Mental health in the West Bank and Gaza – Mental health and conflicts: Conceptual framework and approaches – WB report

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Mental health and conflicts: Conceptual framework and approaches

Florence Baingana, Ian Bannon and Rachel Thomas 

Paper prepared for World Bank, Health, Nutrition and Population, Human Development Network, with the support of the National Institute of Mental Health of the US Government. 

Abstract: The paper provides an overview of the Bank's role in conflict and development, and explores the links between poverty, social capital and mental and psychosocial disorders in conflict settings. The premise of the paper is that increased understanding and targeted interventions to deal with mental health can play an important role in effective post-conflict reconciliation and reconstruction. It also argues that there are effective approaches that can be adapted to different conflict settings. The paper presents a conceptual framework based on experiences in and outside the Bank that can help guide interventions and approaches to address mental health and psychosocial disorders in conflict-affected countries. The paper briefly examines mental health approaches adopted by the Bank in West Bank and Gaza, Bosnia-Herzegovina, Uganda, Burundi and Afghanistan. These brief country illustrations suggest there are a variety of approaches and a growing body of experience on which Bank country teams can draw. The paper concludes by noting areas where additional research would seem appropriate and presenting suggestions for further Bank analytical and operational work.

Keywords: mental health, mental disorders, conflicts, psychosocial disorders, programming services

Disclaimer: The findings, interpretations and conclusions expressed in the paper are entirely those of the authors, and do not represent the views of the World Bank, its Executive Directors, or the countries they represent.

Correspondence Details: Florence Baingana, World Bank, HDNHE MSN G7-701, 1818 H St. NW, Washington, DC 20433. Tel: (202) 458-5939; Fax: (202) 522-3489; Email: fbaingana@worldbank.org
Ian Bannon, World Bank, SDV, MSN MC 5-508, 1818 H St NW, Washington DC, 20433, Tel. (202) 473-9042, E-mail: ibannon@worldbank.org

INTRODUCTION 

Until recently, there had been little recognition of the role of mental health in post-conflict reconstruction. As described by Mollica, most aid organizations subscribed to the "rubber band" model of mental health, which assumed that once food, water, shelter, and essential services are provided, individuals will snap back and resume their normal lives (Gewertz 2005). A growing body of research and experience, however, has shown that individuals and communities traumatized by conflict and displacement, experience lasting mental health and psychosocial disorders and they do not easily revert to normal once the violence ends. As a result there is increasing recognition that addressing mental health and psychosocial needs in conflict and post-conflict situations is critical for reducing the likelihood of future conflicts and ensuring effective and sustainable reconstruction. This paper provides an overview of the role of the World Bank in conflict-affected countries; explores the links between conflicts, poverty, mental health and psychosocial consequences; and examines the relationship between mental health, conflicts and social capital. It presents a conceptual framework for psychosocial and mental health interventions, and briefly examines five Bank-supported cases of mental and psychosocial interventions in conflict settings to illustrate possible approaches. It reviews remaining challenges and presents recommendations on the Bank's role in addressing mental health in conflict settings.

BACKGROUND: THE WORLD BANK AND CONFLICT 

The World Bank's early involvement in post-conflict reconstruction, dating from the end of World War II, focused on providing financial capital and rebuilding physical infrastructure. However, in a post-Cold War era marked by an increase in the number and severity of intrastate conflicts, the Bank has had to adapt to different and more complex challenges. The Bank's involvement in Bosnia-Herzegovina and in the West Bank and Gaza prompted a re-examination of its broader engagement and mandate in conflict-affected countries. In 1998, mindful of the new challenges, the Bank's Operations and Evaluation Department (OED) took a careful look at the institution's post-conflict performance (World Bank 1998b). Although it found many unanswered questions, and judged that the Bank's performance could be improved in a number of important respects (e.g., greater efforts to rebuild human and social capital), it concluded that the institution had a definite comparative advantage in supporting the special needs of countries emerging from conflict. The Bank realized that it faced more complex challenges, so in 1997 it had created a Post-Conflict Unit in the Social Development Department, defined a framework for Bank engagement in post-conflict reconstruction, and set up the Post-Conflict fund (PCF) to support countries in transition from conflict to sustainable peace and early Bank engagement in conflict-affected countries.

