Establishing the foundations for integration of Mental Health and Psychosocial Support (MHPSS) in primary health care targeting children and adolescents in the Middle East and North Africa Region

Mental health of children and adolescents aged 0-18 years is one of the most neglected health issues globally. Before COVID-19, the World Health Organisation (WHO) estimated that 10–20 per cent of children and adolescents worldwide experienced poor mental health, with half of mental disorders beginning by age 14. In the Middle East and Northern Africa (MENA) region, around 1 in 6 adolescents aged 10-19 years are estimated to be living with a mental disorder, with suicide the fifth leading cause of death of 15-19 year-olds. Additionally, many more children and adolescents experience psychological distress that may not meet diagnostic criteria for mental disorder but has significant impacts on their health, development and wellbeing.
Poor mental health can have profound impacts on children’s and adolescents’ health, learning, social wellbeing, and participation, limiting opportunities for them to reach their full potential. This age group encompasses a time of critical brain growth and development, and when social, emotional, and cognitive skills are formed laying the foundation for mental health and wellbeing Into adulthood. In addition to mental disorders arising during this age, many risk factors for future poor mental health also typically have their onset in this developmental stage. In the MENA region, exposure to conflict and violence, displacement, and the impacts of the COVID19 pandemic are likely to be significant contributors to poor mental health.
Despite this significant burden, there is a substantial unmet need for mental health and psychosocial support (MHPSS) for children and adolescents. Globally, government expenditure on mental health accounts for only 2% of the total health expenditure,8 despite accounting for 7% of the total burden of disease. In low- and middle-income countries, the estimated ratio of mental health specialists with expertise in treating children and adolescent is <0.5 per 100,000 population, and there are fewer than two outpatient facilities for child and adolescent mental health per 100,000 population. These constraints have also been described in the MENA region.10 There are also many gaps and missed opportunities to prevent poor mental health and promote wellbeing, with approaches often fragmented and small-scale. In addition to inadequate human and financial resources, lack of coordination between sectors (including health, child protection and education sectors), and substantial stigma remain significant barriers to ensuring children, adolescents and their families have access to quality services and support. 2, Additionally, many efforts have been focused on humanitarian settings with less attention to actions needed to address child and adolescent mental health and wellbeing in non-emergency contexts. Addressing child and adolescent mental health and wellbeing requires a tiered response, that includes services and supports to ensure responsive care for mental health conditions, preventive interventions to address risk factors and enhance protective factors, and actions to ensure safe and enabling environments that promote mental health and psychosocial wellbeing. This tiered and multi-sectoral approach is at the core of global MHPSS guidance, including UNICEF’s Global Multisectoral Operational Framework for mental health and psychosocial support of children, adolescents and caregivers across settings, and the Operational Guidelines on Community-Based Mental Health and Psychosocial Support in Humanitarian Settings: Three tiered support for children and families. These include actions to promote mental health by targeting the social determinants of mental health and wellbeing; prevention of poor mental health by addressing risk factors; and responsive mental health services focused on early intervention and limiting functional disabilities. Additionally, there is also a need to support the mental health and wellbeing of parents and carers, including mental health for pregnant and new mothers, to address the significant burden of poor perinatal mental health and its impacts on child health and development.
While a comprehensive package of MHPSS for children and adolescents requires coordinated action delivered by multiple sectors, the health sector (particularly primary health care) provides a critical platform for identifying and responding to mental health needs, delivery of key interventions to address risk factors, and engagement with communities and families to support health promotion and mental health literacy. Since 1975 WHO has advocated for the integration of mental health care into primary care, shifting from the over-reliance on highly specialised and institutional-based services. Most mental health conditions can be effectively diagnosed and managed by non-specialist providers through primary care, that is also likely to be more accessible, affordable and acceptable to children and their families, less stigmatising, and with greater capacity to provide person-centred care and support. There are also critical opportunities to identify and address risk factors (such exposure to family violence) and integrate mental health promotion.
The need to strengthen primary and community-based mental health care has also been emphasised in the WHO Mental Health Action Plan,19 UNICEF’s Global Multisectoral Operational Framework,13 and the Scaling up mental health care: a framework for action for the Easter Mediterranean region.20 Despite this, effective integration of mental health into primary health care remains an unrealised goal in many countries and contributes to significant unmet need for services. Insufficient training and support for primary-level health providers, inadequate coordination and referral with specialised services, insufficient financial resources, and lack of clear guidance and protocols for integration of MHPSS into primary care services are common challenges globally.
This study is part of a larger UNICEF-funded project aiming to identify how MHPSS for children, adolescents, and maternal mental health can be more effectively integrated into primary health care in the MENA region. The overarching project includes two main phases:

PHASE 1: Overview of mental health needs of children and adolescents across MENA:
1. Establishment of an Advisory Group of key MHPSS stakeholders from the region, including focal points for MHPSS, child and adolescent health, and child protection from government and UN agencies, key academic partners, and youth representatives.
2. Desk based review of available data. The desk review will focus on high level data describing mental health needs, risks and determinants for 0-18 year-olds and pregnant women / new mothers that is available and comparable across 20 countries in the MENA region. Where primary data are lacking the potential for modelled estimates (from the Global Burden of Disease study) will be explored.
3. Desk-based review and synthesis of key MHPSS global and regional frameworks. This will include the UNICEF Global Framework, Joint WHO/UNICEF agreement, Regional Operational Frameworks to identify the potential actions and roles of primary health care.
4. Desk based review of national mental health policies for 20 countries in the region, to map MHPSS for children, adolescents, and maternal mental health, MHPSS that are (or recommended to be) provided through primary health care (including maternal and child health), and identify gaps

PHASE 2: In-depth qualitative inquiry in six priority countries
The purpose of this phase will be to explore, in-depth, how MHPSS can be effectively integrated and implemented through primary health care. This phase will include:
1. Further desk-based review to explore in more-depth the extent to which MHPSS is integrated into primary health care, education, and child protection policies, and review of peer-reviewed and grey literature to explore existing approaches, barriers and enablers to integration of MHPSS in primary care.
2. Key informant interviews will be conducted with key stakeholders (government, non-government, private sector, youth representatives) from health, child protection and education sectors in each country to explore how MHPSS for children, adolescents and maternal mental health identified in Phase 1 can be integrated into primary health care.
3. Country level meetings with UN agencies, government, non-government organisations, funders and youth organisations will be held to present the findings, co-develop recommendations, identify key knowledge gaps / research questions, and identify priorities for the next phases of the research project.
4. Finally, findings from both phases will be presented for reflection and discussion at a regional event attended by key stakeholders (to be co-facilitated by UNICEF)