Contemporary Psychiatry in Africa: A Reviview of Theory, Research and Practice

Preface

This book brought together some of the leading African based psychiatrists, who as leaders in their specific areas of interest and expertise were best placed to critically assess the status quo of the literature both generally and with specific reference to Africa as well as infuse their contributions with their clinical experience . There are many challenges facing psychiatry on the continent, not least is an evidence base that informs the continent based on credible research undertaken by psychiatrists working in Africa. Hence, Contemporary psychiatry in Africa. One assumes that psychiatry in Africa should be practiced according to established norms and standards, based on sound evidence that informs the discipline. Africa is vast, and not homogenous. There is wealth, but also tremendous poverty. Resources are limited and it is not possible to contextualize practice unless one understands limitations and potential solutions- hence the chapters on resources and partnerships.

There are also cultural realities that may operate side by side with psychiatry and potentially hold sway. As a psychiatrist one is both mindful and respectful in this regard and the chapters dealing with culture, traditional healers and ethics address such issues. The chapter on psychotherapy explores the meaning and relevance of such approaches in an African context.

There is relevant content related to publishing in Africa, and the challenges facing the discipline. There are a number of chapters dedicated to a range of conditions, covering the most prevalent as well as some emerging conditions ranging from HIV related psychopathology to eating disorders. Additionally, the book provides a focus on a related and pertinent subspecialist field - that of neuropsychiatry. In addition, a chapter is devoted to child and adolescent psychiatry- a subspecialist area that is sorely underserviced.

The elderly are not forgotten, and whilst much is spoken of the youth it is well to consider the ageing members of society too. Psychiatry and the law may have different meanings in different settings, but there are fundamental principles that should be the basis of understanding and the chapter on forensic mental health serves to emphasize this point. The hope is that this book will provide a meaningful and realistic appraisal of African psychiatry as it exists, as well as assist in charting the way forward. An indigenous knowledge base is critical for the discipline and most importantly for our patients. We have attempted to be as comprehensive as possible in the chapters selected for inclusion. Whilst some are focused on disorders, others deal with issues. Psychiatry is not practiced in a vacuum, and Africa is no exception. It is time to harness the collective wisdom of African psychiatry, and with that in mind the current content should serve as a departure point for ongoing efforts to refine our practice in accordance with best practice and local needs.

Christopher P. Szabo

David M Ndetei

Chapter ONE

Resources for mental health services in Africa:

A Situation Analysis

Alan J. Flisher and Crick Lund

*Note: Prof Alan Flisher died

tragically of Leukemia in April

2010, before the book went to

press

Introduction

It is reasonable to ask why it is necessary to document the current situation as regards mental health services in Africa. After all, it is widely known that almost all of the continents' resources are meagre in relation to the need for services. However, quantifying the availability of resources can serve important purposes. First, it can be used to provide a rationale for addressing any shortcomings that are identified. For example, an argument that the numbers of mental health professionals in a country should increase is more convincing to a policy maker or treasury official if the salient staff to population ratios can be provided. The impact of such an argument is amplified if the proportion is prima facie inadequate, or if it is lower than other countries of a similar level of development. Second, it can be used to monitor changes over time. If, for example, it can be demonstrated that increased resources allocated to training mental health professionals resulted in more favourable staff to population ratios, this would provide evidence that the decision had the desired effect. If the contrary were the case, policy makers would be well advised to uncover the reasons for the failure with a view to implementing the necessary corrective actions. Finally, data can be used to identify positive scenarios, which is good for the morale of those responsible and can provide models for other settings. In this chapter, we provide data for each African country regarding the existence of selected resources in the following domains: Policies, programmes and legislation, mental health service financing, bed to population ratios, staff to population ratios and mental health reporting systems. The data were derived from the following sources:

The WHO Atlas database,¹ which provides an overview of mental health resources in all United Nations member states, the most recent update of which was conducted in 2005

The WHO Assessment Instrument for Mental Health Systems (WHO-AIMS),² which has been used to conduct a national analysis of mental health systems by several African countries (Benin, Burundi, Ethiopia, Nigeria, South Africa, Tunisia and Uganda)

The detailed situation analysis of the mental health systems in Ghana,³ South Africa,⁴ Uganda⁵ and Zambia⁶ that was conducted by the Mental Health and Poverty Project (MHaPP), a Research Programme Consortium funded by the UK Department for International Development (DfID);⁷ and

Studies addressing the mental health systems of specific countries.⁸,⁹

When data about the same indicator for a specific country was available from more than one source, data that was most recent or valid was used. In addition to the situation analysis described above, a set of recommendations for addressing each of the resource domains is provided. These recommendations are necessarily brief and selective. However, each section contains references to WHO publications, which should be consulted for further information.

