This years’ theme for the world mental health day ‘’Mental Health in an unequal world’’ aligns seamlessly with my observations and thoughts as a registered mental health nurse who has been in active clinical practice spanning over fourteen years and additionally has had the privilege to work in a low-middle income country, Ghana and a more developed western world, United Kingdom. I therefore found it prudent to share my perspectives on this subject matter to raise the awareness of how the existence of inequalities continues to endure and play a key role in the development of mental health challenges and have significant effects on the provision of and access to effective mental health services worldwide, most severely in most African countries with focus on the Ghanaian Mental Health service.
The two-way relationship between mental illness and social inequalities can prove difficult to unravel with common epidemiological approaches. In the more developed western world, Racial/ethnic, gender, and sexual minorities often suffer from poor mental health outcomes due to multiple factors including inaccessibility of high-quality mental health care services, cultural stigma surrounding mental health care, discrimination, and overall lack of awareness about mental health. Some subgroups are more exposed and vulnerable to unfavourable social, economic, and environmental circumstances. These subgroups, interrelated with ethnicity, gender and age, are at higher risk of mental health problems; black and minority ethnic groups (BAME), people living with physical disabilities, learning disabilities, alcohol and/or drug dependence, prison population, offenders and victims of crimes, LGBT, people with sensory impairment, homeless people, refugees, asylum seekers and stateless person, this list not exhaustive.
The African continent, however, faces a peculiar challenge of poverty in addition to some of above-mentioned inequalities as the main driver of cause of mental health conditions as well as inadequate provision and access to effective mental health care. Poverty in Africa is linked to the continent’s rapid population growth that supersedes its economic growth, war, crisis, and related conflicts, devasting climate conditions due to climate change which affect agriculture and crop failures, diseases such as Ebola, AIDS and malaria coupled with inadequate medical care leading to decreased life expectancy, inadequate job structure, and unjust trade structures imposed by rich continents and countries, leaving Africa to suffer from the outset.
Ghana is a democratic republic with a population of 25,904,598 million people with 59.1% between the ages of 15 and 64 years and considered as a middle-income country since 2015(2). The World Federation for Mental Health estimates that between 75% to 95% of people with mental disorders in low and middle-income countries are unable to access any form of mental health services at all and the treatment gap for mental disorders in Ghana is estimated to be 98% (4). Ghana has become increasingly unequal and polarized where the benefits of health, economic growth, poverty reduction, protection of human rights and the provision of universal basic quality services (potable water, quality education, housing and quality health care including mental healthcare) are not equally distributed across the nation, across gender, across minority and stigmatized groups, including people living with mental disorders. Such inequalities contribute to some of the social determinants that leads to poor mental health. This situation is synonymous to most middle-income countries on the African continent.
Resources are vital for the effective delivery of mental health services. However, in Ghana, resources are inadequate for mental health service delivery. This may be explained by the decades-long neglect of the field of mental health. Notably, less than 1% of the total health budget is spent on mental health (2). For example, less than 10% of the total approved budget allocated to the mental health service has been released for 2021. These funding limitations could explain why there is use of existing facilities at the primary, district, and regional levels to create psychiatric units for the delivery of mental health services instead of the construction of new infrastructure, that are fit for purpose. Insufficient funding has compromised effective service delivery particularly area coverage (4,8). There is a lack of regional and district management structures for mental health with multiple negative consequences including very inadequate systems for planning, monitoring, service, and quality improvement. There is no sustained financing of the mental health service in Ghana (2,4,8). The most prudent way to fund mental health services in Ghana would have been to include mental disorders in the national health insurance scheme coverage, hence it is very difficult to understand why the National Health Insurance Scheme, a key social intervention for health that is targeted at the poorest and most vulnerable in the Ghanaian society will exclude mental disorders in its coverage. The mental health Act 846 of 2012 set up a mental health fund but disappointingly, up to date, the mental health levy has not been established.
