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Rapid Mental Health and Psychosocial Support Situational Analysis: Services, supports and perceived needs in the context of the January 2015 Malawi Floods

February 12th 2015

1. Goals The overall goal of this rapid situational analysis was to inform the potential program design of any International Medical Corps (IMC) MHPSS activities that would fill existing gaps as part of the Malawi 2015 flood response. Data collection focused on assessing the availability of existing mental health and psychosocial support services as well as community aspects of mental health and well-‐being among affected populations. This assessment focused on identifying needs as well as resources. For questions or to learn more about this assessment, please contact: Dr. Inka Weissbecker, IMC Global Mental Health and Psychosocial Advisor, [email protected] 2. Methodology The rapid MHPSS situational analysis was conducted by IMCs Global Mental Health and Psychosocial Advisor (Inka Weissbecker) from February 6th to 12th 2015 as part of a multi-‐sectorial assessment carried out by the IMC Emergency Response Team (ERT). The assessment tools were adapted from the UNHCR/WHO (2012) publication “Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Major Humanitarian Crises”. A desktop review of current policy documents included:

• Malawi flood sitreps and reports (e.g. UNRCO, UNCEF, UNDAC) • Malawi Mental Health Policy -‐ http://www.mindbank.info/item/784 Published 2001. • Malawi Malawi Health Sector Strategic Plan 2011 -‐ 2016: Moving towards equity and quality -‐

http://www.mindbank.info/item/2307 Published in 2011 Interviews, Focus Group Discussions and Site Visits: MHPSS assessment data collected included discussions with stakeholders such as camp managers, representatives from Department of Disaster Management Affairs, District Health Management Team (DHMT), organizations working on MHPSS in Malawi (SMMHEP, REPPSI) and the flood affected population; field visits to the affected areas (camps and health facilities) and a health coordination meetings in Blantyre.

3. Background and Context 3.1. Malawi Floods The current flood crises in Southern Malawi has affected more than 600,000 people (116,000) households in a total of 15 districts due to damage to crops; 63,976 Hectares of land are flooded 174,000 are displaced throughout the country. Three of the districts; Nsanje, Chikwawa and Phalombe are severely affected. There are 79 recorded deaths and 153 are missing1. 63,976 Hectares of land flooded, the floods have washed away crops and destroyed massive amounts of farmland, for which much of the agricultural community in Malawi is dependent. IMC has no current country office in Malawi. 3.2. Mental Health Policies and Strategies in Malawi Malawi has a national Mental Health Policy (2011) and a Department for Non-‐Communicable Diseases and Mental Health under the Ministry of Health. The Malawi Health Sector Strategic Plan 2011 – 2016 includes mental health services under the Essential Health Package (EHP). This includes mental health promotion and awareness as well as treatment of Depression, Bipolar Disorder, Psychotic Disorders, Alcohol and Drug Use, Epilepsy. 4. Assessment Results 4.1. MHPSS coordination and assessments There is a PSS technical working group coordinated by the Ministry of Gender, Children, Disability and Social Welfare in Lilongwe, Malawi. There is a health coordination group for health in response to the floods led by WHO, but no current group or coordination efforts for MHPSS. Assessments carried out among flood-‐affected populations have focused on immediate needs related to health, nutrition, protection, shelter, NFIs but have not yet included MHPSS. CBM reportedly carried out quick assessments to identify the impact of floods on persons with disabilities and immediate needs. 4.2. Characteristics and health care access at visited camp sites Basic data on the affected population and access to health facilities was collected during site visits at camp sites is shown below. Table 1. Summary of general data collected at camp sites District Chikwawa Chikwawa Nsanje Camp Khungubwe Camp Konsere Camp Bangula Camp Camp Population 2,770 1,357 4,640 HSAs in camps 4 (2 female) 2 2 Nearest Health Services

Sargin Health Center (4-‐5 km) Ngabu (10-‐15km) Dolo

Sargin Health Center (4-‐5 km) Dolo Health Center (15km), Once received outreach visit from medical team (Ngabu Hospital)

Mission Hospital (only free of charge for pregnant women), walking distance, MSF outreach medical clinics 3x/week*

1 Malawi: Department of Disaster Management Affairs (DoDMA) United Nations Office of the Resident Coordinator Situation

MH problems noted

No reports of epilepsy or psychotic disorders, at least 2 children with developmental disorders.

