to relevant professionals who were active in response. The main question was related to the progress in scaling up and sustainability of MH services in the areas targeted by programmes post-disaster. Seven professionals were contacted and included two staff of the WHO and one Medical Officer of Mental Health (MOMH) in Sri Lanka, one psychiatrist and one government representative in the Philippines and one general practitioner and one psychologist in Haiti. This yielded a good response from Sri Lanka and the Philippines, but not from Haiti. Data obtained from Sri Lanka and the Philippines covered the current status of programmes in Kalmunai and Eastern Visayas. This information was used to fill in gaps in the information already collected.
Table 2 Overview of documents reviewed

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Data analysis

After the research team agreed on the main research question for this study, the main author identified the relevant documentation. The authors established inclusion criteria to apply to this study and included documents that mentioned in any way MHPSS programming in Sri Lanka, Haiti and the Philippines. The relevant information from reviewed documents was extracted using the data charting form method (Arksey & O’Malley, 2005), covering a set of narrative topics, programme and outcome indicators and transferred into text files. The data extracted included both descriptive details of the programmes (e.g. programme management and staffing, nature of intervention, etc.) and their activity outcomes (e.g. number of trained personnel, number of reached beneficiaries and outcomes of intervention). Both qualitative and quantitative programme data were integrated separately for each programme to get a more complete understanding of each programme and its specific strengths and weaknesses, but also to identify common challenges to all programmes. In order to triangulate and extend findings of the reviewed documents, up-to-date programme information from the individuals contacted by e-mail was added to the text files.

The main author analysed text files according to the narrative topics, programme level and outcome indicators. Common themes and issues were identified and then summarised into the categories discussed below. They were shared with other co-authors for their agreement and possible comments. To present the results here, we have arranged information about the programmes into the following domains: history, context and organisation; accessibility of MH services; pathways to care and characteristics of clients; capacity building interventions; clinical interventions; psychosocial interventions and outcomes.


  Results Top


History, context and organisation

What is common to all programmes discussed here is that they began operations after natural disasters (2004 tsunami in Sri Lanka, 2010 earthquake in Haiti and 2013 typhoon Haiyan in the Philippines). They all had a common objective to alleviate the emotional suffering of disaster-affected populations (Mahoney, Chandra, Harischandra, De Silva, & Suvendraan, 2006; Budosan et al., 2007; Budosan & Jones, 2009; Budosan, O’Hanlon, & Aziz, 2014; Budosan et al., 2016). All the programmes functioned in regions with high levels of poverty. According to the Human Development Index (HDI), a composite measure of life expectancy, education levels and standard of living, the areas in which the Haiti programme operated appear to be the poorest (see [Table 4]). The programmes were all implemented in areas with insufficient MH services and shortage of MH professionals. Before the tsunami, MH services in Kalmunai were provided by two MOMH (general physicians with three month MH training). They were occasionally supervised by one psychiatrist. MH services in Hambantota were provided by two primary healthcare (PHC) physicians with some additional MH training and supervised occasionally by one psychiatrist. Public MH resources in Haiti were highly centralised, and consisted of two psychiatric hospitals in Port-au-Prince (PaP), both of which were understaffed and in a poor state of repair (Rose Hughes, Ali, & Jones, 2011). Most services provided by MH professionals in Haiti were in the private sector, and based primarily in the capital, PaP. Compared to Sri Lanka, MH services in areas targeted by the Haiti programme outside the capital were practically non-existent. In E. Visayas, public MH resources were still the best of all the programmes and consisted of Eastern Visayas Regional Medical Centre (EVRMC) in the regional capital city of Tacloban and the schistosomiasis hospital in the municipality of Palo in Leyte. However, PHC providers would refer virtually every patient that presented with MH concerns in rural or city health units (RHUs, CHUs), which are PHC facilities in the Philippines.

While programmes in Sri Lanka primarily aimed to improve availability and access to MH services in PHC, the Philippine programme aimed to improve availability and access to MH also at a secondary healthcare (SHC) level and affordability of psychiatric medications. In comparison, the Haiti programme primarily aimed at improving wellbeing and resilience of targeted beneficiaries at the community level. While programmes in Sri Lanka and the Philippines closely cooperated with governments and local authorities, the Haiti programme primarily cooperated with its 15 local NGO partners.

