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Intersectoral Collaboration for People-Centred Mental Health Care in Timor-Leste, a South-East Asian Country in the Process of Strengthening Its Mental Health System

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Intersectoral Collaboration for People-Centred Mental Health Care in Timor-Leste, a South-East Asian Country in the Process of Strengthening Its Mental Health System Hall et al. Int J Ment Health Syst (2019) 13:72 https://doi.org/10.1186/s13033-019-0328-1 International Journal of Mental Health Systems RESEARCH Open Access Intersectoral collaboration for people-centred mental health care in Timor-Leste: a mixed-methods study using qualitative and social network analysis Teresa Hall1* , Ritsuko Kakuma2,3, Lisa Palmer4, Harry Minas3, João Martins5 and Greg Armstrong1 Abstract Background: Intersectoral collaboration is fundamental to the provision of people-centred mental health care, yet there is a dearth of research about how this strategy operates within mental health systems in low- and middle- income countries. This is problematic given the known attitudinal, structural and resource barriers to intersectoral collaboration in high-income country mental health systems. This study was conducted to investigate intersectoral collaboration for people-centred mental health care in Timor-Leste, a South-East Asian country in the process of strengthening its mental health system. Methods: This study employed a mixed-methods convergent design. Qualitative data elicited from in-depth inter- views with 85 key stakeholders and document review were complemented with quantitative social network analysis to assess understandings of, the strength and structure of intersectoral collaboration in the Timorese mental health system. Results: There was consensus among stakeholder groups that intersectoral collaboration for mental health is impor- tant in Timor-Leste. Despite resource restrictions discussed by participants, interview data and social network analysis revealed evidence of information and resource sharing among organisations working within the health and social (disability and violence support) sectors in Timor-Leste (network density 0.55 and 0.30 for information and resource sharing, respectively). Contrary to the assumption that mental health services= and system strengthening are led by the Ministry of Health, the mixed-methods data sources identifed a split in stewardship for mental health between subnetworks in the health and social sectors (network degree centralisation 0.28 and 0.47 for information and resource sharing, respectively). = Conclusions: Overall, the fndings suggest that there may be opportunities for intersectoral collaborations in mental health systems in LMICs which do not exist in settings with more formalised mental health systems such as HICs. Holistic understandings of health and wellbeing, and a commitment to working together in the face of resource restrictions suggest that intersectoral collaboration can be employed to achieve people-centred mental health care in Timor-Leste. Keywords: Intersectoral collaboration, Governance, Global mental health, Timor-Leste, Asia Pacifc *Correspondence: [email protected] 1 Nossal Institute for Global Health, University of Melbourne, 333 Exhibition St, Melbourne, VIC 3004, Australia Full list of author information is available at the end of the article © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Hall et al. Int J Ment Health Syst (2019) 13:72 Page 2 of 13 Background However, intersectoral collaboration is difcult to People-centred approaches to mental health care are achieve. Collaboration is often challenged by systemic increasingly promoted in low- and middle-income factors (e.g. inadequate resourcing, lack of shared inter- countries (LMICs) through global mental health pol- organisational structures, goals, and trust) and interper- icy, practice and research directives [1, 2]. Te World sonal factors (e.g. poor communication) [5, 17–20]. In Health Organisation defnes people-centred health care many LMICs, partnerships are challenged because Min- as: “an approach to care that consciously adopts the istries of Health are hierarchically structured and seen as perspectives of individuals, families and communities, solely responsible for health activities [19]. Hence, there and sees them as participants as well as benefciaries of may be feasibility issues for promoting intersectoral col- trusted health systems that respond to their needs and laboration for mental health in LMICs. preferences in humane and holistic ways.” [ 3]. People- Despite the global imperative to increase the people- centred health care is proposed to apply to people with centredness of mental health care in all countries [2, 3], all types of health conditions. there is a dearth of research investigating intersectoral Intersectoral collaboration is one of the key strategies collaboration for mental health care across the multitude for achieving people-centred health care in the World of sociocultural and resource settings that constitute the Health Organisation Framework on Integrated People- grouping LMICs. To fll this knowledge gap, this study Centred Health Services (WHO IPCHS) [3]. Tere is no was conducted in Timor-Leste, a LMIC in South-East defnitional consensus on intersectoral collaboration. Asia in the process of strengthening its public mental In line with recent conceptual developments in global health system. health, we adopt a broad defnition of intersectoral col- laboration for mental health as: any planning, informa- Study setting: Timor‑Leste tion and resource sharing to institute mental health Timor-Leste is a small island nation of 1.3 million peo- care between organisations from diferent sectors (i.e. ple [21]. Promoting mental wellbeing is a government public, private, not-for-proft) and/or across thematic priority in Timor-Leste due to a range of sociocultural areas (i.e. health, social services) [4, 5]. Tis defnition and economic risk factors for distress including poverty, encompasses collaborations for mental health service unemployment, and past and continuing experiences referrals and back referrals, as well as for the purposes of violence [22, 23]. Rigorous estimates of the popula- of mental health system governance, including the tion prevalence of mental illness are limited and incon- involvement of mental health service user and family sistent. Te only household survey of mental illness in organisations. Timor-Leste was conducted in 2004 with 1544 adults in Emerging from the 1978 Declaration of Alma Ata [6], the aftermath of the confict, and estimated an adjusted and subsequent action to embed Health in All Policies 5.08% population prevalence of mental disorders [24]. (HiAP) [7, 8], intersectoral collaboration underpins cur- However, this estimate is now 15 years old and likely does rent global movements to achieve health equity and sus- not represent the burden of mental illness in present day, tainable development [9]. Intersectoral collaboration is more stable Timor-Leste. As well, their validity is weak- fundamental to the provision of people-centred mental ened by the predominantly urban sample and the use of health care because many of the sociocultural and eco- assessment tools that may have missed culturally mean- nomic determinants of mental health and wellbeing lie ingful idioms of mental distress. Te 2016 Global Burden outside the health sector [10–12]. Furthermore, in many of Disease study estimates a 11.6% prevalence of mental LMICs, people rely on customary (traditional, religious and substance use problems [25]. or faith-based) or private mental health providers, par- Multiple stakeholders are involved in mental health ticularly in the absence of well-developed public health care in Timor-Leste. Family and civil society includ- infrastructure [13–15]. ing customary healers are the main form of support for Intersectoral collaboration for mental health has been Timorese people with mental health problems [26, 27]. shown to be efective. A systematic review of research Within government, responsibility for mental health from high-income countries (HICs) revealed that col- is split between the Ministry of Health (MoH) and the laboration between mental health and non-clinical ser- Ministry of Social Solidarity and Inclusion (MSSI). MoH vices improves clinical recovery and other outcomes for coordinates the integration of a basic package of mental mental health service users (e.g. employment, housing health care into primary health care, and the training and stability), as well as system outcomes (e.g. service and deployment of the mental health workforce [28]. Com- cost efciency) [16]. Such collaborations included service munity-based mental health care is mainly provided by co-location, joint interorganizational training and use of mental health nurses, and there is one psychiatrist and a shared information system between services [16]. one psychologist working in the National Hospital. MSSI Hall et al. Int J Ment Health Syst (2019) 13:72 Page 3 of 13 coordinates the 2012 National Disability Policy [29], and Health Strategy [27], and was conducted to inform the the social protection program and disability pension, implementation of this Strategy. which some people with psychosocial disability result- ing from mental illness receive. Ministries of Education Methods
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