TDH Annual Report Master

Mapping of Mental Health and Psychosocial Support Services in the Gaza Strip

Final Report, 2010DR. ITAF ABED - KEVEN BERMUDEZ - MOHAMMED AL FAR

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erre des Hommes – Lausanne (TDH) and the Technical Unitteam at its Gaza office wish to express their gratitude to UNICEFin Occupied Palestinian Territory (OPT) for financing the

project to develop a Comprehensive Mental Health and Psychosocial Sup-port (MHPSS) Mapping Tool for Gaza and for the professional adviceand unflagging support provided by its Child Protection Officers basedin Jerusalem and Gaza (Ruth O’Connell, Reem Tarazi, SaudaminiSiegrist, and Mioh Nemoto) throughout the entire process.

Not least is our appreciation to Claire Colliard, who, as Technical UnitCoordinator and, therefore, directly responsible for the mapping tool’sinitial development, saved no effort to make sure the project remainedon course.The project would have neither achieved its intended objectives withoutcritical inputs provided by the TDH Jerusalem Office represented by Fed-erica Riccardi (Country Delegate) and the specific contributions of AnaCarrizo, (Field Coordinator) Mohammed Rozzi, (Child Specialist) andWail El Madhon, (Translator and Coordinator Assistant).

A special word of thanks to Mr. Walid Sabah, Director of Departmentof Coordination with NGOs and Mr. Mahmud E’Damma, Health spe-cialist at Community Training Center and Conflict Management inGaza City for their generous ‘insider’ guidance throughout the differentphases of this project. The efforts of the Technical Unit’s support team, composed by HeshamAbu Lamzy, (Logistician) Heba Abu Hamda (Accountant) and driversReyad El Neaizi and Iyas Abu Hamda were equally indispensable for thesuccess of this project.

Sincere thanks to all of them and to all the volunteers who took part inthe data collection.

Acknowledgements

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Final Report, 2010DR. ITAF ABED - KEVEN BERMUDEZ - MOHAMMED AL FAR


Annex 1Questionnaire 40Annex 2Activities IASC oriented 44Annex 3MHPSS Glossary 48Annex 4MHPSS Organizations Contact Information 53

PROCESS SUMMARY - METHODOLOGY10

INTRODUCTION9

MAPPING FINDINGS15

GAPS IN MHPSS SERVICE PROVISION35

RECOMMENDATIONS36

ANNEXES39


Index

he need for a comprehensive map-ping of existing MHPSS servicesin the Gaza Strip became obvious

following Cast Lead (January 2009) due tothe large influx of organizations conduct-ing activities in this sector in absence of aninter-agency coordination framework. This,quite foreseeable, resulted in an incoherentand fragmented overall response character-ized by considerable duplication, even trip-lication of MHPSS services to address cer-tain needs, while other important needs wentunaddressed.MHPSS Cluster leaders in Gaza, (MoH,UNICEF, WHO) therefore, echoed con-cerns expressed by multiple operating part-ners as regards the need to plan appropri-ately for future crisis by promoting the ini-tiative to develop a mapping tool that wouldprovide public and private sector actors with

basic understanding about existing MHPSSservices throughout the strip, as required tojointly build a coherent response, establishnecessary collaborations, improve coordi-nation and information sharing, as well asassist in referrals.The Technical Unit in Terre des Hommes -Lausanne’s Gaza office was established inJanuary 2010 with a mandate to developthis initiative with the collaboration of sec-tor actors, many of which are active mem-bers in the MHPSS Working Group andsubgroups. The first version of the mapping databasewas finalized in early December 2010, af-ter completing a database validation proce-dure. What follows is a description of theintervening process through its various stagesof development, the major findings, andsome recommendations.

Introduction

T

9MHPSS Technical Unit

Terre des hommes Lausanne

he following chapter summarizes

the mapping process, including

instrument development, data col-

lection, database development, verification

process, updating the sector and challen-

ges faced.

1 Initial stage The initial stage of the mapping project,

which lasted 4 months, consisted in secur-

ing an agreement with the MoH in Gaza to

implement this initiative. This first required

defining the conceptual framework to map

the existing resources and reaching a shared

understanding with the MoH regarding MH-

PSS-related activities, in order to make the

database as integrative as possible. The IASC

Guidelines on Mental Health and Psychoso-

cial Support in Emergency Settings, as well

as similar mapping experiences carried out

in the region, were referenced for this pur-

pose. Meanwhile, reduced-scale mapping

resources available in different Gaza-based

agencies were identified and relevant infor-

mation contained in them was retrieved and

collated to form the basis for this new, broad-

based mapping tool.