No reports of psychotic disorders, 4-‐5 people with epilepsy (HAS encouraged to go to HC)

No reports of epilepsy or psychotic disorders

*Sargin area: MSF mobile medical clinics do currently not include MH. They previously had a clinical officer trained in MH (who had observed people “traumatized by loss” but he is not with the team anymore

4.3. Current problems and stressors among the flood-‐affected population Key informants and focus groups were asked about current problems affecting people in their community. Results are shown below. Table 2. Current problems among people in the affected communities

• Physical health (e.g. malaria due to not having mosquito nets, worries about disease outbreaks, some people cannot walk to health facilities)

• Shelter (e.g. tents are not enough and existing tents are crowded, no means of rebuilding houses)

• Food and Nutrition (e.g. lack of food diversity, no firewood needed for cooking)

• No livelihoods and livestock due to losses during flood (most affected were farmers, e.g. no seeds for recovery)

• NFIs (e.g. No basic household items and clothes due to loss of properties during floods (e.g. not enough kitchen items, blankets, buckets, tissues, sleeping mats)

• Education (e.g. children have no appropriate clothes to go to school, no school supplies such as books and pens)

• WASH (e.g. not enough latrines) Social concerns:

• Family separation due to floods (e.g. family members in different camps, men and women in different tents so families are separated)

• People who lost family support (e.g. orphans, widows) Psychosocial concerns:

• Loss and uncertainty, some people have lost property and livestock (e.g. goats, cows, sheep, chicken), some even have lost relatives, they are worried about the future

• No burials, People have not been able to bury those who died, have not seen the bodies

Informants also note that affected people cope with loss by “leaving things in God’s hands” and praying. Some have relatives who help, others engage in “piecework” (temporary work). 4.4. Prevalence of mental neurological and behavioral problems and psychological distress No data on mental health problems is currently available from affected areas. The World Health Organization (WHO) estimates that the majority of people affected by disaster will experience stress reactions while a minority will develop mental health problems. Rates of common mental disorders such as anxiety disorders and depression may double in the context of humanitarian emergencies from a baseline of about 10% to 20% while people with severe mental disorders (2-‐3%) are especially vulnerable in such contexts and need access to care.2 Primary health care facilities are often an important entry point for identification of people with mental health problems. One study involving 22 health centers with outpatient facilities in Malawi (Machinga district) and 3,487 patients attending those health centers, found that 28.8% of patients had a common mental health problem and 19% had depression. None of them had been detected or treated at baseline before primary health workers had received the relevant training3.

2World Health Organization & United Nations High Commissioner for Refugees. Assessing Mental Health and Psychosocial Needs and Resources: Toolkit for Major Humanitarian Settings. Geneva: WHO, 2012. 3 Malawi Malawi Health Sector Strategic Plan 2011 - 2016

“Our friends are gone, everything is gone, is there a plan B, where to start? We see nothing and don’t dream of anything. And organizations may stop helping us any day” ~ Expression of loss and uncertainty during FGD in Khungubwe camp

4.5. Local concepts of psychological distress and mental illness and ways of coping Informants were asked about current problems in the community (see section 4.3 above) and further probing questions (about signs, causes, support) were asked when informants mentioned mental health related concerns (e.g. problems related to emotions, thinking or behavior). The words ‘mental health’ or ‘psychosocial support’ were not used and participants own phrases were repeated when asking further questions. Table 3. Local concepts of MHPSS related concerns MHPSS Problem

Signs/Symptoms

Perceived Cause

Ways of coping

Current Community Support

Suggested support

Possibly stress and grief reactions

No peace of mind, no appetite

Loss Praying Talking to them and comforting them

Replacement of lost belongings For children: Help them play and forget about the floods, give them things to play and to get busy (e.g. balls for football games, chess) For families: Give house/shelter so they can comfort one another and have “freedom of mind”

Possibly depression (has also been called ‘hysteria’ by one informant)

