Innovation summary

In Palestine, mental health resources of the Ministry of Health remain concentrated in tertiary psychiatric facilities, leaving minimal investment in community mental health clinics in the West Bank and Gaza Strip. Other problems include lack of training for primary health care workers in diagnosis and treatment of mental disorders and the large treatment gap for people who need mental health care but are not able to attain it due to stigma and discrimination.

Through a partnership between the World Health Organization (WHO) and the Palestinian Ministry of Health, the innovation seeks to:

  • Improve access to quality mental health services in all levels of care
  • Develop the mental health care system into a community-based care system
  • Improve health care seeking behavior among patients in need of care
  • Redistribute existing resources
  • Integrate mental health into general health care
  • Collaborate with other sectors (e.g. non-governmental organizations)

Impact summary

  • Ten community mental health centers in West Bank and six in Gaza are operational, each staffed by at least one mental health team since 20041
  • Management of care for more than 600 patients experiencing mental health problems in primary care in Gaza1​

Our approach is to develop the capacity of mental health workers within the existing mental health and primary care services to provide competent and continuous help, regardless of the episodic escalations of war and violence.

-Dr Mustafa Elmasri, Psychiatrist in Gaza (2011)2

Innovation details

In 2001, the World Health Organization conducted an initial assessment and started working with the Ministry of Health to provide assistance on reform. In 2004, this partnership was leveraged to develop a five year Strategic Operational Plan with further Italian and French collaboration.  The Strategic Operational Plan aimed to:

  • Deinstitutionalize mental health services
  • Redistribute mental health resources
  • Collaborate with other sectors

In 2007, the European Union supported the World Health Organization and Ministry of Health for a three year program that achieved many of the Strategic Operational Plan’s objectives (see impact section for achievements). Five years later, the World Health Organization signed another three year agreement with the European Union, aiming to complete the achievements started in the first phase.

By 2015, the second phase is expected to achieve strategies focusing on:

  • Integration into primary health care
  • Stigma and discrimination programs
  • Human resource development
  • Monitoring and evaluation

Key drivers

  • Political commitment, a clear plan and stakeholder consensus
  • Flexibility during a time of conflict and unrest
  • Ministry of Health ownership of all activities related to the innovation
  • Long term support by the European Union that enables continuous development

Challenges

Political context

The Israeli occupation and the ongoing escalation of the aggression and humiliation of those living in the West Bank and Gaza can lead to exacerbation of mental distress that can increase the burden of mental disorders.

Planning for mental health services and care with intermittent conflict – economic hardship, repeated violence and human rights violations – can contribute to fragmented care and resources and an imbalance of service provisions for each territory.

Barriers to a sustainable system

The siege on Gaza, the system of checkpoints and the isolation wall in West Bank impede the possibility for natural development of the mental health system and drive health planners to focus on emergency response rather than long term development of the system.

Physical separation

The physical and political separation between the West Bank and Gaza Strip contributes to a lack of even distribution of care and service provision.

Continuation

The innovation has not been replicated in other areas; however, the successful integration of mental health into primary health care has shown that it is possible to develop mental health services in low-resource and conflicted-affected settings.

Partners

Funders

Evaluation methods

The second phase of the reform includes a monitoring and evaluation component expected to be achieved by 2015.

Cost of implementation

Estimated total cost: $6,831,500 USD, since 2007

Impact details

Palestine has seen a decrease in number of beds in mental hospital in Gaza by 10%. In addition, Bethlehem’s psychiatric hospital in the West Bank has been reformed through:

  • Reduction of beds for long term patients (2007: 280 beds; 2010: 180 beds)
  • Development of outpatient services, occupational therapy, vocational rehabilitation program and support to a family association
  • 40% increase in Ministry of Health general practitioners and nurses who have received initial training on the management of mental disorders in primary care in the West Bank and the Gaza Strip

The following Strategic Operational Plan objectives were achieved through the WHO-MOH-EU program by 2011:

  • Established mental health unit in West Bank and mental health directorate in Gaza
  • Trained 40-50% of primary health care general practitioners and nurses on integrating mental health into primary health care
  • Established a master’s program to train 45 Ministry of Health nurses on community mental health nursing
  • Established a postgraduate diploma on psychological therapies to train 20 Ministry of Health psychologists
  • Established two family and users associations
  • Established a social inclusion program in Bethlehem hospital

Expected achievements by 2015:

Reach of Care

  • 10,000 people are expected to receive mental healthcare in primary health care
  • 3,466 patients will receive specialized mental health care in community mental health centers

Integration of Services

  • Integration of mental health into primary healthcare in all governmental primary healthcare facilities in Gaza and 12 primary health centers in West Bank
  • Integration of mental healthcare in two general hospitals in Gaza
  • Integration of social inclusion programs in the two psychiatric hospitals and all community mental health centers in the West Bank and Gaza

Training and Educational Programs

  • Organization of anti-stigma and community education programs led by users and family associations
  • Provision of continuous training and supervision for mental health professionals in key clinical interventions

Strategies and Information Management

  • Development of operational policy, human resource development plan, monitoring and evaluation strategies and code of practice for mental health professionals
  • Improvement of mental health information management

References

1. World Health Organization (2013) Building back better: sustainable mental health care after emergencies. Geneva: WHO Press.

2. Fleck F (2011) Mental health beyond the crises: an interview with Dr Mustafa Elmasri. Bulletin of the World Health Organization, 89:326-327.

Research

Tools

Reports
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