MHPSS refugee response in South Sudan
To deliver integrated mental health and psychosocial support services as part of the primary health care package.
Integrated mental health and psychosocial support to refugee populations in South Sudan.
Since its independence in 2011, South Sudan has experienced frequent and severe bouts of violence spurred by political instability. The resulting internal conflicts have displaced thousands over the country leading to highly vulnerable populations experiencing trauma and stress. There is evidence to suggest high rates of anxiety disorders such as Generalized Anxiety Disorder (GAD) and Post-Traumatic Stress Disorder (PTSD) can range between 3 - 28% among South Sudanese who stayed in the country post conflict1-2. In its Health Policy, the Government of Southern Sudan indicated that it saw mental health as an essential component of public health, leading efforts to integrate packages of care within essential services3.
International Medical Corps has been working in southern Sudan more than 20 years providing lifesaving services to people affected by the war including IDPs, refugees and host communities. As a UNHCR main partner, IMC has been providing mental health psychosocial support services (MHPSS) to three refugee camp within Maban, South Sudan since 2014 with the following components:
- Comprehensive community based MHPSS services including provision of integrated mental health care in primary health care centres
- Refugees with pre-existing and emergency induced priority mental, neurological and substance use disorders receive both pharmacological and psychosocial support services
- Capacity building of general health care staff with support supervision from a mental health specialist
- Community outreach activities provided by trained community volunteers
From July 2014 to June 2018, the program:
- Enrolled and provided mental health assessments and services to 3,650 clients living in refugee camps in Maban, South Sudan
- Approximately 92% of clients reported a reduction in the severity of symptoms as well as improved functioning
- Provided mental health training and supervision to 661 health and community workers according to national, WHO’s mhGAP and PFA guides
- Promoted key mental health awareness messages to 37,081 people through community outreach programs
“I can now cook for my children, bring water from the river, go to the forest to collect wood…Earlier I never used to do this…when I was sick…”
- Female enrolled in MHPSS programme
Image Credit: All Rights Reserved © Patrick Meinhardt
In emergencies, providing mental health as part of general health care is more accessible, cost-effective and less stigmatizing. In 2014 International Medical Corps (IMC) began implementing integrated maternal and child health and mental health psychosocial support services to refugees from Blue Nile Region of Sudan in three camps at Gendrassa, Kaya and Doro in Maban, South Sudan. These services are integrated with general health services within the area to account for the stigma associated with mental health disorders and also due to limited referral services for mental health and local mental health professionals (0.03 psychiatrists for 100,000 of the population) in the country4.
MHPSS Refugee Response program components:
Treatment and service delivery
- Since the beginning of the MHPSS refugee response, IMC’s staff has been providing integrated health services at clinics including:
- Pharmacological and non-pharmacological management of priority mental illnesses and health promotion activities at both facility and community level
- Management of acute and chronic diseases by outpatient consultations, provision of essential drugs
- Basic laboratory services, Routine immunization
- Maternal and child healthcare
- The frequency of sessions was informed by the individual treatment plan and related to the severity of the symptoms. Clients with more severe mental health conditions require more frequent follow and sessions
- The program also organizes regular clients forums in which patients are able to identify their own needs in relation to the challenges they experience as a result of their condition
- Clients are encouraged to find personalized solutions, suggest areas of support and select their own leadership to represent their needs to the respective persons and agencies
- In these forums, clients are able to understand their basic human rights and discuss their challenges, coping mechanisms and strategies
- Referral pathways and linkages to available services such as livelihood, protection, gender-based violence (GBV), physiotherapy services, shelter, and other community-based services are also made available to clients in need
Detection and outreach
- The mobilisation and engagement of existing community assets such as community health promotions, lead mothers and birth attendants, teachers, youth and community leaders and the Village health nutrition committee were sought to improve holistic mental health services as well as healthcare seeking behaviour among beneficiaries
- Community Health Promoters (CHPs) are trained to provide support to the clinicians in referring clients to the clinic, support clients at the household level and also contribute valuable data and information in reporting
- CHP’s also played a pivotal role in mobilization, patient tracing and community awareness on mental health issues.
- Non-specialized health care providers were trained in the pharmacological management of mental health disorders using WHO’s mhGAP Intervention guidelines and national guidelines. The training and subsequent on the job support supervision was conducted by an IMC psychiatrist and a national psychiatric nurse. Refresher trainings were also conducted on site focusing on areas of need observed during the supervision visits e.g. pharmacological interventions
- Capacity building on skills like building rapport, confidentiality, empathy and practical support promoted trust and good communication between clients and health care staff
- Topics covered included: General principles of care, moderate- severe depression, psychosis, seizures/epilepsy, acute stress, Post-Traumatic Stress Disorder (PTSD) and significant emotional or medically unexplained somatic complaints
- A wide array of community workers were also trained to identify mental health symptoms with a particular focus on epilepsy, psychosis, acute stress and PTSD, and depression, to know when to refer to IMC’s clinics for further management and the roles of community members regarding care for their clients.
