Experiences of a junior doctor setting up

Mental Health Services in Somaliland

Dr Djibril I.M HandulehMsc International Health graduate student,

Universitat Heidelberg, Germany

Background on SomalilandSomaliland Vs Somalia• Somaliland is a de facto state

that declared its self independence from Somalia in 1991.

• Though not internationally recognized it is part of Somalia.

• Recovering from civil war with rebuilding efforts and relative stability health services are being redeveloped including mental health.

Mental Health Services in Somaliland

• Mental Health services are available in major towns in the country. Hargeisa

Berbera Borama

Other major mental health player: Traditional Healers

• Mostly spiritual healers mixing traditional healing practices and sometimes prescriptions of medications

Borama, 2012

My experience with mental health systems in Somaliland

• Mental Health Hospitals • Traditional Healer centers• Weaker government oversight• Poor financial systems • Work force is limited • Some places have no access to health care including

mental health.• Somaliland has its own mental health policy in place.

Setting mental health service from Scratch: Case study of Borama

• Growing city just close to Djibouti and Ethiopian border

• Population : 200,000( estimated)

• Mix of local and IDP• No mental Health

services before 2010Sheriff, R. S., & Whitwell, S. (2012). An

innovative approach to integrating mental health into health systems: strengthening activities inSomaliland.Intervention, 10(1),

59-65.

How the Mental Health service was established?

• Partnership between Amoud University and the King’s College London IOPPN in the famous partnership : The King’s THET Somaliland Partnership(KTSP).

• http://www.kcl.ac.uk/lsm/research/divisions/global-health/partnerships/index.aspx

The basic components of mental health service

• Phase 1 2011-13 With UK partners

1. Set up mental health outpatient service

2. Set up inpatient unit3. Community based mental health

service4. Integrated mental health into

maternal care services5. Set up prison MH6. Set up MH practice in Schools7. Integrated psychiatry into Medical

education

• Phase II 2013-2018 with Swedish Development agency

1. Strategy to integrate mental health into Primary health care

2. Trained Female community workers

3. Mental health along with maternal and child health services

Mental Health service in outpatient and inpatient care

• In 2011, outpatient service with two main aims

• Offer outpatient care for patients

• Clinical attachment site for psychiatry particularly undergraduate medical and nursing student in Borama.

Mental Health in Primary care setting

• Work with primary care doctors and nurses/midwives

• Trained them on identification and referral to health service

• Community led home visits for patients who could not access health care with local women Association.

Mental health in prisons• Worked with line ministries• Local prison authorities • Police department

Objectives 1. Train them on common mental health disorders2. Referral to services 3. Trained prison nurse and doctor on mental health disorder4. Weekly observation of patients in prison5. Workplan with judiciary system on medico-legal aspects of mental health• Handuleh J., McIvor R. (2014) “A novel prison mental health in-reach service in

Somaliland: a model for low income countries?” International Psychiatry, 11(3):61-64.

Mental health in Schools

• Trained school teachers Primary- High School on common mental health disorders. Sample of 100/800 teachers

• Worked with MOE on setting up the workshops and referral for students and teachers with mental health disorders

• Once weekly psychiatry service for them in outpatient service

Handuleh, J., Whitwell, S., & Fekadu, D. (2013). Report: School mental health project

in Somalia. Arab Journal of Psychiatry, 24(1), 46-51.

Mental health, community and the civil society

• community based discussion forums on mental health service for Borama.

• Forum A.Local governmentB.Civil society C.Academia D.Youth and women clubs

Mental health ward

• Community and local MOH agreed to set up mental health ward in Borama Hospital

• Partnership with KCL on training aspects where wide range mental health professionals teach and work with local health professionals.

Handuleh, J. (2013). Transforming a Dumping Site Into a Psychiatric Inpatient Unit in Somalia. The American journal of psychiatry, 170(11), 1248.

Mental Health and integration with Primary Health care

• Female community health workers and doctors work daily in the Borama community and two nearly villages

• FCHW are increased from 10 to 55 people• People from the community with their

community leaders.• Community cover the costs of the medications

and the Swedish partners already preparing them to take over.

2013- Perfect storm comes inmental health into primary health care• A senior Somali born Swedish psychiatrist and

SIDA • Training of Female community health workers• Work in 4 primary care centers• First integration of mental health into primary

health care• Nov 2013, Somalia puts mental health into its

national health services package at primary care.

• Somaliland is working on MH PlanHanduleh, J. I., Gurgurte, A. M., Elmi, A., Aye, I.

M., Abubakr, F., Kayd, M. A., ... & Abdi, Y. A. (2014). Mental health services provision in Somaliland. The Lancet Psychiatry, 1(2), 106-108.

2012 talk Topic: can we follow WHO PHC integration approach?

Community ownership and leadership

• Community had teams to suggest the structure of health services, patient groups and advocacy, Somali diaspora community and the general public.

• Mental health owned by the society and integrated actively into health services.

Handuleh, J. (2012). Experiences of a junior doctor establishing mental health services in Somaliland. Intervention, 10(3), 274-278.

Clinical notes from the field

• Cultural • Local • Migration and mental health• Conflict and mental health

Local interpretations of mental health

• Ghosts• Possessions• Witch craft• Jinn• Mental Health does not exist• It is not for me • Religion is protective

Local aspects of mental health

• Every community has its own culture, norm, traditions

• Somali society is conservative and families are nuclear.

• Mental Health is new to the society including the diaspora community. There is growing community in Germany often not reported.

• Autism among Somalis in many English speaking western countries particularly USA.

Clinical examples

• Somatisation disorder• Epilepsy is usually regarded as psychotic• Mental Health in obstetrics • Mental Health and its religious context • Mental health and human rights aspects like

prisons, internally displaced and refugees in the Somali context.

ANY QUESTIONSThank you