REVISITING THE NEED TO STRENGTHEN HEALTH SYSTEMS IN AFRICA FOR BETTER MENTAL HEALTH CARE DELIVERY
Keywords:Health systems strengthening, mental health, WHO Health systems framework, Africa
According to the global burden of disease (GBD) report, it is estimated that 13% of all GBD is caused by neuropsychiatric disorder. That is, a substantial amount of the world's disease today comes from mental, neurological, and substance use disorders (MSN). In Africa, a high percentage of people are affected by MSN and this is attributed to several factors such as poor leadership and governance for health, inadequate access and utilisation of health services especially for mental health, and weak health systems. The weak health system across Africa greatly affects mental health care delivery. This article discusses the state of mental health in Africa. It argues that with the advent of Coronavirus (COVID-19) pandemic the focus of many health systems in Africa has been on addressing the pandemic with less emphasis on mental health care delivery. The article using a WHO health systems framework discusses ways to strengthen mental health systems in Africa. It also offers some useful approaches to strengthen African health systems for improved mental health care delivery. In conclusion, strengthening health systems in Africa for improved mental health care delivery using the WHO framework and other useful approaches is possible. With a health system that is strengthened, the state of mental health delivery across Africa will be greatly improved.
World Health Organization (WHO). The global burden of disease--2004 update. WHO: Geneva; Switzerland. 2008a.
Jacob KS, Sharan P, Mirza I, Garrido-Cumbrera M, Seedat S, Mari JJ, Sreenivas V, Saxena S. Mental health systems in countries: where are we now? Lancet. 2007;370(9592):1061-77. doi: 10.1016/S0140-6736(07)61241-0. PMID: 17804052.
Lawal SA. Health sector development and sustainability in Nigeria using the resilient health systems framework. Ibadan J. Soc. 2016; 4(1):81-115.
Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D. Comparative performance of private and public healthcare systems in low- and middle-income countries: a systematic review. PLoS Med. 2012; 9(6):e1001244. DOI: 10.1371/journal.pmed.1001244.
Whiteford HA, Ferrari AJ, Degenhardt L, Feigin V, Vos T. The global burden of mental, neurological, and substance use disorders: an analysis from the Global Burden of Disease Study 2010. PloS One. 2015; 10(2): e0116820. https://doi.org/10.1371/journal.pone.0116820.
Hanlon C, Luitel NP, Kathree T, Murhar V, Shrivasta S, Medhin G, Ssebunnya J, Fekadu A, Shidhaye R, Petersen I, Jordans M, Kigozi F, Thornicroft G, Patel V, Tomlinson M, Lund C, Breuer E, De Silva M, Prince M. Challenges and opportunities for implementing integrated mental health care: a district level situation analysis from five low- and middle-income countries. PLoS One. 2014; 18;9(2):e88437. DOI: 10.1371/journal.pone.0088437.
Deaton AS, Tortora R. People in sub-Saharan Africa rate their health and health care among the lowest in the world. Health Aff. 2015; 34(3):519–527. https://doi.org/10.1377/hlthaff.2014.0798.
Lawal SA Human resources for health in sub-Saharan Africa: Issues, challenges, and possible solutions. Lapai J. Eco. 2019; 3(2):28-42.
Ruktanonchai CW, Nilsen K, Alegana VA, Bosco C, Ayiko R, Seven Kajeguka AC, Matthews Z, Tatem AJ. Temporal trends in spatial inequalities of maternal and newborn health services among four east African countries, 1999-2015. BMC Public Health. 2018;18(1):1339. doi: 10.1186/s12889-018-6241-8.
Naicker S, Eastwood JB, Plange-Rhule J, Tutt RC. Shortage of healthcare workers in sub-Saharan Africa: a nephrological perspective. Clin. Nephrol. 2010;74 Suppl 1:S129-33.
Ntuli ST, Maboya E. Geographical distribution and profile of medical doctors in public sector hospitals of the Limpopo Province, South Africa. Afri. J. Pri. Health Care Fam. Med. 2017; 9(1):e1–e5. https://doi.org/10.4102/phcfm.v9i1.1443
George A, Blaauw D, Thompson J, Green-Thompson L. Doctor retention and distribution in post-apartheid South Africa: tracking medical graduates (2007–2011) from one university. Hum. Resour. Health. 2019; 17:100. https://doi.org/10.1186/s12960-019-0439-4
Azevedo, M.J. (2017). The State of Health System(s) in Africa: Challenges and Opportunities. In: Historical Perspectives on the State of Health and Health Systems in Africa, Volume II. African Histories and Modernities. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-32564-4_1
Maphumulo WT, Bhengu BR. Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review. Curationis. 2019; 42(1):e1–e9. https://doi.org/10.4102/curationis.v42i1.1901
Anyangwe SC, Mtonga C. Inequities in the global health workforce: the greatest impediment to health in sub-Saharan Africa. Int. J. Environ. Res. 2007; 4(2):93-100.
