Community Mental Health Systems

This pod was driven to recognise, value and support the work of community health workers and organisations within health systems. Members discussed how to change the ways in which decisions are made and enacted about the content and nature of public mental health services, including funding, diagnostics, referral and therapeutics.

They challenged the wider project team to consider the strengths and assets of existing community support systems, rather than emphasising weaknesses and gaps. This positive focus encourages us to value and strengthen what is already working and appreciate family, community and peer networks alongside formal services.

How did this pod shift our thinking and priorities?

How did they go about this?

The group includes members from Ghana, South Africa, India, Palestine, and the UK. They drew on their experiences researching and working in their local contexts to produce country case studies.

These highlight and compare the strengths and assets of mental health systems across countries, with a special focus on the nuances of rural vs. urban settings. They co-produced a presentation (below) summarising their findings.

Listen to this short ‘pod’-cast, summarising the group’s discussions over the past months (January to July 2022).

Browse the pod’s presentation of their country case studies, showcasing the assets and strengths of mental health systems in India, South Africa, Palestine, and Ghana.

What did the pod produce?

Below pod members in each country group summarise the status of their mental health systems:

  • South Africa

    In KwaZulu-Natal, where 11.1 million people from multiple ethnicities are spread over and area of 94 361 km², most of which is rural, it is difficult to pin down community mental healthcare without drawing some contextual boundaries first. In addition, system resources for community mental healthcare are yet to be mapped out. Nonetheless, we can draw from general and subjective experience. If we accept that community mental healthcare means the provisioning of a cascade of services according to the spectrum of need outside the boundaries of primary, secondary and tertiary health facilities, there are assets that we can point out.

    First, an on-going project is piloting a psychoeducation and screening instrument to be used by PHC outreach teams (lay health workers), thereby extending case identification and referral capabilities of the PHC system to households. Then, the province has a high degree of religiosity and spirituality across population groups, and therefore faith-based or spiritual actors are often involved a first point of contact, and often times provide counselling informed by a particular spiritual perspective/approach. This also includes traditional health practitioners, particularly in the northern, more rural areas. A study has recently been done that showed that traditional health practitioners here are particularly helpful in identifying early psychosis and referring to health facilities for specialised diagnosis and care.

    Other noteworthy assets include town-based chapters of the South African Federation For Mental Health, who provide psychoeducation, advocacy and in some cases residential support. The South African Depression and Anxiety Group are currently establishing district-based peer-support groups for mental health. Then, there are multiple NGOs that provide residential (though, unregulated) support for people with severe mental conditions. A social capital perspective is important here, given that people also often rely on neighbours and friends for support in dealing with mental illness.

  • India

    India trails behind in the area of mental health, having only 0.75 psychiatrists per lakh (100,000) population. To aggravate the alarming situation further, the majority of the population resides in rural regions where the availability of trained professionals is even scarcer, with some districts having one psychiatrist to none at all. Nevertheless, the community mental system has been quite an effective tool. It has broken down stigmas by starting conversations on mental health issues in disadvantaged communities and has improved early detection and care for impacted individuals and families.

    The community mental health model in India banks on the close-knit community structures where the community as a whole plays a more significant role in the recovery of the individuals and well-being of the impacted families. Community mental health workers associated with grassroots organizations are trained in basic counselling techniques like Active Listening and Problem Solving. They run self-help groups (SHGs) with the community members and create a stigma-free, safe, and sustainable environment for conversations on mental health issues in the community. These SHGs play a crucial role in helping people connect with institutional mental health facilities in the areas and offer help to individuals and families in times of crisis.

    Unqualified trained mental health workers play a critical role in providing timely, affordable, inclusive, and effective mental healthcare. India needs to work further on the community mental health model and incorporate the community mental health model into its mental health program.

    An example is the community-led programme ‘Atmiyata’. Since 2017, we have been working across 530 villages in the district of Mahesana, in the state of Gujarat, India. Atmiyata is a volunteer driven intervention to address the rural mental health and social care gap. The organisation draws on existing social capital, lived experience and a strong sense of social responsibility within the communities.

