Post on 27-Dec-2015
10th November 2012 University of East London
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Reflections on capacity building in Sri Lanka Dr Shamil Wanigaratne
Consultant Clinical Psychologist, Adjunct Professor United Arab Emirates University, Visiting Senior Lecturer King’s College London
Scope
• What is capacity building• Capacity building in mental health • Sri Lankan context • Mental health services • Civil conflict and tsunami • UK-Sri Lanka trauma group • Samutthana • Some of our activity • Have we had an impact?• The future
What is capacity building? • Definitions: conceptual approach to development that focuses on understanding the obstacles that
inhibit people, governments, international organizations and non-governmental organizations from realising their developmental goals while enhancing the abilities that will allow them to achieve measurable and sustainable results.
• Assumptions?– Giving in an unequal relationship – The giver is more developed than the other – One side has more resources than the other– One side has more technical and scientific knowledge than the other– Reciprocal or return benefits is not often identified– Donor countries may have indirectly contributed to “capacity reduction” in recipient countries
• Lexicon- what does it mean?Capacity development, capacity building “give a man a fish and he will eat one meal – teach him to fish and he will eat for a lifetime”In health care and mental health care it is about knowledge, skills and competencies
Capacity building
Knowledge & skills
Knowledge & skills
Research & development
Research & development
Donor (HIC’s)
Resources
Knowledge, skills and
competencies
Knowledge, skills and
competencies
Research & development
Research & development
RecipientLAMIC’s
Capacity building and mental health
• Global rise in mental health problems • Availability of evidence based treatment but most people
don’t receive it (27% and 30.5% in Europe and USA, less than 2% in Nigeria (Thornicroft, 2007, Alonso et al 2007, Thomas et al 2008).
• Poor allocation of resources for mental health in LAMIC’s • The “10/90 gap” – (10% of global health research resources
were used for health problems of countries which accounted for 90% of world health problems – CHRD, 1990)
• ? Dealng with major disaster in such a context – has any country got the capacity?
Global Mental Health • Returning the debt: how rich countries can invest in mental health capacity
building (Patel, Boardman, Prince and Bhugra, 2006). (UK consultant psychiatrists – general psychiatry 26%, old age psychiatry 32%and learning disabilities 59% trained overseas). (UK 40 psychiatrist per million, Sub Saharan Africa -1, India-4).
• International Journal of Mental Health Systems (2007)• The Lancet series – current mental health situation in LAMIC’s (2007)
“No health without mental health” Prince, Patel and Saxena (2007)
• Movement for Global Mental Health (2008) – improving services for people with mental health disorders worldwide through the coordinated action of a global network of individuals and institutions
• WHO – Mental Health GAP action programme (mhGAP 2008)• Second Lancet series – 2011• McGill initiatives• Harvard Review 2012
Mental Health System Development (Minas, 2012)
• Generate local evidence that would inform decision makers • Developing a policy framework • Securing investment • Determining the most appropriate service model for the context • Training and supporting mental health workers • Establishing and expanding existing services • Putting in place systems for monitoring and evaluation • Strengthening leadership and governance capabilities
Sri Lanka
Sri Lanka Demographics
• Population 20 million • Language Sinhala, Tamil & English • GDP (PPP)2005 estimate - Total$86.72 billion (61st) -
Per capita$4,600 (111th)• 53rd most populated country in the world• Sinhalese 74%, Tamil 18%, Moors 7%, Burghers, Malays and
Vaddas 1%
• Religion: Buddhism 70%, Hinduism 15%, Christianity 8%, Islam 7%
• 92% literacy rate, 83% has had secondary education, 16 Universities • WHO report ranking 76th (India 112, china 144)