Savedoff WD. What should a country spend on health care? Health Aff (Millwood). 2007; 26(4):962-70. doi: 10.1377/hlthaff.26.4.962. PMID: 17630438.
Sankoh O, Sevalie S, Weston M. Mental health in Africa. Lancet Glob Health. 2018; 6(9):e954-e955. doi: 10.1016/S2214-109X(18)30303-6. PMID: 30103990.
Okasha A. Mental health in Africa: the role of the WPA. World Psychiatry. 2002; 1(1):32–35.
Charlson FJ, Diminic S, Lund C, Degenhardt L, Whiteford H.A. Mental and substance use disorders in sub-Saharan Africa: Predictions of epidemiological changes and mental health workforce requirements for the Next 40 Years. PLoS One. 2014;9(10): e110208. https://doi.org/10.1371/journal.pone.0110208.
Hunduma G, Girma M, Digaffe T, Weldegebreal F, Tola A. Prevalence and determinants of common mental illness among adult residents of Harari Regional State, Eastern Ethiopia. Pan Afri. Med. J. 2017;28:262. [doi: 10.11604/pamj.2017.28.262.12508]
Purgato M, Adams C, Barbui C. Schizophrenia trials conducted in African countries: a drop of evidence in the ocean of morbidity?. Int. J. Ment. Health Syst. 2012; 6(1):9. https://doi.org/10.1186/1752-4458-6-9
Musisi S. Mass trauma and mental health in Africa. Afr. Health Sci. 2004; 4(2): 80–82.
Atwoli L, Stein DJ, Williams DR, Mclaughlin KA, Petukhova M, Kessler RC, Koenen KC. Trauma and posttraumatic stress disorder in South Africa: analysis from the South African Stress and Health Study. BMC Psychiatry. 2013; 13:182. https://doi.org/10.1186/1471-244X-13-182
Thapa SB, Martinez P, Clausen T. Depression and its correlates in South Africa and Ghana among people aged 50 and above: Findings from the WHO Study on global AGEing and adult health. J Psychiatry. 2014; 17(6):1000167. doi: 10.4172/1994-8220.1000167.
Duthé G, Rossier C, Bonnet D, Soura, AB, Corker J. Mental health and urban living in sub-Saharan Africa: major depressive episodes among the urban poor in Ouagadougou, Burkina Faso. Popul Health Metrics. 2016; 14:18. https://doi.org/10.1186/s12963-016-0084-2
Mayston R, Frissa S, Tekola B, Hanlon C, Prince M, Fekadu A. Explanatory models of depression in sub-Saharan Africa: Synthesis of qualitative evidence. Soc. Sci. Med. 2020; 246(112760): 1-13. https://doi.org/10.1016/j.socscimed.2019.112760.
Sweetland AC, Belkin GS, Verdeli H. Measuring depression and anxiety in sub-Saharan Africa. Depress Anxiety. 2014; 31(3):223–232. https://doi.org/10.1002/da.22142
Ojagbemi A, Owolabi M, Akinyemi R, Arulogun O, Akinyemi J, Akpa O, Sarfo FS, Uvere E, Saulson R, Hurst S, Ovbiagele B. Prevalence and predictors of anxiety in an African sample of recent stroke survivors. Acta Neurol. Scand. 2017; 136(6): 617-623. https://doi.org/10.1111/ane.12766Citations: 10
Nel C, Augustyn L, Bartman N, Koen M, Liebenberg M, Naudé J, Joubert G. Anxiety disorders: Psychiatric comorbidities and psychosocial stressors among adult outpatients. S. Afr. J. Psych. 2018; 24. doi:https://doi.org/10.4102/sajpsychiatry.v24i0.1138
Kuringe E, Materu J, Nyato D, Majani E, Ngeni F, Shao A, et al. Prevalence and correlates of depression and anxiety symptoms among out-of-school adolescent girls and young women in Tanzania: A cross-sectional study. PLoS One. 2019;14(8):e0221053. https://doi.org/10.1371/journal.pone.0221053M
Page RM, West JH. Suicide ideation and psychosocial distress in sub-Saharan African youth. Am. J. Health Behav. 2011; 35(2):129-141. doi: https://doi.org/10.5993/AJHB.35.2.1.
