The notion of “public health” within Africa often invokes ideas of infectious diseases and almost always of exclusively physical health needs. In recent decades, public health work on the continent has been virtually synonymous with activities related to HIV/AIDS, malaria, maternal health and malnutrition, with mental health often a neglected topic. In addition, mental health is frequently overlooked as a health policy priority, with 64% of countries in Africa having no, or wholly inadequate, mental health legislation.⁽²⁾ Evidently, the lack of importance placed on mental health is not at all reflective of the scale of the problem as mental illness now accounts for 5% of all reported illness in Africa ⁽³⁾ and 10% of the total disease burden in Sub-Saharan Africa. In fact, a recent study has indicated that across the continent, in excess of 50,000 lives are lost each year as a consequence of mental illness.⁽⁴⁾ These figures are almost certainly underestimates, as this is not only an under-researched area, but also one dogged by stigma and that arguably depends on more subjective diagnostic criteria than other illnesses.

In recent times however, there has been progress. The global mental health movement has been gathering pace over the last few years and seeks to raise the profile – and priority – of mental health in low and middle income countries. This paper explores what defines mental health across cultural boundaries, what progress has been made within mental health in Africa and where future directions may lie. This discussion focuses on the collective of diagnosable mental health disorders, as opposed to issues of general wellbeing by accepting the framework and discourse of the collective.

Understanding mental health

Mental health is conceptualised by the World Health Organisation (WHO) as based on a number of core elements such as well-being, resilience to normal stresses, the ability to work productively and general community involvement.⁽⁵⁾ However, while these elements may be recognisable across a number of contexts, the concept of mental health remains notoriously difficult to measure reliably. Many consider the idea of a homogenized understanding of mental health as being too idealistic. Discussions within the literature employ diagnostic terms such as “depression” or “mania” to reflect states of mental well-being or disorder.

Derek Summerfield argues that mental health is a construct that is dependent on a country’s culture, society and situation. He therefore suggests that since the majority of evidence and definitions of mental disorders are derived from a Western, primarily European approach and body of knowledge, they are likely to be insufficient for use on other continents.⁽⁶⁾ This is certainly a valid argument – particularly given the on-going debates in Western societies on how best to define certain mental disorders. This potential insufficiency further highlights the need for true cultural understanding, sensitivity and appropriately adapted measures when addressing mental health issues in Africa.

Progress in mental health

While the global mental health movement may appear to be led by countries such as Canada, America and the United Kingdom, there are significant steps being taken from within Africa, with many intercontinental partnerships being driven by African countries. South Africa for instance is regarded as a leading nation in Africa in terms of its approach to mental health. It has been suggested that this progressiveness is perhaps due to post-apartheid South Africa’s sensitivity to issues of discrimination.⁽⁷⁾ In 2002, South Africa recognised the human rights of those living with mental illness, and in July 2013, the Department of Health adopted a new mental health policy strategic plan. The plan includes an emphasis on community based services, capacity building, collaboration between key service providers and importantly, active prevention of mental illness. All of these elements have been key areas of focus in recent WHO reports.⁽⁸⁾ Similarly, Uganda has made provisional steps in developing community based services for mental health and launched media programmes to educate the public about the topic.⁽⁹⁾ In 2012, the Ethiopian government showed its political commitment to advancing mental health through the development of their first national mental health strategy.⁽¹⁰⁾ Ethiopian institutions have since called for the integration of mental healthcare services into primary care, citing that addressing stigma and increasing treatment access for mental health could bring social, economic and health benefits.⁽¹¹⁾

Acknowledging and addressing mental health in Africa is essential as issues surrounding mental health are also tied to an abundance of human rights violations. Reports of patients being criminalised and chained within asylums are not uncommon,⁽¹²⁾ which highlights the need for both a cultural and contextual understanding of mental ill-health. For example, in the recent past, Ghana has had a poor mental health record by allowing religious “treatment” facilities to carry out practices such as forced exorcism and complete isolation.⁽¹³⁾ Not only is the need to address mental health issues across Africa clear and well recognised, but as demonstrated, top level action is now being taken in several countries. However, the core challenge that remains is translating these efforts into patient-level outcomes.

Future direction: Further action is essential

The next step is ensuring the implementation of new mental health policies and transforming the research that has been conducted so far into better treatment for individuals. Not only is this vital for the reasons already outlined, it is also necessary to set up health systems and treatment pathways known to work within individual cultural contexts, as demand for these services may well soon increase due to the well cited fact that the African population is both expanding and ageing.⁽¹⁴⁾ Indeed many countries, especially south of the Sahara, are at the mid-point of demographic and epidemiologic transition. The consequences of this are a growing and increasingly ageing population, higher rates of urbanisation and an emerging predominance of non-communicable diseases (i.e. declining rates of infectious diseases). The associations that have been found between urbanisation and mental wellbeing suggest that the initial increase in urbanisation could be linked to increased incidences of mental illness, a phenomenon compounded by the fact that the creation of mental health facilities often cannot “keep up” with the growth of cities.⁽¹⁵⁾ It has also been suggested that urbanisation leads to a deterioration and degradation of the traditional values and practices that are regarded as beneficial to an individual’s mental health.⁽¹⁶⁾ Conversely many would argue that urbanisation is closely tied to level of development,⁽¹⁷⁾ which could include increased jobs, improved healthcare access and a lower prevalence of absolute poverty, all of which can be beneficial for mental health.⁽¹⁸⁾ Furthermore, there are also a number of mental health conditions related to ageing, which will lead, by default, to more elderly patients presenting with mental illness in an increased and ageing population.

