A case study in Colombia: implementation of the IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings

Colombia is one of the first countries in the world to implement the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings in the form of a ‘case study' It was shown that the guidelines are in general terms applicable and adaptable to the Colombian context. The guidelines were a useful coordination tool for the stakeholders from three different communities in identifying their priority needs and planning according responses from a holistic mental health and psychosocial support (MHPSS) perspective. Reccomendations are made to improve implementation of the guidelines, as well as how to continue supporting the process at both national and local levels.

Keywords: Inter-Agency Standing Committee (IASC), guidelines, mental health, psychosocial support, implementation, Colombia

Colombia was one of the first countries in the world to implement the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings in form of a ‘case study' which includes a mixture of capacity building and external documentation. Peru has also conducted a similar exercise, with the communities affected by the August 2007 earthquake.

The Pan American Health Organization (PAHO/WHO) in Colombia took the lead of the case study, with the agreement of the

Colombian Ministry of Social Welfare. An initial step was to form a Task Force Group in Bogota, in order to design this exercise. Several governmental organizations, including the Ministry of Social Welfare and agencies in charge of internal displacement and child protection, as well as nongovernmental organizations (NGOs), such as the Colombian Red Cross, Medecins Sans Fron-tieres Holland and Pastoral Social (part of Caritas International), the Colombian Psychiatry Association and the Psychology Department of Javeriana University participated in this Task Force (TF) Group. The United Nations joined the process through the participation of the United Nations Children’s Fund (UNICEF), the UN Office for the Coordination of Humanitarian Affairs (OCHA) and the International Organization for Migration (IOM). The United Nations High Commissioner for Refugees (UNHCR) was a bridge with local Internally Displaced Persons (IDP) associations. The Task Force decided to implement the guidelines in three different municipalities in Narifio (southwest province of Colombia bordering with Ecuador) and Norte de Santander (northeast province bordering with Venezuela). Narifio Province, one of the most heavily affected by the armed conflict and narcotics cultivation and trafficking, has a significant presence of illegal armed groups and the Colombian Army, all of which fight for territorial control. This has led to the forced displacement of between 59,036 and 87,129 IDPs since 2000, according to government and national Human Rights NGO CODHES estimates. There are also an ill-defined number of refugees, and many civilians are constricted in their movements due to the deployment of antipersonnel mines and weapons.

We used the following criteria to select the three municipalities for implementation:

•    High impact of the conflict on civilians (massive displacement, confinement).

•    Presence of ethnic groups (with the aim of favouring a ‘differential approach’).

•    Presence of humanitarian organizations to participate.

•    The possibility of a follow up, post case study.

We initially selected the following locations, contexts and target populations:

•    Tumaco (Narifio): recently displaced Afro-Colombian population in an urban setting on the Pacific Coast.

•    Ricaurte (Narino): displaced and confined, indigenous population (Awa community), close to the Ecuador border.

•    Tib⁵ (Norte de Santander): population of survivors of massacres in the past, relatively active conflict. As a location, Tib5 was eventually replaced by Leiva, an area of peasant Andean mountain communities, survivors of a recent massacre.

We had three main objectives for the case study:

•    To test the applicability, adaptability and acceptability ofthe guidelines in the field.

•    To build capacity in these three locations, at the level of both participating agencies, institutions and community organisations.

•    To promote a common language between different humanitarian actors and authorities regarding Mental Health and Psychosocial Support (MHPSS), improving coordination and thus practice.

‘‘Dos Mundos’’ Foundation (a national NGO) was selected as an external observer of the process, in order to assess the guidelines’ practical implementation from a user’s perspective (organizations), a community perspective and to determine the strengths and weaknesses of this tool in a field setting. An observer report will be released soon. Our initial methodology consisted of trying to establish a leading organization for the case study in each location. Medecins Sans Frontieres Holland (MSF-H) was initially the lead candidate in Tib5, but the organization ultimately declined to assume this role. They felt that the identification and strengthening of community networks may put the community at risk, since social networks have often been targeted by armed groups in this location. In addition, MSF Holland feared the potential for a change in the community’s perception of their neutrality, with possible implications for the security of their teams. Meanwhile, the possibility of carrying out the case study arose in a third location in Narino after a massacre that took place in the municipality of Leiva leading to the displacement of 20 families. During the initial intervention of government and humanitarian actors, the community identified psychosocial support as a priority in order to prevent further displacement. The Task Force considered this as a relevant context for the case study.

