An emerging public health issue in Africa
The idea of health as a holistic concept is widely acknowledged. World Health Organization (WHO) defines mental health as a state of well-being in which the individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community.
The slogan ‘no health without mental health’ is immensely popular, but its application in the African context leaves a lot to be desired.
Facilities for mental health are scarce, with their finite resources stretched beyond capacity. Mental health specialists are equally unavailable, particularly in the publicly funded health system. It is safe to say that access to mental healthcare on the continent is almost impossible, and when available, extremely expensive, putting it out of reach for millions of people who are in need.
October being a mental health month, Healthcare Africa explores the mental health situation in Africa and progress being made to enhance access to this very critical form of care.
Mental health services almost nonexistent in Africa
Mental health services in Africa are scanty, to say the least, mainly due to the blind eye turned to the problem by African governments. Worldwide, 24% of countries that reported to the WHO’s 2014 Mental Health Atlas survey did not have or had not implemented standalone mental health policies; in Africa, this proportion rose to 46%. The lack of supporting mental health policy manifests itself in the low numbers of personnel and critical infrastructure. According to the “Mental health in Africa” report by Lancet Global Health, “The region has 1.4 mental health workers per 100 000 people, compared with a global average of 9.0 per 100 000.”
Lancet Global Health also notes that “Africa performs relatively poorly with regard to the number of psychiatrists, the number of hospital beds for patients with mental illness, and the coverage of outpatient facilities.” Their observation could not be far from the truth if a sample of Africa’s top economies is anything to go by. According to a 2017 United Nations report, Kenya had only about 80 psychiatrists, 30 clinical psychologists, and fewer than 500 psychiatric nurses, of which only 250 work in mental health. More prosperous South Africa boasts of 22 psychiatric hospitals and 36 psychiatric wards in general hospitals, while oil-rich Nigeria only had 130 psychiatrists in the country of 174 million people (now more than 200 million). This is, however, not surprising as Most African governments spend less than 1% of their allocated health budget on mental illnesses.
Partly as a consequence, the proportion of Africans who receive treatment for mental health problems is extremely low. According to Lancet Global Health, the annual rate of visits to mental health outpatient facilities in Africa is 14 per 100 000 population, an extremely low figure when compared to a global annual rate of 1051 per 100 000 population. In Sierra Leone, for example, the treatment gap (that is, the proportion of those in need who go untreated) for formal mental health services has been estimated at 98.8%. In South Africa, only about 14% of the population have access to mental health services, of which one-third are afflicted with mental diseases, according to experts.
Mental Illness, a reality we wish never existed
One would be persuaded to think Africa has no mental health problems, but statistics on the ground suggest otherwise. Between 2000 and 2015 the continent’s population grew by 49%, yet the number of years lost to disability as a result of mental and substance use disorders increased by 52%, according to WHO estimates. Additionally, the world health body noted that 17.9 million years were lost to disability as a consequence of mental health problems. Such disorders were almost as important a cause of years lost to disability as were infectious and parasitic diseases, which accounted for 18.5 million years lost to disability.
Depression, the most prevalent mental illness in the world, has also been on the rise in Africa. Currently, an estimated 100 million people in Africa suffer from clinical depression, including 66 million women, according to data from the World Economic Forum. Regionally, 2017 estimates show that a fourth of the Kenyan population of 44 million suffer from a range of mental diseases, including schizophrenia and other psychotic disorders, bipolar disorder, depression, and severe anxiety. WHO estimates that the number of mentally ill Nigerians ranges from 40 million to 60 million. Disorders like depression, anxiety, and schizophrenia are common in the country. The WHO estimated in 2017 that 450,000 people in Sierra Leone—which has a population of just over 7 million—suffer from depression every year and that 75,000 suffer from schizophrenia.
Prohibitive costs, stigma hinder access
Payment for mental healthcare is mainly out-of-pocket, putting a significant burden on individuals and families and sometimes causing severe financial strains. As a case study, the cost of treating mental illness in Kenya ranges between KES50, 000 (US$414) to KES100, 000 (US$828) before factoring in the doctor’s consultation fee of KES 10, 000 (US$82). The cost of treatment in private hospitals is much higher with patients having to part with between KES 3000 (US$25) to KES 5000 (US$41) every time a psychiatrist attends them. In a country where a majority of the people live on less than US$2 a day, this is an impossible amount to put together.
The socio-cultural bias toward mental health disorders remains an age-long barrier to seeking care in Africa. As earlier noted, mental health is such a non-issue that African languages never bothered to create a word for it. In severe cases, mental health patients are considered dangerous and until recently, several of them were forced to wear chains in hospitals such as the Kissy National Referral Psychiatric Hospital (now Sierra Leone Psychiatric Teaching Hospital). Afraid of the stigma, patients choose not to seek help, assuming the problem would go away on its own. Sometimes, family members decide not to seek care for the same reason. Also, help is sometimes sought from traditional and spiritual healers, as mental health is sometimes believed to be a spiritual problem.
