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Mapping of mental health and psychosocial support in post conflict Libya

Intervention 2012, Volume 10, Number 2, 88 - 200

Mapping of mental health andpsychosocial support in postconflict Libya

Colleen Fitzgerald, Amera Elkaied & InkaWeissbecker

The violent con£ict that erupted inLibya and toppled

theGadda¢ regime in 2011hassigni¢cantly impacted

social services and the health infrastructure in the

country. The in£ux of international humanitarian

organisationshas led tomany initiatives tostrengthen

mental health care and psychosocial support services

for the Libyan population. However, with a new and

fragile government and many di¡erent international

actors, in addition to emerging national initiatives, it

was di⁄cult to determine who was doing what. As a

result, the situation was somewhat unclear. On the

requestofthe newLibyanhealthauthorities, the inter-

national NGO International Medical Corps con-

ducted a 4Ws mapping (Who is Where, When,

doingWhat)ofthe currentmentalhealthandpsycho-

social support activities in Libya that focused on

vulnerable areas impacted most by the con£ict.The

authors, who were involved in the 4Ws mapping,

describethemainresultsanddiscussthechallengesthey

faced.They conclude that this was a useful exercise

fororganisingand sharing information that was pre-

viously unavailable. The tool helped link di¡erent

organisations, that previously did not know which

services werebeingo¡ered elsewhere, and thereby con-

tributed to a better understanding and cooperation

amongactors.

Keywords: 4Ws mapping, coordination,Libya

IntroductionLibyan context

Major unrest against Muammar Gadda¢’sregime erupted in Benghazi, eastern Libya,on 17 February 2011, days after the

ht © War Trauma Foundation. Unautho188

resignation of Hosni Mubarak, the formerpresident of Egypt. Gadda¢, and his support-ers, retaliated violently as the uprisingsgained popularity throughout the country.Soon after, the situation descended intointense armed con£ict between the regimeand protesters. NATO coalition forcesbecame involved when air-borne bombard-ments of civilians continued, despite the 17March adoption of UN Security CouncilResolution1973, which imposed a no-£y zoneover Libya (BBC News, 2012). The con£ictwas characterised by a series of o¡ensivesand counter-o¡ensives between oppositionand rebel-led forces. Rebels eventuallygained control of all remaining Gadda¢loyalist pockets in the country. On 20October 2011, Gadda¢ was captured andkilled by rebel forces, and on 23 October,Libya was declared ‘liberated’ from Gadda¢’srule. The National Transitional Council(NTC) has been in place since 27 February2011, and general elections are scheduled for2012. It is estimated that some 30,000 Libyansdied in the war (Laub, 2011) and that therehave been thousands injured, some of whomhave required amputations.As in all con£ict a¡ected population centres,the violence severely impacted socialservices, the health infrastructure, and thedaily lives of civilians. Normal supply chainshave been disrupted, resulting in shortagesof food, critical medical supplies and equip-ment.Keymedical sta¡ £edat the same timehealth facilities were attempting to treat

rized reproduction of this article is prohibited.

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Fitzgerald et al.

and manage increased caseloads. Inaddition, electricity and water cuts, as wellas destruction of the physical infrastructure,have all added to civilian hardships. As ofApril 2012, the situation in many con£icta¡ected parts of Libya that had experienced¢ghting, is continuing to stabilise. In theseareas, humanitarian organisations arephasing out their emergency response, andswitching to longer term planning andrecovery activities. It was, therefore, essen-tial to map initiatives and support servicesin order to optimise activities.

Project context

The International Medical Corps (IMC) isan international nongovernmental organis-ation (INGO), and has been has been onthe ground responding to the crisis in Libyasince February 2011. IMC has been support-ing health services in eastern Libya,Misrataand Zliten, the Western Mountains, andTripoli, as well as the Egyptian andTunisianborder regions. They have supported ser-vices by means of mental health and psycho-social support (MHPSS) activities, such astraining in psychological ¢rst aid (PFA) forsta¡ working in health care and communityorganisations. IMC also worked with Lib-yans, in leadership roles, to set up a coordi-nation group consisting of national andinternational organisations that wereengaged in mental health or psychosocialactivities. This group met weekly inTripolito share information and discuss needs.Withthe support of the World Health Organiz-ation (WHO) in Libya, similar coordina-tion groups have also been set up inBenghazi and Misrata.Although coordination e¡orts existed, itremained di⁄cult for the mental healthleadership to keep track of which agencieswere where doing what. This was particu-larly di⁄cult, as prior to the con£ict, INGOs

