Background
People-centred approaches to mental health care are increasingly promoted in low- and middle-income countries (LMICs) through global mental health policy, practice and research directives [
1,
2]. The World Health Organisation defines people-centred health care as: “
an approach to care that consciously adopts the perspectives of individuals, families and communities, and sees them as participants as well as beneficiaries of trusted health systems that respond to their needs and preferences in humane and holistic ways.” [
3]. People-centred health care is proposed to apply to people with all types of health conditions.
Intersectoral collaboration is one of the key strategies for achieving people-centred health care in the World Health Organisation Framework on Integrated People-Centred Health Services (WHO IPCHS) [
3]. There is no definitional consensus on intersectoral collaboration. In line with recent conceptual developments in global health, we adopt a broad definition of intersectoral collaboration for mental health as: any planning, information and resource sharing to institute mental health care between organisations from different sectors (i.e. public, private, not-for-profit) and/or across thematic areas (i.e. health, social services) [
4,
5]. This definition encompasses collaborations for mental health service referrals and back referrals, as well as for the purposes of mental health system governance, including the involvement of mental health service user and family organisations.
Emerging from the 1978 Declaration of Alma Ata [
6], and subsequent action to embed Health in All Policies (HiAP) [
7,
8], intersectoral collaboration underpins current global movements to achieve health equity and sustainable development [
9]. Intersectoral collaboration is fundamental to the provision of people-centred mental health care because many of the sociocultural and economic determinants of mental health and wellbeing lie outside the health sector [
10‐
12]. Furthermore, in many LMICs, people rely on customary (traditional, religious or faith-based) or private mental health providers, particularly in the absence of well-developed public health infrastructure [
13‐
15].
Intersectoral collaboration for mental health has been shown to be effective. A systematic review of research from high-income countries (HICs) revealed that collaboration between mental health and non-clinical services improves clinical recovery and other outcomes for mental health service users (e.g. employment, housing stability), as well as system outcomes (e.g. service and cost efficiency) [
16]. Such collaborations included service co-location, joint interorganizational training and use of a shared information system between services [
16].
However, intersectoral collaboration is difficult to achieve. Collaboration is often challenged by systemic factors (e.g. inadequate resourcing, lack of shared interorganisational structures, goals, and trust) and interpersonal factors (e.g. poor communication) [
5,
17‐
20]. In many LMICs, partnerships are challenged because Ministries of Health are hierarchically structured and seen as solely responsible for health activities [
19]. Hence, there may be feasibility issues for promoting intersectoral collaboration for mental health in LMICs.
Despite the global imperative to increase the people-centredness of mental health care in all countries [
2,
3], there is a dearth of research investigating intersectoral collaboration for mental health care across the multitude of sociocultural and resource settings that constitute the grouping LMICs. To fill this knowledge gap, this study was conducted in Timor-Leste, a LMIC in South-East Asia in the process of strengthening its public mental health system.
Study setting: Timor-Leste
Timor-Leste is a small island nation of 1.3 million people [
21]. Promoting mental wellbeing is a government priority in Timor-Leste due to a range of sociocultural and economic risk factors for distress including poverty, unemployment, and past and continuing experiences of violence [
22,
23]. Rigorous estimates of the population prevalence of mental illness are limited and inconsistent. The only household survey of mental illness in Timor-Leste was conducted in 2004 with 1544 adults in the aftermath of the conflict, and estimated an adjusted 5.08% population prevalence of mental disorders [
24]. However, this estimate is now 15 years old and likely does not represent the burden of mental illness in present day, more stable Timor-Leste. As well, their validity is weakened by the predominantly urban sample and the use of assessment tools that may have missed culturally meaningful idioms of mental distress. The 2016 Global Burden of Disease study estimates a 11.6% prevalence of mental and substance use problems [
25].
