Sorour E., Materia E., Khoweiled A., Genchi M., Amin Nelson S., Forcella E., Gaddini A., Serrano M., Minervini C., Pini P., Saeed K. *

Background

Until recently mental health was not given sufficient importance in the public health agenda with particular reference to low and middle-income countries where improvement of mental health services rarely occurred. Several barriers at global, national and local level contributed to this fact, including difficulties in decentralization and integration of mental health services in primary health care settings, scarcity of mental health professionals and of public health perspectives among mental health leadership (Saraceno et al, 2007).

During the last decade, however, mental health has gained momentum by means of global initiatives addressing the scaling up of service care (Patel et al., 2010; Patel et al., 2011; Eaton, 2011; Kleinman, 2009), advocacy for human rights (Kleinman, 2009; May, 2011; Drew et al, 2011), research priorities (Collins et al, 2011) and the role of social determinants of mental disorders.(Patel et al, 2010b; Lund et al, 2010; Lund et al, 2011). As a consequence, the 65th World Health Assembly, held in May 2012, recognised the global burden of mental disorders and the need for a comprehensive response at the country level, urging the Member States to strengthen policies concerning promotion, prevention, treatment and recovery, and requesting to the WHO to develop a mental health action plan. Meanwhile, several low- and middle-income countries (LAMIC) have started to give greater attention to mental health to tackle the large treatment gap- estimated to be between 76% and 85% in LAMIC (WHO, 2008) - and the human rights scandal.

In Egypt, as in other countries of the Eastern Mediterranean region, mental health still has to be considered a neglected priority as evidenced by the huge treatment gap deriving from the mismatch between needs and resources. The one-year prevalence of mental disorders is estimated at population level between 17% and 19% (Ghanem et al, 2009; Hamdi et al, 2009; Hamdi et al, 2012), while the expenditures for mental health are no more than 2% of the total health spending (WHO, Ministry of Health Egypt, 2006), a value that echoes the regional mental health spending of 0,10 US$ per person. (WHO, 2010) Egypt has a population of about 86 million people and an average per capita income of about 6,600 international $ in 2011. It is classified by the World Bank as a low-middle income country. Egypt ranks at 113/187 countries according to the Human Development Index, with a literacy rate oft 66.4%, unemployment for young generations still very high and its wealth quite concentrated: 22% of the population live below the poverty line, and the Gini Index is 32% (UNDP, 2011).

The mental health system in the country operates with limited resources in terms of infrastructure, manpower and finances, with an imbalance between urban and rural areas. Mental health care continues to rely on large psychiatric hospitals - most of them managed by the Mental Health Secretariat (MHS) of the Ministry of Health and Population (MOHP) - while community services, rehabilitation programmes and social support measures are lacking. Personnel of the primary care centres (Family Health Units, FHUs) do not receive adequate training to address psychosocial problems and, especially in rural areas, traditional and faith healers play a key role as private frontline caregivers (see: http://www.asplazio.it/forum/mehenet_forum/ index.php) Nonetheless Egypt got started on reform of its mental health legislation enforcing a new Mental Health Act (Law n°71, May 2009) "for the protection of psychiatric patients" which replaced the 1944 law. The new law acknowledges the rights of persons with mental illness, establishes national and regional commissions to supervise hospitalization, providing safeguards for patients who are nvoluntarily admitted. The law does not address the issue of reorganisation of the mental health care services but it will avoid cases such as that of a Sudanese patient detained for twenty years within a mental hospital because he was deemed to be affected by AIDS and had no family support (Saleh, 2007).

While the Family Health Model - merging several vertical programs within the primary care services - was implemented at a district level in the 27 governorates according to the Health Sector Reform Program launched towards the end of the '90s, mental health care services remained mainly based in the 17 psychiatric hospitals with 5,239 beds run by the MHS with their own independent catchment areas. These hospitals absorb 60% of mental health expenditures (WHO, 2006). No accurate data are available concerning bed capacity in forensic, private and university hospitals.

The biomedical approach prevails in psychiatric hospitals and the efforts recently made to improve their infrastructure, grant patients' privacy and respect basic human rights still need to be strengthened, especially for patients who have been detained for decades. Social deprivation, difficult family relationships and domestic violence may be responsible for the hospitalization of a proportion of patients with questionable mental disorders at their admission, as a documentary film recently shot in two Egyptian mental hospitals has pointed out¹.