ht © War Trauma Foundation. Unautho

had a limited presence in Libya and it waschallenging to understand the work of eachagency. Furthermore, the coordinationgroupand the leadership were relatively isolated inTripoli, with little knowledge and communi-cation with actors outside of the city. InOctober 2011, IMC accepted the request ofthe Libyan Ministry of Health, and othergovernmental o⁄cials involved in mentalhealth, to conduct a 4Ws (Who is Where,When, doingWhat)mappingof currentmen-tal health and psychosocial support activitiesin Libya, which focused on vulnerable areasimpacted heaviest by the con£ict (Benghazi,Misrata,Tripoli and the Nafusa Mountains).The organisationwas well positioned for thistask, due to its having a presence in the fourmain a¡ected regions in the country. Inaddition, there was good communicationbetween sites, aswell as theability to dedicateresources quickly for the mapping, includingsta¡ and operational support such as drivers.Furthermore, as a co-leader of the coordina-tion group, andhavingbeen engaged inmen-tal health activities and needs assessments,relationships had already been establishedwithboth several international organisationsand local actors involved in mental healthandpsychosocial activities.The following goals were agreed upon:

1) I

rize

dentify gaps in current MHPSS activ-ities and services

2) A
void duplication of activities 3) I mprove coordinationbetween di¡erent
organisations and agencies
4) P rovide information to better plan for
future activities and services

Methods and proceduresThe 4Ws mapping tool and adaptation to the

Libyan context

The 4Ws mapping tool used in Libya, wasdevelopedbyWHOand the IASCReference

d reproduction of this article is prohibited.189

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Intervention 2012, Volume 10, Number 2, Page 188 - 200

Grouptoprovide detailed informationaboutwhich organisations or agencies were imple-menting what kinds of activities, in whichregions, and within which speci¢c timeframes (O’Connell et al., 2012).The di¡erenttypes of activities were organised in a waythat ¢ts within the IASC (2007) pyramid,showing the range of di¡erent mental healthand psychosocial responses in emergencies,from the very specialised to the more basictypes of support (Inter-Agency StandingCommittee, 2007).The mapping was conducted from Novem-ber^December 2011. As a ¢rst step, the teamdrafted a 4Wsmapping tool for Libya, basedon discussions with regional and globalexperts fromWHOand IMC, andonexperi-ences from previous mapping in Jordan(Baca et al., 2012).After the draft was created, the 4Ws teamsought out NGOs, agencies and individualsfor feedback. All NGOs participating in thecoordination group were requested to nomi-nate other organisations that were imple-menting relevant activities. This ‘snowballe¡ect’ had been successful within other con-texts, but proved to be di⁄cult in Libya asa result of the £uid context with newly form-ing civil society organisations.All known organisations, involved in imple-mentation or planning of relevant activities,received the 4Ws draft and were asked toprovide suggestions for improving the toolin order to be of the most use within the Lib-yan context. Based on those suggestions,the following changes were made to the tool:

1) I

ht 190

nclusion of national actors, such as govern-

ment and nongovernmental agencies, including

pre-emergency services and supports

The original 4Ws mapping tool hadbeen designed for humanitarian emer-gencies where international organis-ations implemented various MHPSS

© War Trauma Foundation. Unauthoriz

programmes. The Libyan authoritiesand leadership speci¢cally requestedinclusion of national organisations andagencies, including those that existedbefore the con£ict, especially as thisinformation had not been systematicallycollected previously. Taking such aninclusive approach was better suited tothe Libyan context where various newlocal civil society organisations wererapidly forming. Some individuals werealso taking up mental health initiativesandwere providing new services tomeetthe signi¢cant needs of isolated commu-nities, such as those in the NafusaMountains, Zawarah, and Zawiah.There were also signi¢cant gaps incoordination between actors in di¡er-ent parts of the country. The inclusiveapproach was therefore taken to assistboth national and global organisationsin planning and coordination.

2) C
apturing training details
At the time of the mapping, severalnational and international organisationswere training specialised sta¡ (psychol-ogists, social workers, general healthworkers and paraprofessionals) invarious topics to improve mental healthand psychosocial support services.However, these various trainings werenot always carefully planned norcoordinated. In order to capture thetraining activities, and plan for morecoordinated and longer term capacitybuilding of key sta¡, additional detailsof training activities (e.g. groups trainedand hours of training) were added tothe mapping.

