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Introduction and Overview¹

Mental, neurological, and substance use (MNS) disorders have a substantial impact on global health and well-being. Disorders such as depression, alcohol abuse, and schizophrenia constitute about 13 percent of the total burden of disease (WHO, 2009). Worldwide, MNS disorders are the leading cause of disability, and the 10th leading cause of death (WHO, 2008a). Despite this high burden, there is a significant shortage of resources available to prevent, diagnose, and treat MNS disorders. Approximately four out of five people with serious MNS disorders living in low- and middle-income countries do not receive needed health services (WHO, 2011).

This treatment gap is particularly high in sub-Saharan Africa (SSA). Although data are limited, depression, schizophrenia, anxiety disorders, bipolar disorder, epilepsy, stroke, and alcohol abuse appear to be some of the most prevalent MNS disorders in SSA (Baingana et al., 2006; Silberberg and Katabira, 2006). Challenges to MNS care in SSA countries include a lack of trained mental health professionals, few mental health facilities, and low prioritization for MNS disorders in budget allocations. African countries, on average, have one psychiatrist for every 2 million people, whereas European countries have one psychiatrist per 12,000 people (WHO, 2011). Africa’s ratio of mental health facilities to

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¹The 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. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

population is less than one-tenth of the global ratio (0.06 per 100,000 in Africa compared to 0.61 per 100,000 globally) (WHO, 2011). Many countries in Africa spend less than 1 percent of their national health budgets on MNS disorders (Saxena et al., 2007). In these resource-scarce settings, MNS disorders compete with communicable diseases such as HIV/AIDS and malaria, which are often the top priority of governments and funders (Omar et al., 2010).

Several current efforts are being made to improve mental health care in SSA and around the world. The World Health Organization (WHO) launched the Mental Health Gap Action Program (mhGAP) in 2008 to address the serious treatment gap for MNS disorders in low- and middle-income countries. mhGAP aims to scale up services for several priority MNS disorders—depression, schizophrenia, suicide, epilepsy, dementia, alcohol and drug disorders, and mental disorders in children—in resource-constrained countries such as those in SSA (WHO, 2008b). Although mhGAP focuses specifically on low-resource settings, another WHO program has a more global scope. The Mental Health Action Plan (MHAP) 2013–2020 was developed to provide guidance to member states in improving mental health systems. Its core principle is that there is “no health without mental health,” and its goals are “to promote mental well-being, prevent mental disorders, provide care, enhance recovery, promote human rights, and reduce the mortality, morbidity, and disability for persons with mental disorders” (WHO, 2013, p. 9). The plan has six global objectives, and member states are expected to adapt the objectives appropriately based on their own national priorities and circumstances. The targets, to be accomplished by the year 2020, include reducing suicide rates, increasing service coverage for severe mental disorders, routinely collecting mental health indicators, and aligning mental health policies with human rights instruments.

ORIGINS OF THE WORKSHOP

Recognizing the importance of reducing the treatment gap for MNS disorders in the SSA region, the National Academies of Sciences, Engineering, and Medicine Forum on Neuroscience and Nervous System Disorders convened a number of workshops to address the development and improvement of sustainable mental health systems in SSA. In August 2009, the Neuroscience Forum and the Uganda National Academy of Sciences convened a joint workshop in Kampala, Uganda. This work-

shop, Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa: Reducing the Treatment Gap, Improving Quality of Care, focused on the entire sub-Saharan region. Participants examined the burden of MNS disorders, assessed the current system, and explored opportunities to improve quality of care and health care systems (IOM, 2010). The goal of this workshop was to identify major barriers to mental health care in SSA and then to develop a series of workshops to address these barriers. At this initial workshop, two critical barriers were identified: a lack of health care workers with appropriate training in care of MNS disorders, and a lack of access to essential medicines.

