Up scaling mental health and psychosocial services in a disaster context : Lessons learnt from the Philippine Region hardest hit by typhoon Haiyan

1 Vocarsko Naselje 22, 10000 Zagreb, Croatia. 2 Finger Lakes Health, Geneva, NY, USA. 3 Centre for Global and Cultural Mental Health Melbourne School of Population and Global Health 207 Bouverie Street The University of Melbourne Parkville 3010 VIC Australia. 4 490 Mansehra Road, 22010 Abbottabad, KPK, Pakistan. 5 WHO office. Avenue Mamba, P.O. Box 316, Monrovia, Liberia. 6 Capiz Emmanuel Hospital Inc., Roxas Avenue, Roxas City, Capiz, Philippines.


INTRODUCTION
The mental health effects of disaster are best addressed through existing services and capacity building initiatives to enhance these services; rather than the development of parallel systems (Perez-Salez et al., 2011).Countries have improved their mental health services following major manmade or natural disasters (World Health Organization, 2013a).In Sri Lanka after the 2004 tsunami, 500 community-level workers were recruited, trained and appointed by the WHO to 14 tsunami-affected districts (Mahoney et al., 2006) and in two districts, nonspecialized healthcare providers were trained (Budosan et al., 2007;Budosan and Jones, 2009).In Aceh, an area in Indonesia hardest hit by 2004 Tsunami, 483 people received mental health services in the first year after the disaster thanks to the joint effort of INGO International Medical Corps (IMC) and the Ministry of Health (MoH) to build local capacity at the primary healthcare (PHC) level (Jones et al., 2007).In Haiti, after the 2010 earthquake, 190 community-level workers and 115 non-specialized healthcare providers were trained and 616 mental health consultations were provided by INGO Cordaid in cooperation with local NGO partners (Budosan et al., 2014).
The Philippines has a natural vulnerability to disasters, and resources are scarce for disaster preparedness and response (Landoy et al., 2015).Although Philippine research demonstrated the feasibility of mental health (MH) care at the primary level; prior to typhoon Haiyan its integration was predominantly within a demonstration project (Conde, 2004).After typhoon Haiyan struck the Philippines, mental health services including psychological first aid to typhoon survivors and referral services for post-traumatic stress disorder, were identified by the WHO as one of priority interventions (World Health Organization, 2013b).In addition to addressing the immediate mental health needs of affected communities, WHO Philippines and the Philippine government collaborated to strengthen mental health services in regions affected by typhoon Haiyan.Eastern Visayas (Region VIII) was selected as the model region for the intervention.The main objectives of the intervention were to increase availability, accessibility and affordability of mental health services.
Pre-typhoon epidemiological data on prevalence of mental health problems were unavailable for Eastern Visayas.The WHO Disability Assessment Schedule (WHODAS) survey was undertaken in Eastern Visayas during the period from May to July 2014.It was based on WHODAS 2.0, a 36-items disability assessment tool that examines individuals' functional capabilities in the previous month as affected by a health condition.Survey results (World Health Organization -Department of Emergency Risk Management and Humanitarian Response, 2015) indicated that 40% of the people living in the affected communities had severe disability, physical or mental-that resulted in difficulty with mobility, understanding and communicating, and participating in society.While mobility issues likely resulted from physical disability post-typhoon, the high scores in the other two domains more likely resulted from mental and psychosocial problems.The community based rehabilitation intervention in Eastern Visayas has already been described elsewhere in the literature (Benigno et al., 2015).This study's rationale was to determine the success of the intervention in strengthening mental health services in Region VIII as measured by availability, accessibility and affordability of mental health care for the general population.The primary assumption of the study is that the intervention resulted in greater availability and accessibility of mental health services in Region VIII and that these services were affordable at the level of the general population.