3) I
mplementing activities of speci¢c types of
MHPSS professionals

In Libya, many di¡erent types of pro-fessionals have been engaged in train-ing others in mental health, including

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Copyright ©

Fitzgerald et al.

general sta¡ (e.g. nurses and medicalstudents) and non-specialised volun-teers. One reason for this was that alimited number of mental health pro-fessionals existed in Libya, while theneed for relevant activities and serviceswas high. Therefore, an additionalcategory was added to the mapping,indicating which types of professionalsimplemented activities.

4Ws mapping implementation

The 4Ws team was co-led by an expatriateMHPSS programme manager (C.F.), andone national sta¡ (A.K.), it also includedtwo Libyan programme sta¡ that providedsupport for follow-up data collection. The¢nalised 4Ws data spreadsheet ¢le packagewas emailed to 45 actors in November 2011and contained three active sheets:

1) S
heet 1 for ¢lling out information aboutthe organisation
2) S
heet 2 for ¢lling out details of activities 3) S heet 3 with a list of the 11 MHPSS
activities and their corresponding sub-activities

The 4Ws team actively approached par-ticipants for outstanding submissions andclari¢cations, as well as made site visits toall four regions, for three to 10 days each.Preliminary ¢ndings were presented to theMHPSS working group in Tripoli. Thereport was also emailed to all participantsand shared with the IASC MHPSS Refer-ence Group and theWHO.

Results of Libyan 4WsmappingWho: participating actors (Table 1).Where: geographic locations (Fig. 1).Before the con£ict, health services, includingmental health, had been centralised withinthe main geographical locations such as

War Trauma Foundation. Unautho

Tripoli and Benghazi, which is re£ected inthe mapping. Another reason for the higherlevel of activities in Benghazi is that it hasbeen under control of the transitionalgovernment since February 2011, whileMisrata and Tripoli have only been undertransitional government control since lateAugust/early September 2011 (Figures 2and 3).Figure 3 displays where INGOs are located.It is important to note that some organis-ations had planned programmes, but hadnot yet started. Similarly, several agencies’activities were scheduled to end in the begin-ning of 2012.When: initiation and duration of activitiesBefore 2011, MHPSS activities and serviceshad been mainly con¢ned to the psychiatrichospitals in Benghazi and Tripoli, whichopened in the 1960s. A considerableincrease in services started to occur in2011, with the beginning of the Libyancon£ict. Out of 117 activities, 36 had con-¢rmed end dates, most in early 2012, but27 of them were planned to continue iffunding could be found. Many INGOrespondents cited the uncertainty of futurefunding as a barrier in identifying a speci¢cend date.Another observation was that most inter-national organisations had short term pro-jects, and as a result were uncertain aboutfuture programming; this in turn createdchallenges for planning and longer termsustainability (Figure 4).What: types of MHPSS activitiesTable 2 lists MHPSS activities from the 4Wsdata collection spreadsheet that were mostfrequently provided in emergencies.This listof activity codes and sub-codes is notintendedtobe exhaustive. Code11for ‘Generalactivities’ broadly includes assessment, train-ing, orientation, supervision and research(Table 2 and Figures 5 and 6).

rized reproduction of this article is prohibited.191

Copyright © War Trauma Foundation. Unauthorized reproduction of this article is prohibited.

Table1.

Participatingactors

Nationa

lNGOs

Internationa

lNGOs

Governm

entb

odies

Independ

ent/privateactors

LibyanAssociation

ofPsycholog

icalHealth

Dan

ishChu

rchAid

TripoliP

sychiatricHospital

DrA

ssim

AlH

aban

iand

DrW

ejda

AlM

ashHad

ani(Misrata)

LibyanAssociation

ofPsychosocialS

uppo

rtInternationa

lMedical

Corps

(IMC)

Bengh

aziP

sychiatricHospital

DrA

kram

Idrisi(Z

warah

)

LibyanRed

Crescent

Hilfsw

erkAustria

Internationa

lTripoliC

entralHospital

AmalAlgha

dPrivateClin

ic(M

israta)

O⁄ce

forMartyrsan

dMissing

Statistics

Internationa

lOrgan

isationfor

Migration

Bengh

aziM

edicalCentre

Psycholog

yDepartm

ent

DrA

buSa

lam

(NafusaMou

ntains)

