Kigozi mental health service delivery in africa

Mental Health and Poverty: Challenges in Service Delivery in Sub-Saharan Africa (SSA)

Global Mental Health and Africa: Opportunities, Challenges and

Collaboration

15th – 16th August 2011: Mbarara University (Uganda)

Fred N. Kigozi M.DSenior Consultant Psychiatrist/Executive Director, Butabika National Hospital

Outline

IntroductionPoverty and mental healthChallenges in service deliveryConclusion

Sub-Saharan Africa region

Introduction - Africa

Second largest continent (11, 700,000 square miles)

Population: 1,022,234,000 (UNFPA, 2011)

- Continent with highest birthrate Average population growth rate: 2.3%Low life expectancy, average = 54 years۷ 50% of population in sub-Saharan Africa live on less than a dollar a day (World Bank Development Indicators, 2007)

SSA – Population and Devpt indicators

Total Population: 870 million people - Highest birthrateAverage rural population = 61.2% of total populationAverage life expectancy = 52 years

Average literacy rate: 65%

GDP: $ 1.184 Trillion (2009 est.)

Little Data Book on Africa, 2010

Burden of Disease – Mental Disorders in SSA

Mental illnesses are common and universal

MHD- New and old morbidity make a significant contribution to the burden of disease in SSA (WHO- WHR, 2001)

Nearly 75% Global burden of HIV/AIDS contribution by SSA (UNAIDS, 2008)

Massive internal/external displacements arising from civil strifes lead to PTSD related disorders

Rampant poverty, declining economies and unemployment for rural folks (UNDP reports) → stresses

SSA faces a double burden of disease and insufficient resources

Resources - SSA Continent with highest birthrate:۷ 69% of population in sub-Saharan Africa live on less than a dollar a day (World Bank Development Indicators, 2010)Africa has an average 0.34 psychiatric beds per 10,000 population. C.f Europe has an average 8.7Africa has an average 0.05 Psychiatrists per 100,000 population. C.f 9 Psychiatrists per 100,000 for Europe 79% of African countries spend less than 1% of the health budget on mental healthMany African countries have no Clinical Psychologists and Social workersUnemployment rates are very high in many African countries

Inequity in the distribution of resources

Essential Resources – A few selected countries

The Little Data Book on Africa (World Bank, 2008); World Dev’t Indicators, World Bank 2010WHO ATLAS, 2005, 2010

Country Population (millions)

Per capita income (USD)

MH policy No. of Psychiatrists

Zimbabwe 12.08 460 √ 12

South Africa 50.59 6,100 √ ~ 500

Tanzania 42.74 530 X 19

Kenya 41.07 780 √ 77

Rwanda 11.37 8 X 2 (Visiting Psychiatrists from U.S)

Uganda 33 490 Draft 34

Ethiopia 90.8 380 X 40

Sierra Leone 5.8 340 Draft 1

Malawi 15.8 330 √ 1

Liberia 3.78 190 √ 1

Zambia 13.8 1,070 X 2

Burundi 10.21 160 X 1 (Visiting Psychiatrist)

Poverty and Mental HealthMental disorders make a significant contribution to burden of disease in LAMICs

Poverty is widespread in LAMICs: Absolute poverty Relative poverty

Poverty shown as a major risk factor for mental disorder in HICs

o Poverty is a strong precipitating and mediating factor for MH problems: stress, frustration, anxieties & depression

o Delayed help seeking & incomplete dosage are all typical of the poor PWMI. -Their affordable medicines mostly have negative side effects.

Poverty and Mental health

o Many poor and unemployed persons resort to alcohol to cope with their frustrations. Alcoholism → mental illness

o MH problems more among the two extremes (very rich and the very poor)

o Most PWMI are unproductive and a burden to the family & national economy

o The mentally ill tend to be destructive and wastefulo Parents’ mental illness results in loss of human capital

and a vicious cycle of poverty in the family o Breaking the link requires more than addressing

poverty o Only a few local studies on poverty and mental ill-

health (e.g MHaPP)

