592323 research-article2015
APY0010.1177/1039856215592323Australasian PsychiatryRyan et al.
Australasian
Psychiatry
Regular Article
Mental health in the Solomon Islands: developing reforms and partnerships
Australasian Psychiatry –5 1 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856215592323 apy.sagepub.com
Brigid Ryan St. Vincent’s Mental Health, Asia-Australia Mental Health, Melbourne, VIC, Australia Paul Orotaloa Integrated Mental Health Services, Ministry of Health, Solomon Islands Stephen Araitewa Integrated Mental Health Services, Ministry of Health, Solomon Islands Daniel Gaoifa Integrated Mental Health Services, Ministry of Health, Solomon Islands John Moreen Integrated Mental Health Services, Ministry of Health, Solomon Islands Edwin Kiloe Integrated Mental Health Services, Ministry of Health, Solomon Islands William Same Integrated Mental Health Services, Ministry of Health, Solomon Islands Margaret Goding St. Vincent’s Mental Health, Asia-Australia Mental Health, Melbourne, VIC, Australia Chee Ng Asia-Australia Mental Health, Department of Psychiatry, The University of Melbourne and St. Vincent’s Mental Health, Melbourne, VIC, and; Professorial Unit, The Melbourne Clinic Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
Abstract Objectives: The Solomon Islands face significant shortages and geographical imbalances in the distribution of skilled health workers and resources, which severely impact the delivery of mental health services. The government's Integrated Mental Health Service has emphasised the importance of greater community ownership and involvement in community-based mental health care, and of moving from centralised services to increased local and accessible care. Methods: From 2012 to 2014, the Solomon Islands Integrated Mental Health service worked with Asia-Australia Mental Health to build workforce capacity and deliver sustainable community mental health programs. Results: Supported by the Australian Aid Program’s Public Sector Linkages Program, this project shared resources and fostered links between public sector agencies in Australia, Fiji and the Solomon Islands. Conclusions: Key learning points from the collaboration included the critical need to establish partnerships with community stakeholders, the importance of sustaining a well-functioning mental health team, and optimising the strengths of the local resources in the Solomon Islands. Through this project, national policies, promotion and service delivery were strengthened, through the exchange of experiences and mobilisation of north-south (Australia-Solomon Islands) and south-south (Solomon Islands-other Pacific nations) technical expertise. This project demonstrates the potential for international partnerships to contribute to the development of culturally-appropriate and integrated mental health services. Keywords: Asia-Australia Mental Health, Australian Aid Program, collaboration, international partnerships, mental health, mental health reform, problem solving, optimisation, Solomon Islands
T
he Solomon Islands is a country of more than 900 rugged mountainous and low-lying atolls, with an approximate area of 28,000 square kilometers. Its population is more than one-half million people, with > 40% under 14 years of age.1 While > 90 indigenous dialects are spoken across the islands, English is the official language, with ‘Pidgin English’ commonly spoken. The Solomon Islands’ economy, based on agriculture, forestry and fisheries, is in the low-income group, according to
2010 World Bank criteria. The total expenditure on health as a percentage of the gross domestic product (GDP) is 5.45% and the per capita government expenditure on
Corresponding author: Brigid Ryan, St. Vincent’s Mental Health, Asia-Australia Mental Health, Melbourne, VIC, Australia. Email: [email protected]
1 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
Australasian Psychiatry
health is $91.0.2 In the Solomon Islands, neuropsychiatric disorders are estimated to contribute to 12.6% of the global burden of disease.3 Mental health in the Solomon Islands is centrally administered by the Ministry of Health and Medical Services. The services consist of a 20-bed National Psychiatric Unit in the provincial capital of Malaita Province, Auki, a 4-bed Acute Care Unit and a community mental health team in Honiara, the Solomon Islands’ capital city on Guadalcanal Island, as well as mental health coordinators in each province. Human resources consist of 15 qualified mental health nurses, 16 general registered nurses and 28 registered nurse aides, a driver and domestic workers. There is one practicing psychiatrist and another whom is completing training.4 With no other health professionals working in this sector, the human resources of 0.19 psychiatrists and 1.12 nurses per 100,000 in the population are lower than in other Pacific countries, and well below the global median of 4.95 nurses per 100,000 people in the population. The data for training of health professionals in educational institutions have not been available for the World Health Organisation’s (WHO’s) Mental Health Atlas.2 Shortages and geographical imbalances in the distribution of skilled health workers and resources impact on the delivery of health services, particularly to poor and rural populations. The mental health services rely on growing partnerships with health and other sectors. For example, the small Acute Care Unit in the National Referral Hospital closed for repair in early 2012, so without inpatient services, the mental health staff worked collaboratively with the Honiara police to provide treatment in police holding cells.5 Challenges facing mental health services in the Solomon Islands include the fast-growing population, a high frequency of natural disasters, and an increasing demand for services.5 Delivering services to remote islands is a particular challenge; accessing psychiatric hospital services could entail a 2-week journey by boat. The Solomon Islands is experiencing transformation in political, economic and social dimensions, including technological, and climate changes. The country is also recovering from a sustained period of violence, when ethnic tensions escalated and destabilised the country in the late 1990s.