2 Instruments 2.1 The questionnaire

The next stage consisted in developing a

questionnaire adapted to the Gaza context

to be used to conduct interviews with iden-

tified stakeholders. While the activity cate-

gories in the Global Mapping tool develo-

ped by WHO (4w’s) provided a good star-

ting point to develop the questionnaire, it

became apparent that these needed to be

further refined to reflect local realities.

2.2 Pilot test

Once the MOU was signed with the MoH

for the project’s implementation, the resul-

ting questionnaire was pilot-tested among

13 major MHPSS organizations prior to es-

tablishing its final version.

3 Data collection A list of MHPSS organizations operating in

Gaza was developed on the basis of diffe-

rent resources. 600 were identified in total.

Emails were then sent to these organizations

to confirm their involvement in psychoso-

cial projects. The response was minor. Thus,

phone calls had to be made to all organiza-

Process SummaryMethodology

T



tions on this preliminary list to determine

the exact number of actors conducting psy-

chosocial projects at this time and to take

appointments with focal points for inter-

views. The results of these phone contacts

reduced the number of identified organiza-

tions to 162, among which were found a

number of different Palestinian Ministries,

NGO’s, CBO’s, INGO’s, and UN offices.

Subsequently, a team of 8 interviewers, in-

cluding the TU coordinator, 2 psychosocial

specialists, and 5 appropriately-trained vo-

lunteers, was formed to conduct face-to-face

interviews with the contacted focal points

within each identified organization, using

the developed questionnaire. Appointments

were arranged to visit 4-6 organizations on

a daily basis. The questionnaire and a cover

letter explaining the purpose of mapping

was handed to the focal point within each

organization. All information regarding the

TU UNICEF project was discussed with the

focal points before signing the letter of

consent and starting the interview.

4 Database development and data analysis Throughout this process, which lasted ano-

ther 4 months, the IT specialist attached to

the Technical Unit, with the support of a data

entry volunteer, created a computer-based,

user-friendly IT application using MYSQL

and Delphi IDE technology to facilitate the

task of filtering collected data, in preparation

for analysis and final display. The aim was

to, ultimately, provide online access to this

database to simplify browsing and direct up-

dating by the MHPSS service providers.

5 Sector updating The Technical Unit organized a system-wide

meeting to update involved actors on pro-

gress made in the development of the map-

ping tool and kept them updated through

monthly MHPSS Working Group meetings.

6 Verification process Upon completion of the first version of the

mapping tool, the final stage prior to its pu-

blic dissemination involved designing, jointly

with the MoH, a data verification proce-

dure and implementing it in partnership

with MoH officials. 22 organizations were

included in this data validation process,

which was considered a sufficiently repre-

sentative sample (35% of the total).

7 Database updating Finally, a questionnaire to facilitate the pro-

cess of updating stored information on or-

ganizational activities was designed, to be

distributed among MHPSS service provi-

ders at regular intervals by a local organiza-

tion that will be responsible to assist the

MoH to keep the database current.

8 Challenges faced and steps taken:At the outset, it became apparent that local

health authorities held a different view about

the inclusion of non-specialized services in



Final Report 2010

Mapping of MHPSS Services In the Gaza Strip

the mapping database. They didn’t construe

their activities as holding a narrow link with

the improvement of the local population’s

mental health status. Consequently, there

was initial resistance to develop an all-in-

clusive mapping database. Much discussion

took place to reach a common understan-

ding with these health authorities about the

importance of integrating community-ba-

sed agencies in the overall response, espe-

cially in view of possible future emergen-

cies, where there is less of a need for men-

tal health expertise in the immediate after-

math of a crisis and more of a need to streng-

then community resilience by building on

available resources and capacities. The prio-

rity, especially in anticipation of such situa-

tions, ought to be to build an integrated

support system consisting of various layers,

as reflected in the following IASC pyramid:

This ensures that the local population is

consulted and actively participates in deci-

sion-making during a crisis that affects them

directly or indirectly, rather than having to

rely entirely on external expertise to plan

the response, which may lead to their in-

creased passivity.

At the point where it became possible to de-

velop the MHPSS questionnaire, another

difficulty was to match the ongoing MHPSS

activities in Gaza with the categories and

sub-categories outlined in the WHO 4W’s

system. New definitions were required to

reflect Gaza’s reality. Furthermore, nume-

rous identified services were operating pro-

jects at level 1 of the IASC pyramid; had

this category of activity been included in

the questionnaire, the mapping database

would now contain upwards of 600 orga-



Process Summary - Methodology

nizations. Reaching them to verify these ex-

tremes was time-consuming and frustrating

at times, since their published information

was outdated; some never replied to calls

or emails.

