Written By Angelina Wilson, with contributions from Emily Fisher and an unidentified Staff Member at BasicNeeds
Mental health and inequality in Africa
Mental health is “a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community” (1) and as clearly described by the WHO, mental health is not simply the absence of mental disorder. Unfortunately, as a result of the lack of resources in middle and low-income countries, mental health resource allocation has been skewed towards psychiatric care (with a focus on disease-treatment) and there has been a general neglect of community-based care and the integration of mental health in the primary health care system (1). Mental health promotion aims to scale up the value of mental health so that the decisions by government and businesses do not compromise the population’s mental health but instead enables individuals to make informed decisions about their behavior (2).
Mental health in Ghana is in a deplorable condition because it is estimated that 650,000 people are suffering from severe mental disorder and a further 2,166, 000 suffer from mild to moderate mental disorder. The treatment gap is 98% of the total population (3). This is further compounded by the extreme focus on specialized psychiatric care which is concentrated in the south to the neglect of the rest of the country (3). The few community based programs are private and there is relatively low government funding on primary health care for mental health (3). In addition, on a policy level, while steps are being taken for a mental health bill to be passed in the nearest future, the current absence of a mental health act in Ghana has made it difficult to incorporate mental health into primary health care. The aim of this article is to provide empirical evidence on the condition of mental health in Ghana drawing from the experiences and work of an NGO called Basic Needs (http://www.basicneeds.org/ghana/).
Contributing to a healthier Ghana
BasicNeeds was established in 1999 by Chris Underhill with funding from Andrews Charitable Trust and the Joel Joffe Charitable Trust (4). BasicNeeds is primarily concerned with helping mentally ill patients not only to recover but also to develop a sustainable livelihood once they are living, playing, and working in the community. BasicNeeds has program locations mainly in developing countries across Africa, Asia, Latin America and Australia.
The model for mental health and development has five modules that include sustainable livelihood, capacity building, research, management and administration. This model represents a framework with which BasicNeeds works in the field of mental health. The module of sustainable livelihood requires that individuals are not only treated for their illness but also given an opportunity to develop an adequate livelihood. This will help increase individual independence and also help in resettling in their community. The staff at BasicNeeds outlined that capacity building as “empowering mentally ill patients to speak up for themselves and to contribute to policies affecting their lives”. The module of research requires that research be done into issues such as shortage of psychotropic medicine, reasons for delayed recovery among certain patients, and questions about why there are currently more epileptic cases. Management and administration includes activities ranging from coordinating funds and auditing financial resources to ensure that these funds are disbursed appropriately.
The activities of BasicNeeds reflect how this model can be used practically in mental health. One activity includes sponsoring a psychiatrist to go into the community to practice community mental health care. In addition, access to primary health care is ensured by routinely sending psychiatric doctors to four polyclinics in Accra. The psychiatric doctors are encouraged to pay a quarterly visit to the communities to standardize diagnoses and treatment for the psychiatric nurses to continue even in the absence of doctors. Some of these activities provide empirical evidence for the government that primary health care and community care is possible. This evidence can improve outcomes for individual patients: admission to psychiatric hospitals can make the reintegration of mental health patients more difficult, so enabling them to receive care in the community helps individuals avoid an unnecessary transition. This effort also helps to reduce stigma as receiving care in an institution is highly stigmatized.
After treatment, sustainable livelihood is ensured by finding out from the patient what kind of occupation they are interested in and then providing funds for them to embark on their chosen vocation. BasicNeeds helps to ensure sure that the occupation chosen by the individual is suitable for them. One example described by staff at BasicNeeds is that due to safety issues, “epileptic patients would not be allowed to operate heavy machines or drive”. In line with the principle of occupational therapy BasicNeeds has developed ten acres of land for the inmates at Pantang hospital which is a psychiatric hospital in Accra. Inmates at Pantang have been treated at the facility, but their families have refused to come for them, so they are encouraged to engage in horticulture work in the Pantang hospital. In describing the work, staff at Basic Needs tell us that “It is like a community for these inmates and it also helps to develop their in-built skill.”
It is important to note that BasicNeeds is not a service delivery organization; they work in partnership with the Ghana Health Service and are affiliated with the Ghana federation of the disabled. People are referred by the Polyclinic to BasicNeeds for support not treatment. BasicNeeds provides livelihood, empowerment and, capacity building. Medical care is within the jurisdiction of the Ghana Health Service. BasicNeeds only funds medical care to get to the hinterlands. For example, in the Northern region of Ghana, the upper east and upper west, there is no single psychiatrist as there are only community psychiatry nurses. They fly psychiatrists to Northern Ghana to render the different services (staff at BasicNeeds). This is to demonstrate to the government that community care is possible.
Stigma, Mental Health and BasicNeeds
Stigma was found to cut across both the patients, doctors, and other personnel that are involved in the treatment and care of these patients. BasicNeeds endeavors to reduce stigma by writing articles about stigma and sensitizing the community about the truth of mental health. Stigma around mental illness is quite extensive in Ghana because it affects not only the patients but their families and anyone associated with them. Many people believe mental disorder is hereditary so marriage with a sibling or child of a mentally ill patient is not allowed. The community psychiatric nurses (CPN) are also stigmatized in the polyclinics and even resource allocation is a product of the stigma: the tables and telephones that are faulty are pushed to the offices of CPN.
Incorporating traditional medicine, spirituality, and mental health
BasicNeeds also works in partnership with traditional healers or faith based organizations especially in Northern Ghana. Traditional healers have been trained to understand that their work is not being condemned, but is part of the treatment and that they should work in partnership with the Ghana Health Service. For instance, when an aggressive patient visits a traditional healer, there is an orthodox way of making the patient calm by giving an injection (tranquilizer) to reduce aggression (staff at BasicNeeds). This is better than the historical way of treatment which was to tie a person with a chain or put them in shackles and tie them around a tree and to engage in an exorcism. Traditional healing can also be combined with medicine. Traditional healers are usually willing to be trained in mental health care, but the involvement of traditional healers in the healing process is more predominant in the North than in the south. Traditional healers need to be included in the process and educated because people tend to consult them first before going to the psychiatric. In return, BasicNeeds provides free asbestos sheets to improve the built environment of the traditional healers.
In conclusion, Ghana is one of the many countries across the globe experiencing inequity in the allocation of resources for mental health. In the African continent only Nigeria and Tanzania are known to have a half-way home for those with mental illness. This stands to show that there is still a lot to be done to reduce this inequity. BasicNeeds is contributing immensely to reduce the inequity in allocation of resources for mental health but more can and should be done. As a first step an increase in government commitment to mental health is necessary. Passing of the mental health bill is also a step in the right direction. This will in turn increase community care, awareness of the state of mental health, and reduce the stigma associated with mental illness. For mental health promotion to succeed, all hands need to be on deck. Psychologists, social workers are all necessary in the rehabilitation process (staff at BasicNeeds).
This article is based on the interview with a staff at BasicNeeds whose identity will not be disclosed.
1. WHO | What is mental health? [Internet]. [cited 2012 Feb 15]. Available from: http://www.who.int/features/qa/62/en/index.html
2. Herman H, Jané-Llopis E. Mental health promotion in public health. Promotion & Education. 2005 Jun 1;12(2 suppl):42–7.
3. WHO | GHANA [Internet]. WHO. [cited 2012 Feb 15]. Available from: http://www.who.int/mental_health/policy/country/ghana/en/