Collaboration in a community mental health development program For 3 years (2012–2014), the Solomon Islands’ Integrated Mental Health service worked with Asia-Australia Mental Health (AAMH) to build a workforce capacity and to deliver sustainable community mental health programs. The public sector mental health agencies in Australia, the Solomon Islands and the Fiji Islands were supported by the Australian Aid Program’s Public Sector Linkages Program to share resources and foster links in mental
health workforce development. While this paper looked at the impact of this collaborative program in the Solomon Islands in particular, the mental health institutions in Fiji also positively contributed to the improvement of mental health services in the Solomon Islands, by providing peer support, inspiration and additional training resources.
Materials and methods Approach
The program was a new initiative for both the Solomon Islands’ Government and the Australian Aid Program, but follows recommendations from the 2010 WHO ‘Mental Health and Development Report’,6 which highlights the vulnerability of persons with mental disorders, and current marginalisation of this group, in terms of development aid and government attention. The Government of the Solomon Islands, through its Ministry of Health and Medical Services supported this collaboration, which aimed to assist mental health services to develop practical, affordable, achievable, equitable and integrated approaches to improve the quality of service provision in all provinces. The project aligns with the WHO Mental Health Action Plan 2013–2020, with its focus on the central role for provision of community-based care.7 This plan sets out ambitious targets, including increased service coverage by the year 2020, and proposes a series of actions to achieve these objectives, such as to systemically shift the focus of care away from long-stay mental hospitals and towards non-specialised health settings. Recent research8 on the effects of collaborative community-based interventions, including supervised community health workers, for people with serious mental illness show that this model is more effective than providing only facilitybased services. Taking the Government’s national motto ‘to lead is to serve’ as a guide, the Ministry of Health and Medical Services stressed the importance of greater community ownership and involvement in community-based mental health care, and of moving from centralised services to increased local, accessible care.9
Activities This 3-year project aimed to build on the strengths of the organisations involved in the partnership: the Solomon Islands’ Integrated Mental Health Service and AAMH’s consortium partners, the University of Melbourne and St. Vincent’s Mental Health, as well as St. Giles Hospital and Fiji’s College of Medicine, Nursing and Health Sciences (CMNHS). The Australian Aid Program supported a range of activities between the three countries, and this article focuses on the activities that involved the Solomon Islands directly.
2 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
Ryan et al.
Component 1: Policy and decision-making support. For this component, the headline activities included: a workshop to engage mental health stakeholders held in April 2012, the Training and Workforce Development Forum held in Suva during August 2012, the presentation at the Solomon Islands’ National Health Conference in September 2012, and a workshop to build collaboration between the community mental health stakeholders that was held in Honiara in October 2014. Component 2: Professional development, postgraduate training and clinical support for mental health clinicians. Supported by the Australian Aid Program and with resources from Fiji’s College of Medicine, Nursing and Health Sciences, we had four nurses from the Integrated Mental Health Service and one nurse from the Solomon Islands College of Higher Education successfully complete a 4-week course in Community Mental Health and Psychosocial Rehabilitation, through the Fiji CMNHS inaugural postgraduate diploma of mental health, in August 2012. The course, based in Suva, included clinical placements with St. Giles Hospital and facilitated workshops. Using a public health approach, this course presented a theoretical framework for leadership, service development and setting of priorities in mental health. While participating in the course, the nurses gained valuable on-site learning from extensive exposure to the Fijian mental health services. Shortly after the tsunami, which struck the Solomon Islands’ Temotu Province in February 2013, we had 25 stakeholder representatives and mental health nurses participate in a 3-day Mental Health Disaster Preparedness Training/Workshop, facilitated by AAMH and the Australian Red Cross. This resulted in an increased understanding of the psychosocial and mental health impacts of disaster, as well as improving training skills to support mental health professionals and relevant nongovernmental organisations (NGOs). In September 2013, we had 20 nurses successfully complete a 10-day (block mode) training course in community mental health and psychosocial training, in Honiara. Focusing on practical strategies for mental health workers, the program utilised a bio-psycho-social approach to mental health, with a focus on delivering client-centred and goal-oriented care in the context of the Solomons Islands, and explored the possibilities for adopting standardised assessments and client service plans. With the limited availability of specialised clinicians, the program placed strong emphasis on collaboration with families, including the extended family network, village communities and the primary health care sector. Participants gained awareness of mental health promotion through conducting small community surveys about the knowledge and attitudes toward mental illness. All training programs were evaluated using reflection sessions and written feedback. The evaluation demonstrated
high engagement and uptake, especially of the practical elements of community-based mental health. The course objectives and the method of delivery were rated highly for effective learning of the principles of community mental health. The participants found the topics and training both highly relevant to their professional development and useful to their work.
