A descriptive qualitative study_ exploring factors effecting quality of MH services in primary care level setting in Kabul, Afghanistan. Thesis Defense

1. Presenter: Dr. Mohammad Ismail Zubair MD, MSc. HPM
Authors: Dr. M. Ismail Zubair, Dr. Tazeen Saeed Ali ,Dr.
Narjis Rizvi, Dr. Nargis Asad, Mr.Atif Riaz
EXPLORINGTHE FACTORSAFFECTING QUALITY OF
MENTAL HEALTH SERVICESAT PRIMARY HEALTH CARE
LEVEL IN KABUL,AFGHANISTAN.AN EXPLORATORY
QUALITATIVE STUDY

2. Presentation Outline
2

3. Global Scenario
Mental health issues are a concerning burden in both developed and
developing countries.
12% of global burden of disease
Contribute to economic burden and reinforce poverty
Mental health is integrated part of health /No health without mental health
Mental disorders have negative consequences on quality of life
Sub-optimal productivity at individual and national level
Predisposing/reinforcing factors
Drug-use
Domestic violence
Extremism / terrorism
Poor quality of services as significant factor toward mortality and morbidity
seen in MH patients.
Background
( WHO, Martin-2006, Abuse, S.2010, Bleich, 2003, Hegarty, Knapp -2006)

4. National Scenario
More than 3 decades of war and political conflict
More than 40% people live below poverty line
Low literacy rate: Female 12.6% and Male: 43.1%
A hidden epidemic of PTSD in Afghanistan
More than 2 million people suffer from mental illnesses
Half of the Afghan population aged 15 years or older is affected by
one of mental disorders
Women and disabled are more susceptible to mental disorders
Therefore, now Mental health is among top five priorities of
MoPH
4
( WFP -2015, Country literacy rate – 2015, The Guardine, 2014, WHO -2014, MH in Afghanisatn- 2011, National MH strategy
2009)

5. Study Aim
5
Objectives
This study aims to explore factors influencing quality of MH services at
PHC level.
To identify the perceived barriers of quality of mental health services
at PHC level in Kabul province, Afghanistan.
To identify the perceived facilitators of quality of mental health
services at PHC level in Kabul province, Afghanistan.

6. Rationale of study
6

7. *IDI….In depth Interview
*KII…...Key Informant Interview
*PHC……Primary Care Level
*BHC….Basic Health Center
*CHC…..Comprehensive Health Center
* DH……District Hospital
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Study Method

8. 8
Study Method

9. 9
Source: D’ Ambrouso, 2009
Conceptual Framework
EXPLORING THE FACTORS AFFECTING QUALITY OF MENTAL HEALTH SERVICES

10. 10
Ethical Considerations

11. 11
Qualitative data analysis Miles, M. B., Huberman, A. M., & Saldaña, J. (2013)
Data Analysis

12. Results
12

13. 13

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“And the most important factors are … and low
economy of people. In addition public awareness is very
low and excessive accumulation of people in Kabul has
caused lack of job opportunities and poverty...”
[IDI#14-P-D]
“And the most important factors are … and low economy of
“When my brother got this problem, we took him to a
famous Agha sahib (religious scholar), he said that
your brother is affected by a very dangerous black
magic. He demanded a large amount of money from
us to cure my brother…” [IDI#4-PA]

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“I went many times to the CHC and DH near to us, but
they told me we don’t have MH doctor or psychosocial
counselor, you better go to that hospital” [IDI #7- P]
“ you know our culture better, people let their females die
at home instead of being checked by male doctor, also if
we have female MH doctor here, I will always come here,
and it is easy for me to explain her my problems”
[IDI#2-P]
“There should be a separate room where we can talk to
psychosocial counselor in privacy. We have a lot to speak,
but how can I discuss my private issues in front of too
many patients and staff. I feel shy” [IDI# 7- P]

16. 16
Cont…
Shortage /Low Quality
Medicines
Short Functional Hours
Inappropriate Case Management
 Confusing MH Cases
 Medicalization of MH Cases
Poor Compliance to Referral
System
Long Waiting time
High Turnover of Staff
 Work Load
 Low Motivation
 Low Salary
 Low Staff satisfaction
Theme 1
Perceived Barriers to Quality of MH Services at PHC level
“ the clinic is open till noon, I reached here around
10:00 AM but still waiting to visit doctor, you see
the crowd….hmmm…I don’t think that I can be
checked by doctor today…in this case, I have to come
tomorrow again….it is very difficult” [IDI#8-P]
“No, the clinic didn’t give me medicines, they gave
me the prescription, here it is…..now I don’t know
from where I should buy it, I am poor and can’t
afford to purchase medicine.” [IDI#9-P]
“…we took our patient there, we were waiting from
morning till afternoon then they gave her only 3 or 4
tablets and said you can go….” [IDI#5-PA].
“ I am a medical doctor, I am working here because
currently I don’t find a job anywhere else, the day I
find, I will go…..I have no future here” [IDI#14-
P-D].