Currently, the international trend is focus on a shift towards the process of de-institutionalization and decentralization of mental health services from main psychiatric hospitals to the primary health care centres and grass root levels. However, there are limitations to this process in Ghana, hence mental health services remain largely in psychiatric hospitals, decentralization and deinstitutionalization has been sadly weak and the system is too strongly focused on inpatient care (2,8). The three main inpatient hospital services are situated in the southern part of the country, two in the country’s capital and one in the central region. This results in inaccessibility for most of the population, facilities overburdened in terms of the high patient number, inadequate resources, and limited space. The highest percentage of funding available are channelled to inpatient services, yet still woefully inadequate. Even with the focus on inpatient care, there are Insufficient in-patient facilities in the Regions and Districts which puts the burden on families who must travel long distances in search of treatment centred in the southern part of the country, leading to overcrowding in some of the inpatient facilities. The mental health services delivered at primary health centres are mostly physician based, with limited resources, with poor infrastructure, which hampers the improvement of mental health service delivery (8). This situation is common in most mental health services in low- and middle-income countries.
There is lack of structure and effective organisation of the mental health service delivery in Ghana. There is scarce distribution of specialised mental health services within the established in-patient facilities and next to none in primary and district mental health care centres. Management of substance dependence was deficient outside inpatient institutions, insufficient specialist services, particularly for children, the elderly, learning disability, the list continues (8). The few rehabilitation units which exist are ‘blocked’ by long stay patients. There is inequitable distribution of resources such that nearly all the resource are provided via three in-patient hospitals located in large urban centres in the south. The few rehabilitation units which exist are ‘blocked’ by long stay patients Supply of community mental health facilities (e.g., office and clinic space) and resources (e.g., medication supplies and transport) to support community mental health practice was very insufficient (8). The number of communities based psychiatric inpatient units, community-based rehabilitation facilities and community based residential services are very low, whereas there should have been hundreds.
According to research, the diagnosis and treatment of mental disorders in low-middle-income countries and most low-resource settings occur in centralized psychiatric hospitals (2,4). Diagnosis, treatment, and referrals in primary care and community centres are typically lacking due to ineffective collaboration, interaction, and referrals systems faces challenges in various countries, this also applies to Ghana (2,4). Common challenges of integrating mental health care into primary health care in Ghana include limited infrastructure, limited human resources, and less community awareness of mental health; poverty and social deprivation; a high rate of high levels of stigma and discrimination; and variations in mental health conditions which influence the acceptability and uptake of services. There is a lack of referral systems for healthcare workers to know how to refer cases into the mental health system.
The backbone of any robust health care system is the capacity, adequacy, and effectively functioning human resource, however weaknesses exist in this area in Ghanaian mental health service. There is a heavy over reliance on nurses with very few other types of specialists. There is insufficient manpower particularly, psychiatrists, psychologists, occupational therapists, workers trained for community mental health practice and psychiatric social workers (2,4,8). Coupled with insufficient incentives for staff working for mental health, there is little ongoing training needs analysis to identify gaps in knowledge and training. Mental health staff, especially community and district level and primary health care workers do not receive consistent refresher trainings. There is hardly any training of mental health workers on human rights and the balance of treatment for patients is too strongly focussed on medication rather than psychosocial interventions and prevention (). The amount of postgraduate training taking place in psychiatry for doctors are low, regarding an ideal patient doctor ratio, as few doctors choose to specialize in mental health. Mental health services are being provided by inadequately trained staff, such as generic health workers most particularly in the community and district levels.
The passage of the Mental Health Act 846 of 2012 by parliament in March 2012 was a major milestone in addressing mental health as a public health issue and in the protection of the human rights of people with mental disorders in Ghana (3,6). Key aspects and provisions of Ghana’s Mental Health Act 846 of 2012 include; Rights of persons with mental disorder, Protection of vulnerable groups ,Procedures for voluntary and involuntary admission and treatment, Creation of the Mental Health Authority, Establishment of mental health review tribunals, Establishment of regional visiting committees, Establishment of the Mental Health Fund and Introduction of sanctions for the offences of neglect of or discrimination against persons with mental disorder. The implementation of the bill has however been difficult due to a list of challenges (3,6).