Thinking too much, unable to sleep, cannot recover, cannot see the future, does not want to communicate with others, stays away when friends are visiting Possible consequences: Could get ‘disease of any kind’ such as high blood pressure, heart attack or “go mad”

Loss Praying Talking to them and comforting, encouraging them, talking about scriptures and God, put them in playgroups, tell jokes. Volunteers from the Red Cross visit them and talk to them (Vol. report they support them to ‘release’ emotions if people are visibly upset)

They need tangible things (e.g. kitchen utensils, clothes), give them more food rations to make them feel that the community cares for them, give them means to start a business (according to their skills and interests) Give them lost belongings to start over (e.g. 2-‐3 goats, cattle)

One key informant (camp chairman) reported that some people who lost relatives were not even eating when they first arrived, he tried to talk to them, comfort them, “now they are eating but we can tell they are still not ok, still not happy”. He also reported that one child lost both parents, informants and had symptoms of acute stress (e.g. “he seems like he is in another place, he forgets things, his brain is not ok”). The community helps take care of him, the camp chairmen took him for lunch and he wants to involve him in activities (e.g. Youth Committee). Camps are small and children have spaces to play. Bangula camp has a football pitch (2 balls donated from MoY). More supplies to play for children are needed (e.g. more balls, chess). There have also been groups with music and drama (Bangula). 4.6. Mental health services in affected areas The general organization of health services is shown in the table below. According to the WHO optimal mix of services, health systems should provide multi-‐layered services to support the mental health and psychosocial well-‐being of the community (see pyramid). Available mental health staffing and services in the sample of IMC surveyed health facilities serving affected populations are summarized in the table below.

Table 4: Health services in Malawi Figure 1: WHO recommended organization of MH

Psychiatric Hospitals Zomba Mental Hospital offers various mental health services including OPD, IPD (5 male wards, 2 female wards) acute care, long stay care, and rehabilitation services (e.g. recreational and daily living activities such as ball games, arts and crafts, cooking, housekeeping, also trips outside such as to farm national park). A separate private ward is available for paying patients. General medical services (e.g. PHC, ART, family planning) are also available. Zomba is supported by SMMHEP as well as a THET exchange link with the University of York, UK. Psychiatric Services in General Hospitals Psychiatric services are typically available at district hospitals. At Chikwawa District Hospital no psychiatric inpatient unit exists but MH patients are kept with other inpatients unless they are aggressive and referred to Zomba. Psychiatric staff at general hospitals generally conducts outreach visits to Health Centers. The MH team at Chikwawa District Hospital conducts weekly outreach to Ngabu and Dolo health facilities, for example.

Figure 2. Locations of health facilities visited

Mental Health Services through General Health Care In Malawi, there is pre-‐service as well as in-‐service training available in mental health for general health care providers. Zomba MH staff are currently engaged as trainers to train general health care providers on WHO mhGAP Intervention Guidelines focusing on mental health priority conditions (Depression, Bipolar Disorder, Psychotic Disorders, Alcohol and Drug Use, Epilepsy). The trainers also conduct follow-‐up supervision (for 3 months) and train trainers at the district level (district supervisors) who support staff at the Health Centers. The trainers also conduct a 2-‐3 training in mental health for HSAs (e.g. following up, encouraging to take medications or visit health facility when needed, linking with traditional leaders).

Table 5. Available mental health staffing and services in surveyed health facilities serving affected populations Zomba Chikwawa Chikwawa Phalombe Phalombe Zomba Mental

Hospital Chikwawa District Hospital+

Sorgin Health Center

Phalombe Health Center

Mpasa Health Post

Staffing MH Specialized staff

6 medical/clinical psychiatric officers*, 5 MH nurses, other general health staff

5 Nurse Midwife Techn. specialized in psychiatry 1 Clinical Psychiatric Officer*

1 Psychiatric Nurse**, other nurses trained in MH (school)

1 Psychiatric Nurse 1 Chief Clinical (Psychiatric) Officer

No specialized staff. 2 nurses had MH training during academic training

General staff trained in MH

All facilities reported having staff (e.g. nurses) trained in MH as part of schooling or additional training

Community outreach for MH

HSAs were generally not trained in MH outreach, identification or follow-‐up. However they at times identified people with MH problems.

