Current situations and future directions for mental health system governance in Nepal: findings from a qualitative study

Background: Assessing and understanding health systems governance is crucial to ensure accountability and transparency, and to improve the performance of mental health systems. There is a lack of systematic procedures to assess governance in mental health systems at a country level. The aim of this study was to appraise mental health systems governance in Nepal, with the view to making recommendations for improvements. Methods: In-depth individual interviews were conducted with national-level policymakers (n = 17) and district-level planners (n = 11). The interview checklist was developed using an existing health systems governance framework developed by Siddiqi and colleagues as a guide. Data analysis was done with NVivo 10, using the procedure of framework analysis. Results: The mental health systems governance assessment reveals a few enabling factors and many barriers. Factors enabling good governance include availability of mental health policy, inclusion of mental health in other general health policies and plans, increasing presence of Non-Governmental Organizations (NGOs) and service user organizations in policy forums, and implementation of a few mental health projects through government-NGO collaborations. Legal and policy barriers include the failure to officially revise or fully implement the mental health policy of 1996, the existence of legislation and several laws that have discriminatory provisions for people with mental illness, and lack of a mental health act and associated regulations to protect against this. Other barriers include lack of a mental health unit within the Ministry of Health, absence of district-level mental health planning, inadequate mental health record-keeping systems, inequitable allocation of funding for mental health, very few health workers trained in mental health, and the lack of availability of psychotropic drugs at the primary health care level. Conclusions: In the last few years, some positive developments have emerged in terms of policy recognition for mental health, as well as the increased presence of NGOs, increased presence of service users or caregivers in mental health governance, albeit restricted to only some of its domains. However, the improvements at the policy level have not been translated into implementation due to lack of strong leadership and governance mechanisms.</p

Prevalence and correlates of depression and alcohol use disorder among adults attending primary health care services in Nepal: a cross sectional study.

BACKGROUND: Although depression and alcohol use disorder (AUD) are expected to be common among patients presenting to primary health care setting, there is limited research on prevalence of depression and AUD among people attending primary health care services in low-income countries. The aim of this study was to assess the prevalence of depression and AUD among adults attending primary care facilities in Nepal and explore factors associated with depression and AUD. METHODS: We conducted a population-based cross-sectional health facility survey with 1474 adults attending 10 primary healthcare facilities in Chitwan district, Nepal. The prevalence of depression and AUD was assessed with validated Nepali versions of the Patient Health Questionnaire (PHQ-9) and Alcohol Use Disorder Identification Test (AUDIT). RESULTS: 16.8% of the study sample (females 19.6% and males 11.3%) met the threshold for depression and 7.3% (males 19.8% and females 1.1%) for AUD. The rates of depression was higher among females (RR = 1.48, P = 0.009), whereas rates of AUD was lower among females (RR = 0.49, P = 0.000). Rates of depression and AUD varied based on education, caste/ethnicity, occupations and family income. CONCLUSIONS: In Nepal, one out of five women attending primary care services have depression and one out of five men have AUD. Primary care settings, therefore, are an important setting for detection and treatment initiation for these conditions. Given that other occupation is at increased risk for both conditions, it will be important to assure that treatments are feasible and effective for this high risk group

Effectiveness of psychological treatments for depression and alcohol use disorder delivered by community-based counsellors: two pragmatic randomised controlled trials within primary healthcare in Nepal.

BACKGROUND: Evidence shows benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services.AimEvaluating the clinical value of adding psychological treatments, delivered by community-based counsellors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the Mental Health Gap Action Programme (mhGAP). METHOD: Two randomised controlled trials, separately for depression and AUD, were carried out. Participants were randomly allocated (1:1) to mental healthcare delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity, measured using the Patient Health Questionnaire - 9 item (PHQ-9) for depression and the Alcohol Use Disorder Identification Test for AUD, and functional impairment, measured using the World Health Organization Disability Assessment Schedule (WHODAS), at 12 months post-enrolment. RESULTS: Participants with depression in the intervention arm (n = 60) had greater reduction in PHQ-9 and WHODAS scores compared with participants in the control (n = 60) (PHQ-9: M = -5.90, 95% CI -7.55 to -4.25, β = -3.68, 95% CI -5.68 to -1.67, P &lt; 0.001, Cohen's d = 0.66; WHODAS: M = -12.21, 95% CI -19.58 to -4.84, β = -10.74, 95% CI -19.96 to -1.53, P= 0.022, Cohen's d = 0.42). For the AUD trial, no significant effect was found when comparing control (n = 80) and intervention participants (n = 82). CONCLUSION: Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared with only mhGAP-based services by primary health workers 12 months post-treatment.Declaration of interestNone