Situation analysis and way forward

Table I (Appendix 1) provides data about selected aspects of psychiatric resources for all the countries on the continent. For each domain resource, a summary of the situation for each indicator across the 50 countries on the continent is given, after which recommendations about the way forward are made.

Policies, programmes and legislation

In this domain, the year of introduction of the current mental health and substance abuse policies, mental health programme and mental health legislation are provided.

Mental Health Policies can be defined as an organized set of values, principles and objectives for improving mental health and reducing the burden of mental disorders in a population.10 Of all African countries, 48% and 52% have mental health and substance abuse policies respectively. Of these, 25% and 23% respectively have a policy that was completed in the current century. With one exception (substance abuse policy in Guinea), all the countries with a policy that was completed in this century were middle income countries. The general tendency is for countries either to have both mental health and substance abuse policies, or to have neither, but in 22% of countries there is an inconsistency in this regard.

Programmes differ from policies in that they refer to actual interventions. They are focussed on a specific objective, for example a programme to assist patients discharged from hospital to integrate into their communities.10 Of all the countries, 74% reported having a programme, but only 14% had one that was implemented in the current century. Data is not available about whether programmes that were implemented are still functioning; it is probable that in a subset of countries this is not the case. With two exceptions, all the countries that did not have a programme also did not have both a mental health and substance abuse policy.

Legislation complements and reinforces policy, in that it provides a legal framework to address selected critical issues such as access to psychiatric services.11 Of all the countries, 62% reported having mental health legislation, but only 10% and 28% were promulgated since 2000 and 1990 respectively. In many cases, the legislation was promulgated many years ago; for example in the Gambia it was promulgated in 1924 and in Egypt in 1944. There are specific reasons that it is important to have recent mental health legislation. Many of the older laws focus on custodial care and are not informed by modern perspectives on human rights and developments in availability of effective treatments.

For a fully functional mental health system, it is necessary to have contemporary mental health and substance abuse policies, programmes and legislation that reinforce and complement each other. However, only six countries have all these elements in place since 1990 (Democratic Republic of the Congo, Gambia, Guinea, Tanzania, Togo and Tunisia). This fact, read in conjunction with the data presented in Table I (Appendix 1) and summarized above, indicates that almost all countries should be prioritizing this aspect. The WHO extracted key recommendations for developing mental health policies and plans, and legislation, based on the situation analysis conducted by the Mental Health and Poverty Project (Appendix 2).

Mental health financing

There is no benefit in having excellent policies, programmes and legislation if there are insufficient or inappropriately allocated financial resources to translate them into action. Two indicators of mental health financing are reported: the proportion of the national health budget devoted to mental health and the primary financing mechanism for mental health services.

Just over half the countries report allocating none of their health budget to mental health, and only 12% report allocating more than 2% (Guinea-Bissau, Lesotho, Senegal, Seychelles, Tanzania and Tunisia). These proportions are low compared to high income countries, which typically allocate more than 5% of their health budgets to mental health care. A number of strategies have been proposed to increase the budgetary allocations for mental health, including developing and disseminating evidence for the cost effectiveness of mental health interventions; making the economic and human rights cases for improving service and infrastructural quality; building alliances with key stakeholders in government, the private sector and non-governmental organizations; supporting advocacy movements and user groups to create public awareness and hence demand; establishing mental health innovation funds to promote ongoing change and quality improvement; and including mental health in general health initiatives (for example, programmes to provide services for people living with HIV and AIDS).12 However, all such efforts should be considered in the light of two key points. First, significant increases in budgetary allocations for mental health are generally the result of a shift in policy priorities, which occur through political processes. Those advocating for the development of should thus not shy away from engagement at the political level. Second, if maximum benefit for the mental health of the population is to be secured from increase financial resources, it is essential that any new funding is used to improve psychiatric services in line with the policy, programmes and legislation. Failure to do so may result in missed opportunities for service development, or even perpetuation of existing imbalances. The latter can occur, for example, if new funding is allocated to the construction of new psychiatric hospitals, as opposed to the integration of mental health into general health services. It is important to bear in mind that increasing national resources will not necessarily result in improved mental health for the population of a country as a whole. Such a scenario can arise when increased resources are confined to a limited geographical area (for example, a capital city), are only accessible to those with sufficient means to pay for services from personal resources, or are allocated largely in a system where specialists deliver the services directly. Also, if resources are allocated to developing a service system in which mental hospitals are the major site of service delivery, only a small proportion of those with psychiatric disorders will receive services (and are likely to suffer the consequences of isolation for their community of origin including human rights abuses). Finally, allocation of resources for treatment modalities for which there is no evidence of effectiveness and cost-effectiveness will not result in an improvement in the mental health status of the population. Fortunately, there is substantial accumulated evidence for effective interventions in Africa. By 2007 there had been 51 randomized controlled trials (RCTs) of mental health interventions conducted in Sub-Saharan Africa and a further 28 trials conducted in North Africa and the Middle East.13 These include innovative interventions, such as a RCT for group interpersonal therapy for adult depression in Uganda, which found that 93.5% recovered with the intervention, compared to 45.3% in the control group (p<0.001).14 Some of these interventions have also been founded on preparatory work in which the constructs of psychiatric illness have been explored and the tools to measure it validated.15

