Sustain Mental Health Services

A key component of success in integration is the sustainability of mental health services through general healthcare, and transition of these services from the emergency to longer-term development phases. Sustainability should be considered throughout the MH integration process, starting at the very start of project planning. Aspects of sustainability are related to government and policy, local partnerships, human resources and training, programming and services, research and monitoring, and financing.

Why is this component needed?

To promote a smooth transition from emergency to long term development, and to ensure continued availability of accessible, and quality mental health care. Funding streams usually differentiate between short and long-term interventions, creating an artificial division between MH integration programming in the emergency context, and those that focus on long-term development goals. Even where government support or collaboration exists, securing commitments from development donors and/or governments after the emergency phase and in the longer term can be challenging. Finding ways to sustain MH services is important to secure continued services and capacity.

How is this component done?

Work in partnership with governmental health authorities, CBOs/NGOs and donors, to develop national, district or region specific mental health programming. This will be informed by the situational analysis/assessment (step 1), coordination/discussion with stakeholders (Cross Cutting Component: Advocate, Coordinate & Network), and in line with existing health systems and strategies.
Maximize the use of existing local and regional health care infrastructure and resources, and ensure consistency with local capacities and national strategies.
Establish partnerships that can serve to create longer timelines for investment of funds and human capital, thus pooling resources to achieve sustainability. A mixture of support from government, private, academic, faith based, foundation, and NGO funds can effectively support long-term development of human resources and sustainable services.
Advocate for mental health components within national health financing systems (e.g. MH services and medications as part of national basic package of health services, or covered by insurance) which can play an important role towards securing long-term funding.

Minimum elements of sustainability

Involve government and local organizations from the start to discuss how capacity of services providers and supportive systems can be strengthened and sustained at the district level.
Set up peer level supervision organized between PHC staff for sustained supportive supervision system in absence of local mental health professionals and trainers.
Foster continued dialogue with key stakeholders in order to solve issues such as a continued supply of medicine, ongoing supervision, and annual planning for policies and funding.
Advocate for inclusion of longer term support and supervision, scale up and handover as part of donor funding.

Comprehensive elements of sustainability

Design a sustainable capacity building and supervision model as part of mental health PHC integration in close collaboration with the government and key stakeholders (e.g. integrating MH in pre-service training and continued education for health professionals, tasking national MH staff with longer term training and supervision/consultation of PHC providers).
Support government and advocate for incorporating mental health into health policy and legislative frameworks, insurance covered health services and implementation plans, that are accompanied by adequate resources.
Support the formalization of local or regional agreements that sustain and institutionalize services, even in the face of changing government structure or shifts in political will.
Contribute to sustainable long-term improvements in MH systems (e.g. supply of psychotropic medications, processes and forms, HMIS, strengthening referral networks, and annual planning for policies and funding).
Include elements of mental health systems sustainability in monitoring and evaluation framework for MH integration activities.

Key considerations

Do plan for sustainability from the very start of the program design (e.g. discussing and considering handover, exit or phase out from the beginning).
Do advocate for government involvement, partnership during implementation, and overall buy in, as this is central to sustainability.
Do advocate with funders and international agencies for longer integration program timelines to ensure more sustainable outcomes and impacts, and support for transitioning programming from emergency response, to recovery to development.
Do attempt to partner and coordinate with national organizations who can support and advocate for continuation of services.
Do consider pre-existing human resources and MH service structures to identify expertise and service providers that can be sourced locally so that staff members can be trained to function better in their existing roles.
Do explore opportunities to set up a TOT (a cascade of training in which trained and supervised master-trainers teach knowledge, intervention techniques, activities or skills to trainees).
Do provide patients and families with essential information in the case that services are handed over to other agencies or affected populations have to move to different locations (e.g. information about diagnosis, treatment plan, medication given, medication instructions).

Do not depend on government involvement when there are issues of poor governance or political sensitivity related to the provision of services.
Do not solely depend on government involvement or commitment as a standalone strategy for sustaining MH integration services.
Do not expect the government or other organizations to take over activities from international organizations when the emergency phase is over without significant planning and coordination from the start of the emergency phase (e.g. areas of human resources and training, programming and services, and financing).
Do not create staffing positions with very high pay scales that are not commensurate with local ability to pay long term.
Do not make expensive psychotropic medication available that cannot be sustained in the long term but use generic medications in line with the WHO list of essential medicines and national lists.

Plan for and consider sustainability starting in the early stages of assessment & planning (step 1). This includes sustainability planning in the areas of government and policy, human resources and training, programming and services, research and monitoring, and financing.