Sri Lankan Context • Independence from British rule in 1948 • Very good infrastructure, schools, colleges, universities, medical schools
and educated elite (some educated in the UK and the West). Over inflated administrative infrastucutre
• Political changes in the late 50’s and 60’s led to migration of educated classes, particularly the Burgers to Australia, West and other developing countries eg. Africa, Middle East
• JVP insurgency in the 70’s and 80’s and the 30 year civil conflict also contributed to the brain drain which weakened the infrastructure in many ways
• Poor economy also meant lack of investment in education as well as research and development also contributed brain drain
• Migration
Health indices
Prevalence estimates
• National survey of mental health in Sri Lanka (IRD, 2007)– (n = 6120, 16-65, 86% Sinhalese, 7.7% Tamil, 6% Muslims and 1% from
Burgher and Malay)– Prevalence estimates: Major depression 2.1%, other depression minor,
bipolar, dysthymaia 7.1%, somatoform disorder 3%, PTSD 1.7%, alcohol abuse 7%, psychosis 3.6%
– Helplesness 6.3%; hopelessness 4.4%, passive suicidal ideation 4.2%, active suicidal ideation 1.6%
• 6000 commits suicide, 100,000 attempts suicide (Silva, 2010)• Husain et al (2011) Prevalence of war-related mental health conditions
and association with displacement status in post-war Jaffna district, Sri Lanka (JAMA)
– (n = 1448, 30% recently resettled, 2% currently displaced, 86% long term residents)– PTSD 7%, anxiety 33%, Depression 22%
Historical context of trauma
• Communal riots in the 1950’• JVP insurrections in the 70’s• Civil Conflict since the 80’s• Riots and displacement of Tamils 1983• Tsunami 2004• Final phase of the war and end 2009
14Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
Estimation of need Who is traumatised?
15Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
Mental health services
• Asylum • Psychiatry in general hospitals • General practice • Private practice • Community psychiatry?• Voluntary sector
Workforce
• Psychiatrists• MOMH• Psychologists • Psychiatric nurses • Social workers • PHI’s• Counselors • Volunteers
Capacity building
• Volunteers • NGO workers• Nurses • Teachers • PHI & Midwifes • CSO• MOMHS• Psychologists• Psychiatrists
18Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
UKSLTG and History
Context during the formation of the group• Leading figures in Sri Lanka• Expats from UK and other countries as well as
non Sri Lankans made individual contributions with mixed reception
UK-Sri Lanka Trauma GroupTHE UK WORKING GROUP TO FACILITATE WORK TO
MINIMISE PSYCHOLOGICAL IMPACT OF TRAUMA IN SRI LANKAUK Charity Registration Number 1074746
Why was it formed ?• To do some thing about the psychological impact of the civil
conflict in Sri Lanka • Co-ordinate efforts to maximise impact
How were we going to do this? • By working towards increasing awareness• By influencing policy development• By helping to increase the skills of front-line workers in Sri
Lanka • Helping develop mental health infrastructure
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Formed in 1996 (Dr Athula Sumathipala and Dr Shamil Wanigaratne)
First conference on Psychological aspects of Trauma in Colombo 1996
Registered as an UK Charity in 1999 Numerous conferences and training workshops in Sri
Lanka between 1996 and 2005 on civil conflict related trauma
Involvement in early post tsunami work
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History
2005 lobbied for grant to establish a resource centre in Sri Lanka for skills training in mental health
With the help of King’s College and South London and Maudsley NHS Trust obtained a Grant from CAFOD (6 -8 months negotiations and revised applications)
Established Samutthāna with UK and Sri Lankan partners (Forum for Research and Development, Mangrove, BasicNeeds)
Continued
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Objectives UKSLTG
• Working towards increasing awareness• Influencing policy development• Helping to increase the skills of front-line workers in
Sri Lanka• Helping develop mental health infrastructure• Raise funds to help achieve the above
Samutthāna the King’s College London Resource Centre for Trauma, Displacement and Mental Health