Numerous organizations among those vi-

sited had come to a standstill while waiting

for additional funding to implement psy-

chosocial activities and, therefore, could

only respond retrospectively

9 GlossaryIn parallel, a glossary of MHPSS terms was

developed to facilitate information exchange

among involved actors on related topics (see

annex in CD).

10 Ethical considerationThe participation of organizations in the

mapping exercise was voluntary and their

consent for the dissemination of their infor-

mation regarding their services online was

obtained before the start of the interview.



Final Report 2010


Mapping FindingsThis chapter aims to display the main findings generated from mapping the mental health and psychosocial services in Gaza, as reported by 162 identified MHPSS organizations. The main findings were summarized in the following tables.

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I. Organizations in Gaza Governorates

Table 1 shows significant disparities among different areas in terms of service delivery. Italso shows that most of the psychosocial activities are being carried out by NGOs and CBOs(80%, n=126 /162). This indicates that the nongovernmental sector is the major player inthe provision of this type of services to the population in Gaza.

Gaza North Gaza Der Al-Balah Khaqn Yunis Rafah0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

32

34

36

38

40

42

Governatorate NGO INGO UN System CBO’s Private Other



Mapping Findings

2. Organizations MHPSS Activities in All Gaza Governorates

Table 2 shows the number of MHPSS activities per area. It shows, quite distinctly, that thereis a clear, heavy concentration of these activities (nearly half) being implemented in Gaza cityalone, (44%, n=327/751) while the remaining portion take place elsewhere throughout thestrip. This highlights the fact that several areas remain underserved for MHPSS services.

Main MHPSS Activities NORTH GAZA

Psychological counsellingPsychological supportPsychological medicationPsychotherapy

161215

Supporting community self-helpPsycho-education in community settingPsychosocial support in educationStrtuctural activities to support MHPSS services

1947

Case management / social workStructured social activitiesPsychological activities in protectionFacilitating and strengthening

21372

Psychological counselling

Psychological medication

Psychological activities in protection Psycho-education in community setting

Psychosocial support in education

Facilitating and strengthening Supporting community self-help

Case management / social work

Structured social activities

Strtuctural activities to support MHPSS services

Psychotherapy

Psychological support



Final Report 2010


Main MHPSS Activities in GAZA


52495

36


9301742


12551313



Psychological activities in protection

Psycho-education in community setting





Strtuctural activities

to support MHPSS services

Psychotherapy


Main MHPSS Activities in DEIR AL BALAH


3121

215


716

511


529116



Psychological activities in protectionPsycho-education in community setting




Structured social activities Strtuctural activities


Psychotherapy




Mapping Findings

Main MHPSS Activities in KHAN YUNIS


11122

11


2644


41542



Psychological activities in protection






Strtuctural activities


Psychotherapy


Main MHPSS Activities in RAFAH


1813

210


313

58


115

66

Psychological counsellingPsychosocial support in education

Psychological activities in protection Psychotherapy


Structured social activitiesCase management / social work

Supporting community self-help

Facilitating and strengthening

Strtuctural activities to support MHPSS services





Final Report 2010


3. Activities for Each Different Target Group in Different Areas of the Gaza Strip

Table 3 shows the number of activities targeting different target groups and existing dispari-ties. It shows that nearly half of the activities target children and women (47%, n=1093/2310).At the lower end of the scale, men (.5%, n= 13/2310), youth (.9%, n= 23/2310), staff (.9%, n=23/2310) and teachers (n= .2%, 4/2310) appear to be among the least targeted groups. The lowest number of available specialized activities are focused on mentally ill people (5%,n=107/2310), elderly people (6%, n=146/2310) and physically disable people (9%, n=207/2310)



Mapping Findings

MHPSS Activities per Target Groups in NORTH GAZA

Children

Women

Families

Internally displaced persons

Elderly People

People with physical disability

Mentaly il persons

Youth

Staff

Men

Teachers

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62

MHPSS Activities per Target Groups in GAZA

Children

Women

Families


Elderly People


Mentaly il persons

Youth

Staff

Men

Teachers

0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 240



Final Report 2010


MHPSS Activities per Target Groups in DEIR AL BALAH

Children

Women

Families


Elderly People


Mentaly il persons

Youth

Staff

Men

Teachers

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125

MHPSS Activities per Target Groups in KHAN YUNIS

Children

Women

Families


Elderly People


Mentaly il persons

Youth

Staff

Men

Teachers

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70



Mapping Findings

4. Organizations MHPSS Activities per age category

Table 4 shows existing disparities among different age groups in relation to MHPSS sup-port received. It shows that there is less targeting for the age groups 0-6 (3%, n=71/2130),and above 60 (4%, n=93/2130).