O⁄ce

ofMedicalan

dPsychosocialS

uppo

rtfor

17Februa

ryInjured

Mercy

Corps

Bengh

aziU

niversityPsycholog

yDepartm

ent

DrA

nwar

(Alzaw

yah)

TawasselO

rgan

isation

Me¤ decinsS

ans

Fron

tie' res

^Belgium

Nationa

lCentreofDiseaseCon

trol

Actso

fMercy

Misrata

MentalH

ealthCenter

Save

The

Children

WHO



192

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Al Jabal Al Gharbi, 6

Albeda , 2

Alzawya, 2

Zwarah, 1

Derna , 2

Sabha, 3

Sirte, 1

Misrata, 31

Tripoli, 31

Benghazi, 38

Figure 1: Geographical distribution of activities (per

district/shaibya in Libya).

Fitzgerald et al.

A signi¢cant percentage of actors conductedtrainings (39%, 46 out of 117). The types oftargeted trainees included social workers(15), psychologists (9), volunteers (9), teachers(7), medical sta¡ (4), and psychiatrists (2).One primary observation was that whilemany of the activities focused on childrenand adolescents, not one single activity wasfocused on parents, nor strengthening theparent^child relationship.


11 11

8

2

0

2

4

6

8

10

12

Benghazi Tripoli Misrata Al Jabal AlGharbi

AlZ

Figure 2: Geographical distribution of actors (per district/sh

Intervention concentration according to level base on

the IASCGuidelines pyramid

The IASC (2007) pyramid shows a layeredsystem of di¡erent mental health andpsychosocial activities and considerations,ranging from basic support needed by mostof an a¡ected population, to very specialisedmental health services that are needed onlyby a small proportion. The di¡erent typesof activities are complementary, and illus-trate that people are a¡ected in di¡erentways, and require di¡erent kinds of support,following an emergency (Figure 7).The activities mapped in Libya accordingto levels on the pyramid show that most(45, 63%) interventions fall under level 1,‘Specialised services’. This is followed by non-specialised services (14, 19%), ‘Community/family support’ (8, 11%), and ‘Basic services’ (5,7%).Thismay indicate that many psychoso-cial actions at level 1are often not conceptu-alised as such, and may be missed inmapping. It is important to note that directinterventions were accounted for, but nottraining activities.


2 21 1 1

awya Derna Albeda Sabha Sirte

aibya in Libya).

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Tripoli

12 18

Mediterranean sea

Gulf of Sidra

30

24

24

24

30

18

Migrätah

Surt

Niger

0 300 km

300 mi0

CHAD

Aozou strip

Sudan

Benghazi

Al BayadäTobruk

TUN.

ALG

Zuwärah

Sabhä

Egypt

Al Kulrah

SabkhatGhuzayyil

Crere(GR.)

Oasis

Bikku Bitti

Al Jawf

Al Burayqah(Brega)

S a h a r a

Ra’sLänüf

AlKhums

Ghädamis

MHPSS INGO coverage throughout Liby

Darnah: Act ofmercy

Al Beida: Acts ofmercy

Benghazi: Acts ofmercy, IOM, IMC,save the children,WHO

Sirte: MSF-B

Nafusa mountains:IMC

Sabha: IOM

Misrata: DCA, IMC,Mercy Corps, MSF-B,WHO

Tripoli: HW, IMC,IOM, MSF-B, Savethe children

Zawiah: Save thechildren

Figure 3: Geographical distribution of international actors (per district/shaibya in Libya).



DiscussionLimitations

The 4Ws mapping exercise in Libya hadseveral limitations. It should be noted thatthe 4Ws tool is designed to provide infor-mation only, and not to assess whether acti-vities follow guidelines, or are of good


4 8 90

20

40

60

80

100

120

140

1989 19901962

Figure 4: Initiation of activities.

