Capitalization Study AMAL MHPSS sector in Libya at Handicap International – Humanity & Inclusion

1- Presentation of the mission

Title of the process:

A capitalization of mental wellbeing change of persons with mental health lived experiences (psychological distress and/or mental health disorders) in locations affected by the conflict and have seen change in social and economic dynamics in Libya

Humanity & Inclusion/

Handicap International Program:

Action for Mental Health Assistance in Libya (AMAL)

Objective of the mission:

Learn from the experience of the community based mental health intervention on the mental well-being of people with mental health lived experiences: what worked well, what did not work well and recommend learnings from this project to incorporate in future similar programs (what can be reproduced, what can be avoided and how)

Time frame of the mission:

30 days commitment upon signature of the contract

A one phase study.

Place of the mission:

Libya or Tunis remotely

Last ToR update:

26/04/2022

Author of ToR:**

Elif Sipahioglu –AMAL Project Manager

Contributors:

Petra WÜNSCHE – MHPSS Specialist

Nishee Adhikari – Operations Manager

2- General context

People suffering from mental health problems can be found everywhere in the world, in every community and across all age groups, regardless of living standards prevailing in their country. Whereas 14% of the global burden of disease is attributed to these disorders[1], the majority of the affected people – of whom 75% live in low-income countries – cannot receive the treatment they need (WHO, 2017). According to the WHO, depression is the primary cause of morbidity and incapacity, and more than 300 million people globally currently live with this problem. In regions where HI operates, strengthening community-based resilience mechanisms has become a prime lever of change leading towards psychosocial improvement and greater respect for the basic rights of the populations concerned. Our interventions aim primarily at meeting the needs of persons living with mental health problems (psychosocial distress and/or mental health disorders) in order to minimize the risk of social judgement, whether this judgement manifests in the form of discrimination, stigmatization, exclusion or social isolation. With this intention, HI has over the past 27 years been working in more than 25 countries where it has run mental health and psychosocial support programmes.[2] More specifically, HI has since 2014 been implementing the “Action for Mental Health Assistance in Libya” a mental health psychosocial support programme in Libya financed by the European Union (DG-NEAR) for the years (December 2018 – June 2022)

Presentation of the mission’context **

Context of Libya

Since the fall of the regime of Gaddafi in 2011 and renewed conflict since 2014, the political and economic situation in Libya has become extremely fragile. Health services in Libya have gradually collapsed due to depleting human resources, equipment and medicine as well as a gross lack of investment in the sector. The population’s health and social well-being has been severely impacted as a result. With 193,581 current internally displaced persons (IDPs) and 382,222^[3] persons returned to their area of origin in the last two years, the capacity of service providers is challenged by repeated influxes of new patients. In addition, the country is facing a migration crisis with 54,416 registered refugees and asylum seekers and an estimated 662,248^[4] migrants present in Libya today, adding another layer of complexity to the humanitarian context.

UNOCHA estimated that the number of people in need of health services in Libya in 2018 to be 1.1 million, among them 16% IDPs, 19% returnees, 36% non-displaced and 30% migrants or refugees. 44% were female and 56% male. In terms of age groups, the majority of the people in need were assessed to be adults (61%), 33% of children and 6% elderly^[5]. Whereas, returnees were reported by REACH to be the group with the highest difficulties to access adequate healthcare (54%)^[6] as they usually return to conflict-affected areas where basic services are no longer functioning. Furthermore, 24.9% of all assessed households reported at least one member displaying two or more signs of psychological distresses, 46.7% of IDP households and 39% of returnee households (compared to 23.5% of non-displaced households).^[7]

The Mental Health System in Libya

The Mental Health/Psychosocial Support (MHPSS) 4W assessment conducted in Libya in 2017 states that “*Mental Health is a chronically neglected field in the country with many longstanding problems that predate the conflict that started in 2011, including underdeveloped community and specialized services, shortage of qualified workforce, lack of facilities, social stigma towards people with mental illness and funding marginalization”.* In addition, the current and long-lasting violence in the country is believed to further increase the proportion of the population in need of mental health and psychosocial support, requiring a combination of immediate and longer-term interventions.

The MHPSS 4W mapping identified a total of 190 organizations, amongst them 16 that deliver MHPSS services, programs, and activities for communities across Libya. The most common activities provided were general services to support MHPSS, psychological interventions, and specialized clinical management of mental disorders. However, some activities linked to information dissemination, community mobilization, community support, safe spaces, psychosocial support in education, inclusion of psychosocial support in other sectors, case focused psychosocial work, and non-specialized management of mental disorders were also reported. The report stated a lack of information regarding the quality of the services provided by all implementing organisations.