MH treatment available: Depression ✓ ✓ ✓ ✓ ✓ Bipolar Disorder ✓ ✓ ✓ ✓ ✗ Psychotic Disorders ✓ ✓ ✓ ✓ ✗ Substance Use (alcohol, chamba)

✓ ✓ ✓ ✓ ✗

Epilepsy ✓ ✓ ✓ ✓ ✓ Developmental Disorders

✓ ✗ ✗ ✗ ✓

Anxiety ✓ ✓ ✓ ✓ ✗ MH referral (e.g. if aggressive)

N/A Zomba Mental Hospital

Sorgin District Hospital

Zomba, MAP clinic for dev disorders

Phalombe Health center

Patient Data Total patients IPD: 150 pts (400

bed capacity) OPD: 10-‐20pts/day

DK 300/day (50-‐65 from flood affected areas), 7 for MH

200 adult pts/day 27 for MH

200 pts/day 2 for MH

Note: Malawi priority mental health, neurological and substance use conditions highlighted in grey * Some staff currently undergoing psychiatry training ** Currently working as general nurse. Waiting to be transferred to (was trained at Malawi College of Health Sciences) district hospital where there is one more psychiatric nurse and will do psychiatric outreach work to several health centers (including Sorginn) Psychotropic medications WHO essential medications for managing mental and neurological disorders are listed below, with psychotropic medications recommended for the Interagency Emergency Health Kit (IEHK) underlined. Medicines and medical supplies in the IEHK are designed to meet the expected primary health care needs of people exposed to major humanitarian emergencies. During health facility visits it was noted that many health facilities are out of drugs because they have to get it from the "central medical store" (gov). Health staff reported that they used to be able to get a waiver to buy medications from private hospitals but a new regulation do not allow this anymore. However, they can still get donations. Zomba Mental Hospital is prioritized for government supplies of psychotropic medications. Zomba also supplies district hospital with psychotropic medications if needed. However, psychotropic medication supplies at Zomba and other health facilities reportedly often run out due to lack of funding before the end of the fiscal year. Current availability of psychotropic medication at surveyed health facilities is shown below.

Table 6. Availability of psychotropic medication at surveyed health facilities Psychotropic medication on WHO essential drug list (WHO psychotropic medications recommended for Interagency emergency health kit underlined4)

Zomba Mental Hospital

Chikwawa District Hospital



Mpasa Health Post

Generic antidepressant medication (amitriptyline, fluoxetine)

Yes Yes Usually (currently out of stock)

Sometimes (currently out of stock)

No

Generic anti-‐anxiety medication (diazepam tab and inj)

Yes Yes Yes Sometimes (currently out of stock)

No

Generic anti-‐psychotic medication (haloperidol tab and inj, chlorpromazine, Thioridazine)

Yes Yes Yes Yes (short of haloperidol and risperidol)

No

Generic anti-‐epileptic medication (phenobarbital, carbamazepine, diazepam inj, valproic acid)

Yes Usually (currently out of stock)

Yes Yes No

Generic bipolar disorder medication (valproic acid, carbamazepine)

Yes Sometimes No Yes No

Generic antiparkinsonian medicine for the management of side effects from antipsychotic medication (biperiden)

Yes Sometimes No No No

Health facility mental health care links to flood affected areas

• None of the surveyed health facilities provided regular outreach to flood affected areas through medical teams. However, they received referrals from HSAs. There were no outreach activities related to mental health. Barriers to conducting outreach activities to affected areas included having not enough staff and having no fuel for transportation.

• Health staff was not aware of anyone with mental illness coming from flood affected areas, except for Sorgin health center which reported seeing one person from flood affected area with pre-‐existing epilepsy (needed medication). Phalomba Health Center had heard of one person who ‘has gone mad’ after the floods

Current Challenges in Mental Health Service Provision Health care providers (trained in or specializing in mental health) were asked about current challenges n the provision of mental health care. Results are summarized below. Table 7. Current challenges in MH service provision Site Challenges of providing MH Care

