DECEMBER 2018 – JANUARY 2019 Rapid mental health and psychosocial support needs assessment in Mali Regions of Ségou, Mopti, Timbuktu and Sikasso Mental Health and Psychosocial Support Assessment, August 2019 2 ACKNOWLEDGMENTS International Medical Corps is thankful for the generous support of the Swiss Development Cooperation (SDC), which funded this mental health and psychosocial support (MHPSS) rapid-needs assessment. We thank all our informants in the administrative structures as well as the health structures, NGO partners and in the community. Without your valuable information, this work could not have been successful. This report and MHPSS rapid needs assessment was undertaken by Guy Bertrand Tengpe Wabette, MHPSS consultant, on behalf of International Medical Corps Mali country office. We thank the supervisors and investigators who agreed to explore deep in Mali, often in areas where security issues may have driven back people who lacked temerity. Thanks to the International Medical Corps team: I am especially thinking of Dr. Djuma Mnitima, Pacifique Kigongwe, Dr. Kouadio Jules Alla, Karol Bassim, Degninou Yehadji, Dr. Niare Boubakar, Djibril Coulibaly, Sambo Souley, Natalya Kostandova, Dr. Marcia Brophy and Claire Whitney. Your support, advice and feedback were invaluable in carrying out this work. Finally, thank you to Marius Tchassep, Aurèle Njientcheu, Georgia Bodiong and Cyril Mbia from the research action department of 3sh for their quality control and data analysis support. FOR MORE INFORMATION, PLEASE CONTACT: Dr. Jules Alla Dr. Marcia Brophy Medical Director, Mali country team Global MHPSS Technical Advisor, HQ [email protected] [email protected] TABLE OF CONTENTS Acknowledgments 2 List of Abbreviations 4 SECTION 1 Background and Rationale 5 1 1. Socio-political context 5 1.2 International Medical Corps in Mali 6 1.3 Mental health systems in Mali 6 1.4 General objective 6 1.5 Specific objectives 7 SECTION 2 Methodology 8 1 2. Data collection techniques 8 2.2 Collection tools and data analysis techniques 9 2.3 Data collection process 9 2.4 Limitations and challenges of the assessment 10 SECTION 3 Results of the Evaluation 11 1 3. Common problems and stressors 11 3.2 Estimated rate of mental health and psychological distress problems 15 3.3 Frequency of mental health problems identified in health facilities 16 3.4 Local conceptions of mental illness and expression of psychological distress 17 3.5 Community support and coping strategies 18 SECTION 4 Health and Mental Health Services 19 1 4. Resources and practices in health and mental health services 19 4.1.1 Staff in health facilities 19 4.1.2 Availability of drugs for the management of mental and neurological disorders 20 4.1.3 Availability of a laboratory service 20 4.1.4 Staff trained in mental health 22 4.1.5 Mental health care 22 4.1.6 Health and mental health information system 22 4.2 Mental health referrals 23 4.3 Some challenges of integrating mental health care into primary healthcare in Mali 23 SECTION 5 Summary and Recommendations 24 1 5. Summary 25 5.2 Recommendations 25 5.2.1 Mental health training 25 5.2.2 Providing mental health services 26 5.2.3 Referrals 27 5.2.4 Promoting mental health 27 SECTION 6 Annexes 28 1 6. List of evaluated health facilities 28 6.2 Interview charts used 29 6.3 Focus group discussion guide 36 6.4 Questionnaire 37 6.5 Consent Form 45 SECTION 7 Bibliography 47 Mental Health and Psychosocial Support Assessment, August 2019 4 LIST OF ABBREVIATIONS RGA Revenue Generating Activities CHC: Community Health Center RHC: Reference Health Center ADD/ADHD Attention Deficit Disorder with or without hyperactivity PTSD Post Traumatic Stress Disorder HIS Health Information System CHA Community Health Association DCMO District Chief Medical Officer HCTD: Health Centerechnical T Director RH: Regional Hospitals 3SH Synergy of Social and Human Sciences WHO: World Health Organization UNHCR United Nations High Commissioner for Refugees HIS: Health Information System CHO Community Health Officer NGO Non Governmental Organization DHSM Demographic and Health Survey of Mali EPH: Public Medical Facility CHU University hospital center PNC: Prenatal Consultation GPHC General Population and Housing Census NDH: National Directorate of Health MHPH Ministry of Health and Public Hygiene MHPSS: Mental health and psychosocial support DPHSD Decennial Plan for Health and Social Development FACF: French Aid and Cooperation Fund MSF Doctors Without Borders ACTED Agency for Technical Cooperation and Development SECTION 1 Background and Rationale 1.1 Socio-political context Mali is a land-locked country covering an area of 1,241,238 The economy is essentially based on livestock, fisheries km². It is bordered to the north by Algeria, to the east and agriculture. The socio-economic situation is marked by Niger, to the south by Burkina Faso, Côte d’Ivoire by greater poverty in rural areas than in urban areas; this and Guinea, and to the west by Senegal and Mauritania. disparity affects more women than men. Administratively, the country is divided into 10 regions plus the District