Results
Key outcomes of the Community Mental Health Program 1. Improved stakeholder engagement. Engaging stakeholders to participate in the public program was a priority for the mental health team, both in the capital Honiara and in the provinces. The forum explored ways of identifying key players whom had a stake in the way mental health services were delivered and working with other government departments. In line with the WHO’s Mental Health Action Plan, this activity sought to gain consensus, improve coordinated policy and care across formal and informal sectors, as well as build capacity and raise awareness about mental health, law and human rights.8 Through these activities, many resources were identified that could assist in improving mental health services, including traditional village governance structures, such as the chiefs and local committees, community-based organisations (CBOs), national or provincial NGOs, as well as churches and faith-based organisations (FBOs). Despite multiple agendas and a diversity of views, each invited stakeholder identified the benefits of having improved collaboration with the government’s mental health services. As an example of improved stakeholder engagement,on 1 October 2012, World Mental Health Day, the Masuru village, in the Western Province, marched to celebrate and express their support for people impacted by mental illness. Filmed by the Solid-T studio crew, the strong stakeholder engagement of the local government and the community by the provincial coordinator and the national mental health team was evident.10 Led by a civil society-based group, ‘The Mental Health Support Committee’, the celebration demonstrated a new awareness and understanding of mental health issues in this community. The film shows community members participating in a mental health education workshop. A tangible demonstration of social inclusion was demonstrated with the building of new housing for people experiencing mental illness, which was close to other village dwellings and subsidised by community members. This project demonstrated the capacity of communities to cooperatively identify resources to achieve change.11 2. Increased workforce capacity in community mental health. Training delivered by international trainers was developed in consultation with the Integrated Mental Health Services, and utilised case material supplied by
3 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
Australasian Psychiatry
the participants. The training approach emphasised translation to a local context, and adaptation to the current roles and expectations of the mental health services, as well as a focus on comprehensive, integrated and responsive mental health and social care services. While many of the training participants were experienced clinicians, there was a significant variation in the range of qualifications and experience. The theoretical components of the program related to public health and a bio-psycho-social approach provided a framework for practice and standardising care. 3. Development of ‘best practice examples’. The international training provided key tools for community engagement, and assessment of community resources. The training achieved many of the strategic goals of mental health services by engaging the community members in important discussions about the health of their own community, responsibility for caring for people with an illness and strategies for providing effective care within current resource settings. The best practice examples of engaging the community in practical solutions for providing shelter, livelihood support and improved social structures are documented elsewhere.11,12 4. New strategies and roles of mental health services. Feedback from the mental health team indicated that new concepts and strategies came with new expectations from the stakeholders. Successful mental health promotion, advocacy and improving access to mental health treatment involved mental health workers in new activities, such as producing of video clips, roleplaying, dramas, composing theme songs, supervisory visits, managing small funding projects, initiating the celebration of ‘Mental Health Days’, arranging visits from outside partners to the local communities, and the advocacy to political leaders.5 Key issues With limited mental health resources, particularly in the workforce, it was critical to establish partnerships with community stakeholders. By broadening the range of sectors and organisations available to support people with mental health problems, the Integrated Mental Health Service was able to increase access to care and maximise existing resources. Sustaining a small mental team required good teambuilding, a focus on efficient communication, and professional relationship management. Distinct from regular opportunities for professional development and technical support for the mental health team, the fostering of leadership was important for building effective working relationships that can allow sustainable change. Taking the specialised community mental health workforce out of local areas for 2-week training represented a challenge for managing the mental health clients. Despite the lack of formal procedures in place and
limited information technology resources, the mental health workers demonstrated the strengths of informal linkages and personal communication to cover their absence in the workplace during the training. When necessary, the training participants resolved problems in distant areas by use of mobile phones. It was important to recognise and optimise strengths within the local setting, no matter how limited the resources. When acute psychiatric hospital care was unavailable for an extensive period of time during a major refurbishment, the Mental Health Team was able to collaborate with the police, general hospitals and community members. The ‘wantok’ system, where reciprocal obligations, social and cultural practices can provide strong natural support for people experiencing mental illness, is a strength that can be enhanced with community education, to overcome stigma. Rich opportunities for mental health promotion were identified through community resources, local culture and community systems.
