Kigozi mental health service delivery in africa


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Kigozi mental health service delivery in africa

  1. 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)<br /> Fred N. Kigozi M.D<br /> Senior Consultant Psychiatrist/<br /> Executive Director, Butabika National Hospital<br />
  2. 2. Outline<br />Introduction<br />Poverty and mental health<br />Challenges in service delivery<br />Conclusion <br />
  3. 3. Sub-Saharan Africa region<br />
  4. 4. Introduction - Africa<br />Second largest continent (11, 700,000 square miles)<br />Population: 1,022,234,000(UNFPA, 2011)<br />- Continent with highest birthrate<br />Average population growth rate: 2.3%<br />Low life expectancy, average = 54 years<br />۷ 50% of population in sub-Saharan Africa live on less than a dollar a day (World Bank Development Indicators, 2007)<br />
  5. 5. SSA – Population and Devpt indicators<br />Total Population: 870 million people<br /> - Highest birthrate<br />Average rural population = 61.2% of total population<br />Average life expectancy = 52 years<br />Average literacy rate: 65%<br />GDP: $ 1.184 Trillion (2009 est.)<br />Little Data Book on Africa, 2010<br />
  6. 6. Burden of Disease – Mental Disorders in SSA <br />Mental illnesses are common and universal<br />MHD- New and old morbidity make a significant contribution to the burden of disease in SSA (WHO- WHR, 2001)<br />Nearly 75% Global burden of HIV/AIDS contribution by SSA (UNAIDS, 2008)<br />Massive internal/external displacements arising from civil strifes lead to PTSD related disorders<br />Rampant poverty, declining economies and unemployment for rural folks (UNDP reports) -> stresses<br />SSA faces a double burden of disease and insufficient resources<br />
  7. 7. Resources - SSA <br />Continent with highest birthrate:<br />۷ 69% of population in sub-Saharan Africa live on less than a dollar a day (World Bank Development Indicators, 2010)<br />Africa has an average 0.34 psychiatric beds per 10,000 population. C.f Europe has an average 8.7<br />Africa has an average 0.05 Psychiatrists per 100,000 population. C.f 9 Psychiatrists per 100,000 for Europe <br />79% of African countries spend less than 1% of the health budget on mental health<br />Many African countries have no Clinical Psychologists and Social workers<br />Unemployment rates are very high in many African countries<br />Inequity in the distribution of resources<br />
  8. 8. Essential Resources – A few selected countries<br />The Little Data Book on Africa (World Bank, 2008); World Dev’t Indicators, World Bank 2010WHO ATLAS, 2005, 2010<br />
  9. 9. Poverty and Mental Health<br />Mental disorders make a significant contribution to burden of disease in LAMICs<br />Poverty is widespread in LAMICs:<br />Absolute poverty<br />Relative poverty<br />Poverty shown as a major risk factor for mental disorder in HICs<br /><ul><li>Poverty is a strong precipitating and mediating factor for MH problems: stress, frustration, anxieties & depression
  10. 10. Delayed help seeking & incomplete dosage are all typical of the poor PWMI. -Their affordable medicines mostly have negative side effects.</li></li></ul><li>Poverty and Mental health<br /><ul><li>Many poor and unemployed persons resort to alcohol to cope with their frustrations. Alcoholism -> mental illness
  11. 11. MH problems more among the two extremes (very rich and the very poor)
  12. 12. Most PWMI are unproductive and a burden to the family & national economy
  13. 13. The mentally ill tend to be destructive and wasteful
  14. 14. Parents’ mental illness results in loss of human capital and a vicious cycle of poverty in the family
  15. 15. Breaking the link requires more than addressing poverty
  16. 16. Only a few local studies on poverty and mental ill-health (e.g MHaPP)</li></li></ul><li>Cycle of poverty and mental ill-health<br />Social exclusion<br />High stressors<br />Reduced access to social capital/safety net<br />Malnutrition<br />Obstetric risks<br />Violence and trauma<br />Poverty<br /><ul><li>Economic deprivation
  17. 17. Indebtedness
  18. 18. Low education
  19. 19. Unemployment
  20. 20. Lack of basic amenities/housing
  21. 21. Overcrowding</li></ul>Mental Ill Health<br /><ul><li>Higher prevalence
  22. 22. Poor/lack of care
  23. 23. More severe course</li></ul>Increased health expenditure<br />Loss of employment<br />Reduced Productivity<br />Social drift<br />
  24. 24. Vicious cycle of Poverty and poor Mental Health <br />Malnutrition, <br />Domestic Violence, <br />Indebtedness<br />Depression & Anxiety,<br />physical ill-health,<br />Alcohol abuse<br />Reduced productivity<br />Disability<br />Increased health costs<br />