Multiple stakeholders are involved in mental health care in Timor-Leste. Family and civil society including customary healers are the main form of support for Timorese people with mental health problems [
26,
27]. Within government, responsibility for mental health is split between the Ministry of Health (MoH) and the Ministry of Social Solidarity and Inclusion (MSSI). MoH coordinates the integration of a basic package of mental health care into primary health care, and the training and deployment of the mental health workforce [
28]. Community-based mental health care is mainly provided by mental health nurses, and there is one psychiatrist and one psychologist working in the National Hospital. MSSI coordinates the 2012 National Disability Policy [
29], and the social protection program and disability pension, which some people with psychosocial disability resulting from mental illness receive. Ministries of Education and Justice are involved peripherally with the institution of education and legal systems that some people with mental illness have contact with. NGOs provide a psychosocial rehabilitation service (Pradet), long-term stay service (Klibur Domin) and inpatient psychiatric service (São João de Deus, Laclubar). Social and violence support NGO services including for victims of family violence and legal assistance are also accessed by some people with mental health problems. International development organisations provide financial and in-kind support to MoH, MSSI and NGO service providers through health, and disability- and gender-inclusive development activities [
30].
Intersectoral collaboration is a key strategy of the yet-to-be implemented Timor-Leste National Mental Health Strategy 2018–2022, which aims to provide “
comprehensive culturally-
appropriate community-
based mental health and social services” [
22]. To achieve this, the National Strategy specifies collaborations between mental health, general health, maternal and child health and social support services.
However, it is not known how prevailing collaboration is structured and operates between the different stakeholders involved in mental health care in Timor-Leste. This is important to understand given the limited human and financial resources for mental health in Timor-Leste, which have been identified as barriers to collaboration in other settings. Specifically, there are only three mental health professionals per 100,000 people, and less than 0.29% of the 2018 government budget was allocated to the Public Health Directorate (including mental health) [
31].
Hence, this study aimed to investigate intersectoral collaboration for people-centred mental health care in Timor-Leste’s mental health system. The study aimed to answer the following research questions:
1.To what extent is intersectoral collaboration for mental health outlined in existing government, NGO, civil society and international agency documents in Timor-Leste?
2.What are the perspectives and experiences of multiple stakeholders about intersectoral collaboration for mental health?
3.What is the strength and structure of intersectoral collaboration in the national mental health system?
This research builds upon previous research by the authors that informed the Timor-Leste National Mental Health Strategy [
27], and was conducted to inform the implementation of this Strategy.
Discussion
This study is the first to investigate intersectoral collaboration for both mental health service provision and mental health system governance in a LMIC using mixed-qualitative methods and social network analysis (SNA). The key findings were:
1.Consensus among stakeholder groups that intersectoral collaboration for mental health is important in Timor-Leste;
2.Information and resource sharing exist among organisations (e.g. government, NGO, civil society, international development) working within the health and social (disability and violence support) sectors, despite resource restrictions discussed by participants; and
3.SNA proved useful for identifying subnetworks of intersectoral organisations to substantiate data from interviews and documents such that there was a split in stewardship for mental health between subnetworks in the health and social sectors.
The functional intersectoral connections within the Timor-Leste mental health system contrast with the challenges of health governance reported in other LMICs (e.g. weak government institutions, hierarchical structure of MoH) [
19]. Intersectoral collaboration for mental health in Timor-Leste may be facilitated for several reasons. First, the appreciation of the interconnections between mental health and other sectors displayed by Timorese participants reflected the holistic understandings of health found in Timor-Leste [
55] and indigenous peoples around the world [
56,
57]. Second, connections across the mental health system may have been enabled because they were primarily forged to share information, which is assumed in social network science to indicate a less intensive type of collaboration than resource sharing [
5]. However, given that health knowledge is often among the most valuable of resources in LMICs [
58], this finding could also suggest a stronger degree of collaboration. Third, connections between organisations may be forged out of necessity given the low availability of human and financial resources for mental health in Timor-Leste. Fourth, the relatively small number of organisations working in mental health and social services in Timor-Leste (
n = 27) created a bounded community of practice, which contrasted with the fragmentation of mental health and social service systems reported to challenge collaboration in HICs [
16]. The tightly-defined network combined with the reliance on informal and kinship networks for health previously reported in Timor-Leste [
59] may overcome barriers to trust reported in settings with more formalised systems of mental health governance [
17,
18]. This is also in line with broader governance literature which reports that collaborations are most effective when they have clearly defined and agreed upon understandings of which problems they will address [
60]. Hence, it will be important to consider how to maintain these connections as the Timorese mental health system expands and formalises; a key concern for mental health system strengthening in other LMICs.