This paper reports the experience, results and implications of a pilot project aimed at developing community mental health services in the rural district of Kafr El Dawar in the Behera Governorate (Delta region) of Egypt, serving around one million inhabitants.

A community mental health centre in Egypt

The Mehenet project (Mental Health Network) is an Egyptian-Italian initiative implemented within the program for regional cooperation funded by two Italian Ministries (Foreign Affairs and Economic Development), two Italian regional public health agencies (Laziosanità-ASP and Ares Puglia) in partnership with the Egyptian MOHP (the Mental Health Secretariat and the Primary Health Care Department) and the Eastern Mediterranean Regional Office of the World Health Organisation (WHO EMRO).

The project was founded on the Italian experience in psychiatric reform and de-institutionalisation, and as part of it, the first community mental health centre in the country was activated. The centre is located at the premises of the Family Health Unit in the village of Kobania Abu Keer, has been equipped using the project funds and is managed by the MHS with the technical assistance of the involved Italian experts. It was dedicated to Franco Basaglia, the eminent psychiatrist whose name is linked to the psychiatric reform leading to the closure of psychiatric hospitals in Italy (Law n° 180/1978). The Franco Basaglia centre has become the hub for community mental health services in the Kafr El Dawar district, functionally integrated for patients referral with the network of 36 Family Health Units and with the other entities in charge of mental health care in the area: the mental health hospital of Maamura in the bordering Alexandria governorate and the district hospital of Kafr El Dawar.

Photo 1: The entrance of the Franco Basaglia centre in Kobania Abu Keer.

Prior to the opening of the centre, a multi-professional team - comprised of psychiatrists, psychosocial workers and nurses seconded on a voluntary basis from the Maamura hospital - participated in residential training on community mental health and a subsequent study tour in Italy.

A part-time pharmacist and a staff person dedicated to the development of a community mental health information system were also members of the team. Medical and non-medical staff of the Family Health Unit network were also involved in an educational program on mental health including residential courses - which used multiple teaching and learning methodologies including an extensive use of videos and Italian movies on mental health - and a practical training process at the Franco Basaglia centre itself.

The opening of the centre on January 25th, 2011 was accompanied by an awareness campaign on mental health during which information regarding the new services were provided to the district's population (search for "Mehenet" on YouTube). Two vibrant public meetings were held, preceded by interviews on national and local media and by the involvement of the local communities by means of the distribution of informative material.

Photo 2: The public meeting at the opening of the Franco Basaglia centre.

Focus on psychosocial rehabilitation

During the training program and the subsequent follow-up and supportive supervision of the Franco Basaglia centre's staff, much attention was devoted to issues such as the organisation of community mental health care, continuity of care, patient-staff encounters and outreach activities.

The major challenge was to focus on the bio-psychosocial perspective for mental health with the team, which instead was educated and accustomed to the hospital-based biomedical approach. Activities of psychosocial rehabilitation were key in this regard, given that community mental health services not only have to control patients' symptoms using available medications but also should foster patients' recovery - the individual journey of healing and transformation enabling a person with a mental disorder to live a meaningful life in a community of choice while striving to achieve his or her full potential (Foucault M., 2003). Psychosocial rehabilitation may prevent the early disability that is usually established within a few years after the onset of a psychotic disease; it may also reduce inappropriate hospitalisation and combat discrimination and stigma.

The Mehenet project has thus given emphasis to self-help and mutual peer-support activities with users and their relatives, according to WHO recommendations on the role of informal care within the community as an essential component of the optimal mental health care service mix (WHO, 2001). Courses on self-help were delivered to the psychosocial staff of Franco Basaglia centre and to other facilitators from the Family Health Unit network. Socialisation activities were organised as demonstration events with patients and staff (picnic, visit to zoo-safari, music entertainments, and a 5-day cultural tour on the Nile's sites). Italian users and family associations also participated in the meetings, their presence being notable in a country still lacking these types of civil society organisations and because of their significance as an example of people-to-people co-development.

The Franco Basaglia centre personnel maintained a continuous dialogue within the community, including leaders, school teachers and lay people, to assess needs, intercept demand, inform the population about the services available, and be acquainted with social determinants linked to mental illness and resilience.

