Steadily approaching the title of the second highest cause of disability in the world, mental health disorders are an international health concern that is gaining considerable attention.⁽²⁾ Of the global burden of disease, 14% is attributed to neuropsychiatric disorders, indicating a 2% growth since the year 2000.⁽³⁾ It is believed that the figure will have increased by another percent by 2020.⁽⁴⁾ According to the Mental Health and Poverty Project, one in five individuals will suffer from a diagnosable mental disorder in their lifetime.⁽⁵⁾ Among the adults who suffer from these disorders, 75% are found to have developed them in their youth.⁽⁶⁾ In fact, sufferers of persistent mental disorders in adulthood tend to be those whose condition first arose between the ages of 12 and 24.⁽⁷⁾

The 2011 World Health Organisation (WHO) Mental Health Atlas reveals that 110 of its 184 member states have an identifiable mental health policy.⁽⁸⁾ Of the 45 African member states surveyed, 19 reported to have mental health policies in place.⁽⁹⁾ This paper discusses current deficits in mental health services in Africa, as well as the challenges faced by mental health patients and practising mental health professionals on the continent. The paper also illuminates strides made by groups in various parts of the continent in improving service provision to affected populations.

Services available

To describe the current accessibility of mental health services in the majority of African countries as deficient would be an understatement. The psychiatrist-to-patient ratio in Africa is less than 1 to 100 000,⁽¹⁰⁾ and it is reported that 70% of African countries allocate less than 1% of the total health budget to mental health.⁽¹¹⁾ Liberia is a case in point. A 2008 report compiled by the WHO states that there are only 0.06 mental health professionals per 100,000 people in Liberia,⁽¹²⁾ where, the S. Grant Mental Health Hospital is the sole inpatient facility for those suffering from mental disorders. A study conducted by the American Medical Association found that 44% of Liberian adults exhibit symptoms indicative of post-traumatic stress disorder (PTSD).⁽¹³⁾ The likelihood that these individuals are receiving treatment is very low, when taking into account the scarcity of mental health facilities in that country. The Liberia National Mental Health Policy found that of those living in low income areas that need mental health services, only 15% actually receive treatment.⁽¹⁴⁾

Similarly, in Ghana only 1.17% of those who are suffering from mental health problems have received the required treatment.⁽¹⁵⁾ There are only three major psychiatric hospitals in that country, all of them located in the southern region. Furthermore, there is only one psychiatrist allocated to 1.5 million people. With such limited accessibility, many mental health sufferers seek treatment from traditional and faith healers.⁽¹⁶⁾

Compared with the West African countries mentioned, the situation in East Africa is similarly dire. There is an evident shortage of mental health professionals in public practice. In 2001, Tanzania recorded 10 active psychiatrists catering to a population of 30 million. Of the 10, four work at Muhimbili, a teaching hospital, where patients with serious mental health disorders are referred.⁽¹⁷⁾ Kenya is regarded as comparatively better prepared to cater for those suffering from mental health disorders, with 47 practising psychiatrists in the private and public sectors. Twenty-two physicians exclusively provide services in Nairobi, while the remaining 22 practise in other parts of the country.⁽¹⁸⁾ Mathari Hospital, located in Nairobi, is the national referral and teaching hospital for mental health patients. Its 750-bed facility is divided into two wings, a civil wing for stable patients and a maximum security unit for those suffering from severe mental problems.⁽¹⁹⁾ Middle and upper class citizens have the option of seeking services from psychiatrists in private practice.

Risk factors in the African context

Mental health issues among African populations are instigated by an assortment of factors. The financial standing of populations in many African countries may be predisposing them to mental health problems. Various studies state that individuals of a lower socio-economic status are twice as likely to suffer from common mental health disorders, as compared to the wealthy.⁽²⁰⁾ Furthermore, populations in East African countries such as Somalia, Ethiopia, Sudan, Rwanda and the Democratic Republic of Congo (DRC) have encountered armed conflicts and natural disasters in varying degrees. This has resulted into the displacement of more than 1.5 million individuals from the East African region.⁽²¹⁾ A consequence of these hardships may be the emergence of mental disorders. The WHO estimates that 50% of refugees have mental health problems ranging from post-traumatic stress disorder to chronic mental illness.⁽²²⁾ The rise in the numbers of individuals who present with mental health problems places an even greater burden on an already under-resourced healthcare service in Africa.⁽²³⁾

