Strengthening Mental Health Care Services Through a System Wide Approach in Dohuk, Iraq

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BACKGROUND: PUBLIC AND MENTAL HEALTH CARE SYSTEMS IN IRAQ

Following years of conflict, public health systems across Iraq have been weakened, affecting the availability and quality of health services. It is also estimated that since the onset of the armed conflict with the Islamic State of Iraq and the Levant, the proportion of the Iraqi population suffering from moderate (such as anxiety disorders) to acute (such as severe depression or psychosis) mental health conditions has doubled. The United Nations Office for the Coordination of Humanitarian Affairs states that in 2018, one million people in Iraq were in need of mental health and psychosocial support services. This combination of increased psychosocial care needs and decreased capacity of health systems has reduced the resilience of the population.
Since 2013, Action Against Hunger has been supporting the Directorate of Health (DoH) in Dohuk Governorate, Northern Iraq, with the delivery of mental health services and capacity building. Since the hostilities have ended, Action Against Hunger, funded by Agence Française de Développement (AFD) and the DoH have agreed on a shift from humanitarian activities to early recovery and resilience support, which includes collaborating on a new project designed to strengthen the mental health care system in Dohuk.

PILOTING A MENTAL HEALTH SYSTEM STRENGTHENING APPROACH

Action Against Hunger decided to pilot this Mental Health System Strengthening (MHSS) approach across two districts in Dohuk governorate. Drawing on a solid experience in health system strengthening for primary healthcare, Action Against Hunger developed new tools to adjust their original Health System Strengthening methodology to include a strong focus on mental health and psychosocial support.

This new MHSS approach started in July 2018 with the diagnosis phase that provided a thorough analysis of the health system structure, with a focus on mental health and psychosocial services. The main strengths and weaknesses were identified and assessed, through an extensive analysis of the seven building blocks defined by the World Health Organisation: governance, financing, human resources, service delivery, supply, health information system, and users and families associations. The diagnosis phase involved collecting primary data at 52 healthcare centres, a review of secondary data, and a “diagnosis workshop.” During the diagnosis workshop, which gathered all the key actors engaged in mental health and psychosocial support (MHPSS) in the region, five main challenges to improving mental health services were identified and their causes were analysed in detail. These challenges included:

1. Lack of community involvement in the mental health and psychosocial support services.
2. Lack of capacity building for the staff of primary healthcare centres on mental health and psychosocial support topics.
3. Insufficient supply of quality mental health and psychosocial support services at the primary healthcare centre level.
4. Lack of analysis and use of data related to mental health at district level.
5. Lack of essential mental health related medications in health facilities that offer mental health services.

In February 2019, the planning phase began, and solutions to address these challenges were defined at the Primary Health Care Centres, Health District, and Governorate levels. A five-year action plan is being developed as part of this phase. Activities under this plan will include: interventions to improve the core structure of the health system in the long-run (strengthening activities), interventions to respond to the immediate mental health care needs of the population (support activities), and emergency response interventions with the
strong involvement of external partners (substitution activities).

Finally, in the coming years, the implementation phase will take place to carry out these planned activities. Throughout the MHSS process, the close collaboration with the Directorate of Health and the Health Districts is paramount and remains a central condition for the success of the project.

SUCCESSES FROM THE DIAGNOSIS PHASE

By undergoing a robust diagnosis process, Action Against Hunger has developed a comprehensive understanding of the opportunities and needs related to mental health care in Dohuk. This provides a strong foundation on which to develop a systems strengthening approach. Moreover, since the process encourages the health authorities and other partners to reach a consensus on the way the health system is working, it has led to agreement on the current state of the system. This mutual understanding has facilitated buy-in to the project action plan.

Despite some challenges at the beginning of the project, a strong collaboration with the DoH and the health districts was established, enabling open communication and consensual decision-making. As the DoH is expected to lead the process, it is vital to ensure their continued involvement and that they understand the central role they play in mobilising partners. Overall, there has been a good mobilisation of local and international MHSS partners during the diagnosis phase that has allowed us to harmonise understanding of the mental health system as well as foster collaborations and partnerships.

CHALLENGES DURING THE DIAGNOSIS PHASE

Although the diagnosis phase was successful overall, there were several challenges that Action Against Hunger and its partners faced, such as:

• Collaboration with health authorities: At the beginning of the process, it was difficult to build collaboration with health authorities. Indeed, since this type of approach is uncommon, it took time for them to fully understand the process and actively get on board. Extensive administrative processes had to be followed, such as validation by the ethics committee, which led to an initial delay. Since this initial stage, a strong collaboration with health authorities has been developed.
• Accessing quality data: The health information system of the DoH is not fully developed and does not allow access to complete and quality data. This is especially true for data related to MHSS. Moreover, due to the heavy administrative procedures required to access DoH information, the process of data collection can be time consuming or unsuccessful.
• Short timelines: Due to lack of time and availability of relevant data, some of the health systems analysis was shortened. A detailed analysis of resilience components (the various shocks, crises, caseload thresholds, and coping mechanisms in place at the health systems) could not be examined.
• Contextualising and rolling-out the data collection tools: The tools used to collect data at the Primary Health Care level were initially not well adjusted to the context. Questions were not always correctly formulated, which impacted the data quality. Additionally, since these tools were part of a pilot and still being tested, the data collection teams required substantial support and training throughout this process.

LESSONS LEARNED AND GUIDANCE FOR FUTURE PROGRAMMES

Several lessons learned from this pilot can be readily applied to future similar programmes. Several points of guidance that have developed out of the process include:

• Mobilising and establishing key relationships with relevant health authorities will allow the various steps of the MHSS diagnosis to be conducted smoothly and will help to provide a reliable analysis of the main strengths and weaknesses of mental health systems.
• It is important to have a thorough preparation phase before starting the diagnosis phase. An efficient Steering Committee should be created, and their terms of reference should be clearly defined and agreed on with Action Against Hunger and the relevant health authorities. The Steering Committee should be trained on the whole process so that they can actively take part in every step.
• The timing at which this process is rolled-out is key. In Dohuk, the DoH and the Mental Health and Psychosocial Support (MHPSS) working group were already planning to develop the MHPSS Strategy for the coming years. Therefore, the MHSS project aligned with their current priorities, ensuring interest and commitment to the diagnosis and planning phases.
• In Iraq, MHPSS networks work at the primary healthcare level. As a result of this, although the full MHSS approach looks at the health system in general, it aimed to always have a focus on MHPSS. Both MHPSS and general health stakeholders took part in the whole process, and contributed to the various phases. This is a relevant example of integration of mental health approaches at all levels of a health system.

NEXT STEPS FOR THE MHSS PILOT PROJECT

Overall, the diagnosis phase of this pilot has been a success, despite specific data collection limitations. The overall MHSS approach to diagnosing the strengths and weaknesses of health systems was carried out, and the results were well accepted by the health authorities. It has also contributed to positioning Action Against Hunger as one of the major mental health actors in the region, and confirmed the robust technical capacity of the organisation in this area.

Now that the diagnosis is complete and the five priority areas have been identified, the next step is for the action plan to be finalised, including a clear timeline of activities and responsible parties. The action plan will be embedded into the DoH’s own 5-year strategy for MHSS in Dohuk, which will be finalised by the end of 2019. The strategy will not only ensure that mental health services are better integrated into primary care systems but can also be used as an advocacy tool to mobilise additional funds to further support MHSS.

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