Integrating mental health into primary health care in Rohingya refugee settings in Bangladesh: experiences of UNHCR

Abstract

Hundreds of thousands of Rohingya refugees fled from Myanmar to Bangladesh. The greatly increased mental health needs are paired with limited resources for mental health care, particularly human resources. Therefore, UNHCR, the refugee agency of the United Nations, designed a programme to integrate mental health within refugee primary health care, using the Mental Health Gap Action Programme Humanitarian Intervention Guide (mhGAP-HIG) as the central tool. The aim was to scale up mental health services through capacity building of medical staff in refugee health facilities to enable them to identify and manage people with mental, neurological and substance use conditions. This paper is a process description of the programme, using direct experience of the authors, analysis of training evaluations and data from the refugee health information system and clinical supervision reports. Sixty-two primary health care workers were trained. Participants of the mhGAP training showed clear improvements in the post-training knowledge test. These trained staff started providing mental health and psychosocial services after the training in primary health care centres in the refugee camps. Fifteen of them participated in a bi-weekly supervision/on-the-job training visit. Within this period of time, almost 1,200 mental health consultations were realised in the primary health care facilities. Supervision reports of mhGAP-trained participants showed that in order to become effective mental health providers, the participants need to strengthen various skills including performing mental state examinations, providing psychoeducation and using psychosocial support techniques. In conclusion, the integration of mental health within the Rohingya refugee settings faced many challenges but proved to be feasible. Key implications for practice Health system preparation and readiness is an important pre-requirement for integration of mental health into primary health care services. This is particularly significant in humanitarian settings in which the health system is fragile and struggling to keep services at a minimally acceptable level. Capacity-building efforts alone cannot guarantee the success of the integration process, that is, adequate attention should be paid to communication with health policy and decision makers especially on facility and local level to foster the process of integration and support scaling up. On-the-job supervision is a critical factor in mental health capacity building of non-specialist health providers. Without supportive clinical supervision, any plan for integration of mental health into primary care should be considered deficient and ineffective.