We live in a time of unprecedented humanitarian emergencies—many of which are both created and exacerbated by armed conflict. Communities displaced by conflict, more than 80 million people globally, are often forced to leave their homes in extremely difficult conditions and to live without access to even the most basic essentials for day-to-day living.
Having already faced stressful events in their home countries—violence and loss—refugees and internally displaced persons (IDPs) may encounter additional stressors of poverty, discrimination, overcrowding, disconnection from their previous sources of social support and food and resource insecurity. Added to these challenges, the COVID-19 pandemic has led to widespread anxiety, fear and hardship. Consequently, these communities face adversity on multiple fronts, increasing their risk of developing mental health conditions.
Nearly all those affected by humanitarian emergencies experience psychological distress, with one in five likely to have a mental disorder such as depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia.
An influx of refugees requiring mental health and psychosocial support
In early November 2020, Gedaref, a state in eastern Sudan, witnessed an influx of tens of thousands of refugees fleeing from conflict in Tigray in Ethiopia. Already home to 1.2 million refugees—the largest refugee population in the region—Sudan’s health system was quickly overwhelmed. Pieter Ventevogel, senior mental health and psychosocial support officer with UNHCR, who visited refugee camps six months into the crisis, recalls the “high burden of unaddressed grief, loss, trauma and depression that was visible when talking with refugees.” Protection officers explained how unaddressed gender-based violence was rife among female refugees and staff working in child-friendly spaces reported how children were depicting violence and dead bodies in their drawings.
Assefa, a refugee who fled from Tigray with his family, recounted how his family had struggled to support his daughter who was experiencing a mental health condition: “Almaz is my daughter. The situation in Tigray affected her mental health and she started behaving violently and erratically. We didn’t know how to manage things, so we used to tie her up. I tied her up in our car on our way here, I tied her up in the tent we were given, and later at our house. There was no health facility available at the time, nor any medication for her treatment.”
In Sudan, resources for mental health are limited: there is an absence of psychiatric nurses, a shortage of clinical psychologists and only two certified child psychiatrists available in the country. The influx of refugees has placed even greater strain on existing resources. Two psychiatric hospitals in the country’s capital city Khartoum and 17 outpatient mental health facilities serve over 40 million people across Sudan. Only a handful of Sudan’s 18 states have a qualified psychiatrist.
Including mental health and psychosocial support within the humanitarian response
Historically, humanitarian assistance programmes have often overlooked the need to incorporate mental health and psychosocial support services in response efforts—despite overwhelming evidence of heightened vulnerability among displaced communities to mental health conditions. To address this in Sudan, UNHCR and WHO collaboratively work with the government on an approach to mental health and psychosocial support (MHPSS) that includes three core elements: the engagement of community leaders; the integration of support within the broader health system; and ensuring the quality of services provided through supportive supervision.
Engaging community leaders
In Sudan, a key strategy was to involve community “gatekeepers”—religious leaders, respected community leaders and traditional healers—to ensure community buy-in and use of services. Through this approach, community members are supported to rebuild disrupted social networks and support structures and find their own solutions to their problems. Dr Brian Ogallo, a WHO technical officer for mental health explains: “Sudan is a very religious country, so religious leaders and traditional healers are highly influential within communities where we work. They are gatekeepers; their involvement and inclusion are therefore crucial to the success of any intervention. In our most recent MHPSS training of trainers, we involved a traditional birth attendant, who is very respected in her community. She is now equipped to train other community members in basic psychological first aid. But more importantly, she counters prevalent misconceptions about mental illness—reducing mental health stigma and encouraging service uptake.”
Integrating mental health within the primary care system
While community members can be trained in basic psychological first aid (PFA), there is also a need for services for people in need of higher levels of care, including those experiencing severe mental health conditions. In Sudan, people with severe conditions are currently dependent on two tertiary-level hospitals located in the capital city. The programme is therefore working with the Ministry of Health to integrate mental health within primary health centres and to strengthen referral pathways. A key activity in support of this goal has been to run MHPSS integration workshops for health providers at all three levels of the health system. Over 20 psychologists from the Ministry participated in a training-of-trainers workshop on mental health topics including: PFA; Problem Management Plus (PM+), a scalable psychological intervention for people affected by adversity; and WHO’s Mental Health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG), a guide for providing basic mental health care in general health and primary care settings. These master trainers will in turn train other health workers at primary and secondary health centers, thereby accelerating the availability of mental health services at all levels within the health system. This training-of-trainers approach to capacity building enables the formation of a cadre of MHPSS-trained health providers across health facilities—ensuring service continuity following the end of the project. In Gedaref, UNHCR trained 22 health workers who were either involved in humanitarian outreach or were from the State Ministry of Health, using mhGAP methodology and materials developed by WHO and partners.
Ensuring quality services through supportive supervision
The integration of mental health services within health systems are sustained through continuous supervision following training. Dr Fatima Hassan Mohamed, a Sudanese senior resident in psychiatry, was deployed by the nongovernmental organisation ALIGHT, with funding from UNHCR, to a refugee camp in Gedaref to supervise trained health workers and ensure quality control. Fatima said: “Gradually, as we build a system of providing quality mental health services at the community level and within refugee camps, through trained and supervised health providers, I’ve seen a tremendous shift in people’s perceptions of mental health itself. They see how mental health services are offered alongside other health services. They observe how mental illness, like any other health condition, is treatable. As I supervise trained health providers, I realize that I’m not just ensuring quality service delivery, I’m actually part of an effort to transform the way mental health is perceived in communities across Sudan.”
Almaz—who arrived at Gedaref shackled to her family’s car—is an example of how relatively modest mental health resources and investments can bring significant, tangible results. Trained service providers visited her home every third day and supported her recovery through a combination of medication, counselling and psychoeducation—all provided at the community level. They involved family members in her treatment process and demonstrated how vital their support was for her recovery. Her recovery demonstrated to the community—refugees and host community members alike—that mental illness can be treated and everyone deserves access to mental health services.
The approach in Sudan shows how strengthening national mental health systems is possible through responses provided in humanitarian settings. Leveraging a ‘health systems approach’, the programme builds health-care capacity in Sudan and enables its public health-care system to function independently of humanitarian initiatives. Despite systemic challenges, such as barriers to procuring medicines and high rates of staff turnover, efforts in Sudan have strengthened the capacity of health personnel and community mechanisms to provide quality mental health and psychosocial support, which in turn contribute to more resilient communities.