3
MNS Healthcare Policy

Weighed against the massive and growing need, there is a clear demand for well-developed, well-articulated, and aggressively implemented national healthcare policies designed to improve care and reduce the burden on those individuals suffering mental health, neurological, and substance use (MNS) disorders. It may seem odd that something as simple as a set of documents can make a difference in the health of a population, but history shows that it does. Without essential statements of purpose covering a country’s vision and goals, programs to implement those goals with specific strategies, stated objectives and milestones, and finally legislation to provide for the protection of basic human and civil rights, it becomes difficult to engender action (Gureje, 2009; Ndyanabangi, 2009).

According to Gureje, approximately half of the countries in sub-Saharan Africa have mental health policies in place, while few if any have comprehensive policies in place for MNS disorders (Gureje, 2009). Of those that do have policies that address mental health, more than a third of those policies were developed prior to 1990 and consequently are outdated by advances in the scientific understanding of these disorders. Similarly, only 37 percent of these policies address the special needs of children, despite the fact that 42 percent of SSA’s population are minors. But even those countries that have healthcare policies may not be using them. “There are a lot of countries with policies, but they just put these documents up on the shelf, no one looks at them, and they’re never implemented,” said Gureje.

Gureje laid out four core elements that should be included in a healthcare policy:



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3 MNS Healthcare Policy Weighed against the massive and growing need, there is a clear de- mand for well-developed, well-articulated, and aggressively imple- mented national healthcare policies designed to improve care and reduce the burden on those individuals suffering mental health, neurological, and substance use (MNS) disorders. It may seem odd that something as simple as a set of documents can make a difference in the health of a population, but history shows that it does. Without essential statements of purpose covering a country’s vision and goals, programs to implement those goals with specific strategies, stated objectives and milestones, and finally legislation to provide for the protection of basic human and civil rights, it becomes difficult to engender action (Gureje, 2009; Ndyanabangi, 2009). According to Gureje, approximately half of the countries in sub- Saharan Africa have mental health policies in place, while few if any have comprehensive policies in place for MNS disorders (Gureje, 2009). Of those that do have policies that address mental health, more than a third of those policies were developed prior to 1990 and consequently are outdated by advances in the scientific understanding of these disorders. Similarly, only 37 percent of these policies address the special needs of children, despite the fact that 42 percent of SSA’s population are minors. But even those countries that have healthcare policies may not be using them. “There are a lot of countries with policies, but they just put these documents up on the shelf, no one looks at them, and they’re never im- plemented,” said Gureje. Gureje laid out four core elements that should be included in a healthcare policy: 43

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44 MNS IN SUB-SAHARAN AFRICA, IMPROVING QUALITY OF CARE 1. Vision: The orientation of a policy sets realistic but motivating expectations. 2. Values and Principles: These are the overarching philosophies that will guide further action, including what standards need to be followed. 3. Objectives: What goals are to be reached, and what steps make up those goals? 4. Strategies: What resources—financial, staffing, service system, etc.—are necessary to reach the goals that have been set? Gureje continued that a successful policy—one that actually drives action—needs to identify the following: • Resources: including sources of funding, manpower and infra- structure; • Organization: the system of service, including the links among primary, secondary, and tertiary services; • Relevant Legislation: government actions to guide the work of practitioners and others involved in the healthcare system; • The Delivery System Itself: health promotion, preventative ser- vices, treatment services, rehabilitation service, as well as the system for drug procurement and distribution; • Advocacy: a driving force for government action; and • Measurement and Evaluation: research and information to in- form service delivery or policy changes. Two speakers—Ndyanabangi of the Uganda Ministry of Health and Petersen of the University of KwaZulu-Natal—were invited to present their efforts to develop national healthcare (and specifically) mental healthcare policies as working examples of how different healthcare policies might look in sub-Saharan countries. CASE STUDY: UGANDA MENTAL HEALTH POLICY In 2005, officials in Uganda performed a gap analysis of the Ugan- dan mental health system. A number of problems were identified, includ- ing the following: • an inadequate and skewed pattern of distribution of mental health staff;