Religion and spirituality play a vital role in shaping the world view and resultantly influencing the health seeking behaviours of most individuals especially in Africa. Several broad categories of factors have been proposed as linkages between religion and health. These categories include specific lifestyle and health behaviours, including help seeking; social resources; coping resources and behaviours; attitudes, beliefs, and emotional states and feelings; and generalized beliefs about the world (7). Furthermore, within each category, are both the potential positive and negative effects of religion on health, however an in-depth analysis of this is beyond the scope of this discussion and perspectives being shared (7). Like most African countries, in Ghana, the practices of faith healing in the diagnosis, prevention and treatment of a plethora of health issues is pre-historic and dates back into antiquity, more importantly, the recent times have seen a growing utilisation pattern of faith healing services for curative purposes and health. Evidence however indicates that, indicate that patients with mental disorders who visit these healers have no access to proper housing, water, clothing, food, and security due to a lack of resources (1,5). Additionally, these healers have no scientific skills and knowledge of the management of mental disorders; they depend solely on supernatural powers. They have been various levels of recommendations that since society has accepted these healers, periodic training programmes based on scientific principles with certification be organized, focusing on equipping faith-based healers and operators of prayer camps with basic knowledge and skills in handling mental patients (1,5). The training should also focus on mandating them to provide a standardized state-of-art facilities for patient and work within contextual systematic scientific protocols. The aim is that the training will ensure proper monitoring, evaluation, and reporting of the activities of faith-based healers and prayer camps to augment the promotion of mental health services while preventing harm to innocent individuals.
The promotion of mental health education for vulnerable individuals in economically and socially disadvantaged groups will improve mental health outcomes, when resources for education are made accessible, affordable, and available (2,4). In Ghana the role of mental health education is mostly taken on by community mental health nurses who periodically visit schools to offer mental health education, they are however faced with resource constraints. Interventions in schools to promote mental health services are common in high-income countries, however in most low-middle-income countries, like Ghana, school interventions are also lacking making it a challenge to improve school mental health services. Ghana does not have an overall coordinating body that supervise public education and awareness campaigns on mental health. This area of activity is overseen by several different organizations including the Ghana Mental Health Association, government agencies, Non-governmental Organisations, professional associations, and international agencies all engage in the promotion of public education and awareness campaigns (4). These campaigns target the general population and the most vulnerable in society. In addition, there are public education and awareness campaigns targeting professional groups including health care providers and those working in the complimentary/ alternative/traditional sector. Stigma and discrimination do not only affect the mental and physical health of people with lived experiences, but also leads to socio-economic exclusion and poor educational opportunities (8). There is insufficient public education which is likely to adversely affect acceptance of the mentally ill in the community and their rehabilitation.
Additionally, mental health research is lacking in Ghana, Research shows that one per cent of all health publications from the country were on mental health (8). Record keeping and data collection is inadequate and inconsistent. The use of evidence-based practices is vital to ensure effective health care is provided, therefore, health information systems should be improved to facilitate data collection and analysis. Information systems should be properly managed and there should be training in recording and keeping of records. Research and evaluation of foreign based clinical guidelines will highlight specific policies and protocols that is best fit for our system, so that there is successful adaptation into locally owned, tried, and tested manuals that are easy to put into use, based the Ghanaian socio-economic resources.
In the last one and a half years, the world, including Ghana has been ravaged by the Covid-19 pandemic and this has further highlighted the effects of inequalities on mental health outcomes. The impact of the pandemic has led to the worsening of chronic health conditions, deaths, loss of jobs and income and poorer psychological health including anxiety and depression. Whereas the psychological impact of the covid-19 pandemic is still emerging, we should be minded that psychological trauma can take time to manifest hence the need to incorporate mental health strategies in the ongoing Covid-19 prevention implementation plan and even more so in any post covid-19 implementation plan worldwide but particularly in low-middle income countries like Ghana.