Zomba Mental Hospital

Access for patients who live far away, getting in touch with families from a distance Human resources (short staffed, need for staff to take on multiple roles) Limited pool of MH professionals (even those trained in MH often end up working in other fields/roles, may be motivated by financial gain and not want to work with people with mental illness) Basic equipment is needed for maintaining the hospital structure (e.g. doors) Many patients come for follow-‐up because they cannot get needed medications at other health facilities

Chikwawa District Hospital

Shortage of anti-‐psychotic drugs


Those who need inpatient care go from Sorgin District Hospital to Zomba. Health staff needs to do a home visit before patient is discharged to educate family about the condition and medication. But cannot do home visits due to health staff not having

4 van Ommeren M, Barbui C, de Jong K, Dua T, Jones L, et al. (2011) If You Could Only Choose Five Psychotropic Medicines: Updating the Interagency Emergency Health Kit. PLoS Med 8(5): e1001030. doi:10.1371/journal.pmed.1001030

enough time. HSAs are not trained in MH. So patients do not continue medications once discharged. Shortage of psychotropic medications. Some patients needing those medications need to go to higher level health facilities but have no money for transport.


Shortage of anti-‐psychotic drugs (especially risperidol, which Zomba does not have) Transport (for psychiatric nurse)

Mpasa Health Post

Shortage of anti-‐psychotic drugs, stigma of mental illness in the community

4.7. Actors currently active in MHPSS There are some development oriented international organizations in Malawi, supporting longer term mental health academic programs, decentralization of mental health services (e.g. MH PHC integration) and community support (e.g. Scotland-‐Malawi Mental Health Education Project, SMMHEP). However, the flood response has been focused on general health, WASH, distribution of food and NFIs. Some organizations are including psychosocial support (e.g. for children). No organization has explicitly taken on mental health support and or/referral of people with MH problems in flood-‐affected areas. Table 8. Mapping of international and local organizations engaged in MHPSS activities relevant to the flooding WHO -‐Organization and contacts MHPSS

response to flood?

WHAT-‐Current activities

Scotland-‐Malawi Mental Health Education Project (SMMHEP) http://www.smmhep.org.uk/ Dr Jen Ahrens and Dr Ellen Boznak are in College of Medicine, Blantyre, [email protected] www.scotland-‐malawipartnership.org

No Enhancing Mental Health Training -‐ mhGAP in 5 districts. By the end of the project the skills and infrastructure will be in place to roll out the programme to all districts within existing Ministry of Health structures. The project will also develop sustainable e-‐learning based postgraduate and undergraduate mental health courses at the College of Medicine to consolidate the on-‐going training of mental health specialists (doctors, medical students), and reduce reliance on short-‐term volunteers. In addition, annual Malawi Health Conferences will be organised to promote exchange of research findings, knowledge and skills among mental health professionals within and without Malawi. The also support the Malawi mental health users and carers association (Mehuca) which is being scaled up into other districts.

World Vision Considering (PSS activities)

Considering an intervention through child friendly spaces, though this is not yet confirmed.

Swedish Church/ACT Alliance Maria Waade (HQ) or Ulrika Lindblad (Malawi) Melton Luhanga, Director at CARD (and chair of ACT Alliance Malawi)

Planning (PSS training)

ACT Alliance is working in Malawi and planning psychosocial support though its member CARD. CARD has requested support from Church of Sweden on integrating psychosocial components into the ongoing emergency response and ACT will send two psychosocial specialists from our roster in order to support in this aspect.

MSF (Belgium) Amaury Gregoire E-‐mail: Ellie Ford Camara

Considering (MH services)

Considering possible addition of mental health services with providing medical outreach clinics together with SMMHEP.

Action Aid Yes (PSS support)

Supporting 22 schools in Nsanje, with an estimated number of 28 000 beneficiaries, with rehabilitation, notebooks and psychosocial support.

UNICEF supported partners Yes (PSS support, ECD)

An estimated 6,165 (6-‐18 years) and 6, 330 (3-‐5 years) children received psychosocial support and early learning through children corners and community-‐based childcare centres (CBCC), following provision of 5 tents for early childhood development (ECD) centres to 4 displacement sites in Chikwawa district.