Mental health service provision is highly centralized in Benghazi, Tripoli and Misrata, difficult to access and of limited quality. In addition to the two mental health hospitals, Al Razy Psychiatric Hospital in Tripoli and Benghazi Psychiatric Hospital, there are 6 mental health outpatient facilities (one in Al Wahat/Ajdabia, two in Misrata, two in Tripoli and one in Al Jabal Al Gharbi)[8]. Two are in mental health hospitals, two are in general hospitals and two are in polyclinics. In parallel there are a number of private clinics, often run by professionals working in the public hospitals, but that are not accessible to the most vulnerable part of the population primarily due to financial barriers. All in-patients from the two mental health hospitals were discharged in 2014 mainly because of the lack of qualified health professionals (psychiatrics, psychologists, and nurses). A high number of qualified foreign health professionals left the country during the 2014/2015 conflict. Provision of mental health care in Libya is essentially based on prescription of drugs, and counselling and psychotherapy services are rare. In addition, psychotropic medicines are not always available and often not affordable to people with low income.

There is no mental health policy in Libya nor updated mental health legislation. In 2012, an inter-ministerial mental health meeting was conducted with various representatives, proposing to develop a coherent and comprehensive mental health policy focused on six core components: organization of services by developing community mental health services; capacity development of human resources; involvement of users and families; human rights protection of users; equity of access to mental health services across different groups; and quality of services (WHO, 2015). Stigma and lack of awareness about the real extent of mental health needs in Libya, as well as the absence of mental health policy or legislation, have led to limited financing of mental health services. In 2012 the Ministry of Health’s annual budget provided 13 million Libyan Dinars for the two mental health hospitals in Tripoli and Benghazi, accounting for 0.45% of total public health budget.

Needs Assessment (Prevalence of Mental Health Disorders in Libya)

There are no published data on the prevalence of mental health disorders in Libya prior to the 2011 conflict. The WHO estimates that rates of common mental disorders such as anxiety disorders and depression double in the context of humanitarian emergencies from a baseline of around 10% to 20% while people with severe mental health disorders (2-3%) are especially vulnerable in such contexts and require access to care^[9].

According to Charleston’s^[10] predictions on mental health impacts after the 2011 conflict in Libya, the estimated prevalence of depression and Post Traumatic Stress Disorder (PTSD) varies according to levels of population-level political terror, trauma exposure and recurrence of conflict. The study suggests that the prevalence of depression is higher than the prevalence of PTSD and may be as high as 30-40% of the population in areas that are severely affected by conflict. Although the ongoing and recurrent conflict in the country is expected to further increase the proportion of the population in need of mental health and psychosocial support, there is no study revealing the actual mental health impacts of Libya’s population since the upheaval from 2011 began.

A survey amongst 2,692 households conducted by the Danish Institute Against Torture and the Benghazi University in 2013 revealed that 29% of individuals reported anxiety, 30% depression and 6% reported PTSD. Stress levels showed a preoccupation with political instability (63.6%) followed by the collapse of the country (61.2%), insecurity about “life right now” (56.6%) and insecurity about the future (46.4%). Nearly 30% of respondents reported being exposed to violence during demonstrations^[11]. There is an increasing trend of substance use among young people as well as amongst women in Libya^[12]. Unsafe opioid injections have led to HIV infections among drug users^[13]. Accounts from outreach workers, doctors and the media^[14] reveal Libya’s drug-related problems stem from painkiller use, especially Tramadol, and increased alcohol abuse. The situation of non-Libyans in the country (migrants, refugees and people on the move) is also of great concern. It is widely reported in the media of refugees and migrants facing kidnapping, slavery, torture and organized violence, and sexual violence along the migration route.

In 2016 Handicap International conducted an assessment[15] on the availability, capacity and range of services delivered in health structures in Western Libya. The findings of the assessment stressed that the MHPSS sector is undeveloped with a lack of a harmonized statistical system shared by health structures, and the absence of systematic data collection on inpatient flow and pathologies; a lack of trained and experienced MHPSS human resources; an over-medicalization of psychological distress; only a few civil society organisations are active in the field of psychosocial support; and there is a lack of capacity to advocate efficiently for the cause of MHPSS. Moreover, the assessment reported a lack of an integrated rehabilitation system, integrating physical and psychosocial rehabilitation, as well as including health structure departments, coordination, and a referral system.

