Innovation summary

Central African Republic has been experiencing socio-political conflicts for decades, and political change has mainly come about through violence, leaving millions in immediate need of refuge and humanitarian assistance (OCHA, 2016).

Violence and displacement expose vulnerable groups and the community at large to a number of threats and stressors1. In disaster situations, van Ommeren et al (2005) estimates an increase in severe mental disorders from a projected baseline of 2-3% to an estimated 3-4% and an increase in mild or moderate mental disorders from a projected baseline of 10% to an estimated 15-20%2.

This program aims to integrate mental health care in non-specialized health settings.

The mental health Global Action Plan (mhGAP) initiative3 incorporates evidence-based guidelines on managing mental, neurological, and substance abuse (MNS) disorders in the primary care settings by non-specialist healthcare workers4,5. The mhGAP Humanitarian Intervention Guide (mhGAP-HIG), introduced in 2015, is a valuable manual that can be used as a resource in training non-specialists in primary mental health care6.

Impact summary

Based on the “Mental Health Gap Action Programme Monitoring and Evaluation Toolkit”, as of June 2017:

  • 48 non-specialist health care providers including 9 General Practitioners, 28 General Nurses and 11 other health care providers have been trained
  • 24 health facilities are using mhGAP-HIG to assess and manage persons with MNS disorders (4 Hospitals, 20 Health Centers)
  • 380 people with MNS disorders have been seen in those facilities (184 Acute Stress, 55 Post Traumatic Stress Disorder, 20 Depression, 21 Psychosis, 25 Epilepsy, 75 Harmful use of Alcohol and Drugs)

“Before the training, there were no cases of mental disorders. Today, I feel more confident in diagnosing people with a mental disorder, choosing and prescribing the right medication and offering psychosocial care”.

- Daniel, Major (State Nurse), Traumatology Department, Community Hospital Bangui

Innovation details

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.

Key drivers

Prioritization of mental health
Mental Health is identified in CAR as a GAP by major stakeholders, including the Japanese Government who funded the program.

Leadership and governance for mental health
There is a Coordinator of the National Mental Health and Drug Abuse Program. A coordination mechanism exists through the Working Group on Mental Health and Psychosocial Support within the Health Cluster.

Technical support and capacity building
National and local efforts produce better results when they are supported by regional and global action based on evidence-based intervention.

The supervision mechanism allows the trained health care providers to translate the knowledge into more available services.


Limited capacity
Humanitarian emergencies include a broad range of acute and chronic emergency settings arising from armed conflicts and both natural and industrial disasters. Humanitarian emergencies often involve mass displacement of people. In these settings, the population’s need for basic services overwhelms local capacity as the local system may have been damaged by the emergency. Resources vary depending on the extent and availability of local, national and international humanitarian assistance. Challenges include:

  • Heightened urgency to prioritize and allocate scarce resources
  • Limited access to specialists (for training, supervision, mentoring, referrals or consultations)
  • Limited time to train health-care providers

Limited access to psychotropic medications
There is currently no operational system to ensure availability of drugs in health facilities in the country.

Inter sectorial coordination
To coordinate action in emergencies, humanitarian organizations are organized into Clusters designated by the IASC. In CAR, there is a Health Cluster, with a Mental Health and Psychosocial Support (MHPSS) Working Group, and a Protection Cluster, with Child Protection and Gender Based Violence (GBV) Sub-Clusters. A comprehensive approach for MHPSS is needed including the integration of more specialized mental health services at the health facility levels but also a strong community-based component in order to identify, refer and follow up people in need.

Attitudes, beliefs and practices
A lot of work remains to be done in these areas related to mental health both at the community level as well as at service-provision level; for instance the stigma associated and the role of traditional healers.

Staff wellbeing and motivation
These are a concern given the basic conditions of practice, the amount of work and the type of cases they might be facing.

Security constraints
The security constraints have an impact on the access for training and supervision in the “hot spots”.


mhGAP has been developed and implemented under the National Mental Health Programme with the technical support of WHO, with functional and staffed Ministry of Health facilities selected as the implementing health facilities, and Ministry of Health cadres  among the trained health personnel. Sustainability is ensured by national programme support and integration into the general health system.

Humanitarian emergency is not solely a tragedy, but also an enormous opportunity to build a mental health system to support people. Because the rates of a broad range of mental disorders will increase, plans need to be initiated to build long-term, basic, sustainable community mental health services in the districts affected8.

For the health sector, the most essential activities for the long-run are:

  • To revise the National Mental Health Policy (2011)
  • To initiate the development of National Mental Health Plan
  • To work to ensure the sustainability of any newly established mental health services

Networking and exchange of experience among countries:
Exchange between countries with similar religious and cultural norms could strengthen the implementation of the program through exchange of best practices.


  • Ministry of Health, Central African Republic
  • World Health Organization (technical support)


  • Government of Japan

Evaluation methods

Monitoring and Evaluation has been conducted using the WHO mhGAP monitoring and evaluation toolkit, contextualized for the CAR setting.