Mental health stigma

In many African countries, communities are often not empathetic towards mental health patients. The mentally ill face discrimination, social ostracism and the violation of basic human rights, all due to an on-going stigma associated with mental health problems. Ironically, some of these violations occur in institutions where people with ill mental health seek treatment. Mental health facilities have been found with unhygienic and inhumane living conditions, such as the use of caged beds with netting or metal bars to restrain patients.⁽²⁴⁾ There are documented cases of individuals having been tied to trees and logs far from their communities for elongated periods of time without adequate food or shelter.⁽²⁵⁾ A study performed in Uganda revealed that the term ‘depression’ is not culturally acceptable amongst the population, suggesting that mental health issues are not acknowledged or considered a legitimate affliction.⁽²⁶⁾ In another study conducted in Nigeria, participants generally responded with fear, avoidance and anger to those who were observed to have a mental illness. The stigma linked to mental illness in that country can be attributed to a variety of factors, including lack of education, fear, religious reasoning and general prejudice.⁽²⁷⁾ When surveyed on their thoughts on the causes of mental illness, over a third of Nigerian respondents (34.3%) cited drug misuse, including alcohol, marijuana and street drugs as the main cause. Divine wrath and the will of God were seen as the second most prevalent reason (18.8%), followed by witchcraft/spiritual possession (11.7%). Very few cited genetics, family relationships or socioeconomic status as possible triggers.⁽²⁸⁾

Challenges faced in improving services

There are many barriers faced by African mental health workers in their efforts to improve and increase the availability of services in their regions. As mentioned earlier, the lack of funds allocated by most African governments to the mental health field poses a problem in expanding services so as to adequately meet demand. Furthermore, difficulties such as finding adequate transportation and medication are general obstacles for health workers attempting to reach rural dwellers.⁽²⁹⁾

Limited research in mental healthcare has also been cited as a major concern. A study spear-headed by the United States National Institute of Mental Health and the Global Alliance for Chronic Disease found that one of the biggest barriers in mental healthcare is the lack of global collaboration in the conduction of research.⁽³⁰⁾ Research is essential for determining general needs when treating mental health disorders, as well as for creating and monitoring cost-effective interventions.⁽³¹⁾ A WHO mapping project on research capacity for mental health in low and middle income countries indicates that epidemiological studies focusing on burden and risk factors, health systems research, as well as social science, were regarded as most desirable by researchers and other mental health stakeholders.⁽³²⁾

Emerging efforts

Despite the many shortcomings in their field, mental health professionals are resilient in their efforts to serve and challenge the status quo. For example, the Ministry of Health and Social Welfare in Liberia is working towards increasing access to mental health services throughout the country. The Ministry has partnered with organisations such as the Carter Center and Doctors of the World, with the intention being to establish wellness centres in each of Liberia’s 15 counties.⁽³³⁾ The Carter Center is also currently training 150 mental health clinicians in Liberia. Staffed with trained mental health workers, these organisations will offer treatment to mentally ill individuals in the affected communities. In the event of a case requiring knowledge beyond the expertise of clinicians at the centre, referrals will be made to specialists located in Monrovia.⁽³⁴⁾ Dr Meiko Dolo, the Director of the Mental Health Department in Liberia, is confident that these plans will come to fruition. A recently released draft of Liberia’s national budget for 2013 depicts, for the first time ever, provisions made for mental health.⁽³⁵⁾

Following its 11-year civil war, Sierra Leone, established a child-solider rehabilitation project, providing counselling and other support to children living with war trauma.⁽³⁶⁾ In the DRC, women facing gender-based violence can now go to ‘listening houses’ where they can talk through their trauma in a secure setting.⁽³⁷⁾ In addition, the University of Cape Town in South Africa completed a project on mental health and policy, whose goal was to expand mental health research in Africa, evaluate existing mental health policies in Uganda, South Africa, Zambia and Ghana, as well as develop new ones.⁽³⁸⁾

Conclusion

Though not as notorious as HIV/AIDS, tuberculosis and malaria, mental health is a global issue that is in need of more attention than it is currently being given. In 2003, 450 million people worldwide were estimated by the WHO to have some type of mental health issue.⁽³⁹⁾ Eleven years later, it is likely that this number has increased. The WHO also reports that expenditure on mental health is less than US$ 0.25 annually per person in low income countries.⁽⁴⁰⁾ Currently, Africa has the lowest rate of mental health outpatient facilities, at 0.06 per 100,000 people.⁽⁴¹⁾ Given the steady rise in the number of mental health sufferers, African countries need to optimise the delivery of mental health care services and take steps towards making this crisis silent no longer.

