Mental disorders act as a leading cause of disability world wide, especially in war and disaster torn regions. The effects of mental conditions are especially high in women living in “fragile states” such as Afghanistan, where resources to appropriate mental health care are extremely scarce. HealthNet TPO, a Dutch NGO has made an attempt to fill this fundamental health care gap through a three-tiered intervention. This case study critically evaluates HealthNet TPO’s efforts in Afghanistan based on the intervention’s scope, performance, and sustainability. The findings of this case analysis conclude that HealthNet TPO has been successful in sustainably expanding mental health resources; however, it remains unclear if the performance level is satisfactory to meet the elevated needs of the Afghan population.
The Global Burden of Mental Health
Mental disorders are one of the leading causes of illness and disability worldwide, with depressive conditions acting as the fourth leading cause of the global burden of disease. Approximately 1 in 4 individuals will suffer from a mental illness at some point in their lives. (1, 2) Both the rates and severity of depression are exacerbated in individuals living in war and disaster-torn conditions. Furthermore, depressive disorders are twice as common among women due to additional social factors such as gender discrimination, poverty, sexual, and domestic violence. (3) Some treatments are available, yet approximately two-thirds of individuals suffering from these conditions fail to seek help from a health care professional, partially due to the stigma and discrimination that surrounds mental illness. (2) Globally, there is great imbalance in the distribution of mental health resources. In low and middle income countries especially, the lack of appropriately educated health care professionals acts as a central barrier in obtaining appropriate psychosocial treatment. (1) More than 40% of countries worldwide have no mental health policies, while 30% offer no mental health programmes for their distressed populations. (2) Moreover, war and disasters have a major impact on psychosocial well-being, doubling the rate of mental disorders among the population. (1) In addition, approximately 80% of people affected by wars, violent conflicts, and displacement from their homes are women and children. (3) Since mothers are the primary caregivers for their families, changes to their health status may impact their child care abilities, and by extension, the health of their children. As such, the lack of access to appropriate treatment within these nations make mental disorders that much more devastating and debilitating. The objective of our case study is to analyze and evaluate a mental health intervention in Afghanistan. Also, we will present recommendations based on our analysis of the services provided, which we hope will inform future mental health interventions in developing regions.
So what? Mental health is an important aspect of health that is negatively affected in areas of war and destruction. The war in Afghanistan strained the healthcare system, leaving its most vulnerable population – women – with no access to resources. Quality mental healthcare services in low-resource areas must be addressed through the expansion of existing services, collaboration with the government, and the implementation of evidence-based practices.
Afghanistan’s Need for Mental Health Services
After the fall of the Taliban regime in 2001, the Afghan health care system was completely demolished, with the mental health sector disproportionately affected. There were severe shortages in staff, supplies, organization, and infrastructure. Mental health services were limited to a few regional hospitals and the only psychiatric hospital was destroyed. (4) There were no qualified psychiatric nurses or clinical psychologists and only two practicing psychiatrists to treat a population where approximately 60% suffered from mental illness. (4) With these characteristics, Afghanistan was classified as a “fragile state”, as its government lacked the capacity to provide the basic services and necessary security measures for its population. (4) Without a department of Mental Health in the Ministry of Public Health (MoPH) in Afghanistan, it was difficult to categorize the needs of the population.
