Complex humanitarian emergencies, whether arising from armed conflict or natural disaster, challenge the mental health system of a country in many ways. Not least because they increase the risk of mental disorder in the population, and undermine the pre-existing structures of care. They may, however, also bring new opportunities to create change. In this way, new structures and paradigms may emerge from the midst of a crisis. The probabilities for such a change to occur vary from one setting to another. Regardless, it has been seen that interventions in complex humanitarian emergencies should not be limited to the deployment of specialised resources that will disappear once the emergency has lost its urgency, or visibility. Apart from provision of direct services, interventions in these circumstances should also aim to build local capacity and install sustainable systems of mental health care at the time of the intervention. This paper serves as an introduction to this special issue of ‘Intervention’ and examines the various aspects surrounding integration of mental health care and psychosocial support into overall health systems during, or after, complex humanitarian emergencies.

Following the 2010 Haiti earthquake, there was a need for specialist services for severely mentally ill people who were presenting to the emergency medical clinics set up for displaced people. That need was unmet. Using guidelines drawn up by the Inter-Agency Standing Committee (IASC), and piloting the Health Information System (HIS) of diagnostic categories in mental health, weekly mental health clinics were begun in eight mobile clinics. A psychiatric liaison service was also started in the main casualty hospital. Haitian general practitioners and psychosocial workers, who received on-the-job training and supervision from the authors, ran these services. This integrated mental health/primary health care model was successful in engaging severely mentally ill patients in treatment; however, the scale of the disaster meant that only a relatively small proportion of the displaced population could access help. This limitation raised a number of questions about the practicality and sustainability of the IASC model in resource poor countries, with poorly developed community services, hit by large scale emergencies, which the authors address.

The recent earthquake in Haiti exposed all the weaknesses in the mental health care system existing prior to the earthquake. This paper describes the strategy developed by the Dutch nongovernmental organisation Cordaid for providing integrated mental health and psychosocial support in Haiti after the earthquake. The strategy aimed to address mental health and psychosocial needs in the early recovery and reconsolidation phases, and to build mental health capacity of community level and primary health care providers. This would result in the establishment of a referral system between the community and health care sectors. The results of the implementation showed that mental health trainings were a feasible intervention for Haiti, but so far they have not yet resulted in change of practice of primary health care workers, and the goal of a referral system is still in an embryonic phase.

The paper describes the development of a community oriented mental health care system in the Region of Huancavelica (Peru), after a devastating earthquake in 2007. The area is also one of the most inaccessible and disadvantaged areas of Peru. Collaborative efforts by health personnel in the area, the Regional Directorate of Health and the international organization Médicos del Mundo – España, led to a wide range of activities such as: 1) the revitalisation of a dysfunctional Community Mental Health Centre; 2) the development of a Regional Mental Health Plan, through an participatory process; 3) a pilot action research project in the community to identify people with severe mental health disorders who did not receive psychiatric care; 4) the training of general health personnel in mental health and 5) support a mental health reparations programme for survivors of political violence. The authors argue that emergencies and disasters can be an opportunity for fundamental changes in the mental health care that would be very difficult to implement at other times. The first six months of reconstruction after a disaster represent a privileged time for nongovernmental organisations to assess the local mental health care systems, and work hand in hand with survivors and the authorities to elaborate longer term projects and mobilise the necessary support.

The massive influx of Iraqi refugees into Syria in 2006 put an immense strain on the already under-resourced mental health sector. This prompted a consortium of international agencies to create an Interagency Working Group (IAWG) in 2008, with the goal of national capacity building. This Interagency Working group merged into a National Advisory Board that included the Syrian government. An integrated one-year master training programme for mental health professionals was designed. The first cohort of master trainers successfully completed the programme, and started to train frontline worker with very good results. There has been widespread advancement in awareness of integrated psychosocial and mental health approaches, multi-professional teamwork and training methodology among practitioners. This has translated into practical projects improving the quality of care for beneficiaries. In addition, comprehensive training curricula and a bilingual handbook have been drafted with the goal of integrating and streamlining psychosocial, mental health and training methodology. Initial steps have also been taken to create a unified National Mental Health and Psychosocial Council.