Samutthāna meaning “renewal” or “regeneration” in Sanskrit has the following objectives:
Objectives• Training and skills development• Creating a supervision infrastructure• Providing a resource on mental health books and information • Research
• Conflict resolution (peace building) & policy development
The structure of Samutthāna The King’s College London Resource Centre for Trauma, Displacement and Mental Health
3/2 Kynsey RoadColombo 8 Centre Manager: Ms Shikanthini Varma-Atthanayake + 2 staff
Batticaloa OutpostIn partnership with Mangrove Network
Resource Person:Mrs Selvika Sahathevan
Jaffna OutpostIn partnership with Shanthium
Resource Person:
Mr Radnam Jegananthan
Hambantota OutpostResource Person:Mr Duminda Wanigasekare
Colombo Resource Centre
Summary of Samutthana Activities Activity Result
Establish Colombo resource centre and library
Trained 600 people and supervised 50 practitioners,Library resources being consulted by MoH and others
Establish Hambantota resource centre Trained 600 people and started supervision sessions,Small library and huge demand for books in Sinhalese
Establish Batticaloa resource centre Trained 600 people and started supervision sessions,Small library and huge demand for books in Tamil
Establish presence in Jaffna Started low key activities using Shanthiham volunteers. Trained 60 people
Training program for Nurses Trained three groups (180) MoH Nurses in psychosocial care in Colombo
Training program for GTZ Trained school teachers from the Education Ministry
MSc. in Clinical Psychology Established first masters course in clinical psychology in Sri Lanka
International Conference on Renewal and Regeneration
Shared experiences on disaster management with other Tsunami affected countries and promoted a dialogue between North and South
Funding 3 PhD students Trained three students in international research techniques, funded research on post Tsunami mental health challenges
MoU with the Psychosocial Forum of the CHA
The PSF identified psychosocial needs of members, which are met through Samutthāna training workshops and supervision
Mental Health Policy Provided input into policy and implementation through developing mental health infrastructure (e.g. Clinical Psychology Degree)
Disaster Management Policy Provided input into policy and implementation through PhD research to prepare the psychosocial sector and ministry for future disasters
Samutthana
• New strategy• Work-streams• Restructure and moveStrategy • Develop and maintain an organisational identity as a provider of training
and ongoing support.• This will be achieved by networking, developing partnerships and working
with organisations within state and voluntary sectors including religious organisations, in all areas of the country
Work-streams I
Mental health work with children and adolescents
Mental health work with those with disabilities including ex-combatants
Work relating to misuse of alcohol and other substances
Work targeted at war widows
Work that would benefit internally displaced who would not come under the above categories
Work-streams II
General mental health capacity building that includes contributions to psychiatry training, clinical psychology training (M.Phil) and mental health nurse training.
Research including evaluation work and needs assessment
Work that could specifically contribute to peace and reconciliation
Samutthana Activity
Work by visiting
resource persons
Work by visiting
resource persons
Supervision & support
work
Supervision & support
work
Training by staff and local
resource persons
Training by staff and local
resource persons
Liaison work with other
organisations
Liaison work with other
organisations
Samutthana Samutthana
Research work
Research work
Provision of resources
Provision of resources
Training and support
• 3 levels of training 1. Level I – volunteers, NGO workers 2. Level II – NGO workers, volunteers and counsellors
with some experience3. Level III – Professionals (Psychiatrists, doctors,
psychologists, Nurses)
• Supervision (support)• Skype supervision – substance misuse• Repeat attendance at workshops• CBT supervision – Stella Wragg
Samutthana networking for capacity building
Government
Bodies
Government
Bodies