A multi-sector data collection exercise was also conducted by REACH in June and August 2017. A total of 2,978 household surveys were conducted across 8 areas which found that 36.2 % of households reported at least one member experiencing two or more signs of psychological distress. The Ministry of Health (MoH) and other stakeholders have identified MHPSS as a priority area in Libya. A new mental health program based within Libya’s National Centre for Disease Control (NCDC) was set to transform the institution-based approach to a community-based approach to mental health care, to be made available in all areas of the country. In 2013, a 4-year (2015-2019) mental health strategy to improve the services was launched. However, strategy implementation has been impacted by ongoing conflict and political crisis in Libya.

Availability and Training of Mental Health Specialists

A diploma-training programme for mental health specialists started in 2013 under the Ministry of Education (MoE); however, the programme was not fully implemented due to the conflict. There are insufficient numbers of trained staff in the areas of mental health disorders and disabilities, particularly in substance abuse disorders and in mental disorders among children.

Training of Psychologists is mainly limited to BA-level degrees which usually focus on general or educational psychology, but not in clinical training. There is no psychiatric training scheme for clinicians; and general practitioners commonly work as specialists, without having a formal training program. Qualified doctors usually work as GPs and specialists at the same time, without having to go through a formal psychiatric training program^[16]. The curriculum of the Faculty of Nursing only includes a basic module on mental health during the last year of training. Physician, psychologists, and nurses were previously trained through on-the-job trainings in mental health hospitals where many qualified staff were expatriated (especially nurses). As the major mental health hospitals have seen their activity stopped or seriously reduced, this type of training is not available anymore in Libya.

There is no identified education curriculum in social or psychosocial work to support the implementation of a community approach. As a consequence, most of the case workers working in the humanitarian field today are in the best-case psychologists, otherwise people with another academic background (such as teachers). Organizations working in the field of MHPSS are required to provide internal capacity building to ensure implementation of their activities.

ABOUT THE PROJECT: Action for Mental Health Assistance in Libya (AMAL)

Logical framework of AMAL

For HI, a person’s mental health depends not only on their individual characteristics but also on social and cultural factors. community networks, politics, family, peer relations all have influence on a person’s mental well-being.

The ultimate goals of a community based, inclusive MHPSS intervention such as the one implemented are:

• To ensure the emergence of a community-based development process, i.e. the development of local networks, structures for promoting health, prevention actions, local government policy
• To build organizations’ capacities (of professionals and of people with disabilities
• To implement and/or strengthen social inclusion and equal opportunities policy

The overall objective of the project is therefore, to allow the most vulnerable people in Libya (adults, adolescents and children) from host communities, those internally displaced, returnees and migrants, suffering from mental health disorders/psychosocial disabilities to regain or to preserve good mental health by accessing quality interventions at community level, primary health care level, and secondary and tertiary level. The project’s objective is to be attained through three major outcomes focusing on: de-stigmatisation of mental health disorders, provision of community based psychosocial interventions, access to mental health care services and, capacity building of health professionals (specialized, and non-specialized).

Target group of the action

The final beneficiaries of this action are children, adolescents and adults with mental health disorders/psychosocial disabilities living in the three major cities of Libya – Tripoli, Benghazi and Misrata – and their caregivers, including all status of persons: host community members, IDPs, returnees, refugees and migrants. Due to social stigma, difficulty of access and lack of MHPSS services in Libya at all levels of service delivery (community, primary, secondary, and tertiary level) the needs of these people are largely uncovered. Target groups of the action:

· People with mental health disorders/psychosocial disabilities (final beneficiaries) through the implementation of actions at the community level: awareness campaigns and sessions on the most common mental health disorders and access to mental health care to tackle the issue of stigma; direct provision of services at community level such as home visits, individual and group sessions on psychoeducation, low-intensity psychological interventions (such as Problem Management + (PM+) developed by WHO), parenting skills trainings, peer to peer groups. Based on HI current projects, special attention will be paid to provide access to MHPSS to people with functional limitations and to integrate physical and psychosocial rehabilitation. Victims of explosive hazards are also a target group for HI in Libya, linking its current Mine Action activities in the provision of victim assistance services.

· Health professionals (junior and senior, non-specialized and specialized), through a capacity building component: psychosocial workers, nurses, family doctors/GPs, psychologists and psychiatrists. All these professionals, either newly graduated or already active within public health facilities (Primary Health Care Units, Primary Health Care Centres, MHPSS departments of General Hospitals, MHPSS Specialized Hospitals), will benefit from training provided by NEBRAS and HI on clinical and community intervention in mental health.

