Innovation summary

The human rights situation in Lebanon is still heavily linked to its fragile political, economic, and social situation1. There is no authority to oversee the human rights of persons with mental disorders. Furthermore, there are no external reviews/inspections on the respect of human rights in facilities providing mental health services2. Persons with mental disorders are often unaware of their rights and excluded from decisions that affect their lives. While the Convention on the Rights of Persons with Disabilities (CRPD) is signed by Lebanon, it is not yet ratified.

One of the strategic objectives of the National Mental Health Strategy for Lebanon (2015-2020) launched by the MOPH in 20153 to guide the mental health reform- is to monitor regularly mental health facilities to ensure protection of human rights of persons with mental disorders.

To inform the design and scale-up of the monitoring mechanism, a pilot project was conducted by the MOPH-National Mental Health Programme (NMHP) and WHO Lebanon, using the WHO QualityRights Tool Kit4. An assessment of the quality and human rights aspects in two private facilities providing inpatient mental health services was conducted and then an improvement plan was developed jointly with the facility to help improve the quality of the services and human rights promotion of users.

The tool kit establishes standards of care which can be applied in a culturally and socially appropriate manner across five interrelated areas; each addressing an important human rights and quality issue:

  1. Promoting inclusion and independent living in the community
  2. Protecting against inhuman and degrading treatment, violence and abuse
  3. Promoting legal capacity and enhancing autonomy
  4. Promoting the highest attainable standard of physical and mental health
  5. Promoting an adequate standard of living and ensuring that the environment is caring, supportive, comfortable, and stimulating

Impact summary

  • Key indicator of coverage: It is estimated that 250 persons with psychosocial disorders per year are accessing better mental health services through the implementation of the QualityRights intervention
  • Successful engagement of the private health care system in the improvement of quality and human rights protection in mental health services 

“This is an amazing initiative; it was the first time I felt I was being actively involved, rather than passively involved”

– Service user participating as a member of the assessment team in the Quality Rights assessment.  

Innovation details

WHO QualityRights Tool Kit Intervention in Lebanon

The tool kit was implemented in 2 private facilities providing in-patient mental health services in Lebanon. The core elements of the intervention included:

  • Establishing a national team of assessors
  • Building capacities within the national team to assess health facilities using the WHO QualityRights tool kit
  • Adaptation of the tool kit to the Lebanese context
  • Assessment of the quality and human rights aspects of mental health services in the two facilities
  • Development of improvement plans with the facilities

Detailed plan

1- Assessment and management teams

As a first step, an assessment team was established bringing together members from different disciplines namely public health, social work, mental health, human rights advocates and others. In addition, the assessment team included persons with lived experience in mental health. A project management team was also set up to steer and monitor the implementation of the project.  

2- Project plan

The project plan covered the detailed planning and scheduling required for the development and implementation of the project, ranging from the training of the assessment team, the logistics of carrying out the baseline assessments of facilities, the adaptation workshop, and the development of facility-based improvement plans.

The management team met on a weekly basis and coordinated the project plan with the WHO team in Geneva as well as an international expert who implemented the tool kit in India.

3- Capacity building of assessment team (initial and refresher training)

An initial three-day training was conducted in March 2017 preceded by an online QualityRights module. The training was conducted by two international experts; one having developed sections of the tool kit; and the other one having implemented the tool kit. This training included field visits and onsite application in two facilities providing mental health services. Another two-day refresher training was conducted in November 2017 prior to the baseline assessment. The same international expert who has experience in implementing the tool kit supported this refresher training. This training included simulations and applications on how to use the tool kit in Arabic.  

4- Adaptation workshop

Preceding the refresher training in November, an adaptation workshop was conducted with the assessment team. The aim was to identify and address challenges in asking the questions in Arabic from the translated tool due to differences in Arabic dialects. The output of this workshop was a document with suggested changes to the Arabic terms and the question formulation.

5- Baseline assessment

A baseline assessment of the two facilities providing mental health services was conducted using the WHO QualityRights tool kit in November 2017 to measure the degree to which these facilities meet the standards and criteria in the 5 themes of the tool kit.

The assessment team was split in two groups, each covering a facility. The assessment was conducted by the assessment teams, with the assistance of an international consultant who has expertise in implementing the tool kit. One of the facilities was visited over two days and the other facility was visited over one day. Based on the tool kit’s assessment methodology, interviews were conducted with service users, family members/carers, and staff, in addition to the review of the facilities’ documentation and general observations.

6- Rating and reporting

Each assessment team conducted a debriefing session and shared notes after each day of assessment. Following completion of the assessments, each assessment team met over four non-consecutive days in order to discuss the findings, agree on the rating, and propose recommendations for action. The facilities’ reports were finalized by the management team.

7- Improvement plans

A meeting was conducted with each facility to discuss the initial findings of the assessment. The report was shared with each facility for review and feedback. A session was planned with each facility’s team in order to develop improvement plans.