A ticking-time-bomb waiting to explode
As Africa’s population is expected to double over the next three decades, the pressures on young people in particular, who across the region are already struggling to earn a livelihood in highly competitive labor markets, are likely to ratchet up. Many will experience psychological problems as they fail to realize their ambitions, and some will turn to substance misuse as a means of alleviating their frustration, and this will create a mental health crisis that the continent has never experienced before. The problem is already brewing. The most recent systematic review focusing on sub-Saharan Africa reported that one in seven children and adolescents experiences significant psychological challenges, and almost 10% qualify for a psychiatric diagnosis. Across 37 studies published between 2008 to 2020 and spanning 97,616 adolescents, the researchers found the following prevalence: depression (26.9%); anxiety disorders (29.8%); emotional and behavioral problems (40.8%); PTSD in one study (21.5%) and suicidal thoughts (20.8%). It can only get worse from here as the population doubles in size.
New solutions to mental health arise
As mental health problems continue to abound and brick-and-mortar facilities remain out of reach for many, new solutions are cropping up across the continent to provide the much-needed care. Kena Health application recently launched in South Africa to provide private, affordable, and remote care for mental health through digital solutions. The app allows mental health professionals to chat with patients via smartphones, improving access to mental health services across South Africa and helping to alleviate the lack of mental health services in rural areas.
To enhance access to mental healthcare in Kenya, the Africa Mental Health Foundation started project TEAM, which enlists African traditional healers, faith healers, and community health workers to detect mental illness and refer cases to clinicians. Referrals of people suspected of having mental illness rose from zero to 1,593. Of these, 494 went on to be clinically diagnosed with a mental health disorder.
In Zimbabwe, benches have been placed outside health clinics, which people visit for treatment of all kinds of conditions, including HIV and AIDS. Lay health workers, known as Golden Ladies or “Grandmothers, ” are trained to deliver low-intensity cognitive behavior therapy to anyone referred to the benches by clinicians. To date, over 15,000 people have used the Friendship bench. Given its potential, Grand Challenges Canada is funding its roll-out to 60 clinics in the 3 cities, where it’s hoped up to 50,000 people will have access.
Egypt, through its Ministry of Health and Population (MoHP) recently introduced the first-ever free of charge national electronic platform for mental health services and addiction treatment. The platform seeks to contribute to the nation’s mental health wellness by providing educational material around the issue to enhance awareness and by giving citizens access to psychological support and counseling services through virtual telemedicine clinics. Therapists on site also have permission to transfer emergency cases to the General Secretariat of Mental Health and Addiction Treatment for speedy and immediate intervention.
Currently, an estimated 100 million people in Africa suffer from clinical depression, including
66 million women
A fresh impetus to mental health in Africa
Although grim, the outlook of Africa’s mental health landscape has a silver lining in the renewed focus by governments across the continent to alleviate the problem. In Kenya, the Ministry of Health is operationalizing a mental health call center to improve access to mental health services for all Kenyans. The country is also bolstering its human resource capacity for mental health through the recruitment and deployment of 146 psychologists to the 47 counties. To add to these efforts, Kenya unveiled plans to relocate the Mathari National Referral Hospital, the largest facility for mental health in Kenya, from its current location on Thika Road to an 80-acre plot in Karen, one of Nairobi’s affluent suburbs. The new 600-bed capacity hospital will be the largest of its kind in East and Central Africa and will have facilities to handle 1000 walk-in patients daily. Built through a public-private partnership between the government of Kenya and Group San Donato and San Raffaele Research Hospital in Italy, the facility will be renamed National Teaching and Referral Neuropsychiatric Centre and will host a specialist university to train mental health workers.
Elsewhere in the continent, Sierra Leone, in partnership with Partners in Health, opened a newly refurbished Sierra Leone Psychiatric Teaching Hospital, which years of neglect had left it in a near-derelict state. The SLPTH is today a transformed, dignified, and well-resourced with a steady flow of never-before-available psychiatric medications.
Not to be left behind, Nigeria has also started efforts to enhance medical care for its citizens. The Lagos state government, one of the devolved federal units in Nigeria, announced plans to construct a 500-bed Psychiatric Hospital to promote mental healthcare delivery in the country. South Africa has also invested US$120 million to build the Kimberley Mental Health Hospital. Opened in 2021, the hospital has the capacity to accommodate 287 inpatients at a time.
Government efforts across Africa are being boosted by the WHO which is working to help them review mental health legislation and related policies, and to build capacities using the MH-Gap approach, a task-sharing strategy where primary health care workers are trained and then supervised in managing common mental disorders.
The efforts by governments, although commendable, are still a drop in an ocean when compared to the problems at hand. Researchers suggest that mental health should become an integral part of programs related to community empowerment, poverty reduction, HIV/AIDS prevention, and reproductive and sexual health. African governments should also do more to increase their budgetary allocation to mental health as it is the only way they can be able to achieve their commitment to increase service coverage for severe mental health disorders by 20% and to reduce suicide rates by 10%. Without clear and concerted efforts to manage the problem, mental health may snowball into a catastrophic pandemic in the next decade, and Africa will only have itself to blame.
This feature appeared in the June 2022 issue of Healthcare Middle East & Africa. You can read this and the entire magazine HERE
