Innovation summary

In the mid-1980s, the primary mental health care initiative created a modern mental health care system inclusive of deinstitutionalization and integration of mental health into primary health care (PHC). Extensive turmoil following the fall of the Taliban government in 2001, the Afghan national healthcare system was shattered and unable to cope with increasing health demands. This resulted in high rates of morbidity, mortality and psychological distress.

The goal of the reform was to rebuild the Afghan health system whilst integrating mental health into basic health services and using the donor funds available after the government was overthrown. The Ministry of Public Health (MOPH) contracted NGOs to provide health services whilst focusing on regulation and policy-making themselves.

In 2004, the Minister of Health declared mental health a top priority and gave the following strategies importance:

  • Development of mental health integration into PHC strategy
  • NGOs to develop training materials for health workers
  • Basic Package of Health Services (BPHS) document – identifying the minimum package of interventions – to include mental health in its first tier of priorities

Impact summary

  • More than 1,000 health workers have been trained in basic mental healthcare since 2001 at which time there were 2 psychiatrists and 138 other health care staff for over 25 million people
  • Close to 100,000 people have been diagnosed and treated in Nangarhar Province
  • National Mental Health Strategy 2010 aims to have mental health services in 75% of all health facilities by 20141​

Although Afghanistan is one of Asia’s poorest countries, humanitarian recovery programming has paradoxically resulted in one of the continent’s most successful experiences in integrating and scaling up mental health care in selected areas of a country. - Building Back Better (2013)2

Innovation details

The mental health initiatives began in 1986, consisting of the first three-month diploma course in mental health with the technical support from the World Health Organization. Health professional trainings and talks about establishing a National Mental Health Institute soon followed. The detrimental increase in political turmoil shattered the national Afghan healthcare system which took several years before the Afghan health system was rebuilt.

In 2004, mental health was declared a top priority and the following components were a part of Afghanistan’s mental health reform:

New Policies

  • Mental health included in Basic Package of Health Services (BPHS), indicating first tier priority for mental health interventions
  • First National Mental Health Program (NMHP) drafted and implemented with focus on integration of mental health into PHC, awareness campaigns among the population and initiating community-level interventions
  • First Mental Health Act drafted and implemented

Knowledge Dissemination- trainings and interventions

  • General practitioners, nurses and psychosocial counselors (new category of health workers) received mental health training
  • Training manuals written  on mental health and substance abuse problems
  • Behavioral science introduced into Kabul Medical Institute curriculum
  • Non-pharmacological interventions introduced to hospitals

New Care Facilities

  • First mental health hospital established with 100 bed capacity with no long stay patients
  • New de-addiction center
  • Mental health unit established in key provincial hospitals

Key drivers

Political Will

  • Personal commitment of the current and former Ministers of Public Health
  • Adoption of a National Mental Health Strategy with the inclusion of mental health in general health policy documents and health service delivery guidelines essential for ensuring that mental health becomes a matter for all health workers, not only for specialists
  • Greater commitment for advocacy by Department of Mental Health team (MOPH) and related stakeholders

Multi-agency Coordinated Work

  • Coordination between government, donors and NGOs to ensure harmonized service delivery
  • Training general health workers in basic psychiatry accompanied by psychological and social interventions, such as psychosocial counselling and community-based psychosocial interventions
  • Clinical supervision to emphasize and facilitate the use of non-pharmacological approaches to common mental disorders
  • Emphasis on teamwork and a good referral system including close follow up and technical supervision for the psychological and psychosocial treatment

Challenges

Security Concerns

  • Ongoing and worsening security problems interfered with field supervision and training

Public Perceptions

  • Concerns regarding potential over-diagnosis of disorders and overuse of psychiatric medications after training medical staff; however, the addition of psychosocial counselling services within general health services has helped reduce this potential problem

Funding and Human Resources

  • Financial sustainability of mental health services is an ongoing challenge as the health sector is heavily dependent on international donors
  • Staff turnover and recruitment of suitable local staff especially female staff

Cultural Awareness

  • System integration requires awareness and understanding of mental health
  • Culturally appropriate approaches for provision of post care eg female to female counseling

Continuation

Inspiring Example for Others

Afghanistan now has substantial experience in scaling up the integration of basic mental healthcare into the general health system and can serve as an inspiring example for other post-conflict countries.

Scalability

The approach has been successfully implemented in several pilots; all have been evaluated and the lessons learnt have been integrated. The system in place is scalable however funding for additional health staff training remains a challenge.

Partners

Main Implementers

Basic Package of Health Services Implementers

Primary Funder

Additional Funders

Basic Package of Health Services Funders

Additional Funds (Other Activities)

Cost of implementation

Through the integration of psychosocial non-medical treatment medications, costs will be reduced significantly. In this cost comparison from 2008, there was a 14.5% drop in costs of mental health services:

  • Estimated annual costs of providing anti-depressive medicine at one community health center (CHC): $24,000 USD
  • Total cost for adding two counselors: $3740 USD per year ($7,480 USD for 2). Annual cost assuming a 30% decrease in medication through counseling services: $20,520 USD (Savings of $3280 USD)

Another issue is the cost reduction due to early diagnosis and outpatient treatment of cases (for MOPH and family) which otherwise may lead to hospitalization latter but no data is available.

Further cost reductions for the health system can come through secondary benefits such as:

  • Fewer chronic patients and suicides
  • Reduced dependency on medication
  • Reduced hospital admissions
  • Prevention of ill health
  • Increase in reliable diagnosis regarding mental health

Impact details

Service User Outcomes

  • The proportion of mental health consultations in general care has increased from <1% to 5% in a span of 9 years
  • 10 counseling centers in Kabul assisted more than 11,000 clients with 70% reporting significant improvements
  • Till date, the total number of health facilities is 1,789 in primary health care and 107 in secondary care level
  • 100,000 people have been diagnosed and treated in Eastern Provinces

Training

  • Mental Health training center opened in Herat (Western province) resulting in:
    • All primary healthcare professionals in the Western provinces were trained
    • The proportion of primary care patients in Herat diagnosed and treated for at least one mental disorder rose from 1.5% (2005) to 5.2% (2011)
  • Since 2001, more than 1,000 health workers have been trained in basic mental health care
  • In 2008, the Mental Health Director developed standard training manuals for different categories working in primary health care (MDs, Nurses, Midwives, Community Health Supervisors, Community Health Workers and Psycho-Social Counselors)
  • Following endorsement of the National Mental Health Strategy in 2010, around 90 health workers  from all provinces have received mental health training to train staff in primary health care
  • 250 psychosocial counsellors trained resulting in provision of counselling for more than 200,000 clients

Impact on Policy
Mental health has been declared a priority health issue and has been included in the country’s Basic Package of Health Services

Example for Other Countries

Afghanistan’s humanitarian recovery programming has resulted in one of the continent’s most successful experiences in integrating and scaling up mental healthcare

Future Impact Goals

  • Since January 2013, a total number of 1,630 MDs, Nurses and Midwives will receive mental health training according to MoPH approved training materials
  • In 2013, 1600 community health workers (20% of Afghanistan health care providers) will be trained focusing on team working development in health facility level

References

1. Ministry of Public Health (2009) National Mental Health Strategy.

2. World Health Organization (2013) Building Back Better: Sustainable Mental Health Care After Emergencies. Geneva: WHO Press.

3. Ministry of Public Health (2011) Afghanistan National Health Workforce Plan.

Research

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