The primary funding mechanisms were taxation and/or out of pocket expenditure by the family/patient. In 18 of the 48 countries (28%) for which data are available, the primary mechanism was solely the family/ patient. In 13 countries (27%), the sole mechanism was reported as taxation, social insurance or grants, all of which derive directly from government funding. Thus, in 31 (65%) countries, the sole source of funding is either entirely from private or government sources. It is probable that in some of these cases, a proportion of funding emanates from a different source but this was not reported as only the primary funding mechanism was elicited (although many countries provided more than one source). This methodological issue notwithstanding, funding from either private or government sources implies that only a small proportion of the population will have access to mental health services. In the former case, in almost all African countries only a small proportion of the population have access to sufficient resources to purchase the quality and quantity of services required for the effective treatment of mental disorders. In the latter case, the proportion of the health budget allocated for psychiatric services is insufficient to ensure such treatment for those that are dependent on government sources of funding. The achievement of equity should thus be a focus of increased expenditure on mental health. One important step in achieving this is to develop a matrix in which the source of funding (such as general taxation and family/patient) is considered in relation to the mode of funding.12 Such a matrix can provide indications of policy, programmatic and legislative interventions that have the potential to improve equity. Other key strategies include the disproportionate allocation of services funded by taxation to disadvantaged groups, such as those with few financial resources and those living in poverty; instituting user fees at public facilities, such that those with access to private resources or medical insurance pay for services received on a sliding scale; and collaborating with health planners to ensure special access arrangements for people with mental disorders.

Bed to population ratios

A cursory inspection of the bed to population ratios in Table I (Appendix 1) reveals two obvious conclusions. First, there is an absolute low proportion of total beds per 100,000 people; for example, the proportion of beds per 100,000 population was greater than 10 for only 26% of countries. Second, almost all of these beds were situated in mental hospitals. Except for two small countries (Sao Tome and Principe, and Djibouti), the proportion and number of beds in general hospital and other settings was minimal. The status quo on the continent thus stands in sharp relief to the international consensus that there is little justification for the kinds of services provided by mental hospitals in terms of cost, effectiveness, quality of care or the potential for human rights abuses and stigmatization.16 Of course, there will always be a small proportion of people with serious and chronic psychiatric disorders that require long term accommodation in a setting with mental health care services. However, such people are more appropriately accommodated in units in general hospitals or the community. Hospital-based services are most appropriately provided in general hospitals. The majority of contacts with the health service should occur in the primary health care setting. Data are not currently available on the extent to which such services are available, as their absence in Table I (Appendix 1) indicates. The WHO has been advocating for this approach in numerous publications since Alma Ata,17 most recently in the WHO/WONCA report on mental health in primary health care.18 It is essential that core packages of care include a substantive mental health component at PHC level in all African countries. This requires the training of general health nurses and doctors in the treatment and management of common psychiatric disorders, referral pathways to specialist psychiatric staff, and routine supervision by specialist staff. Information systems must be established to monitor the delivery of psychiatric care at primary health care level.

Staff to population ratios

The proportion of staff per 100,000 population was very low for psychiatrists, psychiatric nurses and psychologists (Table I, Appendix 1). The proportions of countries in which there were less than one staff per million are 64%, 32% and 60% for psychiatrists, psychiatric nurses and psychologists respectively. Conversely, the proportions of countries in which there are more than 5 per 100,000 population are 5%, 11% and 1% respectively.