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MNS HEALTHCARE POLICY 45 • poor health facilities with not enough capacity; • wage bill ceilings that did not account for the high population growth rate, resulting in low pay for healthcare workers; • the absence of a systematic continuing education program for mental health workers; • the absence of psychological screening for patients with other primary non-MNS disorders; • low prioritization of treatment of mental health at most levels of care; • low awareness and appreciation for mental health services and disregard for mentally ill patients, especially by the non-medical administrators of health facilities; • an emphasis on symptom management, with limited emphasis on prevention; and • limited community awareness and stigma toward mental illness, possibly due to cultural explanations of mental illness (Ndyanabangi, 2009). In addition, Ndyanabangi said the absence of a structured policy for MNS disorders, not just mental health disorders, has also been identified as a major gap. With these gaps identified, Uganda set about revising its high-level mental health policy, specifically detailing the elements as follows: • Vision: to give the population access to a comprehensive and well-coordinated system of care that promotes mental well-being and full recovery from mental disorders; • Mission (addresses values and principles): to provide quality, evidence-based, and equitable mental health services that are in- tegrated into the healthcare system and delivered by well-trained, skilled, and motivated personnel, with the participation of per- sons with mental illness and their families; • Goal: to reduce the burden of mental disorders using defined ob- jectives; and • Objectives: to reduce the burden of mental disorders, and more specifically, to do the following: o Promote the mental health of the population—everyone needs to understand the importance of mental health. o Provide quality mental health services that are accessi- ble, affordable, and accountable to the community.

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46 MNS IN SUB-SAHARAN AFRICA, IMPROVING QUALITY OF CARE Integrate mental health services throughout the whole o healthcare system through a multisectoral approach. Provide equitable access to quality, evidence-based men- o tal health care to all people in Uganda, especially the vulnerable populations such as children, women, the elderly, persons with disabilities, prisoners, and people in crisis situations. Provide comprehensive and interactive mental health o programs for the rehabilitation and effective integration of clients through community empowerment. Increase the knowledge, understanding, and awareness o of the population about mental health and mental illness. Promote and protect the human and civil rights of people o with mental illness. Organization of the Uganda Health System As a result of the mental health policy, Uganda evaluated the re- sources, systems, and organization needed to implement the policy. With regards to organization, at the top, the country established a mental health services coordinator at the Ministry of Health. The health system was also organized with a national referral hospital, which receives pa- tients from mental health units at the regional hospitals. In the general hospitals, there are integrated services, each of which is to have an MNS focal person appointed by the district health officer. Outside the hospital setting, Uganda maintains four levels of health centers, with the level-4 health centers functioning as mini-hospitals in rural settings. In an effort to improve access to MNS care further into the field, it is in the process of recruiting psychiatric nurses for these level-4 facilities, which are often quite removed from the nearest regional hospi- tal. Level-3 and level-2 healthcare centers, which are even more re- moved, are staffed by general health workers who do what they can with the resources they have available, and they refer the complex cases to more highly trained specialists. The key to success for Uganda, according to some speakers, will be the extent to which mental health care is integrated into primary care, especially in rural communities and level-4 health centers. “We depend a lot on our communities for the care of people with mental illness,” Uganda’s Ndyanabangi said. “We are working to strengthen that compo-

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MNS HEALTHCARE POLICY 47 nent [so] that when patients are treated, they are rehabilitated and reinte- grated by working with already existing community systems.” Village Health Team One component of the organization is the Village Health Team. Vil- lage Health Teams are made up of members of the community who are selected by the community to help address many associated health is- sues—from HIV to malaria to immunizations to mental health. The teams undergo a system of training, giving them basic skills for recogniz- ing various medical conditions. “Mental health has been integrated into that Village Health Team manual so that they can be able to recognize [mental health problems],” explained Ndyanabangi. “If we can change their perception of mental health illness, we believe they can influence their communities.” But training is not enough—retaining trained personnel is very im- portant. Ndyanabangi noted that it is important to not only train and re- cruit relevant staff, but also to offer continuing medical education in mental health for all care providers. A critical need is in developing pro- tocols that can be used at the local level. Given that many community healthcare workers are not professionals in mental health, definitive pro- tocols will not only help the health workers provide care, but also pro- vide quality assurance to ensure the care the patients are receiving is the best possible. Backing all of these efforts is a dedicated fund for mental health medicines set up by Uganda. While the system is working, Ndyanabangi suggested it will always need refinement, especially to ensure that the right drugs are in stock at the right medical centers. Ndyanabangi reported that Uganda is working toward finalizing the draft healthcare policy, and is in the process of aligning it with interna- tional standards and human rights. CASE STUDY: SOUTH AFRICA South Africa does not have a new post-apartheid national mental health policy as of yet, and there is no mention of a health policy ad- dressing substance use and neurological disorders. It uses instead a set of national policy guidelines that were drafted in 1997 alongside a Mental Health Care Act that was developed in 2002 and enacted in 2004 (South