Programmes in Sri Lanka relied on support from local Divisional Medical Officers of Health (DMOH) and local psychiatrists (see [Table 3]). The Haiti programme relied on local programme staff and a number of local consultants (see [Table 4]). The Philippine programme employed a mix of international and local professionals with a number of local consultants (see [Table 5]). In all the programmes, the salaries for local staff were significantly better than average local salaries.
Table 3 Model of scaling up mental healthcare in Sri Lanka post-2004 tsunami

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Table 4 Model of scaling up mental healthcare in Haiti post-2010 earthquake

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Table 5 Model of scaling up mental healthcare in the Philippines, post-2013 typhoon Haiyan

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In Sri Lanka and Haiti, visiting psychiatrists travelled longer distances using their own cars to reach the beneficiaries (between three and six hours). The programme staff in Sri Lanka used the IMC vehicle and in Haiti public transportation (tap-taps), Cordaid vehicles and their own motorbikes and cars. The transportation costs were covered by IMC and Cordaid respectively. In the Philippines, barangay health workers used public transportation (jeepneys) while medical doctors preferred their own cars. The WHO staff used official WHO vehicles. The transportation costs were covered by the local health facilities and the WHO.

Accessibility of MH services

Access to MH services appeared to be an issue for a number of clients. No van service or transportation incentive for clients was available in any of the programmes. While IMC mobile clinics were able to reach clients in Kalmunai, in Hambantota clients used their own motorbikes and that was costly for clients from remote areas. The services were more accessible to clients in Haiti because of the presence of local NGO partners in targeted communities. In the Philippines, clients used public transportation (jeepneys) and poor families were visited by local health and WHO staff in their homes. In Kalmunai and Hambanota, some of the essential psychiatric medications were available in health facilities and they were free of charge. In comparison, Cordaid provided medications free of charge in Haiti, but only for six months. The best access to medications was in the Philippines where the WHO provided emergency packages of essential psychiatric medications immediately after the disaster for three months. Later, the WHO started to support the Medicine Access Program − Mental Health (MAP-MH), run by the government (Hilton, 2015).

Pathways to care and characteristics of clients

In Haiti, active case finding was conducted by community psychosocial workers of local NGO partners. In comparison, in Sri Lanka it was conducted through IMC mobile clinics in Kalmunai and by local government health workers and NGO Basic Needs in Hambantota. In the Philippines, case finding relied on referrals from local government health workers. Outreach activities were conducted in all the programmes. In Sri Lanka, the main outreach component was consultations with local government officials, local health authorities and WHO Sri Lanka. Similarly, the Philippine programme conducted regular consultations with the local Department of Health (DoH), local government units (LGU), INGO partner IMC and with the Ministry of Health (MoH) in Manila. In contrast, the main outreach component in Haiti was consultations with local NGO partners.

Clients with psychosis and depression were present in all the programmes, but with a disproportionate frequency (see [Table 3],[Table 4],[Table 5]). The most probable rationale behind this is that the priority attention in each programme was given to clients with severe and common MH disorders (psychosis and depression) which are more prevalent post-disaster. Clients with epilepsy presented a significant proportion of clients only in the Haiti programme (see [Table 4]). According to the local health authorities, this was mostly because many clients with epilepsy could not afford medications for epilepsy prior to the disaster. The clients with bipolar disorder and alcohol problems were seen only in the Philippines programme and this can be best explained by the better diagnostic skills of more qualified Philippine programme staff (see [Table 5]).

Capacity building interventions

The most comprehensive capacity building intervention was in the Philippine programme. It was provided to both PHC workers (with supervision) and Barangay health workers (see [Table 5]). In comparison, the Haiti programme provided an extensive capacity building intervention and measured knowledge improvement, but there was no supervision (see [Table 4]). Capacity building interventions in Sri Lanka did not reach as many PHC physicians as in Haiti and in the Philippines. Instead, they provided a cycle of trainings to the same PHC physicians. The Hambantota programme measured post-training knowledge improvement and also provided capacity building interventions to many mid-level public health staff (see [Table 3]).

Clinical interventions

In Sri Lanka, clinical care was provided at MH outpatient clinics. In the Philippines, it was provided at RHUs and CHUs and in Haiti at outpatient clinics of local NGO partners. Trained health workers provided clinical care in all locations. While IMC developed MH protocols and guidelines in Sri Lanka, mhGAP protocols and guidelines were used in Haiti and in the Philippines (World Health Organization, 2010).

Medication from the WHO’s Model Lists of Essential Medicines (14th, 17th and 18th edition) was the mainstay of clinical treatment in all the programmes (World Health Organization, 2019). The quality of medications was generally good although they were of different origins (see [Table 3], [Table 4] and [Table 5]). Health workers did not regularly inquire about side effects. None of the programmes provided formal psychotherapy, and in all of them health and/or community workers tried to see clients at least once a month (see [Table 3],[Table 4],[Table 5]). Only the Philippine programme aimed to offer MH services at secondary healthcare (SHC) level (Budosan et al., 2016) and was able to handle psychiatric emergencies to a certain extent.

