Rebuilding Hope After War: Mental Health and Community Recovery

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Rebuilding Hope After War: Mental Health and Community Recovery

Liberia
Organization type: 
nonprofit/ngo/citizen sector
Budget: 
$50,000 - $100,000
Project Summary
Elevator Pitch

Concise Summary: Help us pitch this solution! Provide an explanation within 3-4 short sentences.

Twenty years of brutal conflict has rendered Liberia nearly the poorest country on earth. Facing the triple threats of resource deficits, workforce gaps, and dispersed rural populations, Tiyatien Health is partnering with local communities to reverse decades of untreated depression and epilepsy. We believe everyone deserves access to quality healthcare.

 
About Project

Problem: What problem is this project trying to address?

As a post-conflict and extremely poor country, Liberia is a perilous place to live. Without a healthy population, it not only will fail to recover, but could also sink again into turmoil and violence. During the civil wars, combatants and civilians suffered physical and sexual violence, leading to high incidence of mental illness. In 2008, a randomized survey of Liberian adults found that 40% met symptom criteria for major depressive disorder and 44% for PTSD (K Johnson et.al., http://www.tiyatienhealth.org/publications/). Another recent survey found up to 10% identified with suicidal ideation. In addition, the high incidence of head trauma and infectious diseases suggests epilepsy is also a significant problem, with prevalence rates possibly as high as 5% (Scott RA, Bull WHO 2001). These individuals are not only at risk for suicide or fatal seizure accidents, but also suffer Liberia’s grinding poverty more intensely and often face high stigma. With personal home-based care and group therapy, as well as socio-economic support to patients, we take a multi-faceted approach to Liberia’s complex struggles. Our steps are small, but hopeful.
About You
Organization:
Tiyatien Health
Section 1: About You
First Name

Pat

Last Name

Lee, MD, DTM&H

Country
Section 2: About Your Organization
Organization Name

Tiyatien Health

Organization Phone

857-383-9506 (U.S.) +231-(0)6644719 (Liberia)

Organization Address

Tiyatien Health, PO Box 426133, Cambridge, MA 02142 OR Liberia: Tiyatien Health, Hospital Road, Zwedru, Grand Gedeh County, Libe

Organization Country
Your idea
Country your work focuses on
Innovation
What makes your idea unique?

We address the most ignored, stigmatized diseases in one of Africa’s poorest countries. Despite claims of infeasibility from policymakers and funders, Tiyatien Health has created an innovative, community-based strategy to break the cycle of mental illness and social isolation following Liberia’s two decades of war. TH treats depression and epilepsy, and works to reduce stigma and false beliefs: epilepsy victims commonly seize and fall into fires where they are often left to burn, due to the false belief that epilepsy is a curse passable through touch.

TH’s model for mental health is based on success in its existing program for HIV/AIDS: another incurable, stigmatized disease. As with that effort, Rebuilding Hope After War relies on communities to partner with the public sector. Liberia has fewer than 50 public physicians for its 3.5 million people, so TH trains non-physician clinicians in simplified, evidence-based protocols, and employs community health workers (CHWs) to identify patients, lead group counseling sessions, directly observe medication when indicated, and monitor side effects. The CHWs make home visits to patients and promote early care seeking among neighbors. TH training and CHW interventions are beginning to reduce stigma for both HIV/AIDS and mental illness.

By employing CHWs, Rebuilding Hope After War generates jobs where unemployment reaches 85%. The CHWs provide an ideal solution to the triple threat of severe resource shortages, extreme deficits of trained health workers, and highly dispersed rural populations. Above all, TH is a local organization—founded by war survivors and people living with HIV/AIDS. The community drives all that we do.

Do you have a patent for this idea?

Impact
What impact have you had?