Dictadura salazarista, descolonización y solidaridad holandesa. El caso del Angola Comité y el CIDAC

In this article I discuss the solidarity activities in Portugal and the Netherlands in the course of the process of decolonization and independence of Lusophone Africa. Firstly, I present the socio-political transformations in the Netherlands during the 1960s and the radical change in Portugal, from Salazar's dictatorship to democracy. Then I narrow the focus on the endeavors and performance of the Dutch Angola Komité in Amsterdam and its support to the Center of Intervention for Development Amílcar Cabral (cidac) in Lisbon. The research is based on primary sources (oral history) and archival research at the International Institute of Social History (iish) in Amsterdam, the Centro de Documentação 25 de Abril, Universidade de Coimbra, and the cidac, Lisbon

The power of silence: Sonic experiences of police operations and occupations in rio de janeiro's favelas

This article examines the sonic dimension of police operations and occupations by tracing how the everyday life changed sonically in favelas in Rio de Janeiro during their occupation by Pacifying Police Units. I tune into the silencing practices of these security policies and conclude that a moral silencing of a racialized and gendered class of people takes place. A focus on silence helps us to understand sound as a technology of power, which enables the Brazilian state to operate along a gendered sonic color line. The cases I discuss are two instances of silencing that are a product of the operations and occupations: first, the silencing of the soundscape of the favela during police operations, and second, the silencing of funk parties. These ethnographic instances elucidate how racialized processes of negation of black subjectivity and black cultural expressions take place in the Olympic city

Walking a Fine Line: Loyalty, Betrayal and the Moral and Gendered Bargains of Resistance

The Kurdish resistance movement, one often hears in Kurdistan, Turkey, and beyond, has brought momentous change to a deeply patriarchal society and in this way paved the way for the empowerment of Kurdish women. Instead of discussing whether such empowerment has “actually” materialized, this article seeks to investigate what moral expectations, normative standards, and gendered subjectivities this narrative generates. The Kurdish case reveals how narratives of empowerment form a crucial part of the moral and gendered bargains that sustain and legitimate resistance movements. As they tie personal lives to political projects of resistance and liberation through notions like sacrifice, gift, and debt, such narratives shape political belonging and render critique a perilous undertaking. Tracing how Kurdish women seek to reconcile the dilemmas that arise as a result, the article reflects on the ways in which the political comes to be refracted in intimate realms of kinship and family. It contends that familial and personal relationships are crucial sites where expectations of political loyalty and allegiance take on shape and substance but are also negotiated and contested

Economic Theologies of Abundance: Halal Exchange and the Limits of Neoliberal Effects in Post-war Bosnia–Herzegovina

This paper questions claims about the all-pervasive neoliberalization of everyday life that dominate many debates in anthropology and beyond. Situated in deprived rural areas of post-war Bosnia–Herzegovina where socio-economic restructuring has led to a reduction in social redistribution and access to many once-guaranteed state provisions, I explore the workings of an Islamic economic theology of halal exchange that mediates divine abundance through an ethics of care and generosity. In a situation of increasing socio-economic inequalities, the economic theology of halal exchange offers villagers a parallel logic of relating to the divine and to each other, as it is concerned with generosity and sharing rather than with the calculative logic of profit and accumulation. Ultimately, this paper addresses the way that specific reconfigurations of cultural values provide a significant basis for moral imagination, innovative practice and virtuous action at a time of radical change and uncertainty