CHACHA
Key individuals
and organisatio
ns
Key individuals
and organisatio
ns
Corporate SectorCorporate Sector
King’s CollegeKing’s
College UELUEL
Government Ministries
• Ministry of Health • Ministry of Education• Ministry of Rehabilitation
Government Bodies
• National Institute for Mental Health (NIMH)• National Institute of Education
NGO’s
• Basic needs• Survivors Basic Needs• Consortium of Humanitarian Agencies (CHA)• Survivors • VSO – Sri Lanka • Aaruthal • Shantiham• Family Rehabilitatation Centre (FRC)• Sunera Foundation• Caritas / SEDEC
Consortium of Humanitarian Agencies
• Psychosocial Forum
Education establishments
• University of Colombo – FGS• University of Kalaniya – (Dept of Psychiatry)• University of Jaffna
Resources
• Translation of childrens manual into Sinhala and Tamil
• Library
CBT Manual dedicated to Padmal De Silva
Research capacity building
• The 3 PhD’s • Through input to M.Phil course
The cost (visible and invisible)
• Early stages minimum cost (airfares for British experts – not UKSLTG members), Sri Lanka costs some covered by the SLMA, some donations)
• Following CAFOD grant – infrastructure, wages, management
• Invisible cost – donation of time by experts and volunteers
Funding picture
0
20
40
60
80
100
120
140
Funding (1996 -2012)
• Personal donations – 10K• Fund raising – 25K• South Asia Forum for Mental Health – 5K • CAFOD – 139K + 55K • King’s – 36K (PhD fees)• Lupina Foundation – 45K • South London and Maudsley Trustees – 74K• Amateurs Trust – 5K• Bromley Trust – 10K Total = 404K
SLaM/IOP contributions towards Sri Lanka
SLaM Trustees • Contribution to support staff member who was coordinating psychosocial response in the immediate
aftermath of the tsunami (Prof Martin Prince, Prof Bill Yule) • Grant to rescue Samutthana and develop fundraising strategy
SLaM• Study leave and support for staff doing voluntary work in Sri Lanka (Dr Anula Nikapota, Dr Shamil
Wanigaratne and staff visiting to teach on the M.Phil course in clinical psychology• Formal Board approval to be linked to Samutthana as a partner • Support of the communications department• Engagement and support for the VSO scheme
IOP/King’s• Study leave and support for staff doing voluntary work in Sri Lanka (Padmal De Silva, Prof Bill Yule, Prof
Philippa Garety, Prof Paul Salkovskis et al)• Address and PO Box for the Charity• Providing venues for meetings and lectures • Services of Development Office and staff for grant writing and fundraising • Support with reporting back to CAFOD • Lending King’s College name to the Resource Centre in Sri Lanka
Measurement of Outcome: tangibles and intangibles
• Counting attendance – over 6,000 attendance
• Counting network (social capital) • Feedback and satisfaction surveying• Improvement of survey template • Qualitative feedback “statements and quotes”• Formal research
Tangibles
• Conferences 4• Attendance at workshops = 6 – 8,000• People trained in child manual = 30 ++• M.Phil in Clinical Psychology = 13• Training of academics at Jaffna University = 30• PhD’s = 3• Psychiatrists • Nurses • Volunteers
Centre for International Mental Health (Melbourne) Project in Sri Lanka
Contributing to UK’s capacity
• Kuhan Satkunanayagam • 4 clinical psychologists • Nurses• SL Volunteers• Seminar programme
Evaluation
• Progress reports to CAFOD• Formal evaluation by Sidartha Prakash• Ongoing evaluations and reviews• Internal evaluation funded by the Bromley
Trust
Siddhartha Prakash recommendations
• Use local resources and experts• Develop a pro-active Steering Committee• Organize frequent activities• Cover more topics• Regular supervision required• Review staffing needs• Promote regional networking• Pilot distance learning coursesDevelop a business model• Translate resources into local languages• Conduct outreach and promotion• Review the PhD Program• Develop certified courses• Develop monitoring and evaluation systems• Conduct staff training and performance evaluations
Reflection on the process of capacity building
• Skills sharing • Developing relationships• Expereince?
Future
• Future of UKSLTG?• Future of Samutthana ?• Should we formally link up and be part of
King’s College Global Mental Health Programme?