Tiyatien Health (TH), founded by survivors of Liberia’s civil war, first partnered with the Liberian Ministry of Health to successfully build the nation’s first and largest rural public HIV/AIDS treatment and care program, the HIV Equity Initiative (HEI). With Global Fund support, HEI remains the only provider of HIV prevention, treatment, and care for a rural catchment of more than 300,000 people. At one year, this intervention has achieved a survival rate of greater than 85% for persons living with HIV/AIDS.

TH’s unique approach to include community health workers in the leadership of its health programs led to the first trained non-physicians ever to administer anti-retroviral therapy in Liberia. This community-driven model now serves as the potential blueprint for a national effort to scale-up and decentralize HIV services across Liberia’s rural southeast region.

The success of TH's HIV Equity Initiative has prompted TH to look ahead to other needs in the community, such as healthcare for mental illness and epilepsy. Because mental illness is such a pervasive condition in Liberia, TH leadership has advocated with senior Liberian Ministry of Health Officials for the creation of a national policy to address this issue. As a direct result, Liberia adopted its first National Mental Health Policy in 2009.

Tiyatien Health is now improving mental health and epilepsy care in the country’s forested southeast, the same community where TH works with CHWs to provide HIV/AIDS treatment. Capacity for chronic disease care grows in conjunction with health system strengthening, because TH integrates the new mental health initiative into existing HIV Equity Initiative and public-sector primary health care. By hiring and training community health workers for new mental health program interventions, TH continues to be the largest employer of the poor in the Tchien district.

Actions

Most importantly, we are building from community trust generated by our HIV Equity Initiative, described above. In 2007, Tiyatien Health provided the first-ever HIV/AIDS treatments in southeastern Liberia. More than 50 employed CHWs conducted 10,000 home visits last year, to provide directly observed therapy and health education, and help monitor livelihood support provided to the most at-risk patients. Therapy adherence exceeds 90%. Our new efforts to provide mental health services will integrate with this successful model, while also operating through the primary care provided by the public Tubman hospital, with no user fees. This new initiative thus connects with both primary care and an existing disease-specific program.

TH also engages advice from world experts (see personal references, below) and uses standardized diagnosis and treatment, including the PHQ-9 for depression screening. Quantitative and qualitative health research methods led to development of innovative protocols and algorithms that can be used by non-physician clinicians and CHWs to deliver mental health services, attending to problems such as depression, PTSD, community disintegration, and social stigma.

Results

We predict improved health and social outcomes for vulnerable populations, including former child soldiers, victims of sexual violence, and those living with HIV/AIDS. The results of medical treatments and group counseling, as appropriate, will be measured using clinical indicators such as quality of life questionnaires, adherence to care, frequency of mental health or seizure events, and patient feedback. Reduced stigma and expanded education will result in increased safety for the whole community, especially those at risk of injury due to seizures, or at risk for self-harm or suicide.

Unemployment will be reduced where TH is active, and training and employment of community health workers will enrich entire communities. For the first time in Liberia, CHWs will be trained specifically in care for mental health disorders. A comprehensive health clinic will be built to house all of the TH chronic disease activities, including HIV/AIDS care. Overall, TH’s investment in the infrastructure and people of the community will result in improved health service provision. We hope our model will used by others delivering mental health and chronic disease care in low-resource settings.

What will it take for your project to be successful over the next three years? Please address each year separately, if possible.

Year 1: We will focus on developing our model for addressing mental illness and chronic disease first in the village of Zwedru, working through the public Tubman hospital. We currently treat depression and epilepsy, but expect to also begin addressing substance abuse and hypertension during the first year of chronic disease care. Funding for supplies and human resources will be crucial for CHW training, recruitment of registered nurses and physicians’ assistants from Monrovia, and construction of comprehensive care clinic. Included in our initial investments will be sustainable energy sources such as solar-powered electricity and data management systems for monitoring and evaluation. In addition to funding, we hope to strengthen our partnerships with local Ministry of Health (MoH) officials and Merlin, a large international NGO also operating in the area.

