Integrating MHPSS into Primary Health Care Centers in Lebanon

In Lebanon, Palestine refugees face restricted access to state-provided services such as health, education and social services. The challenging conditions for Palestine refugees in Lebanon (PRL) have further deteriorated with the influx of Palestinian refugees from Syria (PRS) after the Syrian crisis into the already overcrowded camps in Lebanon. In Lebanon, refugees from Palestine face restricted access to state-provided services such as health, education and social services. A vulnerability targeting exercise conducted by UNRWA in 2016 found that the 89% of PRS in Lebanon are living in poverty, including 9% living in extreme poverty, unable to meet their basic needs including health care. Additionally, violence and abuse against girls and boys in the home, communities and schools are recognized as the main protection concerns affecting PRS and PRL.

MHPSS is a key priority for service provision in the Palestine refugee context in Lebanon. A 2015, a survey on the Socioeconomic Status of Palestine Refugees in Lebanon reveals that self-reported poor mental health and psychosocial wellbeing reached 51.3% for PRL³. Respondents with poor wellbeing were more likely to report feeling worried about not being able to provide for their families, losing their source of income, and fearing for the safety of their families. Moreover, an assessment mission in 2014 showed that exposure to situations which exacerbate psychological distress, including recurring violence, insecurity, and restricted possibilities of employment, travel and free movement, is high, with 86% of PRL and 88% of PRS reporting moderate or high exposure to severe stressors, whether as one-off events or more commonly, as chronic conditions⁴. The mission noted that depression, anxiety and hopelessness are common among Palestine refugees. These conditions disrupt social networks and negatively impact quality of life and the potential for self-empowerment. The limited MHPSS services available to Palestine refugees in Lebanon exacerbates the problem, with services being geographically distant or costly, in addition to the community shame and reluctance to seek out these services.

In response to the MHPSS needs of Palestine refugees in all UNRWA’s fields of operation as well as the limited opportunities for Palestine refugees to access mental health services, UNRWA launched an Agency-wide MHPSS Framework, and developed Health Department Technical Instructions on MHPSS in 2017. Following an internal situational analysis of sample health centers (based on the WHO/UNHCR Assessment Toolkit), UNRWA Lebanon began training multi-disciplinary staff on MHPSS in 2013 supported by various funding sources, and later initiated a full systematic integration of MHPSS services within its PHC centers starting December 2017. The integration was gradual, with 2-4 PHC centers being included into the programme every quarter. To date, all 27 health centers are providing MHPSS services through trained doctors, nurses, midwives, as well as contracted mental health specialists on a part-time basis. To support this work, UNRWA Lebanon has developed filing, documentation & monitoring tools for mental health that are being applied at all health centers in the meantime, until the full absorption of this MHPSS reporting system under the agency’s general e-health system (UNRWA’s Heath Information System). 

The ongoing implementation of the MHPSS programme at UNRWA health centers includes the following components:

1. Training and supervision of PHC staff based on: PAIR PSS approach (prevention, assessment, intervention and referral); & WHO’s MHGAP approach (4 selected modules from mhGAP)
2. Community engagement through awareness sessions on MHPSS
3. Regular peer support groups implemented in each health center, including both an emotional support component as well as a case discussion component
4. Ensure supply of psychotropic medications at the health centers, in line with the WHO’s essential medicine list
5. Coordination and joint work with UNRWA’s Education, Relief and Social Services, and Protection Units (including on child protection and GBV)
6. Coordination with the National MHPSS Taskforce (MOPH/WHO) as well as organizations providing MHPSS services