Conclusions The Integrated Mental Health Service in the Solomon Islands, the AAMH and the Fijian mental health institutions formed a successful partnership, with support from the Australian Aid Program, to develop community mental health reform in the Solomon Islands. Sharing resources between the three countries resulted in the identification of effective strategies for addressing mental health issues, such as multi-sectoral stakeholder engagement, community participation and building of workforce capacity. The program was anchored in the global agenda for mental health, in its focus on the importance of community and primary health care, and in understanding the need for mental health services and resource management. This collaboration contributed to the long-term strategic goals of both the Solomon Islands Ministry of Health and Medical Services and the Australian Aid Program. Acknowledgements The authors would like to thank all of the institutions and mental health workers involved in this program, with both participants and trainers, from the Solomon Islands (Ministry of Health and Medical Services, and Solomon Islands National University), Australia (Saint Vincent’s Hospital, University of Melbourne, Australian Red Cross, Royal Australian and New Zealand College of Psychiatrists, and Centre for Rural and Remote Mental Health Queensland) and Fiji (Fiji National University and Saint Giles Hospital), with mention especially of: doctors Odille Chang, Myrielle Allen, Peni Buikoto and Ruth Vine; as well as Bridget Organ and Kate Brady. We would also like to acknowledge the generous support from consumers and families of those in mental health services in the Solomon Islands, and the Mental Health Committee in Simbo. The authors would also like to acknowledge the invaluable support of the Australian
4 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
Ryan et al.
Aid Program, particularly the Pacific Public Sector Linkages Program.
5. Orotoala P. Mental health services in the Solomon Islands. Mental Health Stakeholder Forum with Asia Australia Mental Health in Honiara, 29 October, 2014. Honiara: Ministry of Health and Medical Services.
Funding
6. Mental health and development: Targeting people with mental health conditions as a vulnerable group. Geneva, Switzerland: World Health Organisation, 2010.
This program was funded by the Australian Aid Program, Department of Foreign Affairs and Trade, Australia.
Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
7. World Health Organisation (WHO). Mental health action plan 2013–2020, 2013. Geneva: WHO, 2013. 8. Chatterjee S, Naik S, John S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): A randomised controlled trial. Lancet 2014: 383:1385–1394. 9. Solomon Islands National Mental Health Policy: 2009. Ministry of Health and Medical Services, Goverment of the Solomon Islands.
References 1. Population and housing census 2009. Report for the National Statistics Office - Ministry of Finance Treasury, May 2009. Honiara: Solomon Islands. 2. Mental health atlas 2011. Geneva, Switzerland: World Health Organization, 2011. 3. Whiteford HA, Degenhart L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet 2013; 382: 1575–1586. 4. Orotoala P. Mental health services in the Solomon Islands. Report. Solomon Islands: Ministry of Health and Medical Services, 2014.
10. Kiloe E. Community mental health psychosocial rehabilitation training. Report, Integrated Mental Health Service, Ministry of Health, the Solomon Islands, 2012. Western province: Solomon Islands. 11. Orotaloa P. Community mental health project in Simbo. Report, Integrated Mental Health Services, Ministry of Health and Medical Services, the Solomon Islands, 2013. Gizo: the Solomon Islands. 12. Oikali DG. Auki carers and relatives training report. Report, Integrated Mental Health Services, Ministry of Health and Medical Services, the Solomon Islands, 2012. Auki, Malaita Province: the Solomon Islands.
5 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
APY0010.1177/1039856215592323Australasian PsychiatryRyan et al.
