Mental health in Africa: The need for a new approach
Innovations, many pioneered in Africa, are making mental health treatment more possible and affordable, but more needs to be done.
Joshua lives in Sierra Leone. His friends and family suffered heavily through the trauma of the civil war in the 1990s, the Ebola epidemic that ravaged the country more recently, and the catastrophic mud slides in 2017. The mental strain of these events on ordinary people was enormous, but when they looked for support beyond their family and communities, there was almost none. That was why Joshua helped set up the Mental Health Coalition of Sierra Leone to find simple, appropriate and affordable ways of helping.
Until recently, many people in Africa suffering from mental health problems have only had two options: traditional or religious healing methods; and out-dated psychiatric hospitals. In both, incarceration with little choice over treatment has been common. With only one psychiatrist per million people in sub-Saharan Africa, more evidence-based and dignified treatment has been out of reach for the vast majority. In many countries, 90% of people with mental illness have no access to treatment. Even where they do, that “treatment” can often be ineffective, painful and more likely to be harmful than helpful, as the recent Human Rights Watch report on mental health in Nigeria highlighted. The challenge is compounded by the fact that in most societies, mental illness is still widely stigmatised, inhibiting both sufferers and their families from admitting the condition and seeking help.
This is why a new approach to mental health is urgently needed across the continent so that people can access good quality, affordable care near where they live and avoid being excluded. Thanks to innovations in awareness and treatment, many pioneered in Africa itself, this is now increasingly possible and affordable. Governments and medical professionals need to adopt these new approaches, aided by resources from both domestic and international sources.
On 20 November, nearly 200 experts, advocates, researchers and practitioners from across Africa and the UK gathered in London to discuss how to bring these new approaches to those who need them. Organised jointly by the Royal African Society and the London School of Hygiene and Tropical Medicine, with support from the World Health Organisation, Bill and Melinda Gates Foundation, Wellcome Trust and others, the conference explored how to promote new attitudes and treatments. It discussed how to mobilise the resources necessary.
One important point that emerged was the economic value of improving societies’ mental health. The cost-benefit analysis is becoming clear from recent research: early diagnosis and treatment, especially among children, can often prevent a deterioration and enable those concerned to play a constructive and productive part in community life. An analysis carried out for the World Bank found a 3-5 times return on investment for mental health services.
The meeting drew seven specific conclusions:
Firstly, it is essential to take a holistic approach to health, whereby mental health is assessed alongside physical health. This is already common in many African countries, but needs to be integrated into primary health care provision. A bigger effort is needed to train health workers to recognise the symptoms of mental health problems and recommend appropriate treatment. The enormous range of mental health problems needs to be recognised, from relatively common conditions such as stress, anxiety and depression, to more serious conditions that can cause severe disability such as schizophrenia.
Secondly, it is especially critical to identify mental health issues in children and treat them as early as possible. Half of all adult mental conditions start by the age of 14. Early prevention and intervention significantly reduces the risk of serious problems later in life.
Thirdly, it is important to work with communities to spread better understanding. Families and carers are often under great strain and incur substantial financial costs so need particular support. Traditional healers should also be regarded as a great potential asset and integrated into the process through outreach and training.
Fourthly, building up self-help groups of those with lived experience of mental health problems, as well as civil society and non-governmental organisations dedicated to helping them, is essential to offer basic support. As the conference heard, this had had a tremendous impact in reducing the stigma and prejudice against HIV sufferers in South Africa and its neighbours.
Such a growing network will, fifthly, help more people become aware of innovations in treatment, such as Zimbabwe’s “friendship bench” initiative which has transformed the treatment of less severe mental health problems in cost effective and culturally appropriate ways. It will thereby encourage the spread of best practice as widely as possible.
Sixthly, mental health needs good governance at the national level. It needs to be mainstreamed in national health strategies and budgets. It should be coordinated by a strong unit in government. Many countries have a mental health policy, but all too often it exists only on paper. Resources need to flow to this priority as a part of wider Universal Health Coverage.
Finally, it is equally important to change attitudes to mental health in the media in Africa – not just in newspapers but on the radio, television and in popular entertainment – to combat the stigmatisation that is such a serious barrier to better treatment and social acceptance.
These conclusions will take time to become embedded, but there is increasing political will nationally and internationally. The conference showed that there are many creative ideas being used to improve the lives of people with mental health problems. Now we need to find ways of helping these ideas to flourish.