In Lebanon, the International Medical Corps is working to address the multiple needs of Iraqi refugees, as well as the long term needs of the vulnerable host population, by integrating mental health services into primary health care (PHC). Over the past two years, 152 PHC providers (doctors, nurses and social workers) were trained in the identification, management and referral of people with mental health problems. The Ministry of Health has certified the completion of a training that includes: 12 theoretical training days, and a minimum of three on-the-job, supervised clinical sessions. Two formative evaluations were conducted to guide training implementation. Trainees completed pre/post tests, and clinical skills were evaluated during the on-the-job supervision sessions. Trainees showed an average of 12–25% improvement in knowledge, and 85% doctors and 91% nurses met minimum competency standards. Results from the evaluation were used to address challenges, including: strengthening referral mechanisms; promoting organisational change through clinic management; tailoring training for different groups of professionals; utilising a team approach to care; providing refresher training on topics such as medication management and planning longer term follow-up. The project provides important input towards integrating mental health into primary health, on the national policy level.

The authors describe a programme in a rural area of the West Bank (occupied Palestinian territory) developed in 2005 by Médicos del Mundo Spain, in coordination with the World Health Organization and the Ministry of Health. The main features include: 1) working with the Palestinian Authority in order to reinforce the existing public health system, rather than developing a parallel one; 2) providing a building, and other long lasting material resources, to the Community Mental Health Centre and the public health system; 3) supporting the incorporation of human resources in mental health teams in the public system; and 4) providing capacity building for mental health and primary care teams, through intensive on the job training, and providing didactic material for mental health and primary care professionals. The integration of mental health care into primary health care structures in conflict settings provides the opportunity of addressing severe and common disorders in their current situation.

In 2008, the local nongovernmental organisation TPO Uganda and the Uganda Ministry of Health began a project aimed of improving the availability of mental health services in three districts in Northern Uganda. The project consisted of: 1) training of general health workers in the primary health care system in mental health; 2) strengthening the capacity of the specialised mental health workers to deliver and supervise mental health outreach services; and 3) increasing the capacity of community members to respond effectively to mental health and psychosocial needs of people within their communities. The project provided assistance to ‘patient support groups’ that then provided support to patients with mental disorders. At the end of the 22 month project, the capacities of health workers and Village Health Teams to provide mental health services were strengthened. Major gaps, that still need to be addressed, were attrition of government health workers and a lack of drugs. Lessons learnt also include: the importance of coordination and joint planning between nongovernmental organisations and the government; the importance of support supervision; the important role of village health team members in community mobilisation and sensitisation; and the roles of patient support groups in complementing medical/clinical activities.

The Spanish Cooperation, through the nongovernmental organisation Sanitary Religious Federation and the financing of the Spanish Agency for International Development Cooperation conducted an assessment of the mental health care system in Equatorial Guinea in 2009. There was no specific mental health policy in place, and no formalised mental health care system. A National Mental Health Policy has recently been approved, and an implementation plan was made by the government and nongovernmental organisations. The plan focuses on integration of mental health into primary care, through capacity building and sensitisation. The implementation is still in the initial phase, and the scaling up process is expected to be slow.

In 2000 the nongovernmental organisation (NGO) HealthNet TPO started mental health and psychosocial support services in Burundi, a country that has been severely affectedby civil war. Within a time frame of eight years, a wide range of mental health and psychosocial services were established, covering large parts of the country. During the programme period the NGO activities shifted from the delivery of direct services to capacity building activities aimed at embedding psychiatric services and psychosocial assistance withinexisting local health services and social systems. Among the strategies used were 1) training and supervision in mental health for government nurses and doctors in provincial hospitals, 2) trainingin psychosocial assistance and supervision of governmental social workers, and 3) building the capacity of psychosocial volunteers and local community based organisations. The handover of mental health and psychosocial services presented formidable challenges arising from difficulties for the state in sustaining mental health and psychosocial services within their systems, and from difficulties for users in contributing financially to the provision of services. Major lessons are that installing basic mental health within general care should be firmly rooted in a general health-system-strengthening approach and also that healing the social wounds of war should be embedded within an approach to strengthening ‘community systems’.

The Iraq war, and the subsequent involvement of various stakeholders in the post conflict reconstruction of the health sector, presented an opportunity to learn about mental health policy development, challenges and obstacles within a post conflict context in 2003. This paper documents and explores mental health policy in post invasion Iraq, using qualitative methods and a health policy framework that analyses context, content and process. Findings indicate that there are many challenges, both in repairing an already weakened health sector, and in maintaining mental health as a health priority. In addition to security issues, fragmentation of power, change of leadership and lack of funding pose significant problems. Achievements are evident, though insufficient to address the overall mental health burden. The policy process is examined over a four-year period. Lessons learned are presented as best practice guidelines for post conflict mental health reconstruction.

