Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective.

BACKGROUND: Major gaps remain - especially in low- and middle-income countries - in the realization of comprehensive, community-based mental health care. One potentially important yet overlooked opportunity for accelerating mental health reform lies within emergency situations, such as armed conflicts or natural disasters. Despite their adverse impacts on affected populations' mental health and well being, emergencies also draw attention and resources to these issues and provide openings for mental health service development. CASE DESCRIPTION: Cases were considered if they represented a low- or middle-income country or territory affected by an emergency, were initiated between 2000 and 2010, succeeded in making changes to the mental health system, and were able to be documented by an expert involved directly with the case. Based on these criteria, 10 case examples from diverse emergency-affected settings were included: Afghanistan, Burundi, Indonesia (Aceh Province), Iraq, Jordan, Kosovo, occupied Palestinian territory, Somalia, Sri Lanka, and Timor-Leste. DISCUSSION AND EVALUATION: These cases demonstrate generally that emergency contexts can be tapped to make substantial and sustainable improvements in mental health systems. From these experiences, 10 common lessons learnt were identified on how to make this happen. These lessons include the importance of adopting a longer-term perspective for mental health reform from the outset, and focusing on system-wide reform that addresses both new-onset and pre-existing mental disorders. CONCLUSIONS: Global progress in mental health care would happen more quickly if, in every crisis, strategic efforts were made to convert short-term interest in mental health problems into momentum for mental health reform.

Emergency obstetric care availability, accessibility and utilization in eight districts in Pakistan's North West Frontier Province.

BACKGROUND: Reducing maternal mortality is a critical issue in Pakistan. Do public health care centers in Pakistan's North West Frontier Province (NWFP) comply with minimum UN recommendations for availability, use, and quality of basic and comprehensive Emergency Obstetric Care (EmOC) as measured by UN process indicators? METHODS: All public health facilities providing EmOC (n = 50) in 30% of districts in NWFP province (n = 8 districts) sampled randomly in September 2003 were included in a cross-sectional study. Data came from health facility records. RESULTS: Almost all indicators were below minimum recommended UN levels. The number of facilities providing basic EmOC services was much too low to be called providing comprehensive coverage. A low percentage of births took place in hospital and few women with complications reached EmOC facilities. Caesarean section was either underutilized or unavailable. The case fatality rate was low, perhaps due to poor record-keeping. CONCLUSION: The findings of this first needs assessment in NWFP province can serve as a benchmark for monitoring future progress. In resource-poor countries like Pakistan, it is important to upgrade existing facilities, giving special emphasis to facilities that provide basic EmOC services, since many problems can be resolved at the most basic level. Health policy makers and planners need to take immediate, appropriate rectifying measures to, inter alia, improve staffing in rural areas, enhance staff skills through training, upgrade management and supervision, ensure medical supply availability, mandate proper record-keeping, and observe progress by monitoring process indicators regularly.