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Integrating Mental Health Services Into Primary Health Care in South Sudan: a Case Study

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Integrating Mental Health Services Into Primary Health Care in South Sudan: a Case Study RESEARCH REPORT Integrating mental health services into primary health care in South Sudan: a case study ANNE DE GRAAFF HEALTHNET TPO/DUTCH CONSORTIUM FOR REHABILITATION DECEMBER 2015 Acknowledgements I would like to express my gratitude to several people who were – in different ways – involved in this study project. First – and most – of all, I would like to thank those people in South Sudan who were willing to take part in the study. Your contributions are reflected in this report, and therefore, without your help, this study would not have been possible. So to all of you: Shokran! Second, I would like to thank the HealthNet TPO and DCR teams. Especially “team Leopards” for data-collection: Charles Kon, Ociti Michael, Madhieu Thiep, Marko Mayen, Michael Lopia, Geofrey Loku, Isaac Uchalla, and Taban Samuel – thank you for making the field trips so enjoyable. Also to James Maputo and Justin Madut for driving us around in Jur River County: Kirii. Special thanks to “Those of Adiga”, the county development officers who introduced me to the communities and helped organizing the field trips and translating interviews. And to Richard Koma and Horasio Kamulete who spent many hours working with me on the surveys. Furthermore, Boniface Duku, Godfrey Kiyimba, Aidan Goldsmith, and all other colleagues in Wau, Juba and Amsterdam: it was a great pleasure working with you. Lastly, I would like to express my special appreciation to Martijn Vink, my supervisor at HealthNet TPO. 1 List of abbreviations CHD County Health Department CHW Community health worker CMW Community midwife CO Clinical officer CSO Civil society organization CSS Community systems strengthening DCR Dutch Consortium for Rehabilitation DHIS District Health Information Software FBO Faith based organization FGD Focus group discussion HDP Health development partner HFC Health facility committee HNTPO HealthNet International/Transcultural Psychosocial Organization HMIS Health Management Information System HPGSS Health Policy for Southern Sudan (2006-2011) HSB Health seeking behaviour HSDP Health Sector Development Plan (2012-2016) IC Informed consent IMC International Medical Corps JTH Juba Teaching Hospital LMICs Low- and middle-income countries MHPSS Mental health and psychosocial services PHC Primary health care PHCC Primary health care center PHCU Primary health care unit PoC Protection of civilians PTSD Posttraumatic stress disorder SSHP South Sudan Health Policy (2006-2011) SSP South Sudanese Pounds (1 SSP ≈ €0,30 or $0,34 at time of research) WBeG Western Bahr el Ghazal WHO World Health Organization WTH Wau Teaching Hospital 2 List of contents Abstract ....................................................................................................................................... 5 Chapter 1: Background of the study .............................................................................................. 6 1.1 SOCIO-POLITICAL CONTEXT OF SOUTH SUDAN ....................................................................... 6 1.2 PRIOR RESEARCH ON MENTAL HEALTH ................................................................................. 7 1.3 HEALTH SYSTEM CONTEXT ................................................................................................ 8 1.3.1 ORGANIZATION OF THE HEALTH SYSTEM ..................................................................................... 8 1.3.2 MENTAL HEALTH POLICIES ......................................................................................................... 9 1.3.3 MENTAL HEALTH ORGANIZATION ............................................................................................. 10 1.4 COMMUNITY PERCEPTIONS ON MENTAL HEALTH ................................................................... 11 1.5 RESTRICTING FACTORS FOR MENTAL HEALTH CARE USAGE ........................................................ 12 1.6 POSITIONING THE RESEARCH ........................................................................................... 12 1.7 STUDY RATIONALE ........................................................................................................ 13 Chapter 2: Conceptual framework .............................................................................................. 15 2.1 WHO’S DEFINITION OF MENTAL HEALTH ............................................................................. 15 2.2 CROSS-CULTURAL UNDERSTANDING OF MENTAL HEALTH ......................................................... 15 2.3 MENTAL HEALTH GAP .................................................................................................... 16 2.4 MHGAP PROGRAMME ................................................................................................... 17 2.5 LIMITATIONS OF THE MHGAP PROGRAMME ........................................................................ 18 2.6 DEFINING THE HEALTH SYSTEM ......................................................................................... 18 Chapter 3: Study’s focal point: Aims and objectives ..................................................................... 19 Chapter 4: Methodological framework ........................................................................................ 21 4.1 RESEARCH METHODS ..................................................................................................... 21 4.2 APPLICATION OF RESEARCH METHODS PER RESEARCH QUESTION ............................................... 24 4.3 METHODS OF DATA ANALYSIS .......................................................................................... 25 4.4 UNIT OF ANALYSIS AND SAMPLING .................................................................................... 25 4.5 LIMITATIONS ............................................................................................................... 27 4.6 ETHICAL CONSIDERATIONS .............................................................................................. 28 4.7 RESEARCH LOCATION ..................................................................................................... 28 Chapter 5: Results ...................................................................................................................... 30 SECTION 1: AVAILABILITY OF MENTAL HEALTH SERVICES ............................................................... 31 5.1.1 PILLAR I: PUBLIC HEALTH SYSTEM ............................................................................................ 32 3 5.1.1.1 AVAILABILITY OF MENTAL HEALTH SERVICES IN PRIMARY HEALTH FACILITIES ........................ 32 5.1.1.2 MENTAL HEALTH SERVICES IN HIGHER LEVELS OF PUBLIC HEALTH CARE ................................ 35 5.1.2 PILLAR II: NGO/FBO HEALTH SYSTEM ..................................................................................... 36 5.1.3 PILLAR IV: INFORMAL TREATMENT OPTIONS ............................................................................. 37 5.1.4 COMMUNITY RESPONSE: SELF-CARE AND THE TRADITIONAL COURT ............................................ 39 SECTION 2: ACCESS TO MENTAL HEALTH CARE ........................................................................... 41 5.2.1 DEMAND ................................................................................................................................ 41 5.2.2 PERCEPTIONS ON MENTAL HEALTH SEEKING BEHAVIOUR ............................................................ 45 5.2.3 CONSTRAINTS TO ACCESS MENTAL HEALTH CARE ....................................................................... 49 SECTION 3: FEASIBILITY OF THE INTEGRATION OF MENTAL HEALTH CARE ........................................... 51 5.3.1 PERCEIVED CHALLENGES .......................................................................................................... 51 5.3.2 PERCEIVED OPPORTUNITIES ..................................................................................................... 53 Chapter 6: Discussion and conclusion .......................................................................................... 56 6.1 CONCLUDING REMARKS ON FINDINGS ................................................................................ 56 6.1.1 AVAILABILITY .......................................................................................................................... 57 6.1.2 ACCESSIBILITY ......................................................................................................................... 58 6.1.3 FEASIBILITY ............................................................................................................................ 59 6.2.1.1 LOWEST LEVELS OF CARE: INFORMAL COMMUNITY CARE AND SELF-CARE ............................. 61 6.2.1.3 POLICY ............................................................................................................................ 63 6.3 RECOMMENDATIONS FOR FURTHER RESEARCH ...................................................................... 64 6.4 CONCLUDING REMARKS ................................................................................................. 65 Bibliography ............................................................................................................................... 66 Appendix A: Dutch Consortium for Rehabilitation ....................................................................... 70 Appendix B: HealthNet TPO ........................................................................................................ 71 Appendix C: Health Facility Survey .............................................................................................
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