10th November 2012 University of East London

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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

Scope

• 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? • Definitions: 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.

• Assumptions?– 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

Knowledge & skills

Knowledge & skills

Research & development

Research & development

Donor (HIC’s)

Resources

Knowledge, skills and

competencies

Knowledge, skills and

competencies

Research & development

Research & development

RecipientLAMIC’s

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 • 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).

• 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)

• 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)

• 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%

• 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)

– (n = 1448, 30% recently resettled, 2% currently displaced, 86% long term residents)– PTSD 7%, anxiety 33%, Depression 22%

Historical context of trauma

• 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

14Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

Estimation of need Who is traumatised?

15Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

Mental health services

• Asylum • Psychiatry in general hospitals • General practice • Private practice • Community psychiatry?• Voluntary sector

Workforce

• Psychiatrists• MOMH• Psychologists • Psychiatric nurses • Social workers • PHI’s• Counselors • Volunteers

Capacity building

• Volunteers • NGO workers• Nurses • Teachers • PHI & Midwifes • CSO• MOMHS• Psychologists• Psychiatrists

18Dr Shamil Wanigaratne King's Health Partners & UK-Sri Lanka Trauma Group 3rd October 2009

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 GroupTHE UK WORKING GROUP TO FACILITATE WORK TO

MINIMISE PSYCHOLOGICAL IMPACT OF TRAUMA IN SRI LANKAUK 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

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)

Continued

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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

3/2 Kynsey RoadColombo 8 Centre Manager: Ms Shikanthini Varma-Atthanayake + 2 staff

Batticaloa OutpostIn partnership with Mangrove Network

Resource Person:Mrs Selvika Sahathevan

Jaffna OutpostIn partnership with Shanthium

Resource Person:

Mr Radnam Jegananthan

Hambantota OutpostResource Person:Mr Duminda Wanigasekare

Colombo Resource Centre

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 moveStrategy • 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

Work by visiting

resource persons

Supervision & support

work

Supervision & support

work

Training by staff and local

resource persons

Training by staff and local

resource persons

Liaison work with other

organisations

Liaison work with other

organisations

Samutthana Samutthana

Research work

Research work

Provision of resources

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 experience3. Level III – Professionals (Psychiatrists, doctors,

psychologists, Nurses)

• Supervision (support)• Skype supervision – substance misuse• Repeat attendance at workshops• CBT supervision – Stella Wragg

Samutthana networking for capacity building

Government

Bodies

Government

Bodies

CHACHA

Key individuals

and organisatio

ns

Key individuals

and organisatio

ns

Corporate SectorCorporate Sector

King’s CollegeKing’s

College UELUEL

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

• 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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40

60

80

100

120

140

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 • 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• 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• 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

• 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

• 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

• Kuhan Satkunanayagam • 4 clinical psychologists • Nurses• SL Volunteers• Seminar programme

Evaluation

• Progress reports to CAFOD• Formal evaluation by Sidartha Prakash• Ongoing evaluations and reviews• Internal evaluation funded by the Bromley

Trust

Siddhartha Prakash recommendations

• 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?