Year 2: We plan to expand chronic disease care to include diabetes, asthma, stroke, and heart failure. Recognizing gender inequality and gender-based violence as threats to mental health, we will foster dialogue about domestic violence through an existing group (“Zwedru Women United for Change”). We will launch research efforts to evaluate our model on a population-based scale, and then communicate results in national and international forums. In preparation for expansion during Year 3, we will disseminate our training curriculum and train a team of ‘CHW trainers.’ We will need to use performance-based management for this effort: assessing staff coverage, motivation, and competence.

Year 3: We plan to expand mental health and chronic disease care geographically by working from Zwedru across the Grand Gedeh County, in partnership with local MoH. Therefore, we will require funding for a larger team of community health workers in order to access an expanded catchment area. Merlin, with its international humanitarian mission, may transfer its services to the public sector and local NGOs such as TH, so we must be prepared to assume more coordinating responsibility. Taking sustainability as a concrete concern, we will train experienced clinicians and CHWs to recruit and educate more workers. By relying more heavily on local expertise and support, our efforts will become stably rooted in the community.

What would prevent your project from being a success?

TH launched the mental health and epilepsy initiative (“Rebuilding Hope After War”) in mid-September 2009, but resources remain extremely limited. This scarcity of resources is our biggest threat.

Our goal is to enroll 300 patients with depression and 150 patients with epilepsy for treatment in the first quarter, with a plan to double this capacity in the second quarter. As mentioned above, local prevalence data suggests up to 40% of the population suffers from depression and up to 5% suffers from epilepsy. We expect the major limitation in patient uptake will be our program's throughput, and we will expand this capacity through workforce training and targeted infrastructure investments.

Capacity building requires secure funding, especially for training and fair compensation for community health workers. TH also strongly believes in providing livelihood support—food packages, transportation stipends, and vocational training—for the most at-risk patients. In order to effectively address mental health needs and accompanying stigma, it is crucial to eliminate economic barriers to care. Yet, with increased resources and continued community engagement, we believe we can begin to break the poverty-mental illness cycle.

How many people will your project serve annually?

101‐1000

What is the average monthly household income in your target community, in US Dollars?

Less than $50

Does your project seek to have an impact on public policy?

Yes

Sustainability
What stage is your project in?

Operating for less than a year

In what country?
Is your initiative connected to an established organization?

Yes

If yes, provide organization name.

Tiyatien Health

How long has this organization been operating?

1‐5 years

Does your organization have a Board of Directors or an Advisory Board?

Yes

Does your organization have any non-monetary partnerships with NGOs?

Yes

Does your organization have any non-monetary partnerships with businesses?

No

Does your organization have any non-monetary partnerships with government?

Yes

Please tell us more about how these partnerships are critical to the success of your innovation.

Our greatest partnership is with the Liberian Ministry of Health. We believe sustainable progress can only occur in Liberia through strengthening the public sector. After decades of dictatorships and civil war, Liberia now has goals for progress, which TH supports. We must continue offering direct technical support and expertise to assist the government with its plan of healthcare access in the poorest, most rural places.

Partners in Health, pioneering NGO, shares our vision. PIH and TH are both guided by core beliefs that healthcare is a human right, and no person or condition can be considered “hopeless.” Through our professional relationships with PIH leadership, we have access to their methods and receive direct input on our adaptations to the model.

TH also collaborates with researchers and professionals at Harvard, UCSF, Columbia, and Johns Hopkins; we have built a multi-disciplinary team for research and dissemination of information.

What are the three most important actions needed to grow your initiative or organization?

First, increased staff and supplies are required for the expansion of our treatment programs, including support of our patient care initiatives, increased active case finding, and community-based education programs. Funding for the services of health care providers and disposable goods such as medical supplies and medications are our most important limitations at this time. TH is fortunate to have the support of volunteer researchers, statisticians, epidemiologists, physicians, economists, health systems experts, health consultants and student workers. However, we must have financial resources to fund on-the-ground action, and support of these activities, beyond what volunteers can provide.

