Integrating mental health into primary care for conflict-affected internal forced migrants in Northern Sri Lanka (COMGAP-S)

COMGAPSince the end of conflict in 2009, Northern Sri Lanka is seeing a rapid rehabilitation and rebuilding process in health and other infrastructure. However, the need for human resources is the least being met, as the rate of capacity building and training new cadres are significantly below that of the growing need in the region.

The COMGAP-S project aims to improve the skills of existing primary care health work force in integrating mental health into primary care services in Northern Sri Lanka.

The relative political, social and economic stability that the region is enjoying after three decades of conflict is highly conducive to training new cadre of healthcare workers and increasing the capacity of existing health work force.

This project, already having being implemented in pilot form in the Northern Province, aims to improve the skills of existing primary care health work force in integrating mental health into primary care services across all districts of the Northern Province.


This project has two specific aims:

Cross-sectional Study

A comprehensive cross-sectional study was completed in 2015-2016 to identify the mental disorder burden at primary care level in the region. The setting was all 5 districts in Northern Sri Lanka and focused on populations who are conflict-affected, forced internal migrants and returnees. Understanding mental health care burden and needs in the region informs the intervention development and delivery to adequately address the treatment gap at primary care level.

Findings from the cross-sectional study (page 2), which was conducted with 1,015 adult participants in 25 primary care clinics across the Northern Province, showed that out of the patients visiting primary care, 59% could reasonably receive a diagnosis of any mental health disorder, while 42% of all patients could be diagnosed with two mental health disorders. These figures paint the stark picture of prevalence of mental health issues in the post-conflict population of Sri Lanka. 90% of the participants lived in the region during conflict, and 77.5% were displaced more than one.

Of the mental health issues taken into account in the cross-sectional study, the prevalence of anxiety was 47%. Depression – perhaps the most ubiquitous mental disorder in the world – ranked second most represented with 42%. Somatoform symptoms made for 28% of the mental health issues detected, and psychosis represented 18% of mental disorders. PTSD, which traces its origins to traumatic events in the life of individuals, stands at 14% of mental health issues. This was not a surprising finding in light of the fact that 37.8% lost at least one family member throughout the conflict, while 56.5% of the sample had family injured during the conflict.

mhGAP Training

The second aim of the study is to use an adapted version of the World Health Organization mental health gap programme (WHO mhGAP) to train primary care practitioners and public health personnel to deliver mental health treatment within the primary care health system in Northern Sri Lanka.

The COMGAP-S research team received training in mhGAP in August 2017 from Dr. Peter Hughes, psychiatrist at the London Springfield University Hospital and trainer in mhGAP with the World Health Organization. The training will be further disseminated during the trial phase of COMGAP-S, when medical doctors, nurses, midwives, health attendants and other health staff at 25 clinics in the Northern Province will receive training in mhGAP and mental health awareness. Community representatives – including teachers, healers, managers and social workers – will also be trained in mental health awareness and referral so that they can provide support and direction to those around them suffering from mental health problems.

This project also includes an economic evaluation component to explore cost-effectiveness of integrating mental health into primary health care. Additionally, programme monitoring and evaluation will be conducted to evaluate success of the training programme implementation and impact on patient outcomes.

This project hopes to:

  • provide a comprehensive account of the prevalence of mental disorders at primary care level within post-conflict Northern Sri Lanka,
  • narrow the treatment gap, and
  • improve patient outcomes by integrating mental health into the primary health care system.


This is a five-year programme, funded by the Office of Global Health, Centers for Disease Control & Prevention (CDC) in the US.


Centers for Disease Control and Prevention (CDC)

Faculty of Medical Science, Anglia Ruskin University

Dr. Chesmal Siriwardhana (Principal Investigator)

The THEME Institute, Sri Lanka

Dr. Kolitha Wickramage

Ms. Giselle Dass

Institute of Psychiatry, Psychology & Neuroscience, King’s College London

Prof. Robert Stewart

Dr. Melanie Abas

London School of Hygiene & Tropical Medicine

Dr. Bayard Roberts

University of Jaffna, Sri Lanka

Education, Training and Research Unit. Ministry of Health, Sri Lanka