International responses to humanitarian and refugee crises bring together a multitude of actors and a plethora of missions, agendas and capacities. This diversity holds great potential, but also considerable risk. The potential is that the involvement of such a diverse set of players can result in a comprehensive and effective humanitarian response. The risk is that the response is fragmented, with duplication and wasted resources; is inconsistent with actual needs; and has unintended and adverse consequences. The multiplicity of actors also increases competition for resources, and upward accountability to donors compromises and eclipses downward accountability to the people the response is supposed to help. This lack of downward accountability is aggravated by the fact that, in countries affected by crisis, government accountability mechanisms usually relate to legal (registration) and financial (reporting) matters, not the quality of operations.
To address these concerns coordination is essential, and is a core function of humanitarian governance. Effective coordination can optimise available resources and increase accountability, minimising duplication, preventing overlaps and ensuring complementarity and the synchronisation of humanitarian work. How should coordination mechanisms be designed to maximise benefits and avoid pitfalls? In an attempt to answer this question, this article explores the mental health and psychosocial support (MHPSS) response to the Syrian refugee crisis in Lebanon.
The MHPSS response in Lebanon
Lebanon is a small, middle-income country, with a history of civil war and political unrest. Its population is around 6 million, including 180,000 Palestine refugees and around 1.5 million people displaced from Syria. Displacement has had a significant impact on the economy, employment and basic services, including health services. Even before the current crisis, the mental health system was inadequate: availability, accessibility and affordability of services were limited, both for Lebanese and non Lebanese, with services mainly provided in the private sector and skewed towards specialised care. Hospitals had occupancy rates of 97%, and outpatient care, mainly provided in the private sector, was affordable for only a few. Mental health was poorly integrated into primary care.
Gaps in services and a lack of coordination between providers were highlighted by a 2013 UN High Commissioner for Refugees (UNHCR) assessment of MHPSS services for displaced people. R. El Chammay, W. Kheir and H. Alaouie, UNHCR Assessment of Mental Health and Psychosocial Services for Syrian Refugees in Lebanon, 2013 http://data.unhcr.org/syrianrefugees/download.php?id=4575 (Accessed 23 July 2014). Building on this report, and recognising that humanitarian crises can be an opportunity to ‘build back better’, the Ministry of Public Health (MoPH) has committed to a long-term vision for sustainable mental health reform, and has taken major strategic steps in that direction, including establishing and leading a national MHPSS coordination mechanism, the MHPSS task force (TF), and launching a National Mental Health Programme to lead reform of the mental health system. The first national strategy for mental health, launched in 2015 and covering the period to 2020, Ministry of Public Health, Mental Health and Substance Use – Prevention, Promotion, and Treatment – Situation Analysis and Strategy for Lebanon 2015–2020, Version 1.1, 2015 (https://www.moph.gov.lb/userfiles/files/Mental%20Health%20and%20Substance%20Use%20Strategy%20for%20Lebanon%202015-2020-V1_1-English.pdf). is intended to build a sustainable mental health system. The strategy aims to move towards the vision that ‘All people living in Lebanon … will have the opportunity to enjoy the best possible mental health and well-being’. Displaced people are one of the vulnerable groups identified in the strategy as needing particular attention. The key objective of the strategy in addressing the needs of these populations is to sustain the MHPSS TF and ensure the development and implementation of an annual action plan for addressing gaps and challenges in responding to these needs. The MHPSS response to the Syrian crisis is anchored within this national policy framework.