Development from People to People in Malawi (DAPP)

Yes (PSS activities)

Will provide psychosocial support for a total of 151 schools in the districts of Nsanje, Phalombe, Chikwawa, Machinga, Mulanje, Zomba and Chiradzulu. With a total of 90 000 enrolled students.

YONECO Yes (PSS support)

In Nsanje and Chikwawa, YONECO has provided psycho-‐social support and sexual and reproductive health services to 6,363 children and adolescents.

Malawi Red Cross No (not Volunteers provide health education e.g. hand washing, hygiene, also listen

5. Summary and Recommendations 5.1. Summary Malawi is a stable country which has a relatively strong system of MHPSS support including national level mental health policies and guidelines, mental health services and professionals working towards increasingly decentralized mental health care, academic programs for general and specialized mental health training as well as local and international partners for mental health capacity building in line with global WHO guidelines. Various local civil society organizations exist who are engaged in psychosocial support activities and mental health service user organization chapters are being scaled up. In the context of the 2015 Malawi floods, and based on this situational analysis, several recommendations can be made as outlined below. In sum, there is a need to strengthen connections between camps and health facilities for people needing mental health care, to ensure staff interacting with the affected population are trained in basic support (e.g. WHO Psychological First Aid Guidelines and MH referral), to improve well-‐being and strengthen social support networks in the camps. Mental health and psychosocial support considerations should also be part of longer term planning for social an economic recovery of flood affected areas. 5.2. Recommendations The Inter-‐Agency Standing Committee (IASC) (2007) Guidelines on Mental health and Psychosocial Support in Emergency Settings recommend levels of mental health and psychosocial intervention based on a pyramid ranging from social considerations in basic services and security up to specialized mental health services (see Figure to the right). The following recommendations take each of the levels of the pyramid into account.

specifically MHPSS)

to people who are upset. Some volunteers from the Red Cross report that they have received no training before going to assist flood affected populations. They would need training in life skills, management, how to help people who suffer and how to provide medical first aid.

REPPSI No (but would consider)

The work through partners and also provide training and capacity building in PSS. Current activities include community spaces for children and youth and children’s corners. They also run a course for community based work with children and youth. They have at least one local partner (Mawga Malawi Girl Guides Association) who has a presence in flood-‐affected areas. They would be interested in support flood affected areas (if resources are made available). Help to flood affected areas could include creating safe spaces for people to connect and express themselves and targeted support for those struggling with loss.

Safe the Children No Planning nutrition activities. Not planning to respond for protection

5.2.1. Improve coordination and mapping for mental health and psychosocial support services and activities IASC MHPSS Guidelines recommend having a MHPSS coordination group to help coordinate MHPSS activities and link to different groups and actors (e.g. health, protection). There is already a national level coordination group for PSS who could link with the health sector coordination group led by WHO, for example. A simple 4Ws mapping of current and planned MHPSS activities as well as of existing MH services at health facilities could strengthen overall coordination for MHPSS (e.g. filling existing gaps, referral pathways, directing affected population to services). 5.2.2. Improve access to mental health services by strengthening camp to health facility continuum of care People in flood affected communities with pre-‐existing mental health and neurological conditions or crisis induced mental health problems currently have limited access to mental health care (e.g. lack of transportation which is likely compounded in hard to reach areas). On the other hand, health staff who are trained or specialized in mental health and psychosocial support are not reaching flood affected populations (e.g. due to lack of transportation and human resources). Recommendations:

→ Map out existing mental health and psychosocial support services provided by health facilities and establish referral pathways from each camp to health facilities (Health Centers, District Hospitals as needed).

→ Strengthen links between camps and health facilities by facilitating transportation to health facilities for patients needing referral as well as transportation for health staff conducting outreach visits

→ Include at least one staff member with mental health training in medical outreach teams (e.g. this could be general health staff who received pre-‐service or in-‐service training in MH).

→ Provide basic training in basic mental health outreach, case finding and follow-‐up (using the already established 2-‐3 day Malawi training curriculum) to HSAs working in the camps.