Mars B, Burrows S, Hjelmeland H, Gunnell D. Suicidal behaviour across the African continent: a review of the literature. BMC Public Health, 2014; 14:606. https://doi.org/10.1186/1471-2458-14-606.
Amare T, Woldeyhannes SM, Haile K, Yeneabat, T. Prevalence and associated factors of suicide ideation and attempt among adolescent high school students in Dangila Town, Northwest Ethiopia. Psychiatry J. 2018; Article ID 7631453. https://doi.org/10.1155/2018/7631453.
Gureje O, Lasebikan VO, Ephraim-Oluwanuga O, Olley BO, Kola L. Community study of knowledge of and attitude to mental illness in Nigeria. Br. J. Psychiatry. 2005 May;186:436-41. doi: 10.1192/bjp.186.5.436.
Gureje O, Lasebikan VO, Kola L, Makanjuola VA. Lifetime and 12-month prevalence of mental disorders in the Nigerian Survey of Mental Health and Well-Being. Br. J. Psychiatry. 2006 May;188:465-71. doi: 10.1192/bjp.188.5.465.
Gureje O, Kola L, Afolabi E. Epidemiology of major depressive disorder in elderly Nigerians in the Ibadan Study of Ageing: a community-based survey. Lancet. 2007;370(9591):957-64. doi: 10.1016/S0140-6736(07)61446-9.
Gureje O, Degenhardt L, Olley B, Uwakwe R, Udofia O, Wakil A, Adeyemi O, Bohnert KM, Anthony JC. A descriptive epidemiology of substance use and substance use disorders in Nigeria during the early 21st century. Drug Alcohol Depend. 2007;91(1):1-9. doi: 10.1016/j.drugalcdep.2007.04.010.
Gureje O, Von Korff M, Kola L, Demyttenaere K, He Y, Posada-Villa J, Lepine JP, Angermeyer MC, Levinson D, de Girolamo G, Iwata N, Karam A, Guimaraes Borges GL, de Graaf R, Browne MO, Stein DJ, Haro JM, Bromet EJ, Kessler RC, Alonso J. The relation between multiple pains and mental disorders: results from the World Mental Health Surveys. Pain. 2008;135(1-2):82-91. doi: 10.1016/j.pain.2007.05.005.
Gureje, O, Abdulmalik J, Kola L, Musa E, Yasamy MT, Adebayo K. Integrating mental health into primary care in Nigeria: report of a demonstration project using the mental health gap action programme intervention guide. BMC Health Serv Res. 2015; 15:242. doi: 10.1186/s12913-015-0911-3.
Gureje O, Nortje G, Makanjuola V, Oladeji B, Seedat S, Jenkins R. The role of global traditional and complementary systems of medicine in treating mental health problems. Lancet Psychiatry. 2015;2(2):168-177. doi: 10.1016/S2215-0366(15)00013-9.
Gureje, O. Oladeji, BD. Quality care for people with severe mental disorders in low-resource settings. Lancet Psychiatry. 2022; 9(1):3-5.doi: 10.1016/S2215-0366(21)00438-7.
Ogunlesi AO, Ogunwale A. Mental health legislation in Nigeria: current leanings and future yearnings. Int. Psychiatry. 2012; 9(3):62-64.
Nwaopara UA. Doctor to patient ratio and infrastructure gap in a psychiatric hospital in oil-rich Eket, Nigeria. J Psychiatry. 2016; 19:356. DOI:10.4172/2378-5756.1000356
Kigozi F, Ssebunnya J, Kizza D, Cooper S, Ndyanabangi S; Mental Health and Poverty Project. An overview of Uganda's mental health care system: results from an assessment using the world health organization's assessment instrument for mental health systems (WHO-AIMS). Int J Ment Health Syst. 2010; 4(1):1. doi: 10.1186/1752-4458-4-1.
Ndetei DM, Ongecha FA, Mutiso V, Kuria M, Khasakhala LI, Kokonya DA. The challenges of human resources in mental health in Kenya. S. Afr. Psych Rev. 2007; 10:33-36.
