The concept of mental health remains ignored in many developing countries, where basic primary healthcare needs are additionally neglected. The World Health Organisation (WHO) lists several risk factors that contribute to the development of long-term, psychiatric conditions.⁽²⁾ This combination of biological (neurochemical imbalance), and psychosocial factors (work stress and unemployment), predisposes individuals to lives rife with inequality and inefficiency.⁽³⁾ While some countries are incorporating mental health agendas into their policy priorities, as many as a third of WHO partners have yet to orchestrate an adequate plan to tackle the issue. In addition, as many as 45% of low-income countries exclude the mentally ill from receiving disability benefits according to their present health policy procedure.⁽⁴⁾ It is these circumstances that force individuals to seek aid from non-governmental organisations (NGOs) and traditional healthcare systems that, in some instances, compromise treatment measures.

The West African nation of Ghana has recently come under intense scrutiny for widening its existing gap in mental health care delivery and access. In addition to compromising basic needs, the country is reported to allow care to be handled by various prayer camps that, under the guidance of religious doctrine, embrace barbaric ‘treatment’ options that advocate complete isolation, being chained to trees, and forced exorcism for demonic possession.⁽⁵⁾ This reliance on antiquated measures is yet another example of resource distribution failing and leaving those seeking treatment uncared for. This paper examines these abuses and suggests effective solutions that parallel measures taking place across both the African continent and globally.

Mental health as a human right

It is estimated that nearly 450 million people are impacted by mental, behavioural, and neurological conditions across the globe, ranging from conditions such as depression to schizophrenia.⁽⁶⁾ A predisposition towards these conditions disproportionately affects women, children and other marginalised groups.⁽⁷⁾ Yet, this issue remains largely ignored by policy developers internationally. Nearly 62% of countries do not have mental health legislation and, even if legislation is in place, it remains out of date and unfit to accommodate modern health requirements.⁽⁸⁾

The evolution of mental health’s journey towards achieving recognition as a human right began with the disability rights movement. Initially, this focused largely on physical disability, ignoring the issues associated with mental and intellectual disability. However, mental disability has subsequently succeeded in procuring legislatively ensured protection under the Constitution of the World Health Organisation (1948), where health is defined as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.”⁽⁹⁾ In addition to the WHO declaration, the Universal Declaration of Human Rights (1948)⁽¹⁰⁾ and the International Covenant on Economic, Social, and Cultural Rights (ICESCR)⁽¹¹⁾ further ensure that all people are entitled to the highest attainable standard of physical and mental health. United Nations (UN) members also drafted the Principles for the Protection of Persons with Mental Illness (1991),⁽¹²⁾ ensuring in principle that the best available mental health care is delivered to its constituent members.

Though momentum for improvements in mental health has built considerably in developed countries, many middle-income countries, such as South Africa (SA) and Brazil, require that the right to mental health be incorporated into their national constitutions and legislation.⁽¹³⁾ The African Charter on Human and Peoples’ Rights also references “the right to enjoy the best attainable state of physical and mental health.”⁽¹⁴⁾ However, in making these promises, many signatory African nations fail to uphold its tenants. An inherent criticism of the claim of an existing right to health lies largely in its nebulous definition, where concrete steps for implementation are seemingly absent. Participating nations may agree to advance the needs of the impoverished, but weigh physical health and access to food over ensuring mental stability. Africa, as discussed throughout this piece, struggles with meeting these needs.

Africa’s fear of mental health

The underpinnings of mental health inadequacy more often than not stem from poor nutrition, depressed socioeconomic status, and elevated, persistent violence. These social determinants of health,⁽¹⁵⁾ further worsened by unstable governmental regimes, make access to basic provisions incredibly challenging for the lowest rungs of the social ladder. This economic blight explains why primary care typically emphasises medical treatment for infections, management of chronic health conditions, and acute care for emergency situations. An issue, like depression or undiagnosed schizophrenia, often gets placed on a backburner when it comes to developing health policy agendas in Africa.⁽¹⁶⁾ Close to 75% of African countries spend less than 1% of their health budget on mental health services, and 90% have less than 1 psychiatrist per 100,000 persons.⁽¹⁷⁾ Ghana’s challenge towards meeting psychiatric needs is further exacerbated by there only being 3 trained nurses per 100,000 persons.⁽¹⁸⁾

An inherent challenge affecting countries across the continent is recognition of the need, but a lack of agency to remedy the growing inequities. When surveyed in 2011, middle-income countries, such as SA,⁽¹⁹⁾ demonstrated an increased recognition of the importance of the issue.⁽²⁰⁾ However, despite making inclusionary policy recommendations, many South Africans and Ugandans felt that policies did not translate into pressing needs being met.⁽²¹⁾ In Zambia and Ghana, government health policy developers characterised mental health as an overall low priority.⁽²²⁾