Study area, provider and population
WHO's Philippines' mental health/psychosocial support (MHPSS) program was conducted in the second half of 2014 and first quarter of 2015.Eastern Visayas with a population of 4.3 million people was selected as a model region for integration of mental health care into primary and secondary care.The effects of the typhoon were variable throughout Eastern Visayas, but all six provinces were selected for the intervention (Figure 1).
Primary healthcare units consisting of rural health units (RHUs) and city health units (CHUs) and government hospitals were involved in the intervention to increase access to mental health care for 4,292,522 beneficiaries (Table 1).WHO selected a multidisciplinary MHPSS team including: a team leader with extensive experience in post-disaster settings, an international health systems expert, an international mental health expert, an international consultant for psychosocial support, five local psychiatrists and one psychiatric nurse.All were selected based on keen interest in assisting the affected population, broad knowledge of primary healthcare and MHPSS issues, and devotion to the integration of mental health care with primary care.Personal characteristics and professional qualifications were also considered.The program was later assisted by one international pharmacist and one international expert on alcohol problems.The areas of responsibility (AORs) were divided among MPHSS team members.
In most cases, international and local staff worked in a close cooperation, especially during delivery of training activities.The full implementation of the MHPSS program in Eastern Visayas was performed in close coordination with the INGO International Medical Corps (IMC).IMC took responsibility for training in 18 municipalities and two cities and took the supervisory role in all 43 municipalities in Leyte.Six international and two local psychiatrists supported IMC's MHPSS activities at various stages of the project.Community workers received training on psychosocial care and support.Nonspecialized healthcare providers received mhGAP training on assessment and management of common mental health conditions and conditions specifically related to stress.These providers also *Corresponding author.E-mail: bbudosan@yahoo.com.
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Design
The training intervention plus supervision lasted 10 months.In all areas, theoretical trainings were provided separately to community workers and non-specialized healthcare providers.Training group size varied from seven to more than 50 trainees.Supervision sessions were provided to non-specialized healthcare providers after the theoretical training.The intervention aimed to strengthen mental health services at three levels: (1) Community; (2) Primary healthcare, and (3) Secondary healthcare level (Table 2).During the initial phase, the existing training module for community workers was reviewed and training materials were piloted.At project end, the modules were modified as appropriate for training of midwives and barangay health workers.The mhGAP Intervention Guide (World Health Organization, 2010) and mhGAP presentations developed previously by WHO were used for training of nonspecialized healthcare providers.The mhGAP module on assessment and management of conditions specifically related to stress (WHO and UNHCR, 2013), was used in training both community workers and non-specialized healthcare providers.
WHO's MHPSS team held training sessions for community workers and non-specialized healthcare providers in rented spaces of hotels and also at the WHO facility.Local consultants assisted with some of the trainings.Learning methods employed during the training were: Guided study with print-based modules, video materials, relevant Web resources, role playing, field demo/practice, case studies, games, group discussions and interactive lectures.Operationalization of mental health services was discussed at completion of the theoretical training.Topics included: (1) Anticipated challenges for provision of mental health services at RHU, CHU and district hospital levels; (2) Mode of post-training supervision; (3) Functional indicators for mental health services at RHU/CHU and hospital level; (4) Resource mapping, and (5) Setting up in-patient and out-patient mental health services.

Data collection and analysis
The intervention was evaluated by the following parameters: (1) Availability and access of mental healthcare services with indicator of government health units in targeted areas with mhGAP trained health staff; (2) Affordability of mental health services with indicator of affordability of psychiatric medications and (3) Improved mental health competencies of trained staff.The number of government health facilities with mhGAP trained staff was monitored by each member of WHO's and IMC's MHPSS team in assigned AOR, as reported on a monthly basis.Each primary healthcare unit prepared monthly medicine consumption reports as medicine requests sent to the National Centre for Mental Health (NCMH)

Ethical considerations
A close cooperation with the Philippine government and its Department of Health (DOH) occurred to ensure approval of MHPSS activities and their alignment with the national objectives for mental health.Informed consent was sought from patients during on-the-job supervision after the purpose of the intervention was explained.Confidentiality of the information was ensured by absence of patient identifying data on the study documents.There was no monetary compensation for this study.

