General News of Monday, 25 September 2017
Stakeholders in mental health care delivery in the country are pushing for a legal backing to enable the Mental Health Authority (MHA) enforce its duties contained in the Mental Health Act.
In a communique issued on the state of mental health delivery in the country after a stakeholders conference in Accra recently, participants note that there exist gaps such as acute shortage of psychotropic medicines, difficulties in accessing services at the community level, and general lack of awareness on mental health within the population.
The communiqué, issued by the Christian Health Association of Ghana (CHAG) revealed that a project commissioned by UK Aid-DFID in 2016 to assess the state of mental health services in Ghana, found that there was “visible absence of government’s optimum commitment to mental health services”, as evidenced by meagre funding or limited budgetary allocations for mental health.
“Although the mental health act enjoins the MHA to champion the course of mental health, there remains legal backing to enforce the duties contained in the Act (846). And so, subsequent to the passage of the new Mental Health Act 846, a Legislative Instrument (LI) is necessitated to facilitate effective implementation of the Act.Accordingly, the passage of the legal instrument (LI) remains imperative and indispensable for mental health,” the communiqué, signed by CHAG Deputy Executive Director, Dr. James Duah.
The Christian Health Association of Ghana is a key service provider in health care delivery in the country.
Read full communiqué published below on the state of mental health services delivery in Ghana.
COMMUNIQUE ON THE STATE OF MENTAL HEALTH SERVICES DELIVERY IN GHANA; A CALL TO PAY ATTENTION TO MENTAL HEALTH SITUATION FOLLOWING A MEETING OF STAKEHOLDERS IN MENTAL HEALTH AT TOMREIK HOTEL, EAST LEGON ACCRA
Achieving universal coverage in mental health delivery has been one of the major goals of Ghana’s Ministry of Health. This goal seeks to expand mental health service delivery which is skewed heavily towards the southern sector, to other parts of the country where coverage is relatively low or in some instances virtually absent. The approach to decentralizing service delivery has been well spelt out by the MH Act 846 – Community Care.
Community care is at the very basic level of care. Care at this level is often provided at the CHPS, Health centres and District hospitals. The Act 846 enjoins that the Mental Health Authority (MHA) ensures mental health service delivery for all, using existing structures and effective collaboration to guarantee integration of mental health services into the general health service provision. This collaboration is to be done with several service providers including The Christian Health Association of Ghana (CHAG), the Ghana Health Services (GHS), and other Civil Society Organizations (CSOs). The MHA has over the past five years since its inception collaborated particularly at the CHPS level with CHAG, and this collaboration continues to be strengthened as mental health delivery in Ghana continues to improve.
CHAG has been running a 5- year project that is aimed at improving the lives of people living with mental illnesses in Ghana. The objectives of the programme comprise:
1. Improving access to mental health services
2. Reducing stigma and discrimination associated with mental illness
3.Re-integration of mentally ill persons who are treated back into their communities
Towards the aforementioned objectives, variousprogrammatic interventions have been carried out. These include formal training of Community Mental Health Officers, Clinical Psychiatry Officers and recently Psychiatrists. Other activities carried out include logistic supply, awareness creation including community education on mental illness amongst others. Intent on scaling up mental health services in the health sector, UKAid-DFID, commissioned a Team in 2016 to assess the state of mental health services in Ghana, wherefore several gaps were identified.Amongst the gaps were; acute shortage of psychotropic medicines, difficulties in accessing services at the community level, and general lack of awareness on mental health within the population.
A significant finding was the visible absence of government’s optimum commitment to mental health services,as evidenced by meagre funding or limited budgetary allocations for mental health.Although the mental health act enjoins the MHA to champion the course of mental health, there remains legal backing to enforce the duties contained in the Act (846). And so, subsequent to the passage of the new MentalHealth Act 846, a Legislative Instrument (LI) is necessitated to facilitate effective implementation of the Act.Accordingly, the passage of theLegalInstrument (LI) remains imperative and indispensable for mental health.
