Investigating people-centred mental health care in Timor-Leste

Abstract

Despite the increased emphasis placed on people-centred mental health care in low- and middle-income countries (LMICs), until this study, there has been no systematic investigation of the paradigm outside Western high-income country settings. Timor-Leste, a lower middle-income country in South-East Asia, is in the process of strengthening its national mental health system to align with people-centred approaches to mental health care. This thesis critically investigates people-centred mental health care in community settings, mental health services, and the mental health system in Timor-Leste.

This study aimed to enhance the understanding of the acceptability and feasibility of people-centred mental health care in Timor-Leste. The study's primary aim was to inform Timor-Leste's ongoing mental health system strengthening, and its secondary aim was to identify potential implications for the implementation of the people-centred paradigm in other LMICs. The study employed mixed-methods framed through a socio-ecological lens to understand the people-centred mental health care paradigm in Timor-Leste across multiple levels of analysis. In-depth semi-structured interviews were conducted with 85 stakeholders from different groups across national and sub-national sites. Informal observation in government and non-government mental health and social care services and a review of publicly available documents were also undertaken. A quantitative complex systems analysis was employed to measure intersectoral collaboration in the national mental health system.

At the community level, the study found a family-centred ecology of mental health in which the needs, preferences and rights of individuals were subordinated to those of their family. Timorese people with mental illness experienced multi-faceted social exclusion, but also had opportunities for social inclusion. At the mental health service level, sociocultural and medical power hierarchies shaped decision making. Priorities for mental health care for families, communities, service providers, decision makers and civil society were influenced by Timor-Leste's broader development context and its lack of resources for health services. At the mental health system level, holistic understandings of health and well-being and the need to overcome resource restrictions provided opportunities for intersectoral collaboration in mental health. A split in stewardship for mental health governance between health and social sectors was detected. There was also limited participation in mental health system governance by people with mental illness, their families and communities.

The study evinced that employing a socio-ecological framework allowed for a deeper consideration of Timor-Leste's sociocultural and development contexts while acknowledging the common elements in people-centred mental health care. The findings present a compelling case for the consideration of both individual and collective care and social rights in global mental health. The implementation of peoplecentred mental health care should be viewed as a staged process to account for limited resources, capacities and priorities for countries. The findings highlight the vacuum of research on the power relations inherent in the concept of people-centred mental health care, its implementation and the hierarchies of knowledge on which the paradigm is based. Accounting for local cultural knowledge and understandings will strengthen the design and implementation of people-centred mental health care in LMIC settings.