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Table 4 Pre- and post-earthquake developments in MHPSS system building

From: Building back better? Taking stock of the post-earthquake mental health and psychosocial response in Nepal

Health system building block Pre-earthquake developments Post-earthquake developments Contribution of the post-earthquake MHSS response: representative quotes
Governance • National mental health policy endorsed (1997)
• Mental health legislation drafted but not passed
• Multi-Sectoral Action Plan for the Prevention and Control of NCDs (2014–2020) including mental health endorsed but poorly implemented
• Revised mental health policy drafted by MOH; endorsement by cabinet pending
• Mental health legislation being drafted through a collaborative effort among stakeholders
• Government focal point for mental health assigned: Primary Health Care Revitalisation Division (PHCRD)
• Mental health focal point continually available in WHO Country Office
• Community Mental Health Care Package Nepal 2074 detailing minimum standards for mental health in primary care prepareda
‘If the earthquake hadn’t happened, the government would not have brought rules. All NGOs, INGOs would work on their own behalf, in different sites, which is duplicated, no policy, no control mechanism…’
‘And after earthquake those focal point started being created which led the whole mental health system in Nepal, like it gave direction to everything.’
‘Now PHCRD is taking leading role and we brought all NGOs and INGOs in one umbrella and then we are working now with coordination side by side.’
‘Our [mental health] policy was not revised for more than a decade. In my view the earthquake showed us the feeling, the need to address that. Now that policy [revision] has moved forward a little… If the WHO did not coordinate here, the policy would have not have reached this point, but the earthquake is the reason WHO came [to have a stronger presence] here.’
Financing • Government funding for mental health mainly limited to one state psychiatric institution • Government allocated a separate budget for mental health for the first time, which will cover implementation of the Community Mental Health Care Package in seven additional districts
• Increased funding from NGOs, international NGOs (INGOs) and international donors
• Increased funding from other sectors and intersectoral collaboration; e.g., the Department of Women, Children and Social Welfare integrated counselling into one-stop crisis management centres for women experiencing violence
‘…for the first time government took some mental health program in their red book [annual budget planning] program, for the first time government gave budget.’
‘Earthquake can be catalyst…. For example, in Canada someone wanted to give us money…but they could not raise [funds for] mental health. But after earthquake, people gave a lot of money.’
‘Bringing people [with mental illness] to Nepalgung or Kathmandu [for treatment] is quite expensive…but post-earthquake when mental health system is so much discussed and talked about, and many actors, also even protection clusters, they started assigning certain budgets for issuing and bringing chronic cases in the residential treatment.’
Human resources • Limited training on mental health in government health education system
• Psychosocial workers and counsellors trained mainly by NGOs
• Primary health care workers in public system in 14 affected districts trained using mhGAP
• Female Community Health Volunteers and other frontline workers trained on identification and referral
• New psychosocial counsellors and community psychosocial workers trained
• Many trained on offering psychological first aid
• Efforts underway to engage medical schools in strengthening mental health curriculum of medical studentsa
‘One important thing was introducing mhGAP in government in Nepal. b Though it has been used in different NGOs in Nepal but government ha[d]n’t acknowledged it and ha[d]n’t started training for that. WHO coordinated with government and we started training the medical officers that were appointed in those [affected] areas.’
Psychotropic drugs • 6c psychotropic drugs on the government list of freely available essential drugs • 12c psychotropic drugs on free drugs list to be provided free of cost in districts where service providers have been trained on assessment and management of mental disorders ‘…if earthquake has not been there, forget about these changes. Even that 5 c medicines also would have been eliminated or not given priority.’
Information and research • PFA and Inter-Agency Standing Committee (IASC) guidelines had been translated in Nepali
• Some relevant experience/protocols from flood-related interventions
• Some intervention effectiveness research
• Community Informant Detection Tool (CIDT) had been developed for some disorders and validated in Nepalia
• Consolidation of information/research available before the earthquakes
• Needs assessments and other research conducted, including on PTSD prevalence
• A version of CIDT for general distress was developed and disseminated
• First national mental health epidemiological survey is being planned, led by the Nepal Health Research Council of MOH
• Information, education and communication materials on mental health prepared and widely disseminated in public
• Desk review of information relevant to MHPSS intervention in Nepal prepareda
‘We had already IASC guidelines, we had PFA and psychological factors already in place, we have other researches that has been published, many NGOs had published their own materials for orientation of mental health and psychosocial awareness…. Those things were not seen before the earthquake but after earthquake it was seen in system.’
‘What earthquake did was, it gathered one to act together so the information was gathered. As a psychiatrist…I didn’t know [PFA] was translated…. WHO gathered everyone as subcluster and everyone came to know things that have gained in the mental health field in Nepal.
Service delivery • Community mental health model/training curricula existed
• Service delivery NGO-led and not integrated into government system
• Services concentrated in cities
• Selected modules of mhGAP Intervention Guide had been adapted to the Nepal contexta
• Translation and adaptation of mhGAP version 2 under PHCRD and design of training manual for medical officers and health assistants under National Health Training Centrea
• Revised Standard Treatment Protocol for delivery of mental health services in primary care settings based on mhGAP and international guidelines endorsed by PHCRD
• Primary care providers in 14 affected districts trained in assessment, management, and follow-up for mental health problems
• Frontline workers trained in identification and referral
• Increased public awareness led to increased presentation at services
• Mass conversion disorder intervention manual developed to facilitate intersectoral action from health and education sectors
‘[Before the earthquake] we couldn’t even cover each and every district as single resources couldn’t be sent to each and every district. But later good thing was with partnership with government, INGOs and NGOs, other organizations, and we started sending resources to various districts…. More than clinical support, psychosocial support was the best, it was all over the earthquake affected areas.’
‘Before, many people wouldn’t address [mental] illness. After the earthquake people who hadn’t been to a psychiatrist, mental health professional, finally started to come, the earthquake also boosted that awareness.’
‘Now after the earthquake many reports of those [mental health cases] came. Wherever mental health actors are in the community, there case reports have increased.’
  1. aThese developments were not explicitly mentioned in focus group but were added subsequently by authors of this article who were present at the focus group and directly contributed to these initiatives
  2. bmhGAP had been integrated into the government system in one district (Chitwan) prior to the earthquakes [26,27,28]
  3. cThis list includes two forms of the same drug, Diazepam (injection and tablet), so some stakeholders considered the total number of psychotropic drugs on this list to be 5 and 11 before and after the earthquake, respectively