Psychosocial interventions

In all the programmes except the Kalmunai one, care providers were trained to provide psychosocial support (see [Table 3],[Table 4],[Table 5]). Public health nurses were doing psychoeducation in Hambantota and barangay health workers in the Philippines. Only the Haiti programme offered a comprehensive, community-based, psychosocial intervention (see [Table 4]). Still, in the Philippines a psychosocial rehabilitation programme was piloted in Guiuan in E. Samar (see [Table 5]).

Outcomes

In all the programmes, the important outcome was the development of MH service capacity and community access through non-specialised healthcare providers and community level workers. The availability, access and affordability of MH care were improved in all the programmes to a certain extent. In Sri Lanka, 13 MH clinics opened in Kalmunai and eight in Hambantota. 97.5% PHC units in E. Visayas (the Philippines) were strengthened by at least one healthcare provider trained in mhGAP. MH consultations were held in four departments of Haiti. The psychosocial intervention in Haiti reduced the level of distress on average by 47.5% and improved wellbeing and resilience by 26.9% and 31.1 % respectively (Budosan, O’Hanlon & Aziz, 2014). Only the Hambantota and Philippine programmes organised data so that statistics were readily available on the number of clients receiving services, clients’ basic clinical and sociodemographic characteristics, the treatments received, the length of time in treatment and/or the consistency with which client accessed services. During the programming period, the programmes did not provide systematic data on impact of clinical interventions, that is improvement of clinical symptoms and functionality by their clients. However, the anecdotal evidence from all the programmes suggested that improvement was present in a significant number of clients. This was most evident in the Philippines where psychotic patients were actually released from chains after receiving psychiatric medications (Dr. Kesavan − personal communication). A data collection system that would enable the generation of routine process and outcome data was piloted in all the programmes to be regularly used in a future.


  Discussion Top


This paper describes three models to scale up MH services post-disaster. The results show a diversity of service models, common and specific strengths and weaknesses of models and common challenges.

A common strength of programmes in Sri Lanka and in the Philippines compared to the Haiti programme was a strong outreach component. Both programmes conducted regular consultations with local and national government and health authorities. In Sri Lanka, regular consultations were held with WHO Sri Lanka and in the Philippines. WHO Philippines actually implemented the programme. The specific strength of the Philippine programme compared to Sri Lanka and Haiti ones was that it had a highly qualified multi-disciplinary programme staff (locals and internationals) and its improved access to MH services at SHC level and ensured the supply chain for psychiatric medicines (Hilton, 2015; Budosan et al., 2016). The specific strength of the Sri Lankan programmes was the permanent presence of an international MH coordinator on the ground which is according to World Health Organization (2008) crucial in steering programmes around challenges and driving forward the integration of MH into PHC. The specific strength of the Haiti programme compared to programmes in Sri Lanka and the Philippines was a comprehensive, community-based, psychosocial intervention which reached approximately 65,000 beneficiaries (Budosan, O’Hanlon & Aziz, 2014).

A common weakness of all the programmes was the impact of clinical MH interventions, i.e. clinical MH consultations were provided to a relatively small number of clients during the programming period (see [Table 3],[Table 4],[Table 5]). It looks as if the time allocated to MH consultations in all the programmes was not enough, that is three months in Kalmunai, four months in Hambantota and in the Philippines and six months in Haiti. An example from Afghanistan shows that two years were needed to increase the initial number of 659 MH consultations to well over 3,000 (Ventevogel et al., 2012). Compared to the Philippine programme, the common weakness of the programmes in Sri Lanka and Haiti was that they did not improve access to MH services at SHC level and to the supply chain of psychiatric medications. The lack of community MH awareness activities was a specific weakness of the Philippine programme.

Three common challenges were found. We think that if they were properly addressed, the sustainability, quality and effectiveness of the programmes would significantly improve. Firstly, it seemed unlikely that all results achieved by the programmes would be sustainable in the longer term. This is especially true for the Haiti programme where Cordaid encountered problems with its local NGO partners who seemed to be oriented more towards their own needs than in the delivery of good quality MH interventions to the earthquake affected population (Budosan & Bruno, 2011). The sustainability of achievements in Sri Lanka and the Philippines seemed more likely because of pledged support of local and national health authorities to sustain results beyond the programme period. However, the problem there was a lack of incentive for PHC workers to practise MH and their overloading with other trainings and responsibilities (Budosan et al., 2007, Budosan et al., 2016; Budosan & Jones, 2009).