In the late 1990’s, the World Health Organization (WHO) Regional Office for the Eastern Mediterranean attempted to organize a comprehensive 3-month diploma to train 20 doctors in psychiatry, but it failed due to the high levels of violence found within these regions. (4) Later, with the help of the WHO, the Basic Package of Health Services (BPHS) was created to provide a standardized package of basic essential services and promote the redistribution of health resources to this underserved Afghan population. (4, 14) At the time, there was a strong need to develop tangible and long-term improvements to the health care system as a whole. Given that the nation had been in a constant state of war for decades, addressing mental health issues associated with the stress and uncertainty of living in these conditions became imperative. (4) When the BPHS failed to accurately describe the targeted mental health interventions, donors doubted the feasibility of integrating them into the basic services and ultimately neglected this crucial health care sector. Therefore, devising a solution now relied on external organizations to develop their own methods and tools. (4) The MoPH realized the necessity for a sustainable mental health program and restructuring of the health care system. An estimated 13 million Afghans suffered from mental health problems, and even more struggled with varying degrees of stress disorders. (5) A survey conducted in Nangarhar Province in 2003 confirmed that the rates of depression and anxiety are high, particularly amongst women. It revealed that 58.4% of all women in the province had depressive symptoms, 78.2% had anxiety symptoms, and 31.9% had PTSD symptoms. (5)
HealthNet TPO’s Global Presence
HealthNet TPO is a Dutch non-governmental organization, established in 1992 by Médecins Sans Frontières to bridge the gap between emergency aid and structure development. HealthNet TPO works to improve health care in war- and disaster-torn areas with an overall mission to “reach accessible health care for all”. (6) To date, HealthNet TPO has implemented projects in 27 different countries, with a long-term presence in several fragile states, including Afghanistan, where they have been active since 1993. (4) In early 2002, HeathNet TPO attempted to begin addressing the mental health needs in Afghanistan. Using the WHO Mental Health Gap Program as a guideline for services and interventions, they designed and implemented a project that aimed to provide comprehensive and diverse training programs for mental health care practitioners in the Nangarhar province (population 1.38 million). (7) After conducting a needs assessment in Nangarhar, they discovered that this population was devoid of any mental health care, and therefore designed a three-tiered, sustainable scheme to enable the existing health care system to address this pressing issue. (4)
The Three-Tiered Intervention
The first goal was to integrate mental health care into basic health services. (4) HealthNet TPO approached this objective by training health care workers in the identification and management of mental health conditions at each of the three levels of the health care system: health posts, basic and comprehensive health centers, and district hospitals. At the basic and comprehensive health centers, health care workers were trained in the identification and treatment of priority disorders. Physicians received additional comprehensive psychotropic training, and nurses and midwives were trained on psychosocial interventions and psycho-education. (4) District hospital mental health services were expanded to include both outpatient and inpatient services. Each hospital was assigned a full-time physician who had been trained in mental health care at the psychiatric department of a teaching hospital in Pakistan, and a psychosocial worker trained to provide support groups and psycho-education. (4) Training sessions were initially conducted in English and translated into Pashto by Afghan doctors on the HealthNet TPO team. The training sessions involved videos, role-play, group discussion, and patient-doctor simulations. (4) To integrate this program throughout the entire province, a multistep approach was taken. First, the population was assessed through focus group discussions to explore the local concept of mental illness, and classified these disorders as either epilepsy, common (such as depression and anxiety), or severe (such as psychosis) mental disorders. Next, materials and methodology were developed and training began in six rural districts, called the Shinwar cluster. The training programs and the provision of psychotropic drugs were then expanded throughout the entire province and integrated within the general health budgets. (4)
The second goal was to strengthen community care and resilience through psycho-education on mental health issues, psychosocial distress, and coping mechanisms. (4) Community health workers now offer support groups and workshops on a variety of topics such as grief, drug use, and domestic violence. They also implemented individual case management through supportive counseling. The final goal was to achieve policy support and integration for mental health. HealthNet TPO was able to reach this goal by initiating the establishment of the Mental Health Department within the MoPH in 2005 by providing financial support and acting as an active partner within the Afghan MoPH. (4)
Analysis of HealthNet TPO’s Intervention
In order to evaluate HealthNet TPO’s intervention in Afghanistan, we conducted a 3-factor analysis. By evaluating HealthNet TPO’s efforts in the Nangarhar region based on their scope, performance, and sustainability, we can analyze both the strengths and weaknesses of the intervention in order to evaluate and adapt the program for future improvements and expansions.
To appropriately determine whether HealthNet TPO’s intervention in Afghanistan was of adequate scope, we applied the framework proposed by the WHO in the WHO MIND project. (8) In this outline, the WHO describes the various types of mental health interventions that should be included, along with the resources and availability that should be allocated to each, in order to execute an effective mental health intervention. This framework is illustrated by a pyramid of health care: the peak represents interventions that require more resources and infrastructure, while the base of the pyramid describes more community-based and self-care oriented initiatives (Figure 1). (8) The key takeaway from this WHO framework is that lower income countries looking to develop their mental health services should focus less on costly resources that often meet a lower demand, such as in-patient mental institutions, but rather should focus efforts on establishing and expanding the use of less costly interventions, such as mass community mental health services, as well as promoting and educating on self-care. Another key point highlighted by the WHO report is that, in order to have the greatest impact, mental health services should be integrated with primary health care, via incorporation within general health facilities.