Australasian
Psychiatry
Regular Article
Mental health in the Solomon Islands: developing reforms and partnerships
Australasian Psychiatry –5 1 © The Royal Australian and New Zealand College of Psychiatrists 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1039856215592323 apy.sagepub.com
Brigid Ryan St. Vincent’s Mental Health, Asia-Australia Mental Health, Melbourne, VIC, Australia Paul Orotaloa Integrated Mental Health Services, Ministry of Health, Solomon Islands Stephen Araitewa Integrated Mental Health Services, Ministry of Health, Solomon Islands Daniel Gaoifa Integrated Mental Health Services, Ministry of Health, Solomon Islands John Moreen Integrated Mental Health Services, Ministry of Health, Solomon Islands Edwin Kiloe Integrated Mental Health Services, Ministry of Health, Solomon Islands William Same Integrated Mental Health Services, Ministry of Health, Solomon Islands Margaret Goding St. Vincent’s Mental Health, Asia-Australia Mental Health, Melbourne, VIC, Australia Chee Ng Asia-Australia Mental Health, Department of Psychiatry, The University of Melbourne and St. Vincent’s Mental Health, Melbourne, VIC, and; Professorial Unit, The Melbourne Clinic Department of Psychiatry, The University of Melbourne, Parkville, VIC, Australia
Abstract Objectives: The Solomon Islands face significant shortages and geographical imbalances in the distribution of skilled health workers and resources, which severely impact the delivery of mental health services. The government's Integrated Mental Health Service has emphasised the importance of greater community ownership and involvement in community-based mental health care, and of moving from centralised services to increased local and accessible care. Methods: From 2012 to 2014, the Solomon Islands Integrated Mental Health service worked with Asia-Australia Mental Health to build workforce capacity and deliver sustainable community mental health programs. Results: Supported by the Australian Aid Program’s Public Sector Linkages Program, this project shared resources and fostered links between public sector agencies in Australia, Fiji and the Solomon Islands. Conclusions: Key learning points from the collaboration included the critical need to establish partnerships with community stakeholders, the importance of sustaining a well-functioning mental health team, and optimising the strengths of the local resources in the Solomon Islands. Through this project, national policies, promotion and service delivery were strengthened, through the exchange of experiences and mobilisation of north-south (Australia-Solomon Islands) and south-south (Solomon Islands-other Pacific nations) technical expertise. This project demonstrates the potential for international partnerships to contribute to the development of culturally-appropriate and integrated mental health services. Keywords: Asia-Australia Mental Health, Australian Aid Program, collaboration, international partnerships, mental health, mental health reform, problem solving, optimisation, Solomon Islands
T
he Solomon Islands is a country of more than 900 rugged mountainous and low-lying atolls, with an approximate area of 28,000 square kilometers. Its population is more than one-half million people, with > 40% under 14 years of age.1 While > 90 indigenous dialects are spoken across the islands, English is the official language, with ‘Pidgin English’ commonly spoken. The Solomon Islands’ economy, based on agriculture, forestry and fisheries, is in the low-income group, according to
2010 World Bank criteria. The total expenditure on health as a percentage of the gross domestic product (GDP) is 5.45% and the per capita government expenditure on
Corresponding author: Brigid Ryan, St. Vincent’s Mental Health, Asia-Australia Mental Health, Melbourne, VIC, Australia. Email: [email protected]
1 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
Australasian Psychiatry
health is $91.0.2 In the Solomon Islands, neuropsychiatric disorders are estimated to contribute to 12.6% of the global burden of disease.3 Mental health in the Solomon Islands is centrally administered by the Ministry of Health and Medical Services. The services consist of a 20-bed National Psychiatric Unit in the provincial capital of Malaita Province, Auki, a 4-bed Acute Care Unit and a community mental health team in Honiara, the Solomon Islands’ capital city on Guadalcanal Island, as well as mental health coordinators in each province. Human resources consist of 15 qualified mental health nurses, 16 general registered nurses and 28 registered nurse aides, a driver and domestic workers. There is one practicing psychiatrist and another whom is completing training.4 With no other health professionals working in this sector, the human resources of 0.19 psychiatrists and 1.12 nurses per 100,000 in the population are lower than in other Pacific countries, and well below the global median of 4.95 nurses per 100,000 people in the population. The data for training of health professionals in educational institutions have not been available for the World Health Organisation’s (WHO’s) Mental Health Atlas.2 Shortages and geographical imbalances in the distribution of skilled health workers and resources impact on the delivery of health services, particularly to poor and rural populations. The mental health services rely on growing partnerships with health and other sectors. For example, the small Acute Care Unit in the National Referral Hospital closed for repair in early 2012, so without inpatient services, the mental health staff worked collaboratively with the Honiara police to provide treatment in police holding cells.5 Challenges facing mental health services in the Solomon Islands include the fast-growing population, a high frequency of natural disasters, and an increasing demand for services.5 Delivering services to remote islands is a particular challenge; accessing psychiatric hospital services could entail a 2-week journey by boat. The Solomon Islands is experiencing transformation in political, economic and social dimensions, including technological, and climate changes. The country is also recovering from a sustained period of violence, when ethnic tensions escalated and destabilised the country in the late 1990s.
