Global health policy - 01/July/2021

Kenya shines light on mental health crisis sweeping Africa

A new commitment by Kenya’s leaders helped move mental illness onto the health agenda, yet political will was only the beginning of the journey. The country’s first steps towards meeting the mental health needs of its population illustrate the broader obstacles to extending psychological care throughout the African continent.

For ten long years, Mutahi Kagwe visited Nairobi’s Mathari Mental Hospital where his close friend, a once brilliant scientist, was confined. Kagwe saw at first hand the conditions at the century-old psychiatric treatment centre, the largest in Kenya, as his friend lost a long battle with mental illness. “It broke my heart when he died,” recalled Kagwe in 2019. At the time Kagwe had just been appointed Kenya’s Minister of Health.

Kagwe did not let his personal knowledge of the tragedy that is severe mental illness go to waste. The experience, he said, changed his perception about mental health in Kenya. He became aware of the scarcity of hospitals dedicated to mental health and the ill-equipped state of those that existed. As Kagwe mourned the loss of his friend, events on the streets were bringing the topic of mental health to the notice of Kenya’s President, Uhuru Kenyatta. A spate of suicides and people annihilating their families in murderous rages had attracted media attention, spooking Kenyatta into speaking out about a growing national health crisis.

Kenyatta used the platform of his Madaraka Day speech in 2019 to call attention to the country’s rising tide of mental illness. The speech, made every June 1, marks the day Kenya assumed self-determination after throwing off the chains of British colonial rule in 1963. Kenyatta recognised in his speech that Kenya needed to also break free of the chains of mental illness. He ordered his health minister to implement programmes and policies to achieve that end. Kagwe was more than ready to rise to the occasion.

As two of Kenya’s most powerful politicians experienced a reckoning with mental health, the psychiatrists, nurses and psychologists who had waited for such a political commitment for decades saw their opportunity. “This was the time to act and we were ready to offer the technical know-how to sort this issue once and for all,” says Frank Njenga, one of Kenya’s most prominent psychiatrists.

 

 

FOR EVERY DOLLAR SAVED FIVE ARE LOST

And act they did. By November 2019 the government had formed a task force to investigate the state of mental health in the country. That investigation, chaired by Njenga, reported back after three months of intelligence-gathering and visits to the few existing mental health facilities in the country. “We told them that for every single dollar they did not invest in mental health, they were losing another five,” Njenga said.

Appalled by the group’s findings—including stories of children as young as eight years old taking their lives—Kenyatta appointed Njenga as his adviser on mental health. Two months later the government had implemented one of the task force’s recommendations and given Mathari National Teaching and Referral Hospital autonomy to run its budget free from
political interference.

It took media reports to jolt Kenyatta into action and Kagwe’s personal experience to achieve at least some results. The crisis, however, had been years in the making, as evident from a mental health policy blueprint for 2015-2030. It contained sobering statistics: one in every four people visiting outpatient health facilities in Kenya and two in every five in inpatient care have mental conditions, including depression, attempted suicides, substance use disorder, bipolar disorder, and schizophrenia. Access to treatment is woefully inadequate. Even today Kenya does not have a mental health budget and few of the policy recommendations, such as training and hiring of more psychiatric specialists, have been acted upon.

 

AN AFRICA WIDE CRISIS

The picture painted by the numbers of widespread and untreated mental illness in Kenya is replicated across many African countries, where psychological well-being is under pressure. The rapid modernisation of society brings people into direct conflict with age-old cultures, yet lack of understanding of the nature of mental illness, cultural taboos and the stigma attached to the disease in many African societies means it goes unrecognised and untreated.

Visits to mental health outpatient facilities in Africa are estimated to be at a rate of 508 for every 100,000 citizens, less than a third of the global rate of 1601 per 100,000, reports the World Health Organization (WHO) in its Mental Health Atlas 2017. Kenya’s health ministry estimates that 75% of people in need of medical services for mental health challenges cannot get it. The numbers are as high as 99% in war-torn countries such as Sierra Leone. Ethiopia, a country with a 117 million people, has fewer than 100 psychiatrists, according to WHO. Africa as a whole has one mental health worker for every 100,000 citizens, compared with 50 in Europe; the number of psychiatric nurses in Africa is 0.5 per 100,000, the lowest of WHO’s seven global regions. Poor diagnosis of mental illnesses is the inevitable result of the lack of investment in psychiatry professionals.

 

Specialist • Saguedin Kpiémam, community mental health worker, Togo

 

“Unlike Malaria, with biomarkers like blood where you test and say, ah, you tested positive, mental illnesses rely on questionnaires, interviews and a physician’s appreciation of what is serious,” says Solomon Teferra, a psychiatry professor and head of psychiatry at the School of Medicine in Ethiopia’s Addis Ababa University. It is common for patients to be shuttled from one hospital department to another and treated for a physical disease because no health worker or clinician suspects a mental illness, he says.

 

As two of Kenya’s most powerful politicians experienced a reckoning with mental health, the psychiatrists, nurses and psychologists saw their opportunity

 

Globally, mental illness on average attracts just 2% of government spending on health, according to WHO. An indication of how little of that is spent on mental health in Africa shows up in a comparison with Europe. Of the just 2% of funds that go to mental health, Europe spends 20 times more per head of population than Africa, according to the WHO atlas. Without money to develop and implement policies, even African countries that do have clear mental health polices are stymied. “The money is not just for the clinical work, but for research, hiring qualified health workers, community engagement to teach the public about mental health,” says Lukoye Atwoli, a psychiatry professor and dean of East Africa’s Aga Khan Medical College.