CHAG, a partner to the MOH and other organizations providing mental health services, wants to play a lead role in harnessing forces to support improvement of mental health services in Ghana. With its 5-year project near its completion, local institutions and actors need to be brought on board to take the service forward. The purpose of this meeting therefore, is to enlist the support of all stakeholders for the improvement of mental health services in Ghana. Specifically, all the players – MHA, MHA, BasicNeeds Ghana etc. will want any institution that has a role in passing the L.I to act now.
CHAG, in partnership with the Ministry of Health and organizations involved in mental health service provision, seeks to coordinate advocacy action and harness collective efforts for sustainable mental health services in Ghana. With CHAG’s 5-year project nearing completion, we must consolidate, maintain and sustain the gains by mobilizing all institutions, stakeholders and civil society for mental health. In particular, we enlist the support of the Mental Health Authority, BasicNeeds-Ghana, and all other partners in mental health to actively advocate and champion the passage of the LI now.
Mental illness has a higher disease burden with serious socio-economic consequences. Presently, only 2% of the people with mental illness have access to mental health care (WHO 2008), leaving a 98% gap. Globally, it is estimated that one in five persons will develop mental illness in their life time. In Ghana, a study has shown that 41% of Ghanaians suffer some form of psychological distress while 19% suffer moderate to severe mental disorder. These statistics are staggering and calls for urgent action by all stakeholders
The following key areas need attention:
1) Psychotropic medicines
a. Since 2011, centralized procurement by government has not happened. Clients that need medication have had to buy it from the open market at a very high cost beyond the what families can ordinarily afford
b. Supply of medicines,which were hitherto subsidized, are no longer available
c. Local pharmaceutical companies are not stocking them routinely because of the tag on psychotropic medicines as programme medicines. They find it uneconomic to trade in psychotropic medicines
d. The following specific medicines are urgently needed but are not available. These olanzapine, risperidone, haloperidol, chlorpromazine (Antipsychotics); phenobarbitone, sodium valproate, carbamazepine (anti-convulsants); amitriptyline, imipramine (Anti-depressants). The acute situation of psychotropic medicines not available makes working in psychiatric units very frustrating.
2) Psychosocial rehabilitation
a.Occupational therapy not well developed and the few ones don’t function well. Nation has not prioritized this and so they are not set-up. The technical people to lead are also not available (we only have occupational assistants. Only two intern occupational therapists are available)
b. Community-based rehabilitation centres and half-way homes where those who are stable could be rehabilitated within the community are not available. The situation challenges the de-institutionalization efforts that are being advocated now. It also contributes to the high relapse (60%) rate in Ghana
3) Limited Human resources to support mental health services
Today, only 16 psychiatrists are in active service, 1,600 Community Mental Health Officers (CMHO), 350 clinical psychologists. These are not enough to take care of the rising population growth in Ghana. Presently, the psychiatrist per capita ratio is worsening (0.06/100,000 in 2014) compared to 2011 (0.07/100,000 in 2011) (Global health Observatory repository data).
Ghana needs a total of at 275 psychiatrists to be included in the 45% of the world’s population that have one psychiatrist per 100,000 population. This leaves a gap of 259 psychiatrists to add to the present numbers. Clinical psychologists are in limited supply. Those that are employed are placed at low grade in on government of Ghana (GoG) payroll. This low placement does not encourage them to work in government institutions, hence the few that could support mental health services provision show preference for industrial settings.
4) Limited Research and information on mental health
Studies have shown that only 1% of all health publications in Ghana are on mental health. This situation does not support evidence-based decisions on mental health. Not surprising that there is not much attention on mental health.