of Bamako, 58 circles and six communes of In recent years, the country has experienced armed Bamako, 703 communes and 13 604 villages. violence in the north and recently in the center, which has led to the displacement of populations and a humanitarian Mali is divided into three climatic zones: the Saharan zone crisis. It has also caused problems with acute stress, (50%), the Sahel zone (25%) and the Guinean Sudano zone grief, moderate to severe depressive disorders and post- (25%). Rainfall is low (200 to 1300 mm/year) with varied traumatic stress disorder, to name but a few1. Though they periods of drought. The country has three seasons: a dry may be widespread, these cases are not treated at the season, a cold season and a rainy season. Temperatures health facility or referral hospital levels. There is very little range from 20 to 45° C depending on the season and information and intervention to deal with these mental health region. Nearly 70% of the population lives in rural areas. issues. This reality has led International Medical Corps to engage in this rapid mental health and psychosocial support In 2015 the population was estimated at 17,819,000 (updated needs assessment. General Population and Housing Census (RGPH) 2009 data). The average annual population growth rate is 3.6%. The female population represents 50.4% versus 49.6% for the male population. 1 Morris, Ashley, “Mental Health in Mali: An Analysis of the Expression of Major Depressive Disorder Across Different Cultures” (2009). Independent Study Project (ISP) Collection. 664. Mental Health and Psychosocial Support Assessment, August 2019 6 1.2 International Medical Corps in Mali FIGURE 1: DIAGRAM OF THE HEALTH SYSTEM International Medical Corps is a non-profit, non- IN MALI denominational international humanitarian organization committed to saving lives and alleviating suffering through National Health Directorate health services and emergency and development programs. University International Medical Corps has been operational in Mali Executive level Hospitals 3rd referral level (5) since March 2013 through interventions 1) in health, nutrition and protection, especially the prevention and management Regional Health of gender-based violence in the health districts of Gourma Hospitals 2nd referral level (6) Rharous and Timbuktu, and 2) focused on strengthening Intermediate level the system of epidemiological surveillance of Diseases with Mandatory Reporting (DMR), including zoonoses (sectors Private District Health Regional Health Sector Hospitals Directorate of human and animal health) in the regions of Sikasso and 1st referral level (60) Ségou from September 2015 to September 2018. Also, International Medical Corps received funding from the Operational level Peripheral Health United Nations Population Fund (UNFPA) for an intervention Facilities on improving access to family planning services in the 1st contact level (1050) Ségou region and for assessing the quality of maternal and neonatal care in the Sikasso region. Directorate of Health (NDH) of the Ministry of Health and Public Hygiene (MHPH). INTERNATIONAL MEDICAL CORPS PROGRAM AND COUNTRY OFFICE LOCATIONS IN MALI The framework of health plans and programs in Mali developed by the MHPH is contained in a Decennial Plan MALI for Social and Health Development (DPSHD) 2014–2023. Under the guidelines of the 2014–2023 PDPSHD, a • Bamako Coordination office 2017–2021 strategic plan has been developed to provide a comprehensive and appropriate response to the mental • Ségou region: San Taoudénit • Taoudenit health problems of the populations in Mali, although it has not yet been published and validated. The Ministry’s efforts • Sikasso Timbuktu are focused on strengthening the quality of mental health care, raising public awareness and making the right use of resources for mental health. Ségou At the operational level, in the public sector, the Point G Bamako Hospital Psychiatric Service is the main national reference LEGEND structure. The pediatric ward at Gabriel Touré Hospital Sikasso Bamako supports child psychiatric activities related to mental health and other mental health issues. In the interests Offices of decentralization of mental health care, six mental health units were created as part of the project for the International Medical Corps intervention sites in Mali development of mental health care supported by the French Cooperation Mission (FAC) in Koutiala, Bougouni, Sikasso, Ségou, Bandiagara and Mopti. 1.3 Mental health systems in Mali The healthcare system in Mali has three levels of care: Other private and civil society initiatives are contributing to this growth of mental health initiatives in Mali. • the central level, composed of the EPH/University Health Center (CHU); 1.4 General objective • the intermediate level, made up of public hospitals The main goal of this rapid assessment of MHPSS needs is: (EPH); and • the operational level, subdivided into two levels: • Gain an understanding of existing services, community health centers (CHCs), and reference weaknesses, strengths and identified needs.