· The Ministry of Health (the Directorate of Primary Health Care Services, the Directorate of Hospital Services, the Directorate of International Cooperation and the Directorate of Nursing and of Human Resources, the Mental Health Department of the National Centre for Disease Control under the umbrella of the Ministry of Health, local departments of the Ministry of Health in Greater Benghazi and Tripoli, selected services (PHC Units, PHC Centers), MH departments of General Hospitals, MH Specialized Hospitals). Selected public health facilities will benefit from increased technical capacities of their staff (see target group above), but also from better working procedures, referral pathways, and guidelines regarding care of people with mental health disorders/psychosocial disabilities.

4 – Presentation of the capitalization study

Why this capitalization study and why it is useful?

There has been a great need to implement projects in the mental health and psychosocial support field in humanitarian and development settings; and prior studies in this area has had limited inputs from practitioners especially in Libya. dI needs to build the evidence around its MHPSS Community-based Interventions in order to understand what worked well and what did not work well in a country such as Libya which is a new MHPSS field of intervention. The capitalisation study therefore aims to focus on the lessons learnt which will feed into the analysis of the outcomes and performance of the project. The study is a chance for HI to improve its practices, identify and promote the know-how, an attempt for the loss in knowledge generated throughout the project cycle in the Libyan context, define and explain some of the challenges. The study is a chance to take a step back and focus on the learning from the implementation of the daily activities. In the context of a capitalization study, it is the “how” that matters, because the ‘how’ will ensure that the good practices can be reproduced and be of benefit in other contexts of intervention. Therefore, the processes that took place, the steps and the ‘how’s are the focus for the study.

The value and use of this capitalization study:

• The results will be used to (re)orient the intervention in Libya
• The used quantitative and qualitative tools and methods will feed a more global reflection on Monitoring and Evaluation of existing and new MHPSS projects within HI
• The Outcomes and Learnings will be shared at local, regional and international level:

o Operational level: Share with National Mental Health (PHCI) and MHPSS TWG, other peers from the civil society, the users’ movements, and the services providers the learnings and challenges in the implementation of such a project.

o Research level: Contribute to knowledge increase in the MHPSS sector on the challenges, gaps, needs and success of implementation of MHPSS activities within Libya.

o Advocacy purpose: Show policy makers, decision makers and donors how it is possible to build effective MHPSS intervention, highlight areas of improvement (and how) the participation of people with lived mental health experiences can be achieved.

Capitalization objectives

As part of AMAL project, HI has implemented low intensity psychosocial community based interventions, directly through HI team of psychosocial workers and indirectly through training of MoH and CSOs staff. The study will explore the practices implemented in order to generate lessons learned and an updated intervention method to help the future development of contextually sensitive MHPSS programmes to better respond to the needs of populations affected by the humanitarian crisis, in particular in Libya.

This study aims to reveal:

· Patterns of profiles of beneficiaries and difficulties faced

· HI processes and the importance of ‘how’ in relation to the activity implementation in relation to meeting the needs of beneficiaries’ psychological well-being and improving their mental health

· Needs for changes in practices as well as recommendations for future programming

· The good practices related to successful outcomes and the ‘bad’ practices that hindered successful activity implementation

Location

The study will take place in Tunis remotely and/or Tripoli with possibility to access the project implementation areas by the time of selection and contracting.

Specific learning questions

The subjects on which to capitalize for this project are in relation to the three outcomes of the AMAL project:

· How did the project reach the beneficiary in need of MHPSS services?

· What was the process to strengthen the capacity of MHPSS provider to fulfil the need of MHPSS beneficiaries?

· What are the key steps that enabled bridging gap between MHPSS needs of beneficiaries and service providers?

· What are the techniques or approaches tested during the project that are successful?

· What are the major challenges/barrier faced and what measures were adopted to overcome them?

Topics identification is to be further discussed with the selected consultant for the capitalization study

Methodology

Quantitative (HI database) and qualitative (structured interviews with HI partners, HI institutional partners, HI implementing partners interviews with beneficiaries to learn more on their profiles, conditions, satisfaction of the services and recommendations and produce success stories).

The methodology adopted to conduct this study will cover:

· Review of project documents in specific beneficiary files of AMAL

· Analysis of the practices implemented during the programme through interviews of HI, HI partner and HI institutional partner staff

· Analysis of HI’s beneficiary’s database to understand better the profiles of beneficiaries and the difficulties they have been or are facing in such context

· Analysis of individual data, through review of beneficiaries’ files and interview to collect the opinion of the beneficiaries on the practices implemented during the project and collection of success stories of beneficiaries via semi-structured interviews

Ethics and Confidentiality

The ethical principles adopted by HI can be transposed into 8 interdependent recommendations specific to the data management:

§ Guarantee the security of all the partners involved

§ Ensure a person/Community-centered approach

§ Obtain the subjects’ free and informed consent

§ Ensure referral mechanisms are in place

§ Ensure the security of personal and sensitive data at all stages of the process

§ Plan and guarantee the use and sharing information

§ Ensure the expertise of the teams involved and the scientific validity of the activity

§ Obtain the authorization from the relevant authorities and organize an external review of the proposed Research.

