Initiating mental health and psychosocial support at the community level in Bangladesh 

In Bangladesh, prevalence of mental health conditions is inconclusive, and the rate is likely to underestimate the real situation at population level. Mental health issues have long been disregarded and ignored; its importance has been downplayed over physical illness. But momentum started, to signify mental health through 7th five-year plan (FYP) and Vision 2021. The Government of Bangladesh has recognized the urgency of addressing mental health and developed a comprehensive implementation plan to establish a referral system. And we are one of the first nations in the WHO South-East Asia Region to prioritize mental health as one of the top ten health issues. 

Mental health is often perceived as a complicated phenomenon that impacts a person's physiological, environmental, social, cultural, and family structure. It needs culturally contextualized intervention to address mental health-related issues in various age groups. Every country has a history of neglecting mental health, and every country is a developing country when it comes to mental health. There are numerous reasons for this negligence, including the fact that mental health is a relatively new area of work in the health sector. Stigma, lack of awareness, knowledge, negligence, and sensitization about mental health, an insufficient number of mental health experts, non-established referral systems, and a lack of funds for mental health and limited research studies are barriers to ensuring the mental health wellbeing of our country's population. To address the community mental health issue, we need to come up with person centered approach, early intervention and offer the service at their doorstep. For that, we need an innovation that will work both as prevention (by creating awareness and sensitization in the population, which needs to be age-appropriate) and provide services. It's impossible for the Govt to achieve this goal alone and ensure mental health wellbeing among this huge population with limited mental health experts. NGOs often contribute as advocates for mental health, working to reduce the stigma associated with mental illnesses; develop and implement innovative programs to address specific mental health needs. 

Sir Fazle Abed, founder of BRAC, envisioned the importance of promoting mental health from the early days long before and was inspired to initiate a mental health programme at community level. The core principle was to sensitize people regarding mental health by raising awareness at the community level with the right sets of information, challenging the stigma by creating an enabling environment with the right information and debunking the misbeliefs and mis-concepts. In alignment with our founder's vision, one of the core functions of BRAC staff engaging with communities throughout Bangladesh for their mental well-being has been a part of BRAC's longstanding ethos of connecting with people. In August 2021, BRAC launched its first mental health strategy in alignment with the Government of Bangladesh's National Mental Health Strategy (2021) and Strategic Action Plan (2021).

As part of taking initiative in this regard, on January 6, 2022, BRAC Health Programme (BHP) and Directorate General of Health Service's Non-Communicable Diseases Control (NCDC) signed a Memorandum of Understanding. This MoU aims to ensure that BRAC and NCDc work together to initiate mental health and psychosocial services at community level. This partnership aims to initiate mental health services into primary health care, assure access to psychosocial services, and incorporate a community mental health model. This approach will include psychosocial assessment, intervention, awareness, and training in community clinics to ramp up mental health promotion and prevention efforts. Prof. Dr. Robed Amin, Line Director, Noncommunicable Disease Control, Directorate General of Health Service (DGHS) and Dr Morseda Chowdhury, Former Director, BRAC Health Programme on behalf of their organizations. 

To test the fidelity and feasibility of a community-based mental health intervention, we jointly conducted a pilot project in urban and rural areas, where community health workers raised awareness on mental health issues and stigma around this. They were proven instrumental in doing so as they relate to the community in various ways, and they are one of the trusted sources of information especially for health. They were also able to identify some degree of problems related to mental health using a very simple tool, provided mental health first aid – assessment and basic psychosocial counseling (under supervision of counselors) and refer them if needed, to relevant providers or facilities. In a situation where there is scarcity of specialized human resources, some of the tasks (awareness raising, identifying persons with possible mental health issues, basic psychosocial support, referral, etc.) can be shifted to auxiliary workers like Community Health Workers to make the services more accessible. This approach can also reduce burden on health system by enhancing prevention and early care seeking practices. A group of mental health practitioners working with CHWs and paraprofessionals for their continuous professional development (CPD) and these skills can be transferred to existing GoB human resources. The impact and process evaluation of this initiative showed remarkable findings in improving a person's service seeking behaviors, improved quality of life and increase demand of services at the community level. 

This initiative at community level ensures that people with mental health conditions receive the proper care and support in their local communities, this effort hopes to lessen the need for institutionalization while also enhancing mental health and well-being. It can be a roadmap for us to develop mental health systems and services widen their focus beyond the biomedical model to also include a more holistic approach that considers all aspects of a person's life. We need us for it, and together, we can! 

The authors are Dr Morseda Chowdhury, Former Director, BRAC Health Programme, and Farjana Sharmin, Programme Manager, Clinical Psychology, BRAC Health Programme.