Clearly, it is an urgent priority to increase the numbers of mental health professionals throughout the continent. One aspect of this involves increasing the motivation for such training on the part of professionals in the early part of their career. The provision of high quality training in mental health by enthusiastic and competent lecturers in the curriculum for the primary qualification can contribute to this. The field of clinical psychiatry is becoming increasingly attractive to young professionals through developments in neuroscience, such as in brain imaging and our understanding of the biological and genetic basis for psychiatric disorders. Whereas the scientific evidence base for diagnosis and treatment in psychiatry has been slender in past years, disorders can now be diagnosed and treated with increasing precision and effectiveness, also making the field more attractive to such professionals. It is also important that training programmes are available for those that seek them. For psychiatrists, postgraduate clinical training facilities for psychiatrists are now established in 48% of African countries.¹⁹ These include Algeria, Angola, Benin, Burkina Faso, Cameroon, Cote d'Ivoire, Democratic Republic of Congo, Ethiopia, Ghana, Kenya, Madagascar, Mali, Mauritius, Nigeria, Senegal, South Africa, Tanzania, Uganda and Zimbabwe. For countries where such training programmes do not exist, we recommend that medical doctors wishing to specialise in psychiatry receive their training in an established programme on the continent, as opposed to the usual trend of receiving such training in Europe or North America. The advantages of this include receiving training that is more salient for the settings in which they will be working; cost savings; reduced brain drain caused by trainees opting to remain in the country in which they received training and promoting the development of networks of African mental health specialists.

However, as for other indicators, an increase in the absolute numbers alone may not produce optimal effects for the population.²⁰ It is not sufficient that specialist mental health service providers have received training and are competent in the direct provision of clinical services alone, as this is not appropriate for a context where it will not be feasible in the foreseeable future for almost all those with mental health problems to be treated by a mental health specialist.

Additional areas in which competence is necessary include training, supervision, consultation, liaison, policy and programme development, health services research and advocacy. Such areas should be included in the curricula of specialist training programmes. In addition, opportunities should be available for qualified specialists who wish to improve their capacity in these areas. A programme to build such capacity in public mental health has recently been established jointly at the University of Cape Town and Stellenbosch University. This distance learning programme will target policy makers, planners, mental health advocates and researchers in Ministries of Health, NGOs and academic institutions in Africa. The work will build on existing networks established over several years in African psychiatry.

Mental health information systems

Table I (Appendix 1) reveals that two-thirds of African countries have a mental health reporting system, which is defined as either a standalone mental health service management information system, or relevant mental health information integrated into the general health management information system. While this figure may appear to be higher than expected given the low level of resources in the other domains, one should bear in mind that in the majority of cases the system is confined to the collection of data about service inputs such as number of beds for people with psychiatric problems. Information about other aspects of psychiatric services, such as services provided by primary health care staff, is frequently not included. Furthermore, in many cases, the information is not processed, analyzed, disseminated or used for policy, planning and management. As a result of these limitations, the information is not able to yield the optimal benefits, which include contributing to service planning and evaluation, monitoring of clinical interventions, and assessing efficiency of resource utilization.²¹ In developing a mental health information system, it is essential to start small, but keep the bigger picture in mind; use indicators to summarize information in the domains of needs, inputs, processes and outcomes; establish a minimum data set and make the system user-friendly.²¹

Conclusion

For the first time there is data to compare and contrast mental health systems in African countries. This data, which was not available even 10 years ago, can now serve as a baseline to assess the future development of mental health systems in Africa. The compilation of this data has required commitment and partnerships between a number of stakeholders, including WHO, Ministries of Health, service providers and researchers, itself an indication of new systems and new commitment to monitoring psychiatric services.

Although the recommendations above were presented separately for each domain, it is necessary to address all five domains in a synergistic and integrated manner to maximize impact on the mental health of the population. For example, it is not an efficient use of resources to develop a policy that cannot be implemented within the target time frame because of a lack of finances, to train mental health specialists to supervise generic health workers at primary health care level when generic health workers do not have the skills or the time to provide mental health care at this level, or to allocate resources to increasing the number of beds for patients with psychopathology in general hospitals if information systems are not available to assess whether this has been achieved. The strengthening of mental health systems requires a multi-pronged approach which includes the development of policy, allocation of adequate resources, training of primary health care workers, and development of information systems.

It is important to note the limitations of this chapter. Firstly, monitoring systems for mental health are still in their infancy in Africa, and inaccuracies in the data that we have presented are inevitable.