The second, common challenge was related to the change of practices of trained PHC providers and their supervision. According to the evaluations of theoretical trainings, on average 50% of trainees in all locations were not confident enough to change their MH practices without continuous supervision in the future. The programmes in Sri Lanka and the Philippines looked more promising in terms of continuous supervision: The team of psychiatrists from Kandy offered to provide supervision to Kalmunai and the team of psychiatrists from Colombo to Hambantota. The psychiatrists in the Philippines pledged supervision in form of remote supervision and occasional supervision on site. However, shortage of their time and lack of incentive were seen as threats to their commitment. In contrast, no psychiatrists pledged supervision in the Haiti programme.

The third, common challenge is related to a lack of systematic data on improvement of clinical symptoms and functionality by clients (apart from anecdotal evidence). Here, it also seems that the time allocated to MH consultations was not enough to register a significant improvement of clinical symptoms and functionality of clients (see [Table 3],[Table 4],[Table 5]). The number of MH consultations per patient was low; in most cases a maximum two per client.

Follow-up

Remote follow-up of programmes in 2019 revealed that the programmes in Sri Lanka and the Philippines were effective as demonstration projects linked to discussions and plans on broader MH reform in these countries. At present, there are acute psychiatric wards in three Base Hospitals in Kalmunai; Kalmunai North, Kalmunai South and Akkaraipattu. There is also a MH unit Sammanthurai with daily MH services and MH clinics in all MoH divisions. (Dr. M.J. Nowfel − personal communication). An acute inpatient unit in a general hospital is also available in Hambantota (Minas, Mahoney & Kakuma (2011). 94.14% health facilities with mhGAP trained personnel in E. Visayas deliver MH services. The average number of MH clients seen per month increased (WHO Philippines, 2019). The number of clients in RHUs is from 28-30 and in CHUs it is 80–85 per month. E. Visayas has an annual mhGAP training now and post-training supervision is conducted by local psychiatrists through facility visits, telephone, email and the use of social media like Messenger and Viber. The EVRMC and Schistosomiasis Hospital have a 10 bed acute psychiatric unit (APU). The Treatment and Rehabilitation Centre (a 100 bed capacity centre) provides care for substance abuse related disorders. Northern Samar Provincial Hospital has a two bed APU, while Biliran Provincial Hospital is working on a two bed APU (Winnie Dorego − personal communication). Unfortunately, in spite of several attempts to get feedback on progress of MH services in programme areas in Haiti, there was no response.

Study limitations

There are several limitations to the methodology in relation to the case studies presented. First, follow-up visits to the areas targeted by programmes would allow the collection of more detailed information about the longer term impact of the programmes. Second, in order to reduce the possibility of bias, it would be recommended that these case studies were carried out by an independent observer. However, this would be an expensive process and it is unlikely that it would be possible to find the resources necessary to commission independent case studies. Third, based on this study we can only speculate on the reasons behind variations in the clinical characteristics of patients. However, only further research would determine the reasons for the variation. Also, apart from the anecdotal evidence, there were no hard data on improvement of clinical symptoms and functionality of clients which would be important for the evaluation of the impact of programmes on beneficiaries (Blanchet & Roberts, 2013).

Recommendations

Based on the results of this study, we would like to highlight the following essential principles/components that must be in place and considered as key standards for MHPSS strategies post-disaster: (1) regular consultations with local and national government and health authorities, (2) a clear perspective on how to continue with longer term supervision after theoretical trainings, (3) enough programme time allocated to MH consultations (including follow-up) and (4) focus on monitoring of symptom severity and functional status of clients. The programmes described here represent a range of service models: from mostly outpatient clinic-based model with some activities in the community (Sri Lanka) to a more community-based model with some outpatient clinic-based activities (Haiti) to a model that provides both outpatient and inpatient clinical care with some activities in community (the Philippines). We think that it would be useful for developers of MHPSS programming post-disaster to respect key standards in designing an innovative service model with an optimal mix of community-based psychosocial intervention to improve wellbeing and resilience of clients at community level and outpatient and inpatient clinic-based interventions to improve access to MH at PHC and SHC level, including affordability of psychiatric medications. This recommendation would also be in tune with the recommendations for the organisation of services for MH (World Health Organization, 2003).


  Conclusions Top


We believe that one of the challenges to effective scaling up MH services post-disaster is the lack of comparative evidence on how different models function in actual practice. The qualitative case study methodology used to describe programmes here seeks to address that need by comparing and contrasting different models. This can be helpful for developers of MHPSS programming post-disaster in the future. Finally, case studies such as these generate questions for further investigation and set the stage for more rigorous evaluations of different models.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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