Availability, accessibility and affordability of mental health services
In one year, the intervention increased the likelihood that 1038 trained personnel would properly provide community based MHPSS services.Those trained were 609 community health workers, 126 teachers and school guidance counsellors, 87 social workers, 127 first responders (firefighters and police personnel) and 89 others (local government unit, NGO, community first responders).The intervention increased the likelihood that 290 non-specialized healthcare providers, [130 medical doctors (MD) and 160 public health nurses (PHN)] would properly manage MH problems in general healthcare.At project end, 155 of 159 or 97.5% primary healthcare units [rural health units (RHUs) and city health units (CHUs)] in Region VIII had at least one healthcare provider (doctor or nurse) trained in mhGAP.Of 24 District Hospitals (DH), 21 or 87.5% had a doctor and a nurse trained in mhGAP.All eight provincial hospitals had at least one doctor and one nurse who could provide early assessment, treatment and management of common mental health problems (Table 3).Consequently, mental health care became more available and more accessible for the population of Eastern Visayas.Mental health medicines were included in the medicine supply packs that the NCPAM regularly delivered to the RHUs and CHUs.Thus, mental health medicines were also made more affordable for the general population in Region VIII.oversight.Provincial and City MHPSS committees were established as well.Use of the Two-Way Referral Form was encouraged for patient consultation to the psychiatrist or back to the referring institution.Figure 2 summarizes the main achievements of the intervention.

Mental health competencies of trained staff
The majority of non-specialized healthcare providers agreed that the most important knowledge / skills learnt in their training were: (1) Assessment and management of workers were able to identify people with alcohol problems and provide them with treatment plans (Czaicki et al., 2015).

DISCUSSION
The study results confirmed the main assumption that MHPSS intervention would result in more available, accessible mental health services in Region VIII and that these services would be more affordable to the general population.At one year, the intervention strengthened the mental health system in Region VIII at the community level by training more than 1000 community workers in psychosocial care.At the primary level, 95% of government facilities had at least one MD or PHN trained in mhGAP-IG.At the secondary level; the Regional Medical Centre, provincial and district hospitals increased capacity to admit acute mental health patients.The Medicine Access Program (MAP) for Mental Health improved access and use for psychotropic medicines according to WHO recommendations (World Health Organization, 2005a).By project end, the NCPAM -a Department of Health administrative unit for the Medicine Access Program; coordinated the supply chain for psychotropic medications in conjunction with other medicines under their administration.This led to the inclusion of mental health medicines in the medicine supply packs that the NCPAM regularly delivered to the RHUs and CHUs.Cross-sectoral collaboration and clinical referral pathways from the community to the tertiary level were established (Figure 3).Collaboration within the health sector and with agencies outside the health sector is essential if outcomes related to mental illness are to be improved (World Health Organization, 2003).
The local environment was quite accepting of the intervention, because the main stakeholders of government and health authorities, health care providers and workers; were highly motivated to improve mental health services in their locales.All of them expressed satisfaction with the results of the intervention.The high level of engagement in this intervention is best evidenced by the participation of almost 1300 non-specialized healthcare providers and community workers from 184 (95%) health facilities in all administrative areas of Eastern Visayas.This level of local support is important because community stakeholders can play a critical role in achieving better outcomes for MH care and psychosocial well-being (Ventevogel et al., 2012).
The project developed a critical mass of mhGAPtrained staff at the local level who can sustain and continue to develop the ongoing mental health care.The Eastern Visayas intervention considerably strengthened the local system of MHPSS services, especially in terms of human resources for mental health.Human resources are the most valuable asset of a mental health system (World Health Organization, 2005b).Because healthcare in the Philippines is managed at the local level, trained staff in local health facilities will play a major role in cementing the progress of the project.Another strategy that will promote sustainability is the strengthening of inter-sectoral collaboration at the local level.
The great majority of patients seen during supervision sessions were those with chronic psychosis who had not received treatment for some time.Patients with bipolar disorder and epilepsy were also seen with disproportionate frequency.The trend of increased utilization of mental health services in Eastern Visayas has been noticed during supervisory visits, but requires ongoing documentation with quantitative means.Supervisions in the field confirmed that it was more difficult for nonspecialized healthcare providers to implement newly acquired methods than to understand them.Challenges in training non-specialized healthcare providers to modify their clinical practice have been documented in other disaster settings.For example, in Lebanon, a significant number of doctors continued to maintain their old prescribing habits in spite of the intervention for change (Hijazi et al., 2011).
Interventions in other countries post-disasters (Mahoney et al., 2006;Jones et al., 2007;Budosan et al., 2008;Ventevogel et al., 2012;Budosan et al., 2014) improved somewhat the systems of mental health services quickly after the disaster, those interventions were less comprehensive than the Philippine program in the first year after disaster.Prior efforts have established such components as a sustainable system of distribution, prescription and use of psychotropic medications; and an increase in local hospital capacity for admission of acute psychiatric patients only later after disaster.One possible explanation is that the WHO is better positioned than INGOs to implement com-prehensive mental health interventions post-disaster because of its positive image and reputation among beneficiaries and humanitarian actors.Moreover, the WHO's apolitical status helps facilitate rapid collaboration with varied actors postdisaster.An incorporated goal of this intervention was a strong and resilient system of MHPSS services across the region which would be prepared for future disasters.Functional resilience of the mental health system in Eastern Visayas was strengthened by augmenting the number of personnel trained in mental health and number of facilities capable of providing mental health services.This better prepares the system to cope with disasters that increase rates of distress and mental health problems.
According to the WHO (World Health Organization -Western Pacific Region, 2015), all routine health services, including routine mental health services should be capable of performing effectively under impact of a new hazard, and handling the workload originating from an emergency.