5.2.3. Improve access to psychotropic medications, especially in health facilities serving affected population All surveyed health facilities (except Zomba Mental Hospital) were reporting stock-‐outs in psychotropic medications included on the WHO essential drug list. This is compromising access to medication for patients and especially those with chronic mental health conditions (e.g. schizophrenia, epilepsy) who may not be able to access health facilities further away, and are vulnerable to relapse and worsening of their condition. For those already affected by the flood disaster, this can have an even more severe impact on activities of daily living, livelihoods and safety for patients as well as families. Recommendations:

→ Address any systems challenges in medication supply for health facilities serving flood affected populations (e.g. problems with distribution, procurement).

→ Provide additional medical supplies and psychotropic medications to fill current gaps at health facilities 5.2.4 Improve capacity of local organizations and volunteers to respond to mental health and psychosocial support needs of disaster-‐affected population Integration of mental health and psychosocial support aspects into different aspects of the disaster response and knowledge of local actors of relevant global guidelines could be further strenghtened. Some volunteers

for example, are faced with challenging situations and human suffering, and may benefit from training in basic psychosocial support including self-‐care. Recommendations:

→ Offer workshops on relevant aspects of global IASC guidelines on mental health and psychosocial support in emergency settings to national and local governmental and NGO partners

→ Work with local community health workers (Health Surveillance Assistants) and partners (e.g. Red Cross) engaged in community outreach and provide basic orientation in WHO Psychological First Aid Guidelines and referral for people needing mental health and psychosocial support

5.2.5. Improve psychological well-‐being and recovery of affected population Affected communities have experienced significant losses including belongings, livelihoods and even loved ones. Those residing in camps have difficulty resuming even basic routines such as living with family (tents are too few and men and women are separated) or cooking meals (not enough cooking supplies available). Camp residents describe psychological effects of the floods such as feelings of hopelessness, uncertainty, worry, social isolation and trouble sleeping. Such experiences of loss and continued stressors (e.g. lack of basic needs, disruption of routines and relationships) increase the risk for developing mental health problems in the longer term. Affected communities and those providing support, are already engaging in and suggesting ways to promote well-‐being and recovery such as replacing lost resources, engaging people in livelihoods and organizing social and recreational activities. Recommendations:

→ Work with local partners (e.g. Red Cross) to organize activities in the camps (e.g. games for children and youth) and provide appropriate supplies

→ Help fill critical gaps in materials and supplies needed for resuming day to day activities (e.g. cooking utensils, school supplies for children etc.)

→ Provide resources to restore livelihoods in the longer term (e.g. seeds, livestock, help with small businesses)

5.2.6. Consider mental health and psychosocial support aspects in longer term flood recovery programming Longer term programming for affected populations returning to flood affected areas and rebuilding lives and livelihoods are currently being planned. Mental health and psychosocial considerations should be an integral part of recovery. The baseline of mental health problems in any population is estimated to be about 15-‐20% while many people may still be psychologically affected by flooding and subsequent loss. Research suggests that people who struggle with untreated mental health problems are less able to take advantage of educational and livelihood opportunities. Although specialized mental health staff may be available at the higher-‐level health facilities in affected districts, the integration of mental health into general health care and at the community level still needs additional support. The SMMHEP project has selected 5 districts for initial piloting of integrating mental health into general health care but none of the flood affected districts except Nsanje are included. Affected populations may be returning to areas with weak community level support and limited access to and awareness of mental health. Furthermore, traditional beliefs and practices about causes of mental illness (e.g. psychotic disorders or depression being caused by witchcraft) may further compromise access to appropriate care.

Recommendations: → Support community level awareness raising and mental health promotion among various stakeholders in

affected communities (e.g. chiefs, religious leaders, community leaders, local authorities, women’s groups, youth clubs) to help identify, refer and support people with mental health problems.

→ Provide basic training and capacity building for community level workers (e.g. HSAs) in identification of people with mental health problems, basic psychosocial support, linking to health facilities and following up.

→ Fill critical gaps in psychotropic medication availability in affected areas and facilitate transportation as needed (e.g. fuel cost)

→ Engage community level actors and stakeholders in creating supportive environments through community activities and events that promote well-‐being and include people struggling with psychosocial and mental health related problems.

International Medical Corps 1313 L St, NW, Ste 220 Washington, DC 20005 Phone: 202.828.5155 Web: https://internationalmedicalcorps.org/mentalhealth

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