Despite these information and resource sharing collaborations, the document review highlighted that mental health had limited specific mention in other key government policies. The commitment to intersectoral collaboration expressed by our participants may not be shared by other stakeholders who are not currently engaged with the mental health system. Thus, the disadvantage of not integrating mental health into intersectoral policies is that resources and political will cannot be mobilized to translate intention into practice [
8]. Timor-Leste could benefit from explicitly incorporating mental health into intersectoral policies in line with efforts throughout the Asia and Pacific region to place ‘Health in All Policies’ (HiAP) [
8,
61]. Increasing awareness and understanding of the importance of mental health among intersectoral stakeholders may be part of achieving this. Given the overlap in scope, people-centred mental health care as a concept would benefit from more explicitly aligning with existing global health movements for universal health coverage and HiAP to relish the learnings and progress already made in these areas over the past 40 years.
The shared stewardship for mental health in Timor-Leste is contrary to the assumption that the health sector is the primary steward for the people-centred health care model. This split stewardship is beneficial in Timor-Leste because it allows for more efficient use of existing resources and also opens up funding channels for mental health service providers through disability- and gender-inclusive development that are not available through traditional health financing [
30]. The central role of the social sector in the mental health system may promote people-centredness because social sector activities tackled the social exclusion of people with mental health problems and their families in Timor-Leste found in previous research (e.g. experiences of stigma, exclusion from employment and education) [
62], which are also key barriers to mental health care access [
63]. This governance structure acknowledges the social determinants of mental health and the co-existing health and social issues affecting families, which are typically under-addressed when there is a myopic focus on treating the mental illness. On the other hand, as one participant explained, government focus on mental health may be diluted without one central champion [
19]. Furthermore, if more resources flow into mental health in Timor-Leste, requiring a greater level of coordination than information sharing, parallel systems of care may emerge over time. Hence, a key consideration is how to ensure that there are no gaps in implementation of strategies to achieve people-centred mental health care in Timor-Leste and other LMICs in which mental health stewardship is shared. This finding also highlights that global mental health efforts should not presume that that Ministry of Health is always the primary steward of mental health.
The prevailing collaborative structures for mental health service delivery and governance in Timor-Leste have important implications for the implementation of Timor-Leste National Mental Health Strategy 2018–2022. Currently, the key role of the social sector in mental health governance is underestimated. Decisions need to be made as to whether the split stewardship for mental health continues or if MoH steps up to lead mental health initiatives in line with their mandate established in the National Strategy. The service delivery collaborations highlighted the importance of social sector NGO service providers (e.g. psychosocial rehabilitation, violence support services), which suggests that training and capacity building that is currently focused on government mental health service providers should also incorporate these NGO providers. Finally, the absence of a mental health service user and family organisation is a key consideration for people-centred mental health care in Timor-Leste because without such a mechanism, the involvement of mental health service users and families in future intersectoral collaborations will likely remain minimal [
64].
Our study had several limitations. SNA data may not have accurately captured the dynamic nature of relationships between organisations because it was cross sectional; assumed that information and resource sharing indicated relationship quality; and relied on participants accurately reporting connections with other organisations. However, we are confident that SNA accurately measured and mapped collaboration because SNA findings triangulated with data from interviews and documents. Our study is also limited because we did not incorporate the role of the customary sector, who we know from previous research by the authors plays a large role in the provision of mental health care in Timor-Leste and have emergent collaboration with the formal mental health sector [
27]. Future research could use SNA to examine collaborations between the formal mental health and customary sectors over time. Research could also investigate the informal processes that drive intersectoral collaboration in Timor-Leste (e.g. trust) so that these can be harnessed to develop the mental health system.
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.