Patients were also offered courses on making artistic mosaics, sewing and knitting within workshops oriented to promote creativeness and relationships among users. The mosaic workshop has a highly symbolic value for its metaphoric meaning and because it provided the Franco Basaglia centre with valuable handicrafts made by the users. Egyptian users were also involved in courses for learning how to conduct in-depth interviews aimed at strengthening self-help practices and exchanging experiences between Italian and Egyptian users. An assessment of the labour market and existing intersectoral measures of social support was also undertaken, with the scope of identifying opportunities to launch in the near future individual supported work placements using tutors and work grants.

Moreover, during the project implementation, multidisciplinary mobile teams from the Franco Basaglia centre were organised in order to offer specialised mental health care in other FHUs of the district to increase accessibility to services and strengthen integration with the primary health care facilities.

Photo 3: Users decorating the "Cavallo Pasha"

Photo 4: Users and staff at the training in artistic mosaic.

Admissions and costs

During the first 15 months after opening, 356 patients were registered at the Franco Basaglia centre: 53% were males; 48% were illiterate and 32% had attended only primary school; 61% of them were unemployed and 20% were housewives. More than 50% of patients were diagnosed as affected by psychosis or mood disorders (Figure 1). 61% of cases were self-referred, 23% were referred from the Maamura hospital, 7% from the district hospital and 8% from the Family Units.

Fig.1: Diagnoses registered at the Franco Basaglia centre according to DSM IV

Admissions from Maamura hospital will be monitored to verify if the opening of the new centre will reduce hospitalisation for people resident in Kafr El Dawar district and the revolving door/repeated admissions phenomenon that became typical of mental hospitals in Egypt after the enforcing of the Mental Health Act.

As assessed during the evaluation of the project, the capital costs for the project amounted to 73,000 USD, used for the centre's equipment and for personnel training. The running costs paid by the MHS for salaries, psychotropic medication and consumables add up to 2,550 USD per month and the cost per patient treated is equal to 95 USD, excluding the capital costs.

Innovative aspects and challenges

An innovative approach for community mental health care in Egypt has been launched within the Franco Basaglia centre. Although the project is operational on a local scale, the strategic relevance for mental health policy derives from several elements worthy to be highlighted.

The catchment area of the centre corresponds to the district of Kafr El Dawar, thus extending the organisation of the general health system to mental health and with the implication that mental health services should be planned for geographically-defined populations. Potentially, this would smooth the integration of mental health care with the primary care services and overcome the separation of mental health from the rest of the health system - a heritage of the custody function of psychiatric hospitals and of separation of people affected by "insanity" from the rest of the society. Moreover, the implementation of mental health care services at a district level will foster the mental health leadership to relate to public health approaches, addressing one of the barriers that impede the development of mental health services in low and middle-income countries (Saraceno et al, 2007).

At the beginning of the project it seemed difficult to activate a constructive dialogue between mental health and primary care officials, due either to the "silos" organisation of Egyptian institutions or to the very different approaches of health care ("vertical" for mental health and "horizontal" for the family medicine model). Nevertheless, this collaboration was positively achieved and it made it possible to locate the new mental health centre within the premises of the Family Health Unit in Kobania Abu Keer.

Community mental health features the bio-psychosocial approach thus challenging the biomedical paradigm dominant at hospital level. Within the Franco Basaglia centre, this is highlighted in its focus on care, rehabilitation and recovery as well as in the multi-professional teamwork and the attention provided to community involvement and to the social determinants of mental health.

Community involvement from the very beginning of the project preparation and all through its implementation proved the importance of melting the ice among service providers, users and their families, and people of the community. It promoted innovative ideas, built stronger relationships between users and their community and created sense of belonging and citizenship. It was very obvious how such involvement positively contributed to alleviating the stigma of mental illness in this community.

Sustainability of the initiative is linked to the fact that the Franco Basaglia centre has been constantly managed and supervised by the Mental Health Secretariat and staffed with governmental personnel. Moreover, the Mental Health Secretariat activated a new division of community mental health aimed at following-up the activity of the centre and at developing guidelines for scaling up. This division opened an autonomous budget line to confer incentives for personnel of the community centre. Furthermore, at the end of the project, the centre was included in the official MOHP register of the psychiatric services active in Egypt.