The MHPSS TF, chaired by the MoPH, the World Health Organisation (WHO) and the UN Children’s Fund (UNICEF), has 50 members from UN agencies, local and international NGOs and government ministries working in MHPSS. It meets each month at central level in the capital and in three of the country’s governorates. The task force has achieved much in various areas, from key coordination functions to capacity-building, service development and the development of national normative documents, including a harmonised list of psychotropic and neurologic medication for prescription in humanitarian settings and standard minimum recruitment criteria for mental health in the humanitarian field. MHPSS indicators have been developed to gather data about the utilisation and quality of services and to inform service planning and policy development. The TF has facilitated service mapping using the WHO ‘4Ws’ tool, and an online mapping platform is being finalised. Capacity-building interventions have been rolled out in evidence-based psychotherapy approaches and to improve the safe identification and referral of people with mental disorders. The TF has also contributed to the implementation of the national mental health strategy, and supports its goal of expanding and reorganising mental health services in line with the WHO service organisation pyramid. In line with the WHO mental health service organisation pyramid, mental health services start with self-care and informal care, generally provided by oneself or one’s network and peers, and are cross-cutting across all levels of care. Formal mental health care services should be offered through primary healthcare services and should be easily accessible and affordable. Specialised psychiatric care is at the tip of the pyramid.
Strengths and challenges of the task force
An action plan for the task force is developed annually through a participatory process that identifies gaps and challenges in the MHPSS response through feedback from implementing actors, triangulated with the results of assessments and service maps. The action plan defines a common vision and priorities and sets out a roadmap for action. The strength of the plan is its alignment with Lebanon’s national mental health strategy, which ensures that actions undertaken fit within the bigger picture and contribute to the building of a national system catering to the needs of Lebanese and non-Lebanese alike.
Another major strength of the TF relates to its role as a meeting point for partners, facilitating links and strengthening relations between government and non-government actors involved in mental health. The collaborative governance model adopted by the MOPH, its commitment to engage with all actors and the participatory processes adopted for the development and implementation of the action plan ensure that all actors are engaged and increase the perceived legitimacy of the MOPH as a leading and governing body. Actors acknowledge that there are system-level challenges in responding to people’s needs that cannot be addressed without the leadership and engagement of the government.
The task force was initially set up at central level and then expanded regionally. This presence at field level ensures that gaps and challenges can be identified more easily and maximises the participation of local NGOs. Participation at regional level is lower than centrally, because of the smaller number of actors active in the regions and because actors attending regional meetings are mostly frontline workers heavily engaged in fieldwork. Around 40 actors take part regularly in meetings. Initially no specific commitments were attached to membership, limiting accountability and the level of commitment of some actors to the work of the TF. Steps have been taken to address this, including:
- Ensuring that meeting agendas cover issues of interest to participants, and efforts to promote interactivity. Discussions around key issues related to service provision are essential, in addition to presentations of new projects and activities, assessments and updates on the implementation of the national strategy.
- Revising the task force’s terms of reference to include defined membership commitments, such as regular attendance and proactive participation in meetings, regular and timely reporting on MHPSS indicators and service mapping and contributions to the implementation of the TF action plan. The new terms of reference will be finalised and implemented later this year.
- An MoPH Director-General circular was issued on 12 July 2017 (number 64) related to projects in MHPSS and substance use in Lebanon. This asked all actors (including local and international humanitarian and non-governmental organisations, UN agencies, local and international universities, associations and donors) to coordinate with the Ministry on new projects, to ensure that the efforts of all actors complement each other and contribute to building the national mental health system in line with the national strategy, and to avoid any duplication of activities. This is proving effective as actors are increasingly engaged and motivated to coordinate and collaborate with the MoPH.
Three major operational lessons emerge from the MHPSS humanitarian response coordination in Lebanon. The first is the importance of an annual action plan, developed in a participatory manner, that can contribute to building the national mental health system. This is essential to ensure consensus on priorities, enhance coordination and ensure that resources are optimised and allocated towards priority areas. The second is the importance of clear terms of reference and membership criteria to increase the accountability and engagement of MHPSS actors. The governance model for coordination must increase commitments to joint action by promoting the move from coordination to collaboration, in line with the national plan. Third is the importance of developing and enforcing normative, contextualised technical documents, such as guidelines and standards, in addition to ‘soft’ governance tools. Such documents constitute the basis for accountability mechanisms that are quality-led. Governance tools can enhance coordination, as exemplified by the circular issued by the MoPH.