The mhGAP Monitoring and Evaluation Toolkit is intended to plan and conduct monitoring and evaluation activities for the mhGAP programme. The overall aim is to enable the use of monitoring and evaluation to support effective implementation of the mhGAP programme. Central African Republic selected and adapted indicators that are relevant to the particular context and employ the most appropriate methods for measuring these indicators, reflected in the Log Frame.

Cost of implementation

The budget requested to the Japanese for the overall project is $ 2,000,019.

Impact details

Since August 2016 an advisory committee for planning and implementation has been established in collaboration with relevant stakeholders. Based on a situational analysis, an action plan was developed targeting 4 Districts (Bangui, Sibut, Bouar, Bimbo).

The mhGAP materials and tools for capacity building and implementation of MNS services have been adapted and validated at National level for the 6 identified priority conditions: Acute Stress, Post Traumatic Stress Disorder, Depression, Psychosis, Epilepsy, Harmful use of Alcohol and Drugs.

A training module for the identification and referral of people with mental disorders as well as a Support and Supervision Guide were also developed and validated.[DP1] 

4 mhGAP training workshops were held and 48 non-specialist health-care providers including 9 General Practitioners, 28 General Nurses and 11 other health-care providers were trained for the clinical management of the 6 priority conditions. 226 non-specialist health-care providers were trained for the identification and referral of people with mental disorders.

As of 31 March 2017, 24 health facilities are using mhGAP-HIG to assess and manage persons with MNS disorders (4 Hospitals, 20 Health Centers) and all facilities have a reporting and information system for tracking care inputs and caseloads.

Antipsychotic and anticholinergic drugs have been donated but no health facilities have an uninterrupted supply of essential psychotropic medicines. The content of 2 mental health kits, for health facilities implementing mhGAP and for the Psychiatric Unit, has been developed.

29 support and supervision visits to the health facilities implementing mhGAP have been done.

380 people with MNS disorders have been seen in those facilities (184 Acute Stress, 55 Post Traumatic Stress Disorder, 20 Depression, 21 Psychosis, 25 Epilepsy, 75 Harmful use of Alcohol and Drugs).

In order to ensure the implementation of the program and to ensure the functioning of the Psychiatric Unit at the Central Hospital, two general practitioners have joined the team.

Based on the WHO checklist for site visits at institutions in humanitarian setting and to ensure care for people hospitalized at the Psychiatric Unit, rehabilitation is under process.


  1. Multi-cluster/sector initial rapid assessment CAR, OCHA, 2014.
  2. Van Ommeren et al. BMJ; 330:1160-1; 2005, Accessed 4 June 2016.
  3. World Health Organization Mental Health Gap Action Programme (mhGAP). Scaling up care for mental, neurological and substance abuse disorders. Geneva: World Health Organization; 2008.
  4. Siriwardhana et al.: An intervention to improve mental health care for conflict-affected forced migrants in low-resource primary care settings: a WHO MhGAP-based pilot study in Sri Lanka (COM-GAP study). Trials 2013 14:423.
  5. Gureje et al. Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide. BMC Health Services Research (2015) 15:242
  6. World Health Organization and United Nations High Commissioner for Refugees. mhGAP Humanitarian Intervention Guide (mhGAP-HIG): Clinical management of mental, neurological and substance use conditions in humanitarian emergencies. Geneva: WHO, 2015.
  7. Inter-Agency Standing Committee (IASC) (2007). IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC.
  8. WHO. Building back better. Sustainable mental health care after emergencies. Geneva, 2013.
  9. World Health Organization. Integrating mental health into primary care: a global perspective. Geneva: WHO Publication; 2008. ISBN 978 92 4 156368 o. 1211.
  10. Lancet Global Mental Health Group, Chisholm D, Flisher AJ, Lund C, Patel V, Saxena S, Thornicroft G, Tomlinson M: Scale up services for mental disorders: a call for action. Lancet 2007; 370(9594):1241–52. doi:10.1016/50140-6736(07)61242-2.
  11. Petersen I, Lund Crick, Bhana A, Flisher A: A task shifting approach to primary mental health care for adults in South Africa: human resource requirements and costs for rural settings. Health Policy and Planning February 2011
  12. Saraceno B, van Ommeren M, Batniji R, Cohen A, Gureje O, Mahoney J, et al. Barriers to improving mental health services in low and middle income countries. Lancet. 2007;370:1164–74.
  13. Rapid Mental Health Situational Analysis Central African republic (2014). International Medical Corps.
  14. Mental Health Atlas 2014 - Department of Mental Health and Substance Abuse, World Health Organization. Accessed 21 November 2015
  15. Plan de transition du secteur santé en république centrafricaine 2015-2016. Ministère de la santé et de la population, 2015.
  16. Save the Children report (in French). 2015. Évaluation des besoins psychologiques des enfants d’ âge scolaire dans les localités de Bangui et de la Ouaka République Centrafricaine 
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