Eaton J, Ohene S. Providing Sustainable Mental Health Care in Ghana: A Demonstration Project. In: Forum on Neuroscience and Nervous System Disorders; Board on Health Sciences Policy; Board on Global Health; Institute of Medicine; National Academies of Sciences, Engineering, and Medicine. Providing Sustainable Mental and Neurological Health Care in Ghana and Kenya: Workshop Summary. Washington (DC): National Academies Press (US). 2016. Available from: https://www.ncbi.nlm.nih.gov/books/NBK350318/
World Health Organization (WHO). Everybody business: strengthening health systems to improve health outcomes: WHO’s framework for action. WHO: Geneva; Switzerland. 2007.
Manyazewal T. Using the World Health Organization health system building blocks through a survey of healthcare professionals to determine the performance of public healthcare facilities. Archives of public health = Archives belges de sante publique. 2017; 75:50. https://doi.org/10.1186/s13690-017-0221-9
Uzochukwu BS, Ughasoro MD, Etiaba E, Okwuosa C, Envuladu E, Onwujekwe OE. Health care financing in Nigeria: Implications for achieving universal health coverage. Niger, J. Clin. Pract. 2015;18(4):437–444. https://doi.org/10.4103/1119-3077.154196
World Health Organization (WHO). Integrating mental health into primary care: a global perspective. Geneva: World Health Organization. 2008b.
Olafsdottir AE, Reidpath DD, Pokhrel S, Allotey P. Health systems performance in sub-Saharan Africa: governance, outcome, and equity. BMC Public Health. 2011;11:237. https://doi.org/10.1186/1471-2458-11-237
Janse van Rensburg BJ, Bhugra D, Saxena S. WPA-WHO Africa Mental Health Forum - recommendations and position statement. World Psychiatry. 2018; 17(1):116–117. https://doi.org/10.1002/wps.20510.
World Health Organization (WHO) (2010). Health information systems. Retrieved on 23rd May 2020, from
Lawal SA, Henderson D, Ogunniyi A. A qualitative analysis on community engagement approaches and primary mental health care delivery in rural Nigeria. Presented at 10th Anniversary Conference (Global Mental Health: Research without Borders). Natcher Conference Center, National Institutes of Health (NIH), Bethesda, Maryland, USA. April 8-9 2019.
Petersen I, Baillie K, Bhana A, Mental Health and Poverty Research Consortium. Understanding the benefits and challenges of CE in the development of community mental health services for common mental disorders: Lessons from a case study in rural South African sub-district site. Transcult. Psychiatry. 2012; 49(3-4):418-437.
Kenya S, Jones J, Arheart K, Kobetz E, Chida N, Baer S, Powell A, Symes S, Hunte T, Monroe A, Carrasquillo O. Using community health workers to improve clinical outcomes among people living with HIV: a randomized controlled trial. AIDS Behav. 2013; 17(9):2927–2934. https://doi.org/10.1007/s10461-013-0440-1
Busza J, Dauya E, Bandason T, Simms V, Chikwari CD, Makamba M, Mchugh G, Munyati S, Chonzi P, Ferrand, RA. The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe. Health Policy Plan. 2018; 33(3):328–334. https://doi.org/10.1093/heapol/czx187
Brooks MI, Johns NE, Quinn AK, Boyce SC, Fatouma IA, Oumarou AO, Sani A, Silverman JG. Can community health workers increase modern contraceptive use among young married women? A cross-sectional study in rural Niger. Reproductive Health. 2019; 16:38. https://doi.org/10.1186/s12978-019-0701-1
Adekannbi JO. Relationship between orthodox and traditional medical practitioners in the transmission of traditional medical knowledge in Nigeria. Health Info Libr J. 2018; 35(2):130-140.
Ameade EPK, Ibrahim M, Ibrahim HS, Habib RH, Gbedema SY. Concurrent use of herbal and orthodox medicines among residents of Tamale, Northern Ghana, who patronize hospitals and herbal clinics. Evid. -based Complement. Altern. 2018; Article ID 1289125:8. https://doi.org/10.1155/2018/1289125
Parker LA, Zaragoza GA. Hernández-Aguado I. Promoting population health with public-private partnerships: Where’s the evidence?. BMC Public Health. 2019; 19: 1438. https://doi.org/10.1186/s12889-019-7765-2.
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