Key considerations for coordination in humanitarian emergencies
Building on the lessons from the Lebanon experience, key considerations for the effective coordination of humanitarian response include:
- Engaging actors around one action plan to increase effectiveness and responsiveness to people’s needs. Setting a roadmap in line with a national strategy reduces haphazard and fragmentary action.
- Recognising that humanitarian response strategies should contribute to and be integrated in national development strategies. Not doing this can hinder or delay the execution of sustainable solutions and continued reliance on humanitarian assistance. UNDP and UNHCR, ‘UNDP/UNHCR Transitional Solutions Initiative (TSI) Joint Programme Phase I (2012–14)’, 2013 Annual Report, http://mptf.undp.org/document/download/12914. Emergencies are unparalleled opportunities to build better systems for everyone in need. World Health Organisation Building Back Better: Sustainable Mental Health Care after Emergencies, 2013 (http://www.who.int/mental_health/emergencies/building_back_better/en/). Government-led humanitarian governance can anchor coordination mechanisms in the national policy framework, creating synergies between short-term humanitarian relief and longer-term development strategies.
This leads to a third consideration:
- Promoting government ownership of the humanitarian response. Government leadership is key to ensuring the effective implementation of all functions of coordination: the coherence of humanitarian action with long-term development, increased accountability, efficiency and effectiveness and improved intersectoral coordination. It is increasingly recognised that government-led coordination mechanisms, unlike cluster-based approaches, have the authority and sovereignty to legitimately set up mechanisms to ensure accountability – downward to populations and upward, not to donors but to the government – for effectively contributing to responding to people’s needs. It is also recognised that a more thorough form of coordination is likely in situations where the government of the affected state sets a single national plan as a standard. W. Ammar et al. ‘Health System Resilience: Lebanon and the Syrian Refugee Crisis’, Journal of Global Health 6(2), 2016; P. Knox Clarke and A. Obrecht, Good Humanitarian Action Is Led by the State and Builds on Local Response Capacities Wherever Possible. Global Forum Briefing Papers. London: ALNAP/ODI; A. Clarke Santoro and M. McKee, ‘Governing the Lebanese Health System: Strengthening the National Response to the Burden of Syrian Refugees’, Eastern Mediterranean Health Journal 23(6), 2017. Government agencies have a unique understanding of the local context, including service provision systems and their building-blocks, and have the primary responsibility for responding to humanitarian crises, as highlighted by UN General Assembly Resolution 46/182 on ‘Strengthening of the coordination of humanitarian emergency assistance of the UN’, which provides the basic framework for humanitarian assistance. The resolution emphasises among its guiding principles that governments are responsible for initiating, leading and coordinating humanitarian assistance; and that actors in the international system must direct their contributions to supplementing and supporting national efforts. UN, 78th Plenary Meeting, Resolution 46/182, 1991 (http://www.un.org/documents/ga/res/46/a46r182.htm).
This last consideration has implications for international guidelines for humanitarian action, including the Inter-Agency Standing Committee (IASC) guidelines for humanitarian response. Despite the recommendation in the guidelines to include representatives from key government ministries, UN agencies and NGOs in the MHPSS coordination group, there is no mention of a more active and engaged role for governments in the leadership and coordination of the response. The guidelines call for the development of ‘interagency national policies and plans for MHPSS emergency response’. Inter-Agency Standing Committee, IASC Guidelines on Mental Health and Psychosocial Support in Emergency Settings, 2007 (http://www.who.int/mental_health/emergencies/guidelines_iasc_mental_health_psychosocial_june_2007.pdf). But can plans be qualified as ‘national’ if no government entity is involved in setting them and officially endorsing them? And how can the recommendation in the guidelines to link emergency response with development activities be applied if the critical role of governments in this process is not well articulated?
Nour Kik and Rabih Chammay work in the National Mental Health Programme in the Ministry of Public Health, Lebanon.