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“In order to improve the quality of services. We need to
have a standard, professional and well established
entity to look after the policies, regulation and
bylaws, update and modernize them, make strategic
plans, conduct trainings and do comprehensive
monitoring.” [KII# 3- DD-MoPH]
“The major issue is unavailability of resources, we
have very limited fund for MH services in the
ministry. Donors are not interested in MH as
compared to mother and child health, vaccination
and TB.” [KII#1-D- MoPH].
“the infrastructure is rented at very high price, in the
open market this is not valued more than
30,000AFG but the directorate pays 80,000AFG
because of the corruption existing in these directorate
and higher level leadership… .”[IDI#13-P-N]

18. 18
Cont…
 Ineffective M&E system
 Manual system in place
 No timely supervision
 No feedback
 No recognition and
punishment
Poor Coordination
 Among MoPH different dep
 Between MoPH &
Implementing NGOs
 Between Central &
Provincial level
 Security Problem
Theme 1
Perceived Barriers to Quality of MH Services at PHC level
“We have many problems in relation to coordination
among different stakeholders, many times we agree
on scheduling provincial level meetings on important
issues. But provincial authorities did not attend the
meetings. “ [KII#4-D-NGO]
“ …we have staff who only come for one hour in
clinic, but nobody asks, you work hard or not doesn’t
matter….and no body admire your hard work”[IDI#
16-P-D]
“Our big problem is security, it is challenging
everything. If there were no war in the country, we
would have much better health system and be able to
provide very high quality health services across the
country” [KII#1-D-MoPH]

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1. Establishment of MH Dep
-Integration of MH in PHC
level
- Integration of Psychosocial
Counseling to MH Treatment
- Development of MH
Treatment Guidelines
- Establishment of National
MH Committee
2. Integration of MH
Education into Education
System
Review and updating of MH
subjects in medical university
curriculum
Establishment psychosocial
department at Ghazanfar Institute
Integration of MH education into
school curriculum
“If we compare the current MH services situation with the past, we
have taken some major steps but still we have a long way to go on
this journey.” [KII#1-D-MoPH].

20.  This study has triangulated the data by involving multiple datasources,
including desk review and interview with clients, healthcare providers and
senior management staff which enhanced the data validity
 Community level factors were also explored by this study
 This study will also pave the way for further descriptive and analytical studies
in the area of MH
 All the interviews (IDIs and KIIs) were conducted by researcher
 This study (to best of our knowledge) was the first of its type in exploring
perceived barriers and facilitators of quality of MH at PHC level at Kabul
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Strengths

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 The researchers were unable to interview some of the key
informants, due to their discomfort of discussing the quality of MH
services at there own institutions.
 Community Health Workers (CHWs) could not be approach to
explore their view points about barriers and facilitators to quality MH
services.
Limitations

22.  More focus was on quantity rather than quality in BPHS
 There were several barriers to quality of MH services such as:
 Low demand of quality MH services at community level
 Low community support
 Unavailability of MH staff
 Short working hours and high turnover of staff
 Lack of resources and ineffective M&E system
 Low management and public health capacity of MH department
 The facilitators to quality of MH services were:
 Establishment of MH department
 Integration of MH services to PHC level
 Integration of MH education into national education system
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Conclusion

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Community Level
Health Facility
Level
Health System
Level
 Strengthen community involvement and support
 Educate through awareness campaigns
 Involve them in decision making
 Empower CHWs and use them as gatekeeper
 Develop community level strategy to fight social stigma
 Ensure recruitment and retention of qualified personnel
 Recruit male and female psychosocial counselors
 Provide initial and refresher training
 Motivation and recognition of staff
 Maintain privacy and confidentiality
 Document all referral in and out clients
 Advocacy and lobby for MH funding
 Train and maintain health system experts in MHD
 Strengthen M&E system and practice
 Assure provision of quality and timely supply
 Take action against corruption
 Strengthen coordination among stakeholders
RecommendationsRecommendations