While an increase in the prevalence of mental disorders can never be accurately predicted, the known population dynamics currently at play provide support for the need to establish good routes for effective mental health care now. In order for this to happen and for policy to translate downwards effectively, one of the key aspects to address will be the stigma that still prevails around mental health in Africa. In order to drive progress and realise gains in this area, true cultural and subcultural understanding is critical. Understanding how mental illness is perceived within a subculture, how it is expressed and what a community’s needs actually are is vital. Strategies aiming to increase awareness and education based on this localised understanding could then be implemented using this understanding. For an example of a successful anti-stigma campaign please refer to the notes below.⁽¹⁹⁾

In addition to addressing stigma and expanding the top level policy work across more African nations so that action translates down, the prevention of mental illness is also vital. The triggers and underlying social causes of mental disorders must be addressed. However, as highlighted in a statement by Dr. Mustapha Sidiki Kaloko, the African Union Commissioner for Social Affairs, these factors cannot be dealt with in isolation.⁽²⁰⁾ Similarly, complementary initiatives to strengthen health services and secure reliable sources of pharmacological intervention are essential to improving mental health, but these should not detract from programmes specifically focussed on mental health.

Conclusion

The work already being carried out within Africa is encouraging and is often a local “first of its kind.” At national levels, there is increasing recognition of the mental health needs of the population and an acknowledgment of the human rights of mentally ill patients. This is not universal across the continent however, and in numerous countries more work is needed to ensure that they at least reach this stage, and soon. Ensuring that this “good start” in mental health continues and transcends from policy to patient is crucial. Maintaining and sustaining funding for the next steps of the global mental health movement will be fundamental to achieving progress in the coming years.

Written by Catherine Rushworth ⁽¹⁾

NOTES:

([1]) Catherine Rushworth is a Research Associate with Consultancy Africa Intelligence (CAI) with an interest in global public health. Contact Catherine through CAI’s Public Health Unit ( public.health@consultancyafrica.com). Edited by Liezl Stretton. Research Manager: Deanne Goldberg.
(2) Tomlinson, M., et al., ‘Setting priorities for global mental health research’, World Health Organisation, June 2009, http://www.who.int
(3) ‘Considering mental health in Africa’, Department for International Development, May 2013, https://www.gov.uk.
(4) Mars, B., et al., 2014. Suicidal behaviour across the African continent: A review of the literature. BMC Public Health, 14, 1, 606.
(5) ‘Mental health: A state of well-being’, World Health Organisation, August 2014, http://www.who.int.
(6) Summerfield, D., 2008. How scientifically valid Is the knowledge base of global mental health? British Medical Journal, 336(7651), pp. 992-994.
(7) Omar, M.A., et al., 2010. Mental health policy process: A comparative study of Ghana, South Africa, Uganda and Zambia. International Journal of Mental Health Systems, 4(1), pp. 24.
(8) Stein, D., 2014. A new mental health policy for South Africa. South African Medical Journal, 104(2), pp. 115-116.
(9) Ndyanabangi, S., 2012. ‘WHO profile on mental health in development (WHO proMIND): Republic of
Uganda’, World Health Organisation, http://www.who.int.
(10) ‘Considering mental health in Africa’, Department for International Development, May 2013, https://www.gov.uk. For more information on PRIME please, see https://www.gov.uk.
(11) Ibid.
(12) Bhui, K., et al., 2003. Cultural adaptation of mental health measures: Improving the quality of clinical practice and research. The British Journal of Psychiatry, 183(3), pp. 184-186.
(13) Ssengooba, M., ‘Ghana grapples with mental health’, CNN, 9 October 2012, http://globalpublicsquare.blogs.cnn.com.
(14) Velkoff, V.A. and Kowal, P.R., 2006. “Aging in Sub-Saharan Africa: The changing demography of the region”, in Cohen, B. and Menken, J. (eds.). Aging in Sub-Saharan Africa: Recommendation for Furthering Research. National Academies Press (US): Washington (DC).
(15) Srivastava, K., 2009. Urbanization and mental health. Industrial Psychiatry Journal, 18(2), pp. 75-76.
(16) Sabone, M.B., 2009. The promotion of mental health through cultural values, institutions, and practices: A reflection on some aspects of Botswana culture. Issues in Mental Health Nursing, 30(12), pp. 777-787.
(17) Chen, M., et al., 2014. The global pattern of urbanization and economic growth: Evidence from the last three decades. PLoS One, 9(8), e103799. See: http://www.plosone.org.
(18) Hanandita, W. and Tampubolon, G., 2014. Does poverty reduce mental health? An instrumental variable analysis. Social Science Medicine, 113, pp. 59-67.
(19) ‘Results of a global advocacy campaign. Stop exclusion. Dare to care’, World Health Organisation, 2001, http://www.who.int.
(20) ‘Considering mental health in Africa’, Department for International Development, May 2013, https://www.gov.uk.