HI has developed numbers of institutional policies which provide an essential reference framework for HI statutory mission. These policies apply first and foremost to HI’s members and staff, whether at the Federation or in our national associations. However, they also include provisions that apply to the other stakeholders in our activities, especially our public, private or associative partners, and companies that provide us with goods and services.

Please refer to: Studies and Research at Handicap International: Promoting data ethical management, Collection: Guidance Note, September 2015; Practical Guide – How to integrate data protection within our operations on data protection September 2021

Specific challenges and constraints

CHALLENGES

HI and its consultants have had issues accessing Libya and project locations. HI MHPSS team based in Tunis will ensure proper presentation of the structure and means of communication with field staff including partners.

KNOWLEDGE TRANSLATION

Following the study and the final workshop and products, HI will implement regular communication on the results and lessons learnt with its regional/HQ offices, MHPSS TWG, and donors to feed our practices in the relevant programmes in Libya.

Presentation of the capitalization’s Implementation

General objective of the expert mission

In close collaboration with HI, the consultant will ensure the planning, the implementation including all final products, are fully implemented, and are corresponding to the results and timeline as per the contract and its annexes.

Deliverables from the consultant

Capitalization study report and sharing outcome during project’s lessons learnt workshop.

Deliverables

Technical Documents related to the study

1. Inception report – with definition of specific learning question
2. Methodological framework
3. Data collection tools
4. Meeting with HI focal points to update and follow up on the inception report

Mid-term Documents/ Reports/ Diffusion

1. Documents review (beneficiary files as well as project documents)
2. Interviews with random sample of beneficiaries and production of 3 success stories and testimonials from stakeholders
3. Interviews with HI staff (PSWs), partners’ staff and institutional partner staff
4. Meeting with HI focal points to update and follow up

Final stage workshop and products

1. Draft of the capitalization report with all annexes
2. Sharing of outcomes of a study with HI team members and feedback from them
3. Sharing the final report including a brief summary report on the study (with HI teams in Libya, Regional and HQ)

Time Schedule & budget

HI expects this capitalization to start in 15 May 2022, for 30 days as explained above. This means obtaining all prior authorizations. The work should be completed by 15 June 2022 with workshop to be conducted in the following week.

Mechanisms for communication and monitoring between the consultant and Handicap International

This study will be monitored by MHPSS Project Manager and will be the focal point for all communications related to the consultancy. MHPSS Project Manager will be lead on international communication and coordination as required.

Requested profile

6-1- Requested profile

The call will be open to Academic partner (Research labs) and independent researchers/consultants.

6-2- Expertise

· Mandatory

• Minimum Diploma: Masters’ Degree (or PhD candidate) in psychology/social sciences or related field (10%)
• Experience in MHPSS Community-based approaches in development and humanitarian settings (10%)
• Familiar with the socio-cultural and political context of intervention would be a strong asset (10%)
• Proven and recognized experience in methods of qualitative and quantitative data collection, treatment, and analysis (quantitative and / or qualitative and / or secondary data) (15%)
• Proven and recognized experience in development and humanitarian settings producing project evaluation, learning from experience, capitalization papers and analysis, synthesis, and writing demonstrated capacity (provide a list of publications) (15%)
• Knowledge working languages ​​(written & oral): English and Arabic mandatory (10%)
• Available for work from mid-May to mid-June, 2022 (30 days from the signing of the contract)
• Financial Proposal (30%)

· Desired

• Recommended experience in conducting surveys including people with MH ISSUES
• (Adaptation of tools or support of communication).
• Ability to work in collaboration with public and associative actors
• Experience conducting research

Application process

Applications must include:

· About the consultant:

• A curriculum vitae (training, experience in the areas mentioned above, lists of key publications)
• References
• A letter of motivation

· About the technical proposal:

• A methodological proposal to conduct the full study including, a minima
• Understanding of the issues of the surveys and of the terms of reference; background of the survey/ research; presentation of the objectives (general & specific); location; target population; presentation of the methodological framework: study design, selection of participants, data collection, data treatment, data analysis, quality monitoring mechanisms; ethical considerations
• A time schedule, clearly detailing activities for implementation, realization, monitoring and exploitation of the survey
• A financial proposal