194

quality. In addition, all of the data collectedare based on self reporting from the organis-ations that were interested in participatingand who may have presented themselves ina favourable way.The mapping is also basedonly on those organisations that were ident-i¢ed by the mapping team, while other


12 16

117

2007 2010 2011

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Table 2. 4WActivity codes and descriptionsa

Activity code Description of 4Ws Activity codes

Activity1 Information dissemination to the community at largeActivity 2 Facilitation of conditions for community mobilisation, community

organisation, community ownership or community control overemergency relief in general

Activity 3 Strengthening of community and family supportActivity 4 Safe spacesActivity 5 Psychological support in educationActivity 6 Supporting the inclusion of social/psychosocial considerations in

protection, health services, nutrition, food aid, shelter, siteplanning or water and sanitation

Activity 7� (Case focused) psychosocial workActivity 8� Psychological intervention (e.g., counselling, psychotherapy)Activity 9� Clinical management of mental disorders by non-specialised

health care providers (e.g. PHC, postsurgery wards)Activity10� Clinical management of mental disorders by specialised mental

health care providers (e.g. psychiatrists, psychiatric nurses andpsychologists working at PHC/general health facilities/mentalhealth facilities)

Activity11 General activities to support MHPSSa See O’Connell et al., 2012.

Fitzgerald et al.

organisations that were not linked with thecoordination group in some way, could notbe captured.

Challenges and lessons learned

Response time Participating organisationswere given two weeks to respond but someof them took up to six weeks. This slowresponse time could be attributed to anumber of factors.Manyof the organisationsmayhave not seen thebene¢t of contributingto themapping, andmayhavebeen reluctantto dedicate the necessary time and e¡ort to¢ll in the tool.Di⁄culties with the data spreadsheet mapping tool

For the most part, gathering informationfrom organisations was time consuming,and required signi¢cant follow up, includingphone calls, emails and site visits. Several


actors had di⁄culty with the tool, andsections were ¢lled out incorrectly or wereleft incomplete (e.g. dates, human resources,etc.). One of the di⁄culties identi¢edwith using the tool correctly was that sta¡from participating organisations were notalways familiar with software programme.Future mapping should provide the optionof ¢lling out a paper version of the tool,or the possibility to gather the data viainterview.Translation and national sta¡ Due to limits oftime and resources, it was not possible tocreate an Arabic translation of the Libyan4Ws mapping tool. A translation would beuseful for further mapping activities. Itshould also be noted that it was essential tohave national sta¡ co-lead the mapping, inorder to e¡ectively connect with national


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4 1 4 4 4 16

29

5

15

43

Info

rmat

ion

diss

emin

atio

n

Com

mun

ity m

obili

satio

n

Com

mun

ity s

uppo

rt

Saf

e sp

aces

PS

S in

edu

catio

n

Incl

usio

n of

PS

S in

oth

erse

rvic

es

Cas

e fo

cuse

d

Psy

chol

ogic

al in

terv

entio

n

Non

-spe

cial

ised

clin

ical

man

agem

ent

Spe

cial

ised

clin

ical

man

agem

ent

Gen

eral

act

iviti

es

Community Focused Case focused General

Figure 5: Number of activities per category.



partners and discuss the importance and useof the mapping.Common understanding of terminology and relevant

activities The meaning of ‘mental health and

psychosocial support’, was not always clear tonational actors who tended to think that thiscategory only referred to specialised mental


0

10

20

30

40

50

60

70

80

90

100

Febru

ary

Mar

chApr

ilM

ayJu

ne July

Augus

t

Septe

mbe

r

Octo

Figure 6: Emergency response activities over time in Libya i

196

health services provided by psychiatrists orpsychologists. There was also a commonpresumption, among many national actorsand some international actors, that thebest way to promote mental health was toprovide psychotherapy or psychiatric ser-vices. Therefore, many organisations may


11. General activities

10. Specilised clinical management9. Non-specialised clinical mangement8. Psychological intervention7. Case focused

6. Inclusion of PSS in other services5. PSS in educatiuon

4. Safe spaces

3. Community support

2. Community mobilisation

1. Information dissemination

ber

Novem

ber

Decem

ber

n 2011.

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Specialisedservices

Focused non-specialisedsupports

Community and family supports

Social considerations in basic servicesand security

The wellbeing of all people should beprotected through the provision ofbasic needs in a way that isparticipatory, safe and sociallyappropriate

People who are able to maintain theirmental health and psychosocial well-being if they receive help in accessingkey community and family supports

Those who require more focusedinterventions by trained and supervisedworkers – psychosocial first aid, basicprimary mental health care

Suffering is intolerable and people have difficulties inbasic daily functioning beyond the scope of existingprimary/general services – psychological orpsychiatric intervention

Figure 7: IASCGuidelines pyramid.