Ghana’s attempt at tackling mental health inequalities  

According to a recent Human Rights Watch report,⁽²³⁾ Ghana has been characterised as a middle-income country, but, despite entering into a higher economic stratum, the majority of its citizens continue to live on less than US$ 2 a day.⁽²⁴⁾ Ghanaians soliciting mental health services must confront the added cost of travel to just three existing psychiatric institutions.⁽²⁵⁾ Discrimination and maltreatment spares no age when it comes to Ghana’s take on children suffering from mental health disorders and comorbidities. Through investigation, Human Rights Watch discovered that the children’s ward at Accra’s Psychiatric Hospital grouped, without differentiation, individuals ranging in age from 14 to 40.⁽²⁶⁾ Chronic understaffing (particularly in psychiatric social workers serving the region) is compensated for through shared usage of wards rife with physical and verbal abuse. In addition to crowding, the individuals housed in these areas face the heightened risk of communicable infection, with limited treatment options. These, among other things, place pressure on Ghana’s government to find solutions.

Following the 2001 meeting of the United Nations Committee on Economic, Social and Cultural Rights, the Committee released General Comment No. 14, which proclaimed that the right to health included public health, health care, and the determinants necessary for health living, including safe homes and work-places.⁽²⁷⁾ In Ghana, however, there are several governmental deficits that need adequate remedying in order to ensure that the human rights obligations are met. Unlike many developing countries, Ghana has the benefit of incorporating mental health services under its National Health Insurance Scheme (NHIS),⁽²⁸⁾ which works to increase affordability and availability of healthcare in the region.⁽²⁹⁾ However, the government fails to recognise mental health as an aspect of this umbrella service, forcing individuals to purchase their psychiatric medications. This fee-for-service regimen forces Ghanaians to seek alternate forms of therapy, often taking up residence in historic prayer camps.

The trap of alternative medicine or no medicine at all

The prayer camps focus on imbuing Christian values into the daily activities of its frequenters, many of whom suffer from crippling mental health conditions.⁽³⁰⁾ In addition to offering a safe space for bereaved women and children, the prayer camps offer an audience with higher powers (connections to angels and spiritual guardians, for example), as well as the use of traditional herbs for remedies.⁽³¹⁾ While the camps exist mainly to lift people out of their ailments, mental health is treated quite differently - sometimes involving chaining to trees, forced fasting and solitary confinement. Detention in these squalid conditions inevitably worsens the outcome for the individuals seeking help - a perpetuated violation of their right to health. To add to this fear, many camp goers additionally solicit the aid of traditional healers, yet another overt violation of adequate care delivery.⁽³²⁾

Forced admissions taking place at the hospital level, largely a result of the failure to rely on local, immediate social support networks, are yet a further example of health service inadequacy. The law leaves limited room for negotiation out of forced admission, as resources are unavailable to sustain the needs of an institutionalised detainee, as well as his or her family. Though legal frameworks, such as the Mental Health Act, are in place to provide self-agency in medical settings, it is otherwise absent in the prayer camps.⁽³³⁾ Consequently, the power of the prayer camps has grown. Though some admitted individuals are struggling with drug abuse, addiction and depression, symptoms as trivial as sleepless nights and mood swings justify the intervention of the camps.⁽³⁴⁾

The challenge of seeking adequate treatment for mental illness is further hampered by overcrowding and poor hygiene.⁽³⁵⁾ Many individuals are confined to a restricted number of beds in both hospital settings and the prayer camps. Patients are also often forced to defecate and urinate in the presence of others. Cleanliness is poor and the limited space forces many to live outside, enduring scorching temperatures. The prayer camps also impose forced fasting upon residents, denying them food in an effort to cleanse them of demonic possession.⁽³⁶⁾

These conditions contradict the promised rights of General Comment No. 14, which acts to safeguard the right of freedom from interference, the right to be free from torture, and medical treatment or experimentation without consent.⁽³⁷⁾ These human rights violations, exhibited within both established medical institutions and prayer camps, provide basis for intervention. The Ghanaian health services, albeit under-resourced, mirror challenges surmounted by other nations actively incorporating mental health into their medical by-laws. There is, therefore, the possibility of workable solutions.

Meeting human rights obligations through mental health improvement in Ghana

A longstanding movement towards health equality involves recognition of mental health as a human right. This, coupled with long-term de-stigmatisation of mental health disorders, will enable countries like Ghana to progress towards better treatment measures. To achieve this, however, Ghana must be willing to accommodate resource shifting.⁽³⁸⁾ Using a majority of the country’s health budgeting as reparations for those providing treatment takes away from valuable input towards quality care services, like counselling and advocacy. Advocacy is cited to have improved breast cancer outcomes in Ghana ⁽³⁹⁾ and overall perception of HIV as a manageable disease in other countries facing similar circumstances, such as SA.⁽⁴⁰⁾ Using advocacy as a mode of education could strip Ghana of its penetrant stigma against mental health disorders. Creating data banks open to surveying health outcomes could additionally provide a crisp image of the inequities present in the country’s health and prayer camp settings. This will provide greater transparency for foreign stakeholders invested in NGOs and those providing monetary aid.