Collaboration in a community mental health development program For 3 years (2012–2014), the Solomon Islands’ Integrated Mental Health service worked with Asia-Australia Mental Health (AAMH) to build a workforce capacity and to deliver sustainable community mental health programs. The public sector mental health agencies in Australia, the Solomon Islands and the Fiji Islands were supported by the Australian Aid Program’s Public Sector Linkages Program to share resources and foster links in mental
health workforce development. While this paper looked at the impact of this collaborative program in the Solomon Islands in particular, the mental health institutions in Fiji also positively contributed to the improvement of mental health services in the Solomon Islands, by providing peer support, inspiration and additional training resources.
Materials and methods Approach
The program was a new initiative for both the Solomon Islands’ Government and the Australian Aid Program, but follows recommendations from the 2010 WHO ‘Mental Health and Development Report’,6 which highlights the vulnerability of persons with mental disorders, and current marginalisation of this group, in terms of development aid and government attention. The Government of the Solomon Islands, through its Ministry of Health and Medical Services supported this collaboration, which aimed to assist mental health services to develop practical, affordable, achievable, equitable and integrated approaches to improve the quality of service provision in all provinces. The project aligns with the WHO Mental Health Action Plan 2013–2020, with its focus on the central role for provision of community-based care.7 This plan sets out ambitious targets, including increased service coverage by the year 2020, and proposes a series of actions to achieve these objectives, such as to systemically shift the focus of care away from long-stay mental hospitals and towards non-specialised health settings. Recent research8 on the effects of collaborative community-based interventions, including supervised community health workers, for people with serious mental illness show that this model is more effective than providing only facilitybased services. Taking the Government’s national motto ‘to lead is to serve’ as a guide, the Ministry of Health and Medical Services stressed the importance of greater community ownership and involvement in community-based mental health care, and of moving from centralised services to increased local, accessible care.9
Activities This 3-year project aimed to build on the strengths of the organisations involved in the partnership: the Solomon Islands’ Integrated Mental Health Service and AAMH’s consortium partners, the University of Melbourne and St. Vincent’s Mental Health, as well as St. Giles Hospital and Fiji’s College of Medicine, Nursing and Health Sciences (CMNHS). The Australian Aid Program supported a range of activities between the three countries, and this article focuses on the activities that involved the Solomon Islands directly.
2 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
Ryan et al.
Component 1: Policy and decision-making support. For this component, the headline activities included: a workshop to engage mental health stakeholders held in April 2012, the Training and Workforce Development Forum held in Suva during August 2012, the presentation at the Solomon Islands’ National Health Conference in September 2012, and a workshop to build collaboration between the community mental health stakeholders that was held in Honiara in October 2014. Component 2: Professional development, postgraduate training and clinical support for mental health clinicians. Supported by the Australian Aid Program and with resources from Fiji’s College of Medicine, Nursing and Health Sciences, we had four nurses from the Integrated Mental Health Service and one nurse from the Solomon Islands College of Higher Education successfully complete a 4-week course in Community Mental Health and Psychosocial Rehabilitation, through the Fiji CMNHS inaugural postgraduate diploma of mental health, in August 2012. The course, based in Suva, included clinical placements with St. Giles Hospital and facilitated workshops. Using a public health approach, this course presented a theoretical framework for leadership, service development and setting of priorities in mental health. While participating in the course, the nurses gained valuable on-site learning from extensive exposure to the Fijian mental health services. Shortly after the tsunami, which struck the Solomon Islands’ Temotu Province in February 2013, we had 25 stakeholder representatives and mental health nurses participate in a 3-day Mental Health Disaster Preparedness Training/Workshop, facilitated by AAMH and the Australian Red Cross. This resulted in an increased understanding of the psychosocial and mental health impacts of disaster, as well as improving training skills to support mental health professionals and relevant nongovernmental organisations (NGOs). In September 2013, we had 20 nurses successfully complete a 10-day (block mode) training course in community mental health and psychosocial training, in Honiara. Focusing on practical strategies for mental health workers, the program utilised a bio-psycho-social approach to mental health, with a focus on delivering client-centred and goal-oriented care in the context of the Solomons Islands, and explored the possibilities for adopting standardised assessments and client service plans. With the limited availability of specialised clinicians, the program placed strong emphasis on collaboration with families, including the extended family network, village communities and the primary health care sector. Participants gained awareness of mental health promotion through conducting small community surveys about the knowledge and attitudes toward mental illness. All training programs were evaluated using reflection sessions and written feedback. The evaluation demonstrated
high engagement and uptake, especially of the practical elements of community-based mental health. The course objectives and the method of delivery were rated highly for effective learning of the principles of community mental health. The participants found the topics and training both highly relevant to their professional development and useful to their work.
