The Situation in CAR
Central African Republic has been experiencing socio-political conflicts for decades. Political change has mainly come about through violence: five decades have seen coups d’état, army mutinies, interference by foreign armed forces and rebel groups, widespread social unrest, stalled development, and progressive impoverishment. The crisis was intensified in December 2013, ultimately turning from a politico-military into an unprecedented inter-community conflict.
According to the overview of humanitarian needs (OCHA, 2016), 2.3 million people in CAR are still in need of humanitarian assistance, including more than 600,000 in Bangui. The security situation is unstable and unpredictable; violations of human rights and international humanitarian law are observed, including attacks on civilians, killings, looting, sexual violence, recruitment of child soldiers, occupation of schools, and intrusion of armed groups in hospitals; and the most basic social services are dysfunctional or non-existent in many cities. In 2016:
- 467,960 people were refugees
- 391,433 were internally displaced, including 235,594 in foster families and 155,839 on sites
- 3,077 incidents of gender-based violence (GBV) were reported
- 13,000 children were associated with armed forces and groups
- 25% of schools were non-functional
- 40% of the population is in acute food insecurity
- Only 30% of the rural population has access to protected water points
Mental Health in CAR
During emergencies, it is recommended to have at least one staff member at every health facility that manages diverse, severe mental health problems7. WHO also recommends ensuring the sustainability of any newly-established mental health service8. Generally, the best way to scale up services for mental health care is primary health care integration9,10. Task-shifting has been recognized as a key concept in this integration in resource-poor settings11, but lack of adequate training for primary care physicians, and lack of adequate human resources (number of physicians), present barriers to integrating mental health into primary care in these settings12.
Although clinical data is very limited in CAR and restricted to the capital city Bangui, a community-based assessment shows that acute stress reactions, adjustment problems, and common mental disorders are widely distributed among the population. Extreme violence presents a particular concern for suspected cases of mood and anxiety disorders (including post-traumatic stress disorder; PTSD) and psychosomatic complaints, which seem recurrent regardless of the condition as internally-displaced persons (IDPs) or host communities13. In Bangui and Ouaka Region, children's psychological difficulties, including PTSD, are significant and represent a significant burden for the children themselves as well as parents and teachers. 10% of the children report having been sexually abused, and in some places in the study, 64% of children had PTSD16.
Before the crisis, mental health had been a highly neglected area in CAR, and absent from key policy documents. A mental health policy is available (2011) but not implemented. There is one psychiatrist and 3 psychologists in the country, and the only mental health service is the Psychiatric Unit at the Central Hospital in Bangui14. Several NGOs are undertaking mental health activities with a limited scope, targeting vulnerable groups and not integrating their activities in the general health system. A transition plan of the health sector 2015-2016 has been developed and integrates mental health activities15.
The Present Innovation
The present program has been implemented over 10 months in 4 selected sub-districts in CAR, using a version of the WHO mhGAP-HIG that has been contextualized for the local setting. The model uses a supervised cascade training model, with Master Trainers providing training for Facilitators, who in turn conduct trainings for front-line health care workers, followed by active support and supervision.
Adaptation of mhGAP
Based on a situation analysis, a 2-day workshop was held to adapt mhGAP to the local context and plan its implementation at the national level in collaboration with the partners involved. Six priority conditions were identified to be included in the program, and the mhGAP adaptation guide was completed for each condition. An implementation plan for mhGAP was then developed, and based on the adaptation guide and international training materials available, the materials were drafted.
Master Trainers & Facilitators
Master trainers were selected based on their clinical expertise in one of the 6 identified priority conditions. 3 Master trainers were national and 3 international. During a national workshop for the validation of the training materials, we strengthened the capacities of the Master trainers in the facilitation of their respective module, and newly recruited 2 general practitioners as mhGAP trainers. There is currently a pool of 5 mhGAP Trainers and facilitators (3 GPs, 2 Psychologists). 4 provide training dissemination (2 GP, 2 Psychologists), and 2 act as Supervisors (1 GP, 1 Psychologist; see below).
Trainees and Training
Trainees come from identified priority Districts and are active in the priority targets FOSA identified. They are GPs and States Nurses (trained with mhGAP) and other health or community workers (trained with mini mhGAP). The main objective is to strengthen the capacity of trainees in managing MNS disorders in humanitarian emergencies. The specific objectives are to train General Practitioners and State Graduate Nurses in diagnosis and clinical management, and other health and community personnel in the identification and referral of people with mental disorders.
Support and Supervision
Clinical and administrative/programmatic support and supervision not only help trained personnel provide better mental health care, but also support mhGAP implementation. Supervision visits include both on-site supervision, where supervisors visit a facility, as well as group supervision, where a group of trained staff working in the same locality meet with supervisors.
For more details see the PROCESS DESCRIPTION report in the Resources section.