With poverty both a cause and a consequence of conflict, in 2000 the Bank sought to redefine its role more broadly, from an approach focused on physical reconstruction to one focused on the root causes of conflict, to integrate sensitivity to conflict in Bank activities and to promote assistance that minimizes the potential causes of conflict. In line with this shift in focus, in January 2001 the Executive Directors approved Operational Policy 2.30 (OP2.30), Development Cooperation and Conflict, which sets the framework and parameters for engagement in conflict-affected countries. To signal this shift in emphasis, the Post-Conflict Unit was renamed the Conflict Prevention and Reconstruction (CPR) Unit.

OP2.30 sets out three stages of Bank engagement in conflict-affected countries and provides a flexible framework for engagement in countries affected by conflict:

While OP2.30 provides considerable flexibility it also makes it clear that, in line with its mandate, the Bank does not engage in peacemaking or peacekeeping, does not provide direct support for disarming combatants, and does not provide humanitarian relief, all of which are functions assumed by the UN and other agencies or donors. OP2.30 notes the need for partnerships, especially with other bilateral and multilateral agencies, as well as civil society and non-governmental organizations (NGOs) that have complementary mandates and concerns. OP2.30 also notes the need to support social recovery, with particular attention to the needs of war-affected groups who are especially vulnerable because of gender, age, or disability. Addressing mental health and psychosocial needs, with particular attention to vulnerable groups is thus fully in line with the Bank's operational policy on conflict, its mandate and its comparative advantage.

This paper illustrates the links among conflicts, mental health and psychosocial disorders, social capital, human development and poverty. A basic premise of the paper is that understanding and addressing these linkages is important to meeting the Millennium Development Goals, especially those relating to poverty (Goal 1), primary education (Goal 2), empowerment of women (Goal 3), child health (Goal 4), maternal mortality (Goal 5), and HIV/AIDS and other infectious diseases (Goal 6).

GLOBAL EXTENT OF CONFLICT 

Since 1980, substantial periods of war have afflicted over 50 countries, and more than 30 wars have plagued Africa since 1970. In its State of the World's Children 2000, UNICEF estimates that there has been a 40 percent increase in complex emergencies over the last decade. Moreover, in recent years the face of war has changed in that civilian populations are being targeted with increasing frequency. According to global estimates, in the 20th century 191 million people lost their lives directly or indirectly due to collective violence, and 60 percent of those deaths occurred among people not engaged in fighting (WHO 2002). The first World Report on Violence estimates that, in the year 2000 alone, a total of 310,000 people were killed by war-related causes (WHO 2002).

Conflict related deaths are heavily skewed toward low-income countries. Viewed globally, the above statistic for war-related deaths in 2000 translates into 5.2 deaths for every 100,000 of the world's population. However, when analyzed by income-level (Table 1), the number of war-related deaths was close to zero in high-income countries in 2000, but 6.2 for low-income countries (WHO 2002). In the past 20 years, at least 15 of the world's 20 lowest income countries have been affected by significant armed conflicts. Moreover, almost all low-income countries that have not directly experienced conflict, border conflict or post-conflict countries (Holtzman, Elwan and Scott 1998). Of the 127 wars that have occurred since World War II, 125 have been in low-income countries (De Jong 2002) with 60 percent of all on-going wars since 1999 concentrated in Sub-Saharan Africa (Carballo et al. 2004).

Table 1: Conflict-Related Deaths by Region

Source: WHO (2002)

Note: ¹ Under new operational procedures, the Bank's Transitional Support Strategy document will be renamed Interim Support Strategy, but its objectives and content will remain unchanged.

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