  25. 25. Poverty, stigma and service utilization<br />Poverty dictates the extent of service utilization<br /> - Access to better MH services extremely hard for the poor <br />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<br />Stigma more hurting and disabling than the illness itself, in many individuals<br />Stigma is a major hindrance to effective service delivery.<br />Stigma is a significant obstacle to service utilization<br /> - Hinders disclosure of the illness, resulting in delayed help-seeking<br /> - Results in concealment of information about their mental illness<br />
  26. 26. The Service Situation<br />Paucity of details regarding the MH systems in Africa<br />Low priority for mental health<br />Inadequate and skewed distribution of human resources<br />Inadequate infrastructure <br />
  27. 27. Service situation-><br />Institutional Organization of Mental Health<br />Services:<br />Central Large Mental Hospital<br />Limited Acute beds in Regional general hospitals.<br />A few Acute beds in District hospitals.<br />All countries embraced integration of mental health into Primary Health Care.<br />Very little community care with no facilities for acute bed/care.<br />
  28. 28. Service situation-><br />Financing Mental Health Services:<br />Usually not easy to track budgets as there is no specified budget allocations for Mental Health:-<br />< 5% GDP expenditure on Health<br />< 1% of Health Budget<br />Main modes in order of importance:-<br />Out of Central Tax Revenue <br />Out of pocket (patients and relatives).<br />Social Insurance<br />Private Insurance<br />Disability benefits absent.<br />
  29. 29. Key issues for MH care in LICs<br />Inadequate appropriate policies and plans<br />Lack of awareness of the magnitude of the problems in mental health<br />Paucity of information among politicians, policy makers and public<br />Minimal data on cost-effective interventions and epidemiological surveys<br />Dilapidated referral infrastructures and systems<br />Ill-equipped general health workers with knowledge and skills in mental health<br />Few central level experts to provide technical support<br />
  30. 30. Key issues -><br />Extremely low coverage of evidence-based services for PWMI in LICs<br />Poor help-seeking behaviour attributable to the cultural explanatory model<br />Lack of support by general health service managers<br />Gross underfunding for mental health<br /> - burden of mental illness is on the increase, but no corresponding increase in resource allocation<br />Inadequate funding<br />Ill-equipped General Health Workers with little knowledge and skills in MH<br />Negative attitude, misunderstandings and stigma.<br />Burn-out among the health workers in rural setting with no peer support.<br />
  31. 31. Key barriers to service delivery<br />Absence of mental health on the public health priority agenda<br />Organization of mental health services<br />» still centralized<br />Inadequate integration<br />» overburdened PHC system<br />Inadequate human resource base<br />Scarcity of effective public mental health leadership<br />Lancet Global Mental Health Group, 2007<br />
  32. 32. Way forward <br />Review of Policies, legislations and strategic plans<br />Mental Health Legislation<br />Significant improvement in provision of financial resources to meet the MDGs<br />Strengthen integration of MH into PHC<br /> - Include MH in public health programmes<br />Capacity building<br />Infrastructure and human resource policy review<br />Collaboration with NGOs<br />Promote research<br />
  33. 33. Way forward-><br />Role of NGO’s, Public Education and Consumer Empowerment:<br />Encourage partnership with all stakeholders including private sector, local and international NGOs.<br />Encourage the formation of consumer organisations at lower levels.<br />Develop appropriate message especially to counter stigma and discrimination against mental illness.<br />Messages on promotion, prevention and early intervention in mental disorders.<br />
  34. 34. Way forward-><br />Psychiatric Education and Continuing Medical Education (CME) & Technical Support:<br />Review Training curricula for all health workers.<br />Develop Training curricula for In-service training.<br />Carry out programmed training for General health workers in the districts & lower levels regularly.<br />Develop guidelines, Monitoring and evaluation tools.<br />Provide technical support supervision.<br />
  35. 35. Conclusion<br />Challenges for rural mental health care still many.<br />Need for infrastructure development.<br />Commitment on new policies emphasizing; Decentralisation, community care and integration of mental health into PHC.<br />Sustainance of resource mobilisation.<br />Involve all stakeholders including NGOs.<br />Community empowerment and fighting stigma.<br />Investing in human capital<br />