 

CULTURAL CHALLENGES

Traditional culture and religious beliefs have a strong bearing on perceptions of mental health. Most people in Ethiopia, medical professionals no exception, view mental illness as a supernatural affliction or punishment from the gods, rather than as a medical condition, Teferra says. Victims and their families turn for help to religious leaders and traditional healers in far greater numbers than to psychiatry professionals, he adds.

Teferra’s observations are backed by studies by Oluyomi Esan of the psychiatry department at Nigeria’s University of Ibadan. He found that traditional and religious healers could accommodate a far greater number of patient admissions than conventional mental health providers in Ghana, Kenya and Nigeria. But the quality of treatment from traditional healers was variable, especially compared with more standard psychiatric practice, and included physical restraint.

Semantics plays its part in maintaining the stigma attached to mental illness, which prevents people from seeking qualified help. Many people in Africa attribute the cause of depression to excessive thinking, reveals work by Emma Louise Backe, a medical anthropologist at George Washington University. In Zimbabwe’s Shona tribe, depression is called kufungisisa, which means “thinking too much”. The cure prescribed by families and at least some health workers is to stop thinking.

 

 

SOLUTIONS GOOD AND BAD

One approach to solving the shortage of mental health specialists has been to provide additional training to primary care and traditional health workers, a process referred to as “task shifting” and already used in HIV and tuberculosis programmes. The treatment of mental illnesses, however, is not an easy task to shift to the shoulders of non-specialists.

In Kenya, a mental health amendment bill in 2019 sought to include mental illness in primary health services, but a red flag was raised by psychiatrist Susan Hinga at Kenyatta University’s school of medicine. She warned that delegating management of mentally ill people in hospitals to psychologists, including admission and discharge, could have potentially lethal results. “Some people may present signs of depression, but perhaps they have deficiencies in the thyroid hormones that makes them lethargic, and not depression,” Hinga said, adding that only a physician would have the training to make such a complex diagnosis.

 

Semantics plays its part in maintaining the stigma attached to mental illness, which prevents people from seeking qualified help

 

The bill was opposed by Kenya’s doctors, who may have been sensitive to tragedies caused by mental health legislation in other countries. In 2016, more than 140 psychiatric patients died when South Africa’s Gauteng provincial government transferred 1711 state-funded psychiatric patients from Life Esidimeni, a private health care provider, to other facilities that were not properly licensed. A government investigation revealed patients had been tortured, starved and suffered head injuries. Subsequent to that scandal, Human Rights Watch, an organisation based in New York, published its Living in Chains global report in 2020, documenting how care homes, state-run and private institutions, and traditional and religious healing centres detained mentally ill people against their will.

Rather than be led by national governments, improvements in care and treatment of the mentally ill in Africa may be more likely to arise from grassroots initiatives developed by well-informed, motivated and highly concerned medical professionals with detailed understanding of the issues and local needs. Cross border collaboration through professional networks is already happening to spread best practice. Mental health reforms across the continent will in no small part depend on sharing and learning across borders from local successes and on pan-African collaboration between organisations and countries. •

 


INSIGHTS – THE POWER OF MOTIVATED PROFESSIONALS

Ethiopoian psychiatrist Solomon Teferra appreciates just how daunting a task it will be to get mental illness accepted as a disease and included into national health policies across Africa. But as part of a disparate network of motivated mental health professionals he is determined to do what he can to stem the rising tide of an illness that is barely recognised as such by many Africans despite the risk it poses to economic prosperity for entire countries, from Kenya, to Nigeria to South Africa.

Teferra and his colleagues laboured to pull provincial ministries of health across Ethiopia to meetings and workshops to write the country’s first 2013-2016 National Mental Health Strategy, a document that in the end was never ratified. That failure was a lesson for other mental health advocates, such as Bonfoh Bassirou, the director of research consortium Afrique One, based in Cote D’Ivoire. It strives to involve regional pan-African bodies in work to im- prove the continent’s mental health.

Bassirou’s primary focus is zoonoses, diseases that afflict human beings but come from animals. As his interest broadened beyond pure veterinary medicine, he rubbed shoulders with people from a broad range of medical disciplines. Mental health was something he read about in passing when studying the suicides of livestock herders whose animals died from drought and disease in the 1980s and 1990s in the Sahel Belt in West Africa. One of his Ph.D. students was studying a neglected tropical disease, Buruli ulcers, that forced patients to stay in hospital for more than four months until the wound healed. Bassirou found himself wonder- ing how such an isolating experience might affect a person’s mental health.

The more he read about the prevalence of mental health disease and the lack of funding, the more motivated he became to approach his own academic networks to find out if there was anything they could do to provide more resources for mental health. Bassirou approached the management of the African Academy of Sciences (AAS), one of the continent’s most prominent research funders, of which he is a fellow.

The African Union-backed AAS formed a task force on mental health in Africa that Bassirou volunteered to chair. Throughout 2020 he worked with other scientists to draft a document that would determine what aspects of this complex public health issue governments should prioritise.

Another member of the task force was Dixon Chibanda, an associate professor of psychiatry at the University of Zimbabwe and the London School of Hygiene and Tropical Medicine. One of just 12 psychiatrists practising in Zimbabwe, Chiban- da is famous for his Friendship Bench in Zimbabwe, a project in which he trained thousands of grandmothers in talk therapy, giving them the skills needed to sit on a bench and successfully communicate with depressed people, deterring many from suicide. Bassirou tried a form of the Friendship Bench on the Buruli ulcer patients, arranging for them to cook and share meals in the hospital.

Ultimately, the members of the AAS task force hope to explore ways of using bench therapy and other successful and cheap treatments for rallying Africa’s regional bodies around the idea of including mental health in national care plans. •

 

TEXT Verah Okeyo — PHOTO Steve Wafula, Robin Hammond and Rainer Kwiote

 

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