Limitations
The intervention and deliverables described in this study were not without limitations.The program lacked a formal needs assessment but baseline data were collected during field visits by WHO's MHPSS team to Eastern Visayas health facilities at inception of the intervention.Initial field visits identified areas of concern for improvement as: Absence of mental health programs, shortages of psychiatric medications and lack of mental health care knowledge/skills of non-specialized healthcare providers; but these concerns were not quantified.Formal predetermined metrics for evaluation were missing, although success was measurable as described previously.A comprehensive mental health education campaign and mental health advocacy with consumer groups were absent from the intervention.

Conclusion
The Philippine project, as evaluated in this study, supplied a critical mass of mhGAP-trained staff at the local level to develop and sustain mental health activities.Because health care in the Philippines is managed at the local level, trained staff at local facilities plays a major role in cementing and furthering the achieved advances.Up scaling of mental health care services after emergencies has been accomplished in diverse areas worldwide, and is best followed by sustainable efforts for health system development.
Future research might focus on routine clinical outcome data and quality of life indicators for beneficiaries, e.g.well-being, resilience and ability to function in daily life (Williamson and Robinson, 2006;Rajkumar et al., 2008;Ayazi et al., 2015).
To increase capacity of various categories of community workers in provision of psychosocial care and supportTraining in psychosocial care and /hospital inpatient care capacity for severe cases and emergency treatment Establishment of units for acute psychiatric care in provincial and district hospitals received on-the-job training (supervision) in their health facilities

Figure 1 .
Figure 1.Map of Eastern Visayas and its provinces.

Figure 2 .
Figure 2. Summary of main achievements of MHPSS intervention in Eastern Visayas.

Figure 3 .
Figure 3. Summary of main lessons learnt.

Table 1 .
Health facilities in Eastern Visayas targeted by MHPSS intervention (by province / city).

Table 2 .
Objectives and activities at each level of healthcare system.
and National Centre for Pharmaceutical Access Management (NCPAM).

Table 3 .
Number of health facilities in Region VIII with trained non-specialized healthcare providers (% in brackets).