This concluding paper of the Intervention Special Issue on integrating mental health care into health systems during and after complex emergencies summarises the main findings and conclusions of each of the programmes presented. This paper further integrates these findings into a common framework in order to extract key factors and recommendations on actions that can be taken, and those to avoid, to enable humanitarian emergencies to be transformed into opportunities in the psychosocial field. The main guiding principle to create such opportunities appears to require taking the post emergency context into consideration, from the first moments of any intervention. It is important that interventions in emergencies are conceptualised as part of the continuum of rehabilitation, construction and reconstruction. As a result, unique opportunities to rethink existing models and to introduce changes and new developments in the provision of mental health care and psychosocial support are created.

The author describes his experiences as a psychiatrist in East Sri Lanka where he was involved in building mental health and psychosocial services in the context of war and disaster. He stresses the necessity of creating patient and family friendly services, and advocates for the principle of distributing basic services over the whole region, instead of providing a highly specialised service that most of the people who need help cannot reach. He discusses the importance of empowering both staff members and patients, and emphasises the important of valuing common sense solutions and approaches to the problems faced by service users.

While working for an international humanitarian organisation in the Sudanese refugee camps at the Chad border, British child psychiatrist Lynne Jones kept a personal diary. In this diary, she reflects on the practical challenges and moral dilemmas facing a mental health practitioner working in this difficult context.

Les situations d’urgence humanitaire complexes, qu’elles soient dues à un confl it armé ou à une catastrophe naturelle, sont un défi pour le système de soins de santé mentale d’un pays et sous-minent les structures et les capacités existantes. Elles peuvent néanmoins apporter également des occasions de changement. Des structures et paradigmes nouveaux peuvent émerger d’une crise. Les possibilités pour de tels changements varient d’un contexte à l’autre et dépendent à la fois du système préalable de soins de santé mentale et des caractéristiques du système national de soins de santé en général (par exemple : centralisé ou décentralisé, public ou surtout privé, centré sur la santé primaire ou sur les hôpitaux et les soins tertiaires). Les interventions en situations d’urgence complexes ne devraient pas être limitées au déploiement de ressources spécifi ques qui disparaîtront quand la situation aura perdu de son urgence ou de sa visibilité. En plus de fournir des services directs, les interventions en situations d’urgence complexes devraient viser le renforcement des capacités et la mise en place de systèmes durables de soins de santé mentale. Cette édition spéciale d’Intervention est une réfl exion sur divers aspects de l’intégration des soins de santé mentale et du soutien psychosocial dans l’ensemble des systèmes de soins de santé pendant ou après les situations d’urgence humanitaire complexes. Le but est de tirer des leçons des expériences de ces dernières années ainsi que d’aider et d’inspirer les praticiens pour appliquer de tels exemples dans leur propre pratique.

Las emergencias humanitarias complejas, sean causadas por confl icto armado o sean el resultado de desastre natural, son un gran reto para el sistema de atención de salud mental de un país, y además debilitan las existentes estructuras y capacidades. Sin embargo, también pueden dar oportunidad al cambio. Es posible que unos estructuras y paradigmas nuevos emergen de la crisis. Los cambios posibles varían según la situación y dependen no sólo de la estructura previa del sistema de atención de salud mental, sino también de las características del sistema nacional de atención de salud (por ejemplo: centralizado o descentralizado, público o sobre todo privado, con el enfoque en la atención primaria o en los hospitales y la atención terciaria). Las intervenciones realizadas en emergencias humanitarias complejas no deben limitarse a la utilización de recursos especialistas que desaparezcan en el momento que la emergencia pierda su urgencia o visibilidad. Las intervenciones en emergencias complejas no deben fijarse solamente en la prestación de servicios directos, sino también en la construcción de capacidades y la instalación de sistemas sostenibles de atención de salud mental. Esta edición especial de Intervention refl exiona sobre los varios aspectos de la integración de salud mental y apoyo psicosocial en los sistemas de atención de salud general, durante o en el período inmediatamente después de emergencias humanitarias complejas. El propósito de esta edición es aprender de las experiencias ganadas a lo largo de los años pasados y asistir e inspirar a profesionales a sacar provecho de estos ejemplos y utilizarlos en su propia práctica.