Global Mental Health Reforms: Mental Health Care in Anglophone West Africa

To examine current resources and practices in mental health care, information was systematically gathered from five countries—the Gambia, Sierra Leone, Ghana, Nigeria, and Liberia—by using a standard framework for country situation analysis that covers several domains, including information on mental health services available in the country, presence of a mental health policy, prevalence of mental health conditions, presence of legislation protecting the rights of people with mental health problems, mental health financing, human resources for mental health, needs for specialist mental health services, availability of drugs, and presence of organizations working in mental health. This framework was developed to inform planning processes for mental health programs, but it also allows measurement of change in indicators or impact when it is used to gather information over time. The framework includes some standard indicators accepted as useful for international comparisons (3,4) as well as more qualitative measures assessing cultural beliefs and historical antecedents to the current context. In each country, relevant stakeholders were identified and invited to participate in the project, including individuals from civil society groups and nongovernmental organizations (NGOs), mental health professionals, and service users. Other sources of information included published epidemiological data and government statistics and information provided by civil societies in each country. Use of such gray data was important given the low level of published empirical data on mental health services in these countries. Ethical approval was obtained for this project.

Factors limiting the growth and evolution of psychiatric practice in the region were identified, including poor funding, stigmatization (of patients and professionals), lack of public awareness about the causes of mental illness, low priority by policy makers, and loss of the few trained professionals through brain drain. In most countries, the absence of a current framework to guide the practice of psychiatry via a comprehensive mental health policy and legislation and a lack of political will to implement existing policies have also been significant challenges.

Several important developments point to a brighter future for mental health services in the West African region. First, there is renewed attention in WHO member countries to update mental health policies and legislation in conformity with best practices and current evidence. These efforts should provide a good foundation and a work environment that enables services development. Second, more attention is being paid to the urgent need for a task-shifting approach to the provision of mental health services in a bid to develop context-specific solutions to the treatment gap for mental disorders. Task shifting, as described by WHO, is the rational redistribution and delegation of tasks among health workers such that health care tasks are shifted from higher-trained health workers to less highly trained health workers to maximize efficient use of resources. These efforts have largely been focused on the successful integration of mental health care into primary care by using the evidence-based principles underlying the WHO Mental Health Gap (mhGAP) Action Program Intervention Guide (18) and associated resources. The efforts are yielding positive developments, including increased recognition and treatment of some priority mental health conditions, such as depression, psychosis, and alcohol use disorders, by primary care workers.

Third, the five countries have seen an increase in political stability, which has also led to improved conditions of service for health workers generally—a development that may discourage brain drain. Fourth, there are growing numbers of mental health NGOs in Liberia, the Gambia, Nigeria, Ghana, and Sierra Leone and other parts of the region, which are focusing on tackling mental health problems in the community through advocacy; mental health promotion, prevention, and treatment; and rehabilitation of individuals with mental illness. The increased reliance on evidence-based standards, such as mhGAP, and close partnerships with governments by such organizations is a significant shift from past ways of working.

Finally, the recent introduction of health insurance in the region (most successfully in Ghana) has the potential to improve access to care by reducing out-of-pocket payments and thereby lessening the burden and costs to caregivers, although coverage for mental health conditions is currently limited.

The current lack of psychiatric services in Anglophone West Africa and very low human and financial resources are a result of a long-term lack of prioritization of mental health issues by governments and policy makers. However, there are promising signs that the situation is slowly evolving, with more qualified personnel in decentralized settings, improved funding, and innovative approaches to scaling up care for mental and neurological disorders through the successful integration of mental health into primary care.

The Australian Aid Agency and CBM International provided financial support for this project. The authors acknowledge the commitment and enthusiasm of the members of the Stakeholders Oyewusi, B.Ed., M.S.W., Humphrey Kofie, B.A., M.Phil., Joshua Duncan, B.A., M.P.A., Sametta Thomas, B.Sc., and Dawda Samba, R.N., E.N. The authors thank Benjamin Harris, F.W.A.C.P. (Sierra Leone), Basic Needs and the Mental Health Society of Ghana, Enabling Access and City of Rest (Sierra Leone), and the WHO representative for providing office space and oversight facilities for the country offices. They are also grateful to the policy makers and mental health leaders and to the WHO country offices for their assistance and support for the project.

The authors report no competing interests.