The future of Ghana’s mental health system currently hinges on the new Mental Health Authority established in November 2013; the body responsible for implementing the Mental Health Act 846 passed in 2012 (3). Mental health structures described in the Act need to be put in place, firstly through the introduction of the Act to the public and education of stakeholders on its application. There should be commissioning of an expert team to work in collaboration with the Ghana ministry of Health and health providers to produce evidence based mental health improvement plans with short-, medium- and long-term goals. In addition, there should be a comprehensive organizational structure of the Mental Health system. The Authority should include a division for Quality Assurance Monitoring and Evaluation. Plans for training/awareness creation and monitoring should also be produced for the changes that will occur from the implementation of the Mental Health Act. The Mental Health Authority should establish a system to maintain oversight of and to coordinate all the different groups working alongside government; contracted and private mental health service, faith-based healers, and international aid providers in the country. There should be measures to correct the inequitable distribution of resources around the country through the effective process of de-centralization and paying critical attention to community, and district level mental health care. Implementation of the Act through decentralization and refocusing on community based mental health care systems. There should be at least one comprehensive mental health service for each specialty in each region, community and district level providing, in-patient, outpatient, and rehabilitation facilities where counselling, social skills training and prevention programmes can be administered, most especially, child and adolescent, old age and learning disabilities. Accordingly, there is a requirement for a concentrated focus for mental disorder prevention programmes through education of the society to reduce stigmatization and marginalization and enhance early identification and access to mental health services, as well as effective treatment for those who are already challenged by mental health problems.
These perspectives shared are by no means intended to disregard or cast a shadow of doubt over the existing mental health system in Ghana. It is purposeful for the enlightenment on the commendable efforts that my noble colleagues in the mental health service in Ghana and in Africa continue to put into the care of the mentally challenged despite the enormous challenges they face. May I take this opportunity to applaud your devotion and commitment to enhance the patient experiences and mental health care outcomes under most unfavourable conditions.
The theme for this years’ mental health day celebrations also raise the awareness of the need for all professionals involved with any facet of mental health care to be duly recognised and celebrated. As I sign off, I would like to salute each individual professional in the mental health service worldwide, for continuously working tirelessly to support the society’s’ most vulnerable, yet most marginalised and stigmatized individuals regardless of the unique inequalities that exist in our peculiar region, country or continents.
- Arias D, Taylor L, Ofori-Atta A, Bradley EH. Prayer Camps and Biomedical Care in Ghana: Is Collaboration in Mental Health Care Possible? (2016 )Sep 12;11(9):e0162305. doi: 10.1371/journal.pone.0162305. PMID: 27618551; PMCID: PMC5019394
- Atakora, Michael & Ibrahim, Mdala & Asampong, Emmanuel. (2020). The Ghana Project in Psychiatry: A Systematic Description of the Mental Health Services.
- Doku, V., Wusu-Takyi, A. & Awakame, J. (2012) Implementing the Mental Health Act in Ghana: any challenges ahead? Ghana Medical Journal, 46, 241.
- Ofori-Atta, A., Reed, U. & Lund, C. (2010).A situational analysis of mental health services and legislation in Ghana: Challenges for transformation. African Journal of Psychiatry 13, pp 99-108
- Ofori-Atta, A., Attafuah, J., Jack, H., Baning, F., & Rosenheck, R. (2018). Joining psychiatric care and faith healing in a prayer camp in Ghana: Randomised trial. The British Journal of Psychiatry,212(1), 34-41. doi:10.1192/bjp.2017.12
- Osei, A., Roberts, M. & Crabbe, J. (2011) The new Ghana Mental Health Bill. International Psychiatry, 8(1), 8–9.
- Peprah, P., Gyasi, R.M., Adjei, P.OW. et al.Religion and Health: exploration of attitudes and health perceptions of faith healing users in urban Ghana. BMC Public Health 18, 1358 (2018).
- Roberts, M., Asare, J., Mogan, C., et al (2013) The Mental Health System in Ghana – WHO AIMS Report. Kintampo Project/Ghana Ministry of Health.