5) Less prioritization of mental health care
Whereas conditions like malaria, HIV, NCDs and others are given much attention by the MOH and its partners, the same cannot be said about Mental Health. Mental health is not prioritized although about 41% of Ghanaians have mental disorders and 1 in 4 persons has a chance of developing mental illness in their life time. It is not on the benefit package of the NHIS and thus is limits access to care
The way forward
1. Psychotropic medicines
a. We call on the government to de-label psychotropic medicines as programme medicines so that private pharmaceutical companies can trade on them. This will ensure that they are available in the open market for people who want to access them to get them. Government should meet the public half-way by ensuring that a certain minimum stock is available for clients to access. Government should institute tax waivers on importation of or on local production of psychotropic medicines. This will make these medicines affordable, available and or more attractive for pharmaceutical companies to provide them. Stakeholders and donor partners should consider these as equally important to malaria and other disease conditions.
2. Psycho-social rehabilitation
a. CHAG calls on government and stakeholders in mental health services provisionto develop more psycho-social rehabilitation centers, including half-way homes, at the facility and community levels and train more personnel to man these centres. This will foster faster re-integration into society, improve recovery of persons treated from mental disorders, reduce rate of relapse and stigma for persons living with mental illness. Institutions should ensure that psycho-social rehabilitation is part of the treatment plan for every new client that they attend to.
3. Limited Human resources
a. The Ghana College and Physicians and Surgeons should target training of 259 psychiatrists to close the wide gap in requirement for psychiatrists (specialists). One way to achieve this will be to get the GETFund to sponsor more doctors to specialize in Psychiatry local and abroad. Attempts should be made to generate doctors’ and medical students’ interest in psychiatry. We call on government to incentivize psychiatry training by reducing the fees or fully fund the training for the next 15 years.
Additionally, the entry requirements to psychiatry training should be lowered (e.g. straight entry into the programme after housemanship training). We suggest that the three years post-housemanship service requirement at the district should not apply here. Furthermore, remuneration for mental health workers should be reviewed to incentivize the workers. Especially the position of the clinical psychologists on the GoG payroll should be adjusted upwards to encourage attraction and retention of the group on the government sector.
4. Research in mental health
a. We implore government to commit funding to research in mental health locally. MOH should also collaborate with other development partners and academic institutions to contribute to research in mental health services in Ghana. Training in research is necessary to attract more doctors and researchers into mental health issues. The Mental Health Authority should embedresearch as part of their strategic plan and or programme of work. A more robust system of data collection should be developed and made available to service providers. This will make relevant data on mental health readily available for informed decision making for policy makers, facility managers, researchers and community
5. Prioritization of mental health services
a. It is imperative that mental health should be given the attention that it deserves. Given that one in four persons has a chance of developing mental illness in their life time and 41% Ghanaians have one mental disorder or the other, it should be given the same attention as the other non-communicable diseases.
Again, with the inclusion of mental health on the Sustainable Development Goals (SDGs) coupled with the fact that it has a role in all aspects of life, government and partners should commit to it. If depression and anxiety disorders alone are among the top three causes of disability globally, it makes economic sense for any government to invest in mental health. Government should budget for mental health services and commit to fund mental health services consistently. Mental health should beone of the benefit packages of the NHIS.
Mental health remains a challenge in Ghana yet very limited resources are committed to its provision at both policy and operational levels. In the last few years, with the enactment of the Mental Health Act (846, 2012) and establishment of the Mental Health Authority, a lot has been done in advancing the cause of mental health. These efforts need to be sustained and organizations like DFID, CHAG, MHA, BasicNeeds Ghana, and Ghana Health Service need to be commended. Given that every $1 invested in management of depression and anxiety leads to a return of $4 and ability to work, Ghana will gain a lot by investing in Mental Health services. Intuitively, it is socio-economically prudent,therefore, for the Government of Ghana to invest adequately in mental health services in order to promote growth and development and enhance the quality of life of Ghanaians.
DR. JAMES DUAH
DEPUTY EXECUTIVE DIRECTOR
CHRISTIAN HEALTH ASSOCIATION OF GHANA (CHAG)
EMAIL: [email protected]