In the three test locations selected, we proceeded to prepare the first visit to the local communities, which included the production of a graphic, summary version of the guidelines in Spanish, adapted for presentation to local communities. We also collected anthropological information on the indigenous community of the Awa, and produced an initial ‘mapping’ of each of the three locations (including needs, existing services and humanitarian actors). A virtual discussion group was created in order to facilitate exchanges between the Task Force members at Bogota and local levels.

Fieldwork

Our first field visit was conducted in early February 2008, with the purpose of presenting the case study project to local and departmental authorities, humanitarian actors and local communities. The main conclusions of this initial field visit were:

•    Departmental and municipal authorities were generally very positive towards the case study.

•    The target communities seemed very receptive to the project; there were important needs from a holistic psychosocial perspective, which confirmed that a coordinated multi-sectorial intervention approach would be relevant.

•    There were relatively strong community organizations in the municipalities (with the exception of Leiva). We considered that it was important to work with these organizations during implementation, in order to adapt the response to priority needs of the target population, as well as building capacity.

•    A support from PAHO to the participating organisations was required during implementation, particularly regarding the overall planning and coordination of different stakeholders. It did not appear viable at the outset for a municipal organization to assume the process of leadership.

The second phase of the case study corresponded to an orientation workshop for the organizations and community leaders from Narino municipalities involved in the implementation. This workshop was initially programmed to occur during the first week of March 2008, but, due to security concerns at that time and to a specific threat to the Awa community linked to a protest march, it had to be postponed until mid April.

Two international experts carried out an initial three-day workshop for staff having a mental health and/or psychosocial support background and working in any of the three municipalities. An important emphasis in this workshop was on the contextualisation of the Action Sheets on community mobilisation and support and health services. A half-day workshop was also held in each location, in order to orient staff from other sectors to the guidelines. The workshop’s methodology was mainly participatory and interactive: a group was formed for each municipality and the majority of subjects were discussed within these groups; the group’s conclusions were presented afterwards to the plenary session. The primary task of each working group was to contextua-lize the guidelines for each location and to identify actions that could be put into practice, or not. An exercise to establish priority needs and a draft action plan was carried out in each municipality. One of the main accomplishments of the workshops was the formation, in each of the locations, of an MHPSS coordination group in charge of leading the local implementation process. The third phase of the case study consisted of the implementation of the guidelines, and focused on the topics and priorities selected in the municipalities. Regular meetings of the MHPSS coordination groups and community leaders were held in each location between May and June 2008. This allowed groups to consolidate, finish the mapping of humanitarian actors and services and finally, produce an assessment of priority needs from a holistic MHPSS perspective. The use ofthe‘‘multilevelinterven-tion pyramid’ concept from the guidelines was very helpful in identifying priority needs. The groups designed a set of essential responses to these needs, in accordance with the guidelines.

Accomplishments and challenges

The case study resulted in the following key accomplishments:

1. At an international level for the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings:

The case study showed that the guidelines are, in general terms, applicable and adaptable in the Colombian context, and for different ethnic groups. In practice, national and local agencies and

institutions are adopting some aspects of the guidelines into their practice and policies. Nevertheless, the external observation pointed out in a preliminary report⁴ that the guidelines do not propose support tools when it comes to situations where security is a major concern (for instance, when mobilisation of communities can represent a potential risk for individuals). The guidelines were a useful multi-sectorial coordination tool, which helped organizations and communities to articulate and to    3.

identify priority needs and to plan minimum responses from a holistic MHPSS perspective.

2. At a national level:

•    The process of planning and carrying out the case study led to the formation of a National MHPSS Task Force Group which led to the construction of common concepts and a common language and reference points in the MHPSS area.

•    The exercise of implementing the Guidelines favoured a growing interest in and awareness of MHPSS aspects at different levels:

• Ministry of Social Welfare (which includes the Ministry of Health): Project of using the guidelines as reference in the production of Colombian Guidelines in Mental Health in Emergency Settings. This means going into detail in domain number six of the guidelines on health services. There is also a Ministry project (supported by PAHO) for the production of Colombian Psychosocial Guidelines addressed to local authorities and communities, in order to orient them

regarding useful and harmful practices in MHPSS.