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48 MNS IN SUB-SAHARAN AFRICA, IMPROVING QUALITY OF CARE African Department of Health, 2010). The Mental Health Care Act sets out the international human rights principles for the care, treatment, and rehabilitation of people with mental health disorders as well as for mass, community-based care and treatment, while the national policy guide- lines serve to inform provincial policies and plans. The nine provinces of South Africa are responsible for planning and implementing health ser- vices within each province—a very different organizational structure than Uganda’s more centralized branches-from-a-common-tree structure. The South African system has had both successes and failures, ac- cording to Petersen of the University of KwaZulu-Natal. The country’s two-part mental health policy has ensured that each province in South Africa now has a dedicated mental health directorate or subdirectorate in charge of mental health in the province, and review boards are responsi- ble for regular inspections of mental health facilities to ensure that pa- tients’ human rights are protected. Fifty-three percent of all general hos- pitals have been designated to provide 72-hour assessment and referral functions, and psychotropic drugs are part of the national essential drug list and are widely available. Despite the success of the autonomous provincial system, Petersen noted that challenges exist precisely due to the differences between and within the provinces. According to Petersen, depression and maternal depression are rampant in parts of South Africa: One study found a 41 percent incidence in Northern KwaZulu Natal (Rochat et al., 2006). Fur- thermore, there are inequalities with regards to in-patient beds, budget allocations, and assessment and treatment protocols. Petersen explained, “The reasons for this inequity across provinces have really been attrib- uted to a lack of a formal mental health policy which provides clear di- rectives for provincial plans.” She went on to note that during a survey of mental health at the provincial levels, interviewees noted a lack of clarity on many issues. “Some provinces have directorates, others have subdi- rectorates, so they have different authority in terms of determining allo- cation of resources to mental health. It is at the discretion of the prov- inces in terms of how much of the budget should be dedicated to mental health.” This naturally leads to differing levels of quality of care. Beyond the interprovincial issues, Petersen noted additional gaps in the current policies: • a lack of deinstitutionalized care for psychosocial rehabilitation at the community level,

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MNS HEALTHCARE POLICY 49 • minimal integration with primary care for the management of common disorders such as anxiety and depression, and • minimal programs for the promotion and prevention of mental health disorders. One reason for these gaps is the healthcare system. In South Africa, basic mental health care is the responsibility of primary healthcare nurses. But due to the heavy burden of HIV/AIDS and tuberculosis in the country, nurses are often only able to provide counseling for a few com- mon mental disorders and a few other MNS disorders. To assist these nurses, the use of a mental health counselor at the primary care level is being piloted in two regions. The counselor’s duties include providing referrals as well as assisting in the training and supervision of commu- nity healthcare workers, who may themselves supply treatment for com- mon mental disorders like depression and maternal depression. Another pilot program follows a Ugandan model, using group intervention to treat both general depression and maternal depression. Going forward, Petersen noted the following challenges: • Provincial inequalities regarding human resources are likely to remain. • Budget allocation will continue to be at the discretion of the provinces. • Mental health is not a priority in South Africa, especially in the context of the heavy burden of treating HIV/AIDS in a resource- poor environment. Integrating MNS Care into the HIV/AIDS Infrastructure To improve MNS care in South Africa, Petersen suggested it was critical to make the link between MNS disorders and other healthcare priorities, particularly HIV/AIDS, and also socioeconomic conditions. “There is a huge need . . . to actually make the links between mental health and poverty and to promote the idea that mental health can actu- ally promote socioeconomic development.” For example, given the bur- den of HIV dementia and its manifestations, it would seemingly be a natural bridge between neurological health and other healthcare priorities such as HIV/AIDS. If these links can be solidified in the minds of politi- cal leaders and non-governmental organizations, it may be possible to refine South Africa’s mental or neurological health policy to provide

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50 MNS IN SUB-SAHARAN AFRICA, IMPROVING QUALITY OF CARE clear direction to the provinces and ensure development of an appropriate infrastructure that provides better care to all those in need.