Transcript Slide 1

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
10th November 2012
University of East London
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Scope
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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?
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Definitions:
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Assumptions?
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.
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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
Donor (HIC’s)
Resources
Knowledge &
skills
Research &
development
Recipient
LAMIC’s
Knowledge,
skills and
competencies
Research &
development
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
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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).
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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)
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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)
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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%
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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)
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– PTSD 7%, anxiety 33%, Depression 22%
Historical context of trauma
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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
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
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Estimation of need
Who is traumatised?
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
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Mental health services
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Asylum
Psychiatry in general hospitals
General practice
Private practice
Community psychiatry?
Voluntary sector
Workforce
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Psychiatrists
MOMH
Psychologists
Psychiatric nurses
Social workers
PHI’s
Counselors
Volunteers
Capacity building
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Volunteers
NGO workers
Nurses
Teachers
PHI & Midwifes
CSO
MOMHS
Psychologists
Psychiatrists
Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009
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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 Group
THE UK WORKING GROUP TO FACILITATE WORK TO MINIMISE
PSYCHOLOGICAL IMPACT OF TRAUMA IN SRI LANKA
UK 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
Continued
 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)
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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
Jaffna Outpost
In partnership with Shanthium
Resource Person:
Mr Radnam Jegananthan
Colombo Resource Centre
Batticaloa Outpost
In partnership with Mangrove Network
3/2 Kynsey Road
Colombo 8
Centre Manager:
Resource Person:
Mrs Selvika Sahathevan
Ms Shikanthini
Varma-Atthanayake
+ 2 staff
Hambantota Outpost
Resource Person:
Mr Duminda Wanigasekare
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 move
Strategy
• 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
Supervision
& support
work
Research
work
Samutthana
Training by
staff and local
resource
persons
Liaison work
with other
organisations
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 experience
3. Level III – Professionals (Psychiatrists, doctors,
psychologists, Nurses)
• Supervision (support)
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Skype supervision – substance misuse
Repeat attendance at workshops
CBT supervision – Stella Wragg
Samutthana networking for capacity building
Government
Ministries
Govern
ment
Bodies
Corporat
e Sector
Education
Establishments
Samutthana
Key
individuals
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organisatio
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NGO’s
CHA
UKSLTG
King’s
College
UEL
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
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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
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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
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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
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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
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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
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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
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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
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Kuhan Satkunanayagam
4 clinical psychologists
Nurses
SL Volunteers
Seminar programme
Evaluation
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Progress reports to CAFOD
Formal evaluation by Sidartha Prakash
Ongoing evaluations and reviews
Internal evaluation funded by the Bromley
Trust
Siddhartha Prakash recommendations
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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?