Cycle of poverty and mental ill-health

Poverty

• Economic deprivation

• Indebtedness• Low education• Unemployment• Lack of basic

amenities/housing• Overcrowding

Mental Ill Health

• Higher prevalence

• Poor/lack of care

• More severe course

Social exclusionHigh stressorsReduced access to social capital/safety netMalnutritionObstetric risksViolence and trauma

Increased health expenditureLoss of employmentReduced ProductivitySocial drift

Vicious cycle of Poverty and poor Mental Health

Malnutrition, Domestic Violence,

Indebtedness

Depression & Anxiety,physical ill-health,

Alcohol abuse

Reduced productivityDisabilityIncreased health costs

Poverty, stigma and service utilization

Poverty dictates the extent of service utilization- Access to better MH services extremely hard for the poor Poverty, mental illness and stigma inter-relate in a vicious cycle, to the disadvantage of poor people with mental illness. Poverty aggravates the stigma attached to mental illnessStigma more hurting and disabling than the illness itself, in many individualsStigma is a major hindrance to effective service delivery.Stigma is a significant obstacle to service utilization- Hinders disclosure of the illness, resulting in delayed help-seeking- Results in concealment of information about their mental illness

The Service Situation

Paucity of details regarding the MH systems in Africa

Low priority for mental health

Inadequate and skewed distribution of human resources

Inadequate infrastructure

Service situation→

Institutional Organization of Mental HealthServices:

Central Large Mental HospitalLimited Acute beds in Regional general hospitals.A few Acute beds in District hospitals.All countries embraced integration of mental health into Primary Health Care.Very little community care with no facilities for acute bed/care.

Service situation→Financing Mental Health Services:

Usually not easy to track budgets as there is no specified budget allocations for Mental Health:-

< 5% GDP expenditure on Health < 1% of Health Budget

Main modes in order of importance:-Out of Central Tax Revenue Out of pocket (patients and relatives).Social InsurancePrivate InsuranceDisability benefits absent.

Key issues for MH care in LICs

Inadequate appropriate policies and plans

Lack of awareness of the magnitude of the problems in mental health

Paucity of information among politicians, policy makers and public

Minimal data on cost-effective interventions and epidemiological surveys

Dilapidated referral infrastructures and systems

Ill-equipped general health workers with knowledge and skills in mental health

Few central level experts to provide technical support

Key issues →Extremely low coverage of evidence-based services for PWMI in LICsPoor help-seeking behaviour attributable to the cultural explanatory modelLack of support by general health service managersGross underfunding for mental health- burden of mental illness is on the increase, but no corresponding increase in resource allocationInadequate fundingIll-equipped General Health Workers with little knowledge and skills in MHNegative attitude, misunderstandings and stigma.Burn-out among the health workers in rural setting with no peer support.

Key barriers to service delivery 1. Absence of mental health on the public health

priority agenda2. Organization of mental health services

» still centralized

3. Inadequate integration

» overburdened PHC system

4. Inadequate human resource base5. Scarcity of effective public mental health

leadership

Lancet Global Mental Health Group, 2007

Way forward Review of Policies, legislations and strategic plansMental Health LegislationSignificant improvement in provision of financial resources to meet the MDGsStrengthen integration of MH into PHC- Include MH in public health programmesCapacity buildingInfrastructure and human resource policy reviewCollaboration with NGOsPromote research

Way forward→Role of NGO’s, Public Education and

Consumer Empowerment:

Encourage partnership with all stakeholders including private sector, local and international NGOs.Encourage the formation of consumer organisations at lower levels.Develop appropriate message especially to counter stigma and discrimination against mental illness.Messages on promotion, prevention and early intervention in mental disorders.

Way forward→

Psychiatric Education and Continuing Medical Education (CME) & Technical Support:

Review Training curricula for all health workers.Develop Training curricula for In-service training.Carry out programmed training for General health workers in the districts & lower levels regularly.Develop guidelines, Monitoring and evaluation tools.Provide technical support supervision.

ConclusionChallenges for rural mental health care still many.

Need for infrastructure development.

Commitment on new policies emphasizing;

Decentralisation, community care and integration of

mental health into PHC.

Sustainance of resource mobilisation.

Involve all stakeholders including NGOs.

Community empowerment and fighting stigma.

Investing in human capital