    Atmiyata has been widely accepted because it (1) uses a relatable day-to-day stress narrative, avoiding bio-medical/illness language, (2) has a participatory approach, (3) relies on existing community resources (bottom-up approach), and (4) includes people with lived experiences and from marginalised communities at each level of intervention.

Ghana

Ghana’s mental health system has origins in the colonial period with the establishment of the Accra asylum in 1906 and the introduction of legislation to detain people deemed mentally ill. After independence, a further two psychiatric hospitals were constructed in 1965 and 1975. Formal community mental health care in Ghana started relatively early, with the training of community psychiatric nurses in 1972; however, until recently this was very limited in scope. Over the last decade Ghana has become a major hub for global mental health activities, hosting many programmes and research in partnership with international actors. This includes WHO QualityRights (2019), the Time to Change anti-stigma campaign (2018), and a current UK FCDO funded programme to integrate mental health into primary care.

Mental health policy and legislation

A revised Mental Health Act (846) was passed in 2012 to replace the Mental Health Decree NRCD 30 which was introduced under the military regime in 1972. This in turn had replaced the 1888 colonial Lunatic Ordinance. Various stakeholders including WHO and NGOs contributed to drafting the new Mental Health Act and advocating for its passage into law. Hailed by the international community as a progressive mental health law, the 2012 Act focuses on improving access to mental healthcare, safeguarding human rights, and advocating for community-based, rather than institutional, mental health care. However, there has been slow progress in implementation due to leadership failure and inadequate resources. One major challenge is the failure of state actors to pass the accompanying legislative instrument that will operationalise the legal process and provide the framework for implementation (Doku et al., 2012; Walker, 2015).

In May 2021, the Ghana Ministry of Health launched a mental health policy for 2019-2030 with a focus on establishing an integrated community-based health model to expand access to quality mental health services. Notably, the policy includes a commitment to train, regulate and monitor traditional and faith-based healers as ‘frontline informal community mental health workers’.

Alongside the Mental Health Act, Ghana has also ratified the UN Convention on the Rights of Persons with Disabilities, and NGOs are active in pushing for consideration of mental health within disability rights.

Organisation of mental health services

The introduction of the Mental Health Act 846 provided for the establishment of a Mental Health Authority (MHA) within the Ministry of Health with the mandate to formulate, regulate and enforce mental health policies with oversight and supervision by a Mental Health Board. Mental health services are delivered via Ghana Health Service, the publicly funded health system.

Mental health coordinators have been appointed to oversee mental health services at the regional and district level. All regional hospitals in Ghana now provide some form of outpatient mental health services. However, community mental health services are unevenly distributed with greater availability in urban rather than rural areas and in the south, rather than the more deprived northern regions of the country. There are currently no specific regional or district mental health plans in place.

Human resources

The number of psychiatrists in Ghana has significantly increased but remains very low. The highest number of psychiatrists are clustered in the two major urban centres, Accra and Kumasi. There are no psychiatrists in the whole of the Bono East region.

Psychiatric nurse training colleges were first established in 1952, initially to train nurses to staff Accra Psychiatric Hospital. Since the establishment of the Mental Health Authority, the number of training institutions has expanded, both in public and private sectors. A percentage of psychiatric nurses are now posted to district-level clinics and health facilities to provide basic mental health services. Since 2011, community mental health officers (CMHOs) have been trained to work at the primary care level to supplement the work of psychiatric nurses, following a public health model of case searching and referral. In practice, however, due to the low numbers of psychiatrists, many nurses and CMHOs take responsibility for diagnosis and treatment. Community health volunteers assist with identifying persons with mental illness in communities.

Psychologists practicing in Ghana are trained to Masters level. Occupational therapists have been trained in Ghana since 2018 and are now working in the three state psychiatric hospitals.

Funding

A small percentage of the Government of Ghana’s overall health budget is allocated for mental health; however, this is mostly absorbed by the psychiatric hospitals. The Mental Health Authority is heavily reliant on donor funding, particularly UK development aid, for most of its activities. The mental health levy, which was mandated by the 2012 Mental Health Act to fund mental health care, has not been implemented.