Second, we are in need of a stronger data management and monitoring and evaluation capacity, and funding for technological innovation and updating of existing data management systems is required for us to further develop this important aspect of TH's work. With monitoring and evaluation and data storage improvements, we will enroll more patients in our programs, expand our catchment areas, and make timely changes in our interventions to more appropriately address the needs of the community. Importantly, updating of our medical records system will allow us to provide improved continuity of care for our patients, and this is crucially important in our chronic disease care programs.

Finally, an improved procurement system will help us transport medications and material supplies to rural Liberia. The expense and logistical difficulty of transporting items to Liberia has presented challenges that we have overcome, and expansion of our programs will require careful planning and a clearly articulated relationship with the government authorities and transportation partners who help us to deliver our goods to southeastern Liberia.

The Story
What was the defining moment that led you to this innovation?

All innovation, all the tireless effort of Tiyatien Health is defined by Liberians committed to transforming their country. Weafus Quitoe fled with his family to neighboring Cote d’Ivoire on foot during the civil war. He grew up in a refugee camp, and learned to etch out a survival by peddling kerosene across the Ivorian border—crisscrossing military fronts to bring fuel for home lamps to Liberians who had stayed behind. After 15 years in exile, Weafus returned home.

He built a mud-brick hut (no larger than the average American closet) in a small, rural town called Zwedru and began to raise his young son as a single-father. Yet, Weafus cared beyond personal survival. He began to notice the influx of very sick young people with AIDS, nearly 10% of adults. But life-saving antiretroviral treatment had never been introduced at a public facility outside the capital. AIDS was not the only crisis, with women dying in childbirth because they couldn’t afford private hospital fees, and chronic diseases utterly ignored. Weafus decided, “I want to change the injustice.”

Along with Raj Panjabi, a Liberian-born doctor, Weafus founded Tiyatien Health to prove a community-based initiative can build a model rural health system in the poorest corner of Liberia. Weafus taught himself nursing skills, and went from not knowing how to use the “on” button of a computer to learning email, budget management, and fundraising work. He continues to serve as TH’s project director, teaching his local colleagues the healthcare management and delivery skills that are vital to building hope in Liberia.

Tell us about the social innovator behind this idea.

Innovation requires three steps: seeing a problem, designing a solution, and dedicating action toward this solution. While professionally directed research accomplished the second step in Rebuilding Hope After War, the first and last steps are driven by local Liberians.

In 2008, CHWs already employed to deliver HIV therapy signed on to administer a mental health survey. They walked hundreds of miles, through heavy forest, to visit more than 1500 households across 40 villages. Through this survey, they discovered the mental health impact of forced conscription and sexual violence against both men and women—the terrible effects of war. Anecdotally, they also reported on stigma witnessed in their own villages. A single worker identified more than 200 epilepsy patients in communities near her own, realizing these people not only had no access to care, but were also marginalized by their disease.

Tiyatien Health joins forces with leaders in both community and mental health, to adapt existing “best practices” to the Liberian situation. Partners in Health, the organization which pioneered training CHWs to deliver anti-retroviral therapy in Haiti, gives TH direct, personal advice on implementing a similar model in Liberia. We have adapted their CHW training materials to the Liberian context. Additionally, we collaborate with Dr. Vikram Patel, a globally recognized leader in mental health; he and others advise TH on diagnostic and therapeutic protocols—novel interventions for contexts lacking in physical resources and trained professionals.

Any innovation would fail without strong desire to implement, and here again, the Liberian team members lead. Although Rebuilding Hope After War has just begun, local TH staff has identified patients at highest risk. They already combat stigma in their communities, and are now ready to work for equitable mental health care.

How did you first hear about Changemakers?

Web Search (e.g., Google or Yahoo)

If through another, please provide the name of the organization or company