Mental health services in Sub-Saharan Africa face significant challenges due to high levels of poverty and limited resources. Poverty exacerbates the effects of mental illness and hinders treatment due to lack of access and stigma. Key issues include inadequate policies, low prioritization and funding of mental health, lack of infrastructure and human resources, and poor integration into primary health care. Moving forward will require policy reforms, capacity building, improved community care, fighting stigma, and multi-sectoral collaboration.

1. Mental Health and Poverty: Challenges in Service Delivery in Sub-Saharan Africa (SSA)Global Mental Health and Africa: Opportunities, Challenges and Collaboration15th – 16th August 2011: Mbarara University (Uganda) Fred N. Kigozi M.D Senior Consultant Psychiatrist/ Executive Director, Butabika National Hospital

2. Outline Introduction Poverty and mental health Challenges in service delivery Conclusion

3. Sub-Saharan Africa region

4. 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 years ۷ 50% of population in sub-Saharan Africa live on less than a dollar a day (World Bank Development Indicators, 2007)

5. SSA – Population and Devpt indicators Total Population: 870 million people - Highest birthrate Average rural population = 61.2% of total population Average life expectancy = 52 years Average literacy rate: 65% GDP: $ 1.184 Trillion (2009 est.) Little Data Book on Africa, 2010

6. 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

7. 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 8.7 Africa 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 health Many African countries have no Clinical Psychologists and Social workers Unemployment rates are very high in many African countries Inequity in the distribution of resources

8. 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

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

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

13. The mentally ill tend to be destructive and wasteful

14. Parents’ mental illness results in loss of human capital and a vicious cycle of poverty in the family

15. Breaking the link requires more than addressing poverty

17. Indebtedness

18. Low education

19. Unemployment

20. Lack of basic amenities/housing

22. Poor/lack of care

23. More severe courseIncreased health expenditure Loss of employment Reduced Productivity Social drift

24. Vicious cycle of Poverty and poor Mental Health Malnutrition, Domestic Violence, Indebtedness Depression & Anxiety, physical ill-health, Alcohol abuse Reduced productivity Disability Increased health costs

25. 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 illness Stigma more hurting and disabling than the illness itself, in many individuals Stigma 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

26. 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

27. Service situation-> Institutional Organization of Mental Health Services: Central Large Mental Hospital Limited 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.

28. 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 Insurance Private Insurance Disability benefits absent.

29. 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

30. Key issues -> Extremely low coverage of evidence-based services for PWMI in LICs Poor help-seeking behaviour attributable to the cultural explanatory model Lack of support by general health service managers Gross underfunding for mental health - burden of mental illness is on the increase, but no corresponding increase in resource allocation Inadequate funding Ill-equipped General Health Workers with little knowledge and skills in MH Negative attitude, misunderstandings and stigma. Burn-out among the health workers in rural setting with no peer support.

31. Key barriers to service delivery Absence of mental health on the public health priority agenda Organization of mental health services » still centralized Inadequate integration » overburdened PHC system Inadequate human resource base Scarcity of effective public mental health leadership Lancet Global Mental Health Group, 2007

32. Way forward Review of Policies, legislations and strategic plans Mental Health Legislation Significant improvement in provision of financial resources to meet the MDGs Strengthen integration of MH into PHC - Include MH in public health programmes Capacity building Infrastructure and human resource policy review Collaboration with NGOs Promote research

33. 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.

34. 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.

35. Conclusion Challenges 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