MHPSS Activities per Target Groups in RAFAH

Children

Women

Families


Elderly People


Mentaly il persons

Youth

Staff

Men

Teachers

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80



Final Report 2010


5. Setting of MHPSS Activities per Place of Implementation

Table 5 shows that the large majority of activities are center-based. This contrasts with re-ports by organizations concerning their lack of resources to implement interventions.

Home Community School Psychiatric hospital

Center Clinic OtherPrimary healthCarc center

0

20

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

340

360

380

400

Yes No

Setting of Individual Activities



Mapping Findings

Home Community School Psychiatric hospital

Center Clinic OtherPrimary healthCarc center

0

140

160180200220240260280300320340

460480500520540560580600620

120100

80604020

440420400380360

Yes No

Setting of Activities in Groups



Final Report 2010


6. Staff Categories per Organization in Gaza Governorates

Table 6 shows that the majority of organizations employ counselors, animators, and social work-ers to carry out MHPSS activities. Priority is given to engage psychosocial frontline workers toimplement activities that are designed by program planners who are external to the organization.

Staff Categories in NORTH GAZA

Social worker

Counselor

Animator

Community worker

Psychiatrist

General practitioner

Psychiatric nurse

Speech Therapist

Physio-Theraapist

Psychiatrist

Occupational Therapist

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15



Mapping Findings

Staff Categories in GAZA

Social worker

Counselor

Animator

Community worker

Psychiatrist


Psychiatric nurse

Speech Therapist

Physio-Theraapist

Psychiatrist


0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50

Staff Categories in DEIR AL BALAH

Social worker

Counselor

Animator

Community worker

Psychiatrist


Psychiatric nurse

Speech Therapist

Physio-Theraapist

Psychiatrist


0 1 2 3 4 5 6 7 8 109 11 12 13 14 1615 17 18 19 20 21 22 23 24 25 26 27 28 29 30



Final Report 2010


Staff Categories in KHAN YUNIS

Social worker

Counselor

Animator

Community worker

Psychologist


Psychiatric nurse

Speech Therapist

Physio-Theraapist

Psychiatrist


0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 5 65,5 6,5 7 7,5 8 8,5 9 9,5 10 10,5 11

Staff Categories in RAFAH

Social worker

Counselor

Animator

Community worker

Psychologist


Psychiatric nurse

Speech Therapist

Physio-Theraapist

Psychiatrist


0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17



Mapping Findings

7. Referral Types per Organization in Gaza Governorates

Table 7 shows that NGOs/CBOs are the most active organizations in terms of making re-ferrals, as compared with UNRWA and the governmental sector.

8. Organizations making Referral.

Table 8 shows that the larger volume of referrals among MHPSS service providers acrossdifferent sectors (NGO’s, CBO’s, UNRWA, Government) originate in NGOs/CBOs in direc-tion to specialized services within UNRWA and Government services; there are few crossreferrals in the opposite direction.



Final Report 2010


9. Organizations receiving Referral from different types of Organizations

Table 9 confirms that governmental and UNRWA sectors are receiving the majority of re-ferred cases, indicating that the referral process is most often triggered at a generalist lev-el towards specialized services.

Organizations Making referral

4

3

2

1

0

0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160

Private

NGO

Other

Unrwa

Governatorate

Other



Mapping Findings

10. Familiarity with IASC Guideline

Table 10 reflects scant awareness of IASC guidelines among MHPSS service providers inGaza, with the highest percentage of informed workers belonging to the NGO sector.

Organizations Receiving referral

4

3

2

1

0

0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160

Private

NGO

Other

Unrwa

Governatorate

Other



Final Report 2010


11. Organizations Conducting and Funding Research

Table 11 shows that, despite the widely recognized value in conducting research for the ev-idence base, the practice of research in Gaza remains limited, with NGO’s being the mostactive in this regard. This suggests the possibility of scarce available funding for researchand lack of qualified researchers.

Government NGO INGO UN System CBOs OtherPrivate0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

Yes No No Answer



Mapping Findings

Government NGO INGO UN System CBOs OtherPrivate0

5

10

15

20

25

30

35

40

45

50

55

60

Yes No No Answer



Final Report 2010


12. Obstacles Faced in the implementation of MHPSS Activitiesper Organization

Table 12 shows that the majority of organizations experience setbacks in the key areas offunding, logistics and cultural issues; capacity building appears as their 4th major concern.