• Interest of different governmental agencies (Child Protection Agency and the Presidential Agency for IDP issues), as well as nongovernmental organizations, such as Pastoral Social-Caritas and the Colombian Red Cross, in integrating part of the guidelines to their programme protocols.

At a local level:

• Formation of operational MHPSS coordination groups in each of the case study’s locations. These groups have been actively working to establishprio-rity needs and adapt initial responses.

• Empowerment of Narino’s Health Department and local health authorities: the former has assumed a leading role to assure follow up of the communities and initiatives born from the proj ect.

•    Inclusion of the guidelines principles in Narino’s Emergency Preparedness Plans.

•    Implementation of Narino’s recently developed Mental Health Policy in the three municipalities, integrating the work carried out during the guidelines’ implementation.

We faced the following challenges in carrying out the case study:

•    Empowering communities and organisations and getting them to assume ownership of the project were difficult, generally.

•    Need of an external support: it became evident during the planning phase of the case study that PAHO had to take its leadership role, since no other organisation from the field level was

ready to assume this role. An important level of support was required from PAHO to ensure effective coordination, which necessitated both financial and human resources from PAHO and other agencies⁵. This additional support may not be available in other settings wishing to implement the guidelines. Besides, the duration of the implementation phase was short (one month and a half) because of the limited external resources available.

•    It was difficult to involve sectors different than health, which canbe partially explained by the leading role of PAHO.

• A coordinated intervention with governmental and UN agencies was perceived in one instance (MSF Holland) as a security threat, impeding their participation.

Recommendations

1. At an international level for IASC Guidelines on MHPSS in emergency-

settings:

- To collect information from other implementation exercises on specific experiences and tools, which would facilitate practical implementation of the different actions of the guidelines. It would help to add specific examples on practical implementation tools at a field level to the general recommendations of the guidelines.

-    To provide orientation on those guide-lines’actions that can be implemented at a local level without additional resources or competencies (organising MHPSS coordination groups, for instance), versus those that require additional external support (guidelines’orientation workshops addressed to field stakeholders).

2.    At a national level:

•    To continue the process of MHPSS coordination among institutions and organisations, using the guidelines as a common language and reference point.

•    To continue to use the guidelines to complement or modify policies and protocols from agencies and institutions.

•    To integrate guidelines’concepts to the National Mental Health Policy, which is currently under development.

3.    At a local level:

•    To assure continuity and follow up of the process, through technical support to Narino’s Health Department.

•    To link the local MHPSS coordination groups to existing local institutional committees, in order to avoid overlapping efforts.

•    To conduct a follow up visit to the three municipalities in six to twelve months time, if resources allow, evaluating what has happened after the external international support ceased.

Acknowledgements

The authors wish to give a special thank you to the communities, institutions and organisations involved for their participation and motivation, which made this case study possible.

The authors would also like to acknowledge Dr. Victor Aparicio (PAHO Mental Health sub-regional advisor), Dr. Mark Van Ommeren (Scientist in the WHO Department of Mental Health and Substance Abuse) and Prof. Michael Wessells (Professor in the

Program on Forced Migration and Health of Columbia University) for their invaluable support in the process of preparing this case study. We would especially like to thank Victor Aparicio and Michael Wessells for their in country support during the case study.

References

Inter-Agency Standing Committee (IASC) (2007), IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings. Geneva: IASC.

¹ International NGO carrying out humanitarian activities inTumaco.

²    Presidential agency for IDP issues.

³    Humanitarian organisation present in northern Narino.

⁴    A final report on the external observation of the case study will soon be available.

⁵    UNICEF New York and Colombia participated in funding the workshop phase in Narino. USAID, through a Columbia University grant, funded the external evaluation consultancy by ‘‘Dos Mundos’’ Foundation.

Dr. Carolina Echeverri, M.D, Psychiatrist, PAHO consultant, caro_echeverri@yahoo.fr Dr. Jorge Castilla, M.D, MScPH, Health advisor for Disasters and Complex Emergencies, PAHO Colombia, castillaj@paho.org