Disorders of the nervous system are common to all countries and cause tremendous suffering. The stigma and violations of human rights directed toward people with these disorders often increases their social isolation and can be the cause of staggering social and economic consequences. In sub-Saharan Africa—where the majority of the world’s poorest countries with the least resources are found—the burden of mental health, neurological, and substance use (MNS) disorders is especially significant. Epilepsy, depression, and drug and alcohol abuse affect the lives of millions of Africans, disrupting the daily course of life, challenging families, and weighing on the social and economic fabric of the region (Prince et al., 2007). Current data from the more than 47 countries that constitute sub-Saharan Africa make it clear that, at a minimum, many of these problems are much more common in this region than in other parts of the world (Forsgren, 2008; The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020, 1996; Ngoungou et al., 2006; Okasha, 2002).
According to the World Health Organization, awareness about the importance of mental disorders for public health has greatly increased
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Introduction1 Disorders of the nervous system are common to all countries and cause tremendous suffering. The stigma and violations of human rights directed toward people with these disorders often increases their social isolation and can be the cause of staggering social and economic conse- quences. In sub-Saharan Africa—where the majority of the world’s poorest countries with the least resources are found—the burden of men- tal health, neurological, and substance use (MNS) disorders is especially significant. Epilepsy, depression, and drug and alcohol abuse affect the lives of millions of Africans, disrupting the daily course of life, challeng- ing families, and weighing on the social and economic fabric of the re- gion (Prince et al., 2007). Current data from the more than 47 countries that constitute sub-Saharan Africa make it clear that, at a minimum, many of these problems are much more common in this region than in other parts of the world (Forsgren, 2008; The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020, 1996; Ngoungou et al., 2006; Okasha, 2002). According to the World Health Organization, awareness about the importance of mental disorders for public health has greatly increased _____________________________ 1 The planning committee’s role was limited to planning the workshop, and the workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. 1
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2 MNS IN SUB-SAHARAN AFRICA, IMPROVING QUALITY OF CARE and has put mental health on the policy agenda (WHO, 2008b). Many countries have developed or revised their policies, programs, and legisla- tion related to these disorders. Despite this, as will be discussed in further detail, the treatment gap is tremendous and the resources provided to tackle the huge combined burden of MNS disorders, not just mental health, are insufficient. The “rich” countries such as the United States and England have roughly 200 times more psychiatrists than most coun- tries in Africa. This ratio is even worse when looking at the enrollment of the medical professionals such as psychiatric nurses and clinical psy- chologists. To add to these challenges, within each country mental health professionals are concentrated in urban areas, where a minority of the population lives. In addition, health professionals are increasingly work- ing in the private sector, resulting in decreased access for a significant proportion of the populations. Many neurological disorders remain undiagnosed because of the lim- ited diagnostic facilities at health centers, which is even worse in the ru- ral places where the majority of the patients reside. Often much-needed drugs are in short supply or are too expensive to purchase. In the end, the patients and their families prefer to stay at home or revert to readily available and accessible remedies within their communities. For many in sub-Saharan Africa, this means relying on traditional healers for health care. These providers are more accessible than mental, neurological, or substance use disorder specialists, and they frequently provide continuity of care and social support for patients. An estimated 60–80 percent of individuals with mental disorders in developing countries first seek care through traditional healers (Abbo et al., 2008). Despite the widespread use of traditional healers in sub-Saharan Africa, there is no standard of care and there is little evidence from which to assess its effectiveness. As a result, there is an ongoing debate about whether traditional healers should be recognized as part of the healthcare delivery system, and, if so, how they could be more formally integrated into the healthcare delivery system. Other solutions to the human resource shortfalls are also being ad- dressed. One suggestion is to use “task shifting,” which transfers a range of medical tasks, where appropriate, from more expensive and special- ized medical workers to people with shorter training and therefore a much lower cost in the health system. Many workshop participants be- lieve this approach makes more efficient use of the human resources that are available in the health system and is one way of closing the mental health treatment gap. However, without the political will of governments and the support of international donor communities, adequate resources
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INTRODUCTION 3 for much-needed drugs, delivery systems, facilities, and professionals are unlikely to be realized any time soon. Within this context, a workshop was held in Uganda to discuss model solutions, promote collaborations, and consider what can be done to improve quality of care for patients in cost-effective ways. ABOUT THE WORKSHOP AND FORUMS In August 2009 the Uganda National Academy of Sciences Forum on Health and Nutrition and the U.S. Institute of Medicine’s Forum on Neuroscience and Neurological Disorders (Box I-1) jointly hosted a workshop in Kampala, Uganda, titled Quality of Care Issues for Mental Health and Neurological Disorders in Sub-Saharan Africa. More than 150 researchers, providers, patient advocates, and policy specialists came together to discuss the current state of care for mental, neurological, and substance use disorders in sub-Saharan Africa. The goal was to uncover strategies to improve the quality and consistency of care delivered in sub-Saharan Africa, taking into account resource constraints, infrastruc- ture limitations, and other realities. Workshop speakers were charged to do the following: • Discuss opportunities to ensure continuity of care and provide sustainable care within a country’s existing healthcare system. • Identify resources that are either currently available, or that could be made available in cost-effective and efficient ways, to aid in the treatment and prevention of disease. • Examine the need for national, evidence-based policies within national healthcare systems that address quality-of-care issues for mental, neurological, and substance use disorders. • Explore opportunities to facilitate collaborations among a variety of stakeholders, including policy makers and healthcare professionals.
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4 MNS IN SUB-SAHARAN AFRICA, IMPROVING QUALITY OF CARE BOX I-1 UNAS Forum on Health and Nutrition The Uganda National Academy of Sciences (UNAS) Forum on Health and Nutrition was established in 2006 to provide a structured opportunity for stake- holder discussion and scrutiny of critical and possibly contentious scientific and policy issues of shared concern related to issues of health and nutrition in Uganda and throughout the world.a The Forum aims to do the following: • Promote a free flow of information between public- and private- sector leaders and groups and individuals, including policy makers and others who influence public policy and opinion. • Clarify research and policy issues, identify options for research, and encourage further exploration in the identified areas. • Inform decision and policy makers, both in the public and private sectors, on issues related to health and nutrition both in Uganda and worldwide. • Enable and develop initiatives that require in-depth exploration, re- view, or analysis, where new strategies are necessary to improve health and nutrition. IOM Forum on Neuroscience and Nervous System Disorders Established in 2006, the Institute of Medicine’s (IOM’s) Neuroscience Forum aims to foster dialogue among a broad range of stakeholders— practitioners, policy makers, private industry, community members, academ- ics, and others—and to provide these stakeholders with opportunities to tackle issues of mutual interest and concern. The Forum’s neutral venue provides a place for broad-ranging discussions that can help in the coordina- tion and cooperation of all stakeholders to enhance understanding of neuro- science and nervous system disorders. The Forum concentrates on six ar- eas: nervous system disorders, mental illness and addiction, genetics of nervous system disorders, cognition and behavior, modeling and imaging, and ethical and social issues.b Specifically, the Neuroscience Forum • sponsors workshops for members and the public to discuss strate- gies to resolve key challenges identified by Forum members; • educates the public, press, and policy makers; • strives to enhance understanding of research and clinical issues associated with the nervous system; and • fosters partnerships and information sharing among stakeholders. _____________________________ a See http://ugandanationalacademy.org/forum_hlthandnut.htm. b See http://www.iom.edu/NeuroForum.