8- Dissemination

The overall communication objective is to highlight the importance and impact of scaling up quality and human rights in mental health services. Following the next phase of the project, dissemination of information will be interactive, engaging with the target populations, and involving policy makers, legal representatives, and human rights NGOs.

Key drivers

Alignment with the national mental health strategy

This project is in line with the National Mental Health Strategy for Lebanon (2015-2020) in which one of the objectives in the service development domain of action is to “conduct regular monitoring of the mental health facilities to ensure protection of human, child, and women’s rights of persons with mental disorders using quality and rights standards in line with international treaties, conventions signed/ratified by the Government of Lebanon, in addition to the National Constitution and laws in place” (strategic objective 2.1.4).

Involvement of the Ministry of Social affairs

The involvement of the Ministry of Social Affairs, through representation in the national assessment team, is also instrumental to ensure successful implementation and the potential scale-up to different types of facilities.    

Commitment of stakeholders and solid partnerships

In addition, the commitment of stakeholders to the implementation of the National Mental Health Strategy for Lebanon and the collaborative governance model of the MOPH which fosters partnerships between the MOPH, namely the National Mental Health Programme (NMHP) and various actors especially MOSA, WHO, UNICEF, International Medical Corps (IMC), are key drivers for the start and sustainability of this initiative.

Pre-existing facilitating factors

Lastly, pre-existing factors facilitated the initiation of this project, namely the availability of funding and the readiness of the facilities for change.


Political and legal barriers

The utmost challenge faced is the legal context of the country that is not conducive to the implementation of the tool kit especially the involuntary admissions, legal capacity, and advance directives as international standards and CRPD principles are not consecrated in the Lebanese laws and policies. However, the current Lebanese mental health law is under review; the proposed new law in line with the national mental health strategy addresses changes in line with the Quality Rights tool kit.

Sustainable funding avenues

Phase 1 of this project relied on donor funding and phase 2 is expected to be implemented in the coming three years, also relying on donor funding. Although this is considered a great opportunity, the main challenge facing the sustainability of the initiative is the lack of dedicated funding for periodic monitoring. The Quality rights standards and principles are however being integrated in the national accreditation standards for mental health, which will contribute to the sustainability of the upholding of these standards.

Privatization of healthcare

Given the private nature of the mental health system in Lebanon, another challenge is maintaining the level of motivation within the facilities. 


A second phase of this project is planned to take place in 2018-2021 covering an additional 3 mental health facilities; a baseline assessment and a post-improvement plan assessment are planned in addition to a series of capacity building workshops on the CRPD, Human Rights concepts, and the revised Lebanese mental health law. 

The MOPH will explore how best to scale-up and integrate sustainably mechanisms for human rights protection within the national mental health system. A key step towards institutional sustainability that is already being undertaken by the Ministry is the integration of the Quality Rights principles and standards in the national accreditation system for mental health care. In terms of policy level sustainability, the MOPH with partners is working on improving mental health legislation to ensure protection of the rights of persons with mental disorders.

The project will capitalize on the experience and training of key stakeholders engaged throughout the project by using them to act as agents of change and resources for scaling up in other facilities. Moreover, the continued engagement and involvement of active Human Rights NGOs, mental health service users, and legal representatives will provide an enabling environment for the sustainability of this initiative. 



  • European Union
  • State of Kuwait
  • People’s Republic of China 

Evaluation methods

After the development of the improvement plans and their implementations by the respective facilities, a second round of assessment is planned to be conducted, targeting the specific areas commonly agreed upon with the facility as key for improvement. Results will be compared to the baseline.

Cost of implementation

An analysis of costs will be determined at a later date.  

Impact details

The impact details for a larger evaluation post-pilot will be determined after the second phase of implementation (2018-2021). The following are some findings for the assessment of healthcare facilities that took place as part of the pilot project:

  • The conditions of the facilities were found to be of good quality, well maintained, and appreciative of service user’s preferences. No cases of abuse or torture were reported but the assessment identified opportunities to make the facilities more disability-friendly
  • While the staff working at the facilities were respectful, highly qualified and used evidence-based medical guidelines, they were found to have limited knowledge on human rights and key recommendations from the Convention on the Rights of Persons with Disabilities
  • Although developing a care plan for users is standard practice, it is led by medical staff and is rarely recovery-oriented. Even though few aspects of the advance directives are implemented, the main decisions on the care of the user are left to the attending physicians’ discretion, in close coordination with the families/carers
  • Even though the facilities are private and more acute-term oriented, no systematic effort is done to ensure continued links with the community
  • Despite their best intentions, these facilities have difficulties in implementing a recovery-oriented model of care due to the absence of a legal framework that facilitates it


  1. Human Rights Watch (2017). World Report. Accessed on 11.05.2018.
  2. World Health Organization (2015) WHO-AIMS report on mental health system in Lebanon
  3. Ministry of Public Health (2015) National Mental Health Strategy for Lebanon 2015-2020
  4. World Health Organization (2012) QualityRights toolkit to assess and improve quality and human rights in mental health and social care facilities. World Health Organization, Geneva
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