Written by Modupeola Dovi ⁽¹⁾

NOTES:

(1) Contact Modupeola Dovi through Consultancy Africa Intelligence's Public Health Unit ( public.health@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Tsholofelo Thomas and was edited by Liezl Stretton.
(2) Fournier, O.A., 2011. The status of mental health care in Ghana, West Africa and signs of progress in the greater Accra region. Berkeley Undergraduate Journal, 24(3), pp. 1-27.
(3) Ibid.
(4) Kleintjes, S., Lund, C. and Flisher, A.J., 2010. MHAPP Research Programme Consortium. A situational analysis of child and adolescent mental health services in Ghana, Uganda, South Africa and Zambia. African Journal of Psychiatry, 13, pp. 132–139.
(5) Ibid.
(6) Ibid.
(7) Ibid.
(8) ‘Mental health atlas 2011’, World Health Organization, 2011, http://whqlibdoc.who.int.
(9) Ibid.
(10) Fournier, O.A., 2011. The status of mental health care in Ghana, West Africa and signs of progress in the greater Accra region. Berkeley Undergraduate Journal, 24(3), pp. 1-27.
(11) Bird, P., et al., 2010. The MHAPP Research Programme Consortium. Increasing the priority of mental health in Africa: Findings from qualitative research in Ghana, South Africa, Uganda and Zambia. Health Policy Plan, 26, pp. 357–365.
(12) Lupick, T., ‘Liberia mental health services: Building from the ground up’, Think Africa Press, 29 August 2012, http://thinkafricapress.com.
(13) Ibid.
(14) Ibid.
(15) Fournier, O.A., 2011. The status of mental health care in Ghana, West Africa and signs of progress in the greater Accra region. Berkeley Undergraduate Journal, 24(3), pp. 1-27.
(16) Chambers, A., ‘Mental health and the developing world’, The Guardian, 10 May 2012, http://www.guardian.co.uk.
(17) Njenga, F., 2002. Focus on psychiatry in East Africa. British Journal of Psychiatry, 181, pp. 354–59.
(18) Leposo, L., McKenzie, D. and Ellis. J., ‘Kenya doctor fights mental health stigma in “traumatized continent”’, CNN, 31 January 2012, http://www.cnn.com.
(19) Ibid.
(20) Patel, V. and Kleinman, A., 2003. Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization, 81, pp. 609-615.
(21) ‘2012 Regional operations profile, East and Horn of Africa’, United Nations High Commissioner for Refugees (UNHCR), 2012, http://www.unhcr.org.
(22) ‘Mental health of refugees, internal placed persons and other populations effected by conflict’, World Health Organization, 2012, http://www.who.int.
(23) Njenga, F., 2002. Focus on psychiatry in East Africa. British Journal of Psychiatry, 181, pp. 354–59.
(24) ‘Investing in mental health’, World Health Organization, 2003, http://www.who.int.
(25) Ibid.
(26) Gordon, A., ‘Mental health remains an invisible problem in Africa’, Think Africa Press, 8 September 2011, http://thinkafricapress.com.
(27) Arboleda-Florez, J., 2002. What causes stigma? World Psychiatry, 1(1), pp. 25–26.
(28) Kabir, M., et al., 2004. Perception and beliefs about mental illness among adults in Karfi village, northern Nigeria. Bio Med Central International Health and Human Rights, 4(3), pp. 1-5.
(29) Lupick, T., ‘Liberia mental health services: Building from the ground up’, Think Africa Press, 29 August 2012, http://thinkafricapress.com.
(30) Collins, P.Y., et al., 2011. Grand challenges in global mental health. Nature, 475, pp. 27–30.
(31) ‘Research capacity for mental health in low- and middle-income countries: Results of a mapping project’, World Health Organization, 2007, http://www.who.int.
(32) Ibid.
(33) Lupick, T., ‘Liberia mental health services: Building from the ground up’, Think Africa Press, 29 August 2012, http://thinkafricapress.com.
(34) Ibid.
(35) Ibid.
(36) Gordon, A., ‘Mental health remains an invisible problem in Africa’, Think Africa Press, 8 September 2011, http://thinkafricapress.com.
(37) Ibid.
(38) Ibid.
(39) ‘Mental health statistics: UK and worldwide’, Mental Health Foundation, http://www.mentalhealth.org.uk.
(40) ‘Mental health atlas 2011’, World Health Organization, 2011, http://whqlibdoc.who.int.
(41) Ibid.