When the state of affairs was compared pre and post HealthNet TPO’s intervention, it was clear that these methods covered a wide scope of mental health services. Before the intervention was implemented, Afghanistan’s population of more than 21 million lacked basic mental health care, with only two practicing psychiatrists and no other health care professionals with any mental health training. (4) There was also no mental health care representation in the MoPH of Afghanistan. The intervention tackled these issues by providing appropriate training for health care workers at several levels of the health care system. (4) Overall, HealthNet TPO’s intervention led to the addition of 931 community health care workers, 275 nurses, and 334 physicians trained in mental health care. (4) A comparison with pre-intervention is described in Table 1. The data also show that the intervention focuses mainly on community mental health care initiatives and self-help/support groups, which is in congruence with the Optimal Mix of Mental Health Services proposed in the WHO pyramid framework. (8) Based on this, it can be concluded that the scope of HealthNet TPO’s intervention in Afghanistan was successful in expanding at levels of the health care system to better serve the needs of the population.
To evaluate the performance of HealthNet TPO’s intervention, the “Triangle of Health Care”, described in Dr. William Kissick’s book titled Medicine’s Dilemmas: Infinite Needs Versus Finite Resources has been used as a framework. Dr. Kissick proposed that health care is constrained by three competing, yet equally important factors: access, cost, and quality. He argues that when one of these factors is changed, it inherently affects the others. For example, if one were to increase the quality of health care, it would subsequently increase the cost of the care offered. To take this further, within an area where medicine is not socialized, an increase in cost would cause a decrease in access to services.
Based on the data reported by HealthNet TPO, overall access to mental health services had increased when comparing the number of consultations for mental health disorders before and after intervention implementation. (4) In 2002, before the intervention was employed, the absolute number of consultations for mental health disorders totaled to 659. (4) This number increased to over 3,000 by 2004 and, finally, over 20,000 consultations in 2005 when the intervention was expanded to the entire province (Figure 2). (4) Therefore, consultations in mental health increased by over 3000% in the province of Nangarhar, and it can be concluded that access did indeed increase, likely as a result of the expanded scope of mental health services.
As mentioned previously, HealthNet TPO had been contracted by the Afghan government to rebuild the health care infrastructure in Afghanistan. Based on HealthNet TPO’s 2009 financial report, the total health care spending in Afghanistan summed to €55 213 726, whereas funds dedicated to their mental health and psychosocial services totaled €993 718. (9) Based on these figures, mental health care expenditures represented 1.8% of HealthNet TPO’s total health care spending in the 2009 fiscal year. In order to extract any concluding information from this figure, we used /the WHO Mental Health Atlas 2011(10) (the 2006-2010 publication were unavailable) as a guideline to compare this value to other nations. In this report, Afghanistan falls into two categories based on its geographical location (Eastern Mediterranean Region) and its World Bank income level (Low). (10) Other countries in these two categories are listed in Figure 3. Based on this data, mental health care spending represented, on-average, 3.75% of total health care spending for countries in the same geographical region as Afghanistan. (10) Comparatively, countries that fall into the same income level as Afghanistan spent 0.53% of their health care budget on mental health services. (10) Therefore, two conclusions can be made when comparing Afghanistan’s mental health care expenditure with geographically or financially similar countries. First, Afghanistan spent less on mental health services in relation to its total health care expenditures compared with other countries in the region, and second, Afghanistan spent more on mental health services than other countries who have similar income levels. It should be noted, however, that this data cannot be used to make a definitive conclusion on whether this expenditure is adequate to support the needs of the country or not.
In order to bring together the other two factors in our analysis of the intervention’s performance, we would need to analyze the quality of HealthNet TPO’s intervention. This analysis could have looked at a number indicators, such as suicide rates, self-reported symptoms, DALYs attributed to mental health disease. Unfortunately, despite numerous attempts to obtain data from HealthNet TPO and the Dutch government, these values were inaccessible. This represents an enormous gap in the quality analysis, as it cannot be determined whether the resources directed towards mental health services in Afghanistan produced effective results.
The sustainability analysis of a global health intervention should consider various factors related to project design, quality, integration, and the community of interest. (11) The Cochrane Handbook for Systematic Reviews of Interventions recommends the model developed by Shediac-Rizkallah as a useful framework for determining sustainability in public health. (11, 12) This model contains three aspects of sustainability that can be used to evaluate the mental health services implemented by HealthNet TPO.
First, HealthNet TPO’s intervention does not appear to be able to maintain or sustain any health benefits achieved through the program. The increased health service coverage in Afghanistan was associated with less time spent with each patient, which in turn potentially lowers the quality of each consultation. (4, 13) Shorter consultation times may largely affect women because they experience higher levels of anxiety and depression than men. (5) With the subordination of women in social life within Afghanistan, these appointments may serve as one of the few opportunities to address their mental health issues. Furthermore, the program may be unable to continue delivering substantial benefits if financial and administrative assistance terminates. There was no projected plan for the program to be financially self-sufficient in the future. The program is currently funded by external sources, with the Global Fund as the primary donor, contributing to 49% of total funding (Figure 4). (9) The increased prioritization of mental health services in the BPHS may lead to more government financial assistance in the future but this is purely speculative. (14) In the short term, the program is sustainable due to the continual external funding by numerous organizations.