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

Yes No No Answer

Government INGO CBOs OtherUN SystemNGO



Mapping Findings

Gaps in MHPSS Service Provision in the Gaza Strip

At close examination of the results displayed through the attached reports, it becomes pos-sible to clarify the current gaps in MHPSS service provision in Gaza Strip:

• Most specialized professionals in this sector are operating in large urban areas, deprivingthe non-urban areas from available expertise. This void is being supplied by non-profession-alized workers, e.g. animators, traditional healers, who also operate with limited trainingand resources. There is no common understanding about acceptable standards of practicefor each category of workers in this sector.

• Priority is being given to women and children, especially the 7-12 age group, (345 activi-ties) the 13-18 age group, (333 activities) and youth (353 activities). Infants and 60+ adultsreceive less attention – 62 out of 622 activities and 66 out of 622 activities respectively.

• Multiplication of similar MHPSS services in high density population areas persists, whichresults in a portion of users likely receiving identical services from different available sources,while others lack support.

• Each organization operates according to project-specific mandates, as a result of whichtraining, intervention, and referral protocols are not unified across the sector. A large ma-jority of MHPSS actors are unfamiliar with IASC guidelines (only 20% reported familiarity).

• The commonly expressed training demands seem to reflect a wide perception that thereis further need to consolidate basic required skills in MHPSS. Training received at univer-sity level doesn’t often match the requirements of the job.

• Most MHPSS interventions are being designed and implemented without an evidencebase, due to minimal investment in research (only 9% of actors are funding research) andlocal expertise in conducting studies, especially of the qualitative type. These interventionsare, consequently, reactive and short-term, with no durable effects.

Coordination and capacity building appear to be central concerns among MHPSS stakehold-ers, beyond the usual ones of funding and logistics.



Recommendations

On the basis of these identified gaps, and in the interest of building a coherent set of MH-

PSS services that integrates the full range of operating partners at different levels of the

pyramid, it would be advisable to focus further attention on the following critical aspects:

• There is a need to distribute specialized human resources more evenly throughout the

strip, even if only in a supervisory capacity.

• There is a need to standardize a definition of the specific roles to be performed by differ-

ent categories of workers operating in this sector, their training requirements, which will

help establish the appropriate boundaries for their projects, create stronger links between

different services, and avoid unnecessary overlap.

• More MHPSS services need to target men, especially young adult males who are current-

ly unemployed and who, therefore, are unable to accomplish culturally-sanctioned life mile-

stones, e.g. marriage.

• MHPSS-oriented organizations need to acquire a clearer understanding of the natural link-

age that exists between mental health care and psychosocial support in order to ensure com-

plementarity and a coordinated response. Broader awareness of the IASC guidelines among

project planners is necessary.

• There is a need to strengthen university-level curricula in MHPSS by incorporating ele-

ments that prepare students to deal with the kinds of issues they will face in their future

work context, and which provides them a basis in practice before graduation.

• There is a need to invest further in research, especially qualitative research, in order to ac-

quire the evidence base that project planners need to design projects that effectively im-

prove the population’s mental health and psychosocial wellbeing.



• There is a need to continually update the mapping database to keep it current and useful.

It is the strong wish of the Technical Unit team in Terre des Hommes – Lausanne that the

first version of the MHPSS mapping database will prove to be a useful tool in support of

these efforts. In particular, the mapping database can serve to generate a variety of detailed

reports on activities being conducted in this cluster, as might be requested by different proj-

ect planners to orient the design of new MHPSS interventions.

For further tailored findings, enquires and information you can contact the MHPSS Technical Unit:Email: [email protected]

Direct line: 00972.(0)8.286.3251



Final Report 2010


AnnexAnnex I MHPSS Questionnaire

Annex 2 Activities IASC Oriented

Annex 3 MHPSS Glossary

Annex 4 MHPSS Organizations Contact Information

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Annex 1MHPSS Questionnaire





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Annex 1 MHPSS Questionnaire





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Organizations in Gaza currently implementing MHPSSactivities at different levels of the IASC pyramid, displayed according to the geographical areas

Annex 2Activities IASC Oriented





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Annex 2 Activities IASC Oriented





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Annex 3MHPSS Glossary





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Annex 4MHPSS OrganizationsContact Information








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Number of organizations: 162

© 2010,Terre des hommes Lausanne - Child Relief

Photos and graphics by Pierfrancesco [email protected]

Alfalasteenya For Printing & Adv.Gaza – Tel: 08 2843080

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TDH Annual Report Master