Fitzgerald et al.

have perceived that the mapping did notapply to their work.This is probably anotherreason why many activities in the bottomhalf of the pyramid (e.g. mental health con-siderations in meeting basic needs, such ashealth and shelter, or connecting familiesand communities) were not captured.Furthermore, some activity codes were alsoperceived to be too vague, which leftinterpretation up to the participant. Futuremapping e¡orts may bene¢t from additionalworkshops to explore a wider public healthapproach, which could also provide infor-mation on a full range of relevant activities,such as community support and the role ofnon-specialised sta¡, including generalhealth care providers or volunteers. Eachcategory of the mapping tool should also bediscussed within a workshop or workinggroup to generate a commonunderstanding,and de¢nitions for each category that are


locally understood. The mapping teamshould also receive additional training incategory de¢nitions, before conductinginterviews.Rapidly changing and increasing number of local

organisations It was di⁄cult to identify allpotential, national actors as new civil societyorganisations have been emerging since thecon£ict. Prior to the con£ict, the few localNGOs o¡ering social welfare services wereclosely monitored and controlled by the gov-ernment. There have been over 250 newNGOs registered by the TNC’s Ministry ofSocial A¡airs in Benghazi. In an 8 monthperiod since 17 February 2011, over 10,000local NGOs were formed under and regis-tered with the Ministry of Society andCulture according to their ¢gures. Therehas also been an increased number of organ-isations starting inTripoli. In May 2011, theTNC Public Engagement Unit conducted a


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one day workshop for 27 Benghazi basedNGOs to assess their needs. Findingsrevealed that the lack of ¢nancial resourcesand facilities, the di⁄cult security situation,and insu⁄cient supplies were major limita-tions. The NGOs expressed the need forstronger communication and relations withthe public authorities, international NGOsand other relevant stakeholders. Further-more, many of these developing NGOs stilldid not have de¢ned missions or activities,so they could not clearly identify themselvesas potential candidates for mapping. Thismade it di⁄cult to capture all local organis-ations. It is very likely that more activities,falling within di¡erent layers of the pyramid(including basic services) could have beenidenti¢ed if data from all national actorscould have been included.Limited pre-existing information about mental

health services and activities Before the map-ping, there were no o⁄cial records nor dataon mental health professionals under theMinistry of Health in Libya, such as thenumber of psychiatrists, psychologists, socialworkers, and psychiatric nurses, and wherethey were working in the country. Inaddition, prior to the con£ict, civil societyin Libya was essentially non-existent, andinformation about rapidly emerging civilsociety organisations was not systematicallyreported nor organised.Thismade it di⁄cultto identify relevant actors to approach.Lack of pre-existing coordination and new

leadership Another challenge in identifyingappropriate actors was that very littlecoordination and referral mechanismsexisted prior to the con£ict. Additionally,since the con£ict, most leaders of institu-tions, such as health facilities, have beenreplaced. Even during themapping exercise,a new cabinet and group of Ministers wereselected. This made gathering informedknowledge of activities di⁄cult.


Geographic limitations The four selected geo-graphic areaswere chosenbecause theywereimpacted by the con£ict, had high popu-lation concentrations, and most INGOswere active in those areas. However, othersmaller cities had also experienced severe¢ghting and destruction, but were notincluded (e.g. Zawiyah). Therefore, it islikely that the mapping did not captureservice gaps in other vulnerable areas (e.g.it was reported that Zawiyah had fewmentalhealth services and activities), thereforenational actors operating in these areas werenot included in the mapping.Mapping categories Based on experiences withthe mapping, some of the categories shouldbe further modi¢ed. For example, havingan activities category on the ‘assessment’ wasconfusing to those ¢lling out the tool, asmany had conducted initial needs assess-ment before starting activities.The question‘do people receive incentives for participation in

activities provided?’ had been added, based onexperiences in Jordan (Baca et al., 2012),but it was found that it was not applicableto the Libyan context and therefore shouldbe omitted from future mapping in Libya.More information on training The detailscollected on training (which was a sub-category, despite being a frequent activity)were inadequate and could have been morecomprehensive.The speci¢cs of the training(length of training, professions of the train-ing participants, and numbers of peopletrained) were absent in several of theresponses. Given that many organisationswere involved in training activities, it wouldhave alsobeen useful to obtainmore detailedinformation, such as how trainees werechosen, time frame, andwhether or not therewas any follow up. In this mapping, theauthors found that training was often veryshort or not followed-up by supervision.Therefore, future mapping would bene¢t


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Fitzgerald et al.

from an additional category focused ontraining in order to obtain more accurateand comprehensive information, as identi-¢ed above.Capturing activities of national organisations It islikely that many local actors involved inrelevant programming have been misseddue to: rapidly emerging new civil societyorganisations, limited pre-existing infor-mation, lack of understanding of mentalhealth de¢nitions, focus on a limited rangeof geographic locations, and di⁄culty com-municating and coordinating across a vastregion. By addressing some of these factors,future mapping should comprehensivelycapture more activities of national organis-ations.