For the second aspect of sustainability, HealthNet TPO was indeed successful in institutionalizing mental health services, allowing activities to continue as part of the general health care system. Mental health services were successfully integrated by educating existing staff at each level of the health care system, while HealthNet TPO continues to provide further and updated mental health training. (15) As such, long-term viability of mental health services is possible because of its incorporation into primary care, but it is questionable whether these services could continue without the administrative support of HealthNet TPO. The improved access to services, based on the increased number of mental, neurological, and substance use (MNS) consultations is a further indication of success from this perspective of sustainability.
Lastly, the program also achieved sustainability from a capacity-building perspective. There is an increased capacity in the Nangarhar community to appropriately treat mental health issues, as the activities of the program can be maintained and continued at the community level. HealthNet TPO strongly emphasizes community involvement to address mental health problems through educational workshops and support groups. Increased access to information helps foster a sense of empowerment within the community, or “community resilience”, because local individuals learn the skills necessary to identify and address mental health problems. (5) It is implied that the trained community members are now able to educate others on mental health and sustain these support groups, should HealthNet TPO remove its services.
In summary, the program, based on its methodology, shows signs of sustainability. However, HealthNet TPO does not provide a clear plan for how mental health services are to be sustained if the NGO’s support and external financial assistance were withdrawn in the future. Furthermore, the evaluation of this program would have benefitted and been further enhanced by statistics and data describing its success at the community and patient level.
Conclusions on Mental Health Care in Afghanistan, Post-Intervention
In summary, the involvement of HealthNet TPO in Afghanistan has lead to the establishment of a mental health department within the government, as well as the integration of mental health care services into the existing health care framework. The lack of program evaluation is the fundamental shortcoming of this case study. While the main goal of the intervention to improve access to mental health services was accomplished, no definitive conclusions can be made regarding its efficacy, particularly due to lack of data on clinical outcomes. The published evaluations are purely quantitative measures of the number of patients passing through the system, with little impact evaluation of the care they are receiving. In terms of clinical outcomes, HealthNet TPO posited that the shortened appointment times due to the increased demand may negatively impact the quality of care, as physicians may turn to favoring psychotropic interventions over the more time-consuming psychosocial alternatives. (4) However, there is no published analytical evaluation of mental health care at the individual patient level. There are indications that women are less likely to make use of social resources for mental health problems. (5) Understanding that women represent a vulnerable group in Afghanistan, it would have been interesting to measure gender differences in uptake of access to care for mental health. This data is integral to health care policy reform as it provides vital information for future improvements and developments.
In order to build an accurate and comprehensive evaluation on HealthNet TPO’s overall impact on mental health care in Afghanistan, it is necessary to investigate how these implemented health care policies translate to clinical practices. Since this information has not been made available to the public, it is assumed that no evaluation was performed. The following are suggested evaluation methods. Patient follow-up is crucial to provide direct feedback and allow for the improvements at the level of the patient. (16) Efficiency is a key factor in health care, and as such, a database containing patient records and medical history would provide for better organization and access to information by the administration and health care professionals. (17) Finally, a specialized task force charged with evaluating mental health practices would provide an overall perspective on how the policy is translated to the clinic and community posts.
As Afghanistan has been in a state of war for over 35 years, the population of this nation has suffered tremendously in terms of their safety, health, and psychosocial well-being. As financial resources allocated towards health care services are often lacking, mental health, especially in fragile states, is often an afterthought. It is important for mental health initiatives to be integrated into basic health services for all nations worldwide, as mental illness is one of the leading causes of global disability. Mental health care must also incorporate evidence-based practices that account for the particularities of women’s mental health, their role in society, and the gender-based issues, discrimination, and biases they face. These mental health initiatives within Afghanistan should not end with HealthNet TPO, as there are still improvements to be made. Additional efforts need to be implemented in order to assess and improve the quality of care, increase access, and promote further education on the topic of mental health in order to reduce the stigma and discrimination surrounding mental illness.
Authors: Monica Bahoshy, Lauren Chun, Leila Farahdel, Ryan Hartley, Adrianna Modafferi, Aryan Shekarabi
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