Results
Key outcomes of the Community Mental Health Program 1. Improved stakeholder engagement. Engaging stakeholders to participate in the public program was a priority for the mental health team, both in the capital Honiara and in the provinces. The forum explored ways of identifying key players whom had a stake in the way mental health services were delivered and working with other government departments. In line with the WHO’s Mental Health Action Plan, this activity sought to gain consensus, improve coordinated policy and care across formal and informal sectors, as well as build capacity and raise awareness about mental health, law and human rights.8 Through these activities, many resources were identified that could assist in improving mental health services, including traditional village governance structures, such as the chiefs and local committees, community-based organisations (CBOs), national or provincial NGOs, as well as churches and faith-based organisations (FBOs). Despite multiple agendas and a diversity of views, each invited stakeholder identified the benefits of having improved collaboration with the government’s mental health services. As an example of improved stakeholder engagement,on 1 October 2012, World Mental Health Day, the Masuru village, in the Western Province, marched to celebrate and express their support for people impacted by mental illness. Filmed by the Solid-T studio crew, the strong stakeholder engagement of the local government and the community by the provincial coordinator and the national mental health team was evident.10 Led by a civil society-based group, ‘The Mental Health Support Committee’, the celebration demonstrated a new awareness and understanding of mental health issues in this community. The film shows community members participating in a mental health education workshop. A tangible demonstration of social inclusion was demonstrated with the building of new housing for people experiencing mental illness, which was close to other village dwellings and subsidised by community members. This project demonstrated the capacity of communities to cooperatively identify resources to achieve change.11 2. Increased workforce capacity in community mental health. Training delivered by international trainers was developed in consultation with the Integrated Mental Health Services, and utilised case material supplied by
3 Downloaded from apy.sagepub.com at Bobst Library, New York University on November 15, 2015
Australasian Psychiatry
the participants. The training approach emphasised translation to a local context, and adaptation to the current roles and expectations of the mental health services, as well as a focus on comprehensive, integrated and responsive mental health and social care services. While many of the training participants were experienced clinicians, there was a significant variation in the range of qualifications and experience. The theoretical components of the program related to public health and a bio-psycho-social approach provided a framework for practice and standardising care. 3. Development of ‘best practice examples’. The international training provided key tools for community engagement, and assessment of community resources. The training achieved many of the strategic goals of mental health services by engaging the community members in important discussions about the health of their own community, responsibility for caring for people with an illness and strategies for providing effective care within current resource settings. The best practice examples of engaging the community in practical solutions for providing shelter, livelihood support and improved social structures are documented elsewhere.11,12 4. New strategies and roles of mental health services. Feedback from the mental health team indicated that new concepts and strategies came with new expectations from the stakeholders. Successful mental health promotion, advocacy and improving access to mental health treatment involved mental health workers in new activities, such as producing of video clips, roleplaying, dramas, composing theme songs, supervisory visits, managing small funding projects, initiating the celebration of ‘Mental Health Days’, arranging visits from outside partners to the local communities, and the advocacy to political leaders.5 Key issues With limited mental health resources, particularly in the workforce, it was critical to establish partnerships with community stakeholders. By broadening the range of sectors and organisations available to support people with mental health problems, the Integrated Mental Health Service was able to increase access to care and maximise existing resources. Sustaining a small mental team required good teambuilding, a focus on efficient communication, and professional relationship management. Distinct from regular opportunities for professional development and technical support for the mental health team, the fostering of leadership was important for building effective working relationships that can allow sustainable change. Taking the specialised community mental health workforce out of local areas for 2-week training represented a challenge for managing the mental health clients. Despite the lack of formal procedures in place and
limited information technology resources, the mental health workers demonstrated the strengths of informal linkages and personal communication to cover their absence in the workplace during the training. When necessary, the training participants resolved problems in distant areas by use of mobile phones. It was important to recognise and optimise strengths within the local setting, no matter how limited the resources. When acute psychiatric hospital care was unavailable for an extensive period of time during a major refurbishment, the Mental Health Team was able to collaborate with the police, general hospitals and community members. The ‘wantok’ system, where reciprocal obligations, social and cultural practices can provide strong natural support for people experiencing mental illness, is a strength that can be enhanced with community education, to overcome stigma. Rich opportunities for mental health promotion were identified through community resources, local culture and community systems.