Costs and bene¢ts of the mapping

Costs The mapping was costly. In order tocarry out the process, committed humanresources were required, including one pro-gramme manager and three national pro-gramme o⁄cers, one of whom wascommitted full time to gathering data, fol-low-up and clarifying inputs from partners,interviewing actors, data cleaning and ana-lysing the data. One of the motivations ofthe mental health leadership in Libya wasto avoidduplication, and to determinewhichactors’ proposals would be approved fornew projects proposed to the MoH. Thiswas problematic, however, because asdescribed above, mapping does not measurethe quality of services being delivered.Following themapping exercise, the ¢ndingswere presented to the coordination groupand recommendations were discussed, butthis could have been more bene¢cial if moreof the mapping participants from di¡erentregions could have been included.Bene¢ts There were several bene¢ts of themapping, consistent with initial goals. Thetool helped link di¡erent organisations,


which previously did not know what serviceswere being o¡ered elsewhere. The mappingalso helped inform national and inter-national actors about best practices in theglobal mental health ¢eld, particularlyaround coordination. Overall, this was auseful exercise for organising and sharinginformation that was previously unavail-able, and as a systematic process involvingvarious actors in mapping, as well as indiscussions on how to develop and improvethe tool.

Future plans andrecommendationsFuture recommendations for the Libyancontext include repeating the 4Ws mappingexercise to re£ect MHPSS services over alonger period of time, as the context in Libyacontinues to change rapidly. Futuremappingshould also aim tobemore inclusive andpar-ticipatory, capturing more of the nationalemerging civil society actors and govern-mental e¡orts. In addition, the mappingcould be used to better link actors providingdi¡erent levels of care. This would includeinviting organisation to coordination meet-ings, with the aim of ultimately creatingreferral pathways. Advocacy and additionale¡orts are also needed to further integratemental health and psychosocial support intoother sectors including health, education,and protection, as well as into the existingprogrammes of national agencies.

AcknowledgementsWe would like to acknowledge the technical

support and guidance for using the 4Ws MHPSS

tool from Mark van Ommeren (World Health

Organization). We also want to thank Mary Jo

Baca and Ahmed Bawaneh, from the IMC in

Jordan, for sharing their experiences and

guidance.We also want to acknowledge the time

and e¡ort from national and international actors


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and organisations that provided input for the

4Ws mapping.

ReferencesBaca,M.J., Fayyad,K.,Marini,A.&Weissbecker,

I. (2012).The development of a comprehensive

mapping service formentalhealthandpsycho-

social support in Jordan. Intervention, 10, this

issue.

BBC News (2012) Libya Pro¢le. Last updated 6

March 2012. http://www.bbc.co.uk/news/

world-africa-13754897. Accessed on April

20th 2012.

Inter-Agency Standing Committee (2007). IASC

Guidelines on Mental Health and Psychoso-

cial Support in Emergency Settings. IASC:

Geneva.

Laub, K. (2011). Libyan estimate: At least 30,000

died inthewar.TheGuardian, Associated Press,


8 September 2011. Retrieved 25 November

2011.

O’Connell, R., Poudyal, B., Streel, E. Bahgat, F.,

Tol, W. & Ventevogel, P. (2012). Who is

Where, When, doing What: mapping

services for mental health and psychosocial

support in emergencies. Intervention, 10, this

issue.

Colleen Fitzgerald,MSW, is theMentalHealth

and Psychosocial Program Manager for IMC

inTripoli, Libya.

email: c¢tzgerald@internationalmedicalcorps.

org

AmeraElkaied isMentalHealth andPsychoso-

cial Program O⁄cer with IMC in Libya

Inka Weissbecker, PhD, MPH, is the Global

Mental Health and Psychosocial Advisor for

theInternationalMedicalCorps, inWashington,

DC, USA.


mailto:[email protected]

mailto:[email protected]

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