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1. World Bank. World development report 1993: investing in health. New York: Oxford University Press, 1993. 2
Murray CJL, Lopez AD.2
2. Cardozo, B. L., Bilukha, O. O., Crawford, C. A. G., Shaikh, I., Wolfe, M. I., Gerber, M. L., & Anderson, M.
(2004). Mental health, social functioning, and disability in postwar Afghanistan. Jama, 292(5), 575-584. 3
3. Knapp, M., Funk, M., Curran, C., Prince, M., Grigg, M., &McDaid, D. (2006). Economic barriers to better
mental health practice and policy. Health Policy and Planning, 21(3), 157-170.
4. Abuse, S. (2010). Mental Health Services Administration, 2011 Substance Abuse and Mental Health Services
Administration. Results from the.
5. Hegarty, K. (2011). Domestic violence: the hidden epidemic associated with mental illness. The British Journal of
Psychiatry, 198(3), 169-170.
6. Bleich, A., Gelkopf, M., & Solomon, Z. (2003). Exposure to terrorism, stress-related mental health symptoms,
and coping behaviors among a nationally representative sample in Israel. Jama, 290(5), 612-620.
7. Knapp, M., Funk, M., Curran, C., Prince, M., Grigg, M., &McDaid, D. (2006). Economic barriers to better
mental health practice and policy. Health Policy and Planning, 21(3), 157-170.
8. Saraceno, B., van Ommeren, M., Batniji, R., Cohen, A., Gureje, O., Mahoney, J., ...& Underhill, C. (2007).
Barriers to improvement of mental health services in low-income and middle-income countries. The
Lancet,370(9593), 1164-1174.9
9. Gadit A. Is there a Visible mental health policy in Pakistan. Journal of Pakistan Medical Association,. 2014.
10. Codony M, Alonso J, Almansa J, Bernert S, de Girolamo G, de Graaf R, et al. Perceived need for mental health
care and service use among adults in western Europe: Results of the ESEMeD project. Psychiatric Services.
2009;60(8):1051-8.
11. Isle B, Jan R, Derrick S, Anthony Z. Community perceptions of mental health needs: a qualitative study in the
Solomon Islands. International Journal of Mental Health Systems. 2009;3.
References

25. 25
11. Hinkle, J. S. (2014). Population-Based Mental Health Facilitation (MHF): A Grassroots Strategy That Works. The
Professional Counselor, 4(1), 1.
12. Lassi, Z. S., Mahmud, S., Syed, E. U., &Janjua, N. Z. (2011). Behavioral problems among children living in
orphanage facilities of Karachi, Pakistan: comparison of children in an SOS Village with those in conventional
orphanages. Social psychiatry and psychiatric epidemiology, 46(8), 787-796.
13. Naqvi, H. A., Sabzwari, S., Hussain, S., Islam, M., &Zaman, M. (2012). General practitioners’ awareness and
management of common psychiatric disorders: a community-based survey from Karachi, Pakistan.
14. D’Ambruoso, L., Achadi, E., Adisasmita, A., Izati, Y., Makowiecka, K., & Hussein, J. (2009). Assessing quality
of care provided by Indonesian village midwives with a confidential enquiry. Midwifery, 25(5), 528-539.
15. Ministry of Public Health, Afghanistan. Basic Package of Health Services (BPHS), a successful strategy for the
implementation of Primary Health Care in Afghanistan. 2009.
16. Ministry of Public Health, Afghanistan. A Basic Package of Health Services for Afghanistan. 2005.
17. Professional Package for Medical Doctors for Mental Health Working in the
18. BPHS in Afghanistan, MoPH. 2009.
19. The Essential Package of Hospital Services for Afghanistan MoPH. 2005.
20. World Health Organization: Mental Health Global Action Programme mhGAP.2001.
21. World Health Organization: Mental Health Atlas. 2011.
22. World Health Organization: Treatment for Mental Health Inadequate and Underfunded.2011.
23. Owens PL, Hoagwood K, Horwitz SM, Leaf PJ, Poduska JM, Kellam SG, et al. Barriers to children's mental
health services. Journal of the American Academy of Child & Adolescent Psychiatry. 2002;41(6):731-8.
24. James BOJ, R. Lawani, A. O. Depression in primary care: the knowledge, attitudes and practice of general
practitioners in Benin City, Nigeria. South African Family Practice. 2012;54(1):55-60.
25. Summers M, Happell B. Patient satisfaction with psychiatric services provided by a Melbourne tertiary hospital
emergency department. Journal of psychiatric and mental health nursing. 2003;10(3):351-7.
26. Aswitaj P, WciArka J, Grygiel P, Anczewska M, Schaeffer E, TyczyAski K, et al. Experiences of stigma and
discrimination among users of mental health services in Poland. Transcultural Psychiatry. 2012;49(1):51-68.
Cont…

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Thank You
Qargha Dam - Kabul, Afghanistan