Evidence from available data and the external evaluation of the project indicate that the Franco Basaglia centre is performing well in providing care. Observations during the supervisory visits highlighted motivation and commitment of the staff and capability in establishing meaningful relationships with the users. A user's relative was reported to say: here there are people who listen to us.

The new model of a community mental health centre should be replicated and evaluated across different geographical and socioeconomic settings in the country to be properly assessed, including Upper and Lower Egypt, in urban and rural contexts, with heterogeneous wealth conditions and health infrastructure. The resistance to change should not be overlooked nor should the difficulties in finding motivated staff deployed from hospitals for community mental health services in a country where the number of workers trained in mental health care is truly scant (Hamdi et al, 2012).

Task sharing with primary health care personnel, as recommended by WHO's Regional Office for the Eastern Mediterranean, in an unpublished document on a regional strategy for Mental Health, is a further area of work for community mental health care in the district of Kafr El Dawar. Although preconditions for implementing mhGAP intervention guidelines have been established in terms of refreshing knowledge on mental health among the general health care workforce and establishing links among professionals, additional resources are urgently needed to transfer and organise the management of selected conditions envisaged by the program at the point of service level. The complexity of integrating mental health care in primary care services should not be overlooked, however, as two actual challenges are guaranteeing continuous supervision and specialist support after training and ensuring an adequate supply of psychotropic drugs.

This experience of enhancing the mental health service at the wider base where needs exist, i.e. community level, with the integration of mental health within the primary care system, was an eye opener for Egyptian policy makers. Working at district level and involving the widely distributed primary care service within the district is a practical approach towards the real reform. A deeper understanding of the needs of the local community, employing some staff from the same community and building a bridge with different community sectors and families are the main domains for success of such an approach. The most difficult challenge was the rigidity of the attitude of psychiatric professionals in accepting a change in direction from treatment only to care and recovery. But the beginning of such a change of attitude is now being witnessed in Egypt.

The concern of dissolving the speciality as a result of sharing responsibilities with other professionals and non-professionals is an illusion. Collaborative work will not be maintained except by the support and supervision of highly-trained clinical psychiatric teams and powerful policymaker professionals with a holistic vision. The specialized professionals and policy makers should have the right motivation, and be able to create effective and practical ways to fill the gap between needs and resources. They should be able to successfully manage a productive intersectoral policy that prioritizes, first and foremost, the benefits and rights of the users, their families and the community.

By all means the work implemented by Mehenet project is a success, and can be sustained only by completing the model, spending organizational effort to establish an independent self-sufficient community mental health services in Egypt, and scaling up the experience in other districts in the country.

Conclusions

In Egypt large psychiatric hospitals continue to dominate even though evidence suggests that most services should be delivered at the community level and avoiding institutionalisation. Intersectoral links and public education against stigma and discrimination require efforts at country level, however, since the liaisons with social affairs, policy, prisons and schools are poor and not supported by an updated legislation. In this frame, as stated by the WHO/EMRO Regional strategy for mental health, there is a need to replicate demonstration projects that have introduced some degree of integration between mental health and the general health system to scale up coverage of services and reduce the treatment gap. However, transfer of positive achievements into political strategies and plans takes time, and requires political will and commitment.

Multidisciplinary approaches and integration, which are core elements of the complex biopsychosocial model of community mental health, may challenge the present compartmentalisation of the health sector and foster greater intersectoral integration. Hopefully the results of the Mehenet project will trigger a reform aimed at reorienting mental health services in Egypt as well as a process of scaling up community care at a country level. Therefore, the new model realised in Kafr El Dawar district may represent the first step of a mental health service revolution. It is aimed at fostering deinstitutionalization by setting up a full range of community mental health services, which are more than simply providing outpatient psychiatric treatment. According to the local context and available resources, these should include mental health centres, supported housing, and psychiatric beds in the district general hospitals. Looking for an Egyptian path toward community mental health, this approach intends to reduce social exclusion, ensure social protection for persons with mental disorders and their families, and promote psychosocial rehabilitation.

However, as for other matters related to human rights and democracy, mental health also summons the broader social and political changes that are crossing Egypt today.

1 "Zelal" by Marianne Khoury and Mustapha Hasnaoui

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