Secondly, the data in Table I (Appendix 1) are implicitly applicable to adults. Clearly, it is important to gather equivalent data for children and adolescents. However, the limited data that are available confirm that services for children and adolescents in Africa are extremely under-resourced.²² In almost all African countries, children and adolescents comprise at least half of the population, and the proportion of them that suffer from psychiatric problems is equivalent to that of adults.²³ Furthermore, the provision of appropriate services for children and adolescents may have beneficial effects throughout the life span, since 75% of psychiatric disorders in adulthood have their onset in youth, and persistent adult disorders tend to have their onset during the ages of 12-24 years.²⁴

It is essential that, in the development of policies and the allocation of resources through health service planning, psychiatric services for children and adolescents are allocated resources in proportion to the burden of disease that is applicable to this age group.²⁵,²⁶ In some countries, where resources are extremely depleted, it may be necessary for psychiatrists and other mental health specialists to develop skills across the age range, until such time as sub-specialist areas (such as child and adolescent psychiatry) can be established.

Thirdly, mental health promotion and the prevention of mental disorders has not been addressed in this chapter.²⁷,²⁸ Clearly, successful efforts in these domains can have implications for psychiatric services, in that the need for treatment would decrease. One particularly important predisposing factor for psychiatric disorder in Africa is poverty, as there is also substantial and growing evidence for increased risk for mental disorders among poorer communities.²⁹,³⁰,³⁴

Development agencies therefore need to be informed about the link between poverty and mental illness, and include mental health in poverty alleviation and development initiatives in Africa. There are also innovative examples of programmes that integrate psychiatric interventions with economic development, such as the BasicNeeds mental health and development model (Appendix 2).

The implementation of our recommendations is supported by recent important international developments. The Lancet series on global mental health, published in September 2007, and the subsequent emergence of the Movement for Global Mental Health³¹ have provided a rallying call for the scaling up of mental health services, not least in African countries.³² The final paper in the Lancet series was a call for action to scale up mental health care, and included specific targets for doing so, namely $2 per capita per year in low income countries and $3-4 per capita per year in lower middle-income countries.³² Similarly, the WHO Mental Health Gap Action Program (mhGAP)³³ has focused international attention on the need to allocate appropriate resources to mental health care, particularly in low and middle-income countries. These initiatives provide clear targets and research evidence to urge Ministries of Health in Africa and development agencies, such as the World Bank, to increase resource allocation for psychiatric services. It is important that the opportunities presented by these initiatives are firmly grasped by those who work towards creating service systems. This is essential to enable those suffering from mental illnesses to have access to the high quality mental health services to which they are entitled.

Acknowledgements

We thank Noxolo Hewana and Robynn Paulsen for their assistance in compiling the data in Table I (Appendix 1).

Apendix 1

Table I: Resources for psychiatric services in Africa

Appendix 2

Key recommendations for developing mental health policies and plans and legislation

Policies and plans

Policy must demonstrate the commitment of government by clearly stating measurable actions to be achieved and using committal language to describe these.

Ministries of Health must identify relevant stakeholders from both inside and outside the health sector (welfare, religious sectors, education, housing, employment, criminal justice, police and other social services) and involve them in policy formulation through extensive consultation so that agreements for action can be made. Service users and family organizations must always be included in consultations.

Policies should set a limited number of objectives, prioritising the most urgent areas for action that can be achieved with the funds that the government will make available for implementation.

Policy objectives need to be accompanied by substantive and well thought out descriptions of policy directions and the actions required to achieve objectives.

Policy makers should organize and incorporate into policy an effective network of mental health services by deinstitutionalization, developing community mental health services and integrating mental health care into general health services.

Policies and strategic plans should include a human rights orientation, building on international human rights standards.

Policy must be linked to a strategic mental health plan that specifies the strategies and activities required to implement the policy. The budget and timeframe for each activity and strategy must be determined, as well as expected outputs, targets and indicators that can be used to assess whether the implementation of the plan has been successful.

Legislation

Laws must be reformed to reflect a shift in approach away from the involuntary treatment and towards the promotion of voluntary treatment and care.

Mental health laws should encourage the development of community-based mental health services and the integration of mental health into primary care and general hospitals

There should be clear statements on patients' and caregivers rights which place the patient at the centre of the mental health system while giving caregivers the rights necessary to enhance patient care and health.

National and international human rights frameworks must inform law in order to ensure that people with mental disabilities are able to exercise their rights on an equal basis with others.

Apendix 3

BasicNeeds

BasicNeeds, an international non-governmental organization (NGO) has developed a comprehensive mental health and