While it is easy to blame the system at large, it is also important to emphasise the necessity of creating checks and balances on internal health revenue and investment. The reliance on prayer camps is the biggest violation of trust in the right to adequate patient care. Though the newly revised Mental Health Act protects Ghanaians from abuses at the medical level, a wide-scale internal review of the practices taking place at the prayer camps should be performed.  The barbaric acts of food denial, chaining, and herbal treatments evidences stark regression compared to countries with available social workers and intervention programmes. It is in Ghana’s best interest to fight the corrupt practices taking place in the prayer camps, and to conduct thorough investigative reviews before admitting patients into either medical facilities or camps.

As a member to the UN Human Rights Committee, it is appalling to realise that Ghana allows its problems to persist at their present level. Through effective resource distribution, allocation of funds for patient care, and strengthened investment in the individuals affected by mental health disorders, Ghana can deconstruct the stigma and discrimination suffocating its mentally disabled. Sister nations, SA and Zambia are making strides towards recognising the importance of alleviating this growing burden. It is time for Ghana to similarly embrace these recommendations and realise its human rights obligations.

Written by Ishan Asokan ⁽¹⁾

NOTES:

(1) Contact Ishan Asokan through Consultancy Africa Intelligence’s Rights in Focus Unit ( rights.focus@consultancyafrica.com). This CAI discussion paper was developed with the assistance of Laura Clarke and was edited by Kate Morgan.
(2) ‘The global burden of disease’, World Health Organisation Report, 2008, http://www.who.int. 
(3) Ibid.
(4) ‘Mental health atlas’, World Health Organisation, 2005, http://www.who.int.
(5) Ssengooba, M., ‘Ghana grapples with mental health’, CNN World News, 9 October 2012, http://globalpublicsquare.blogs.cnn.com. 
(6). Lance, G., et al., 2009. Mental health as a human right. Wayne State University Law School Legal Studies Research Paper Series, 9(15), pp. 249-261.
(7) Ibid.
(8) Ibid.
(9) ‘Constitution of the World Health Organisation’, 1946, World Health Organisation: Geneva, http://www.who.int.
(10) ‘Universal Declaration of Human Rights (art. 25)’, 1948, United Nations: New York, http://www.un.org.
(11) ‘International Covenant on Economic, Social and Cultural Rights’, 1966, United Nations: New York, http://www2.ohchr.org.
(12) ‘Principles for the protection of persons with mental illness and the improvement of mental health care’, 1991, General Assembly of the United Nations: New York, http://www2.ohchr.org.
(13) Gable, L., 2007. The proliferation of human rights in global health governance. Journal of Law, Medicine and Ethics, 35, pp. 534-544.
(14) Ibid.
(15) ‘World conference on social determinants of health report’, World Health Organisation, 21 October 2011, http://www.who.int.
(16) Jacob, K.S., et al., 2007. Mental health systems in countries: Where are we now? The Lancet, 370, pp. 1061–1077.
(17) Ibid.
(18) Bird, P., et al., 2011. Increasing the priority of mental health in Africa: Findings from qualitative research in Ghana, South Africa, Uganda and Zambia. Health Policy and Planning, 26, pp. 357-365.
(19) Draper, C.E., et al., 2009. Mental health policy in South Africa: Development process and content. Health Policy Planning, 5, pp. 342–356.
(20) Faydi, E., et al., 2011. An assessment of mental health policy in Ghana, South Africa, Uganda, and Zambia. Health Research Policy and Systems, 9, pp. 17.
(21) Ibid.
(22) Ibid.
(23) ‘Like a death sentence: Abuses against persons with mental disabilities in Ghana’, Human Rights Watch Report, 2 October 2012, http://www.hrw.org.
(24) Ibid.
(25) ‘Mentally ill patients in Ghana chained up for months: Group’, New York Daily News, 2 October 2012, http://www.nydailynews.com.
(26) Ibid.
(27) ‘General comment 14: The right to the highest attainable standard of health’, 2000, United Nations Committee on Economic, Social, and Cultural Rights: New York, http://www.unhchr.ch.
(28) Blanchet, N.J., et al., 2012. The effect of Ghana’s national health insurance scheme on health care utilisation. Ghana Medical Journal, 46(2), pp. 76-84.
(29) Ibid.
(30) ‘Ghana: Misery of ‘prayer camps’ for mentally ill’, IRIN News, 4 October 2012, http://www.irinnews.org.
(31) Ibid.
(32) Ibid.
(33) ‘725,000 Ghanaians are suffering from severe mental disorders’, Ghana Broadcasting Corporation, 30 October 2012, http://www.gbcghana.com.
(34) Ibid.
(35) Ibid.
(36) Ibid.
(37) Ibid.
(38) Lancet Global Mental Health Group, 2007. Scale up services for mental disorders: A call for action. The Lancet, 370, pp. 1241-1252.
(39) Reichenbach, L., 2002. The politics of priority setting for reproductive health: Breast and cervical cancer in Ghana. Reproductive Health Matters, 10, pp. 47–58.
(40) Kakuma, R., et al., 2010. Mental health stigma: What is being done to raise awareness and reduce stigma in South Africa? African Journal of Psychiatry, 13, pp. 116–124.