- A number of incentivized community workers, teachers and selected lead mothers were trained in basic of psychological first aid. These trainings were facilitated by the national mental health officers who received training of trainers (TOT) sessions on Psychological First Aid (PFA) and spoke the local language
Promotion and awareness
- Promotional mental health messages were disseminated by trained community health workers at the registration, triage and waiting areas of primary health clinics in Kaya, Gendrassa and Doro. Messages included information on symptom recognition, referral processes, and psychoeducation for families and community members
- CHPs and mental health officers also conducted supportive home visits to assess levels of family support and care for clients, stigma, involvement in family activities, strength of the client in doing self-supportive activities and to promote socialization, human dignity in care and check for gaps which require support and intervention
- Need-based group sessions were held to support families of people with severe mental illness, groups of patients and other interested parties. The groups provided a social support system and an opportunity to discuss common issues in the camps, learn from one another and receive relevant information from staff. These sessions were facilitated by community workers and some beverage, games and play activities were also provided for children receiving services.
Strong level of community engagement
- The program has relied heavily on the work of CHWs, as a way to interact positively with the community. This is especially important for addressing the stigma related to mental health and for raising awareness of mental health support at the family and community level
- The mental health team also organised sports and games in commemoration of world mental health days where selected beneficiaries who recovered with the support of mental health services gave different testimonies encouraging the community to seek consultations
- IMC has recruited some of the mental health beneficiaries as community health promoters in order to ensure social inclusion and set an example for others
Efficacy of services
- With regards to beneficiaries receiving mental health services, the program achieved its target of 80% throughout the program
- This achievement can largely be attributed to capacity strengthening projects for health care workers focused on mental health disorders and their management. Other successful strategies included door-to-door visits, defaulter tracing, and client follow up by the community health promoters and the mental health officers on weekly basis
- Staff attrition, especially of highly qualified Medical Doctors and those in management positions presented a difficult challenge, especially as the recruitment process to replace highly skilled staff was extremely lengthy
Limited staff dedicated to MHPSS
- There were no Community Health Promoters dedicated only to the mental health program. Initially, the program was able to train and mobilize a group of the CHPs to send out for referrals and do follow up visits with clients in the community. However, because those CHPs also had duties with the General Health, Nutrition, and Reproductive Health programs, the amount of time they were able to dedicate to the Mental Health program was limited
- A major security incident in the program’s fourth year severely impacted program activities due to the immediate evacuation of IMC staff and destruction to the IMC office supplies, vehicles computers and the enforcement of restricted movement
- A multi-disciplinary team was put together in an attempt to mitigate the implications of the incident on the services provided to the refugees. While the team could not visit the camps every day, they were able to provide necessary support to refugee workers in the facilities with regards to supervision, case review, referral, supplies and reporting
The programme is now continuing into its fifth year of implementation and has expanded to two additional Internally Displaced Persons (IDP) camps in the country. Since July 2018, 110 new clients with priority mental, neurological and substance abuse (MNS) conditions were identified and enrolled into the MHPSS programme. Moreover, of the 4,998 beneficiaries/caretakers who were invited to evaluate the benefit of the psychosocial activities and interventions, 3,751 (75%) provided positive feedback regarding the activities and were viewed as contributing to the wellbeing of the refugee population.
- Functioning was measured using a simple 10 item scale based on set criteria including daily living activities, personal hygiene and participating in house activities
- Beneficiaries reported and rated functioning during initial assessments, and then again at each subsequent session. Improvement was measured against the last session’s rating
- Pre- and Post- training assessments were given to test the knowledge of new trainees acquired during each reporting period
- Scores of 75% and above were used as the gold standard indicator to show adequate knowledge
- IMC’s mental health integration checklist was also used to assess the extent to which mental health was integrated into Primary Health Care services within the sites
- All programme heads under the guidance of the site manager worked together to achieve both client satisfaction as well as meet the expected standards of care. Internally program support visits were conducted to assess progress and identify any gaps and ways of improving performance. Objective feedback was given to the team for continuous improvement
- 3,351 (92%) of 3,650 clients enrolled in the mental health program reported improved functioning on a rated functioning scale responding positively in terms of behavioural change, socialization and taking responsibilities in household and individual activities
- Seizure/Epilepsy and psychosis were the leading conditions of consultation followed by depression, psychosis, PTSD and substance abuse
- An average 22 new clients per month were identified with psychological distress or MNS disorders and provided either pharmaceutic or basic psychological interventions
- A total of 24,014 beneficiaries (families and care-givers, patients and other vulnerable groups) attended need-based group sessions during the project and 20,892 (87% - female 12,525, male 8,357) reported to have benefited from the sessions.
- A total of 661 individuals were trained in the identification, management and referral of mental health disorders including general health staff (81), community health volunteers (235), lead mothers and traditional birth attendants (196), health and nutrition committee members (82) and community leaders (67)
- A total of 37,081 people (roughly 38% of the total refugee population in the camps) received key mental health messages through community outreach programs
- Ayazi T, Lien L, Eide AH, Ruom MM, Hauff E (2012) What are the risk factors for the comorbidity of posttraumatic stress disorder and depression in a war-affected population? A cross-sectional community study in South Sudan. BMC psychiatry, 12(1):175. [Link]
- Ayazi T, Lien L, Eide A, Swartz L, Hauff E (2014) Association between exposure to traumatic events and anxiety disorders in a post-conflict setting: a cross-sectional community study in South Sudan. BMC psychiatry, 14(1):6. [Link]
- Ministry of Health South Sudan (2011) The Basic Package of Health and Nutrition in Primary Care. South Sudan. [Link]
- World Health Organization (2014) Mental Health Atlas Country Profiles; South Sudan [Link]