Conclusions The Integrated Mental Health Service in the Solomon Islands, the AAMH and the Fijian mental health institutions formed a successful partnership, with support from the Australian Aid Program, to develop community mental health reform in the Solomon Islands. Sharing resources between the three countries resulted in the identification of effective strategies for addressing mental health issues, such as multi-sectoral stakeholder engagement, community participation and building of workforce capacity. The program was anchored in the global agenda for mental health, in its focus on the importance of community and primary health care, and in understanding the need for mental health services and resource management. This collaboration contributed to the long-term strategic goals of both the Solomon Islands Ministry of Health and Medical Services and the Australian Aid Program. Acknowledgements The authors would like to thank all of the institutions and mental health workers involved in this program, with both participants and trainers, from the Solomon Islands (Ministry of Health and Medical Services, and Solomon Islands National University), Australia (Saint Vincent’s Hospital, University of Melbourne, Australian Red Cross, Royal Australian and New Zealand College of Psychiatrists, and Centre for Rural and Remote Mental Health Queensland) and Fiji (Fiji National University and Saint Giles Hospital), with mention especially of: doctors Odille Chang, Myrielle Allen, Peni Buikoto and Ruth Vine; as well as Bridget Organ and Kate Brady. We would also like to acknowledge the generous support from consumers and families of those in mental health services in the Solomon Islands, and the Mental Health Committee in Simbo. The authors would also like to acknowledge the invaluable support of the Australian
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Ryan et al.
Aid Program, particularly the Pacific Public Sector Linkages Program.
5. Orotoala P. Mental health services in the Solomon Islands. Mental Health Stakeholder Forum with Asia Australia Mental Health in Honiara, 29 October, 2014. Honiara: Ministry of Health and Medical Services.
Funding
6. Mental health and development: Targeting people with mental health conditions as a vulnerable group. Geneva, Switzerland: World Health Organisation, 2010.
This program was funded by the Australian Aid Program, Department of Foreign Affairs and Trade, Australia.
Disclosure The authors report no conflict of interest. The authors alone are responsible for the content and writing of the paper.
7. World Health Organisation (WHO). Mental health action plan 2013–2020, 2013. Geneva: WHO, 2013. 8. Chatterjee S, Naik S, John S, et al. Effectiveness of a community-based intervention for people with schizophrenia and their caregivers in India (COPSI): A randomised controlled trial. Lancet 2014: 383:1385–1394. 9. Solomon Islands National Mental Health Policy: 2009. Ministry of Health and Medical Services, Goverment of the Solomon Islands.
References 1. Population and housing census 2009. Report for the National Statistics Office - Ministry of Finance Treasury, May 2009. Honiara: Solomon Islands. 2. Mental health atlas 2011. Geneva, Switzerland: World Health Organization, 2011. 3. Whiteford HA, Degenhart L, Rehm J, et al. Global burden of disease attributable to mental and substance use disorders: Findings from the Global Burden of Disease Study 2010. Lancet 2013; 382: 1575–1586. 4. Orotoala P. Mental health services in the Solomon Islands. Report. Solomon Islands: Ministry of Health and Medical Services, 2014.
10. Kiloe E. Community mental health psychosocial rehabilitation training. Report, Integrated Mental Health Service, Ministry of Health, the Solomon Islands, 2012. Western province: Solomon Islands. 11. Orotaloa P. Community mental health project in Simbo. Report, Integrated Mental Health Services, Ministry of Health and Medical Services, the Solomon Islands, 2013. Gizo: the Solomon Islands. 12. Oikali DG. Auki carers and relatives training report. Report, Integrated Mental Health Services, Ministry of Health and Medical Services, the Solomon Islands, 2012. Auki, Malaita Province: the Solomon Islands.
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