Following this workshop, the Neuroscience Forum and the African Science Academy Development Initiative held two more workshops, each focused on one of the two critical barriers identified. Strengthening Human Resources Through Development of Candidate Core Competencies for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa was held in Kampala, Uganda, in September 2012. Workshop participants examined the human resource needs of African health districts and discussed training and partnership opportunities to improve capability (IOM, 2013). The participants developed a list of 111 core competencies that providers might need to ensure effective delivery of MNS care. The competencies applied to multiple disorders—depression, psychosis, epilepsy, and alcohol use—and to providers at all levels of the system, from community health workers to psychiatrists. Competencies focused on the areas of identification, diagnosis, and treatment and included skills such as awareness of common signs and symptoms, knowledge of when to refer to another provider, and communicating to the public about MNS disorders.

The third workshop, Improving Access to Essential Medicines for Mental, Neurological, and Substance Use Disorders in Sub-Saharan Africa, was held in Addis Ababa, Ethiopia, in January 2014 (IOM, 2014). The workshop focused on four critical barriers to access to essential medicines: insufficient demand, inappropriate selection, ineffective supply chains, and high pricing and poor financing. Workshop participants discussed potential strategies to ameliorate these barriers to improve the treatment and care of MNS disorders, including the development of coherent and comprehensive national strategies, the creation of national task forces to advocate for MNS disorders, and the development of evidence-based policies.

WORKSHOP OBJECTIVES

Expanding on these efforts, the Neuroscience Forum, in collaboration with the Academies’ Board on Global Health and African Science Academy Development Initiative, convened this 2015 workshop series, Providing Sustainable Mental Health Care in Ghana and Kenya, bringing together key stakeholders to examine country-specific opportunities to improve the health care infrastructure in order to better prevent, diagnose, and treat MNS disorders. While mental health disorders were the primary focus of this workshop series, there was some discussion on neurological and substance use disorders. Given the mental health progress in both countries, stakeholders from all sectors of the health system, including government, providers, industry, nongovernmental organizations (NGOs), and others gathered in Nairobi, Kenya, on January 14–15, 2015, and Accra, Ghana, on April 28–29, 2015, to discuss the key elements of a sustainable mental health care system and the challenges to creating or maintaining such a system. Challenges discussed included inadequate health system infrastructure, a lack of national policy frameworks for mental health, deficient health information systems, and poor access to medicines. The workshops examined how stigma and a lack of awareness can negatively affect demand for care and treatment, and identified the need to increase the number of trained health care providers who can diagnose and treat MNS disorders in both hospital and community settings (see Box 1-1, Statement of Task). Participants in the workshop series were asked to identify specific opportunities to advance sustainable access to mental health care in order to ensure that the right patients get the right care and treatment, at the right time, and in the right setting.

ORGANIZATION OF THE WORKSHOP SERIES
AND REPORT

The workshops were organized around four major challenges to care of MNS disorders: (1) lack of diagnosis and treatment; (2) poor access to medicines; (3) stigma; and (4) inadequate mental health information systems (MHISs). Local experts from each country presented an overview of the health care system and the mental health care system in each country. Presenters discussed issues such as current gaps in the system, recent changes in laws and policies, and how funding and human resources are distributed. Each of the four challenges was presented by an expert who described the current situation and identified some opportunities for improvement. Case studies were presented by organizations that have had success in improving mental and/or other related health services in countries within and outside of SSA.

In addition to the overview sessions and the discussion of challenges, part of the workshop series focused on developing potential demonstration projects for a sustainable and scalable mental health system that could be integrated into the broader health system. Workshop participants had focused discussions on the four challenges, outlining the key elements of potential demonstration projects that are

• Comprehensive and holistic: Addressing a wide range of issues that affect the life of a person diagnosed with a MNS disorder, and offering services encompassing biological (medical), psychological, and social interventions (often in combination).
• Accessible: The services offered should be as easy to use as possible, considering issues such as proximity, cost, and cultural acceptability.
• Integrated: Should not create a parallel system for MNS disorders, but rather one that can be integrated into the structures and processes already present in the general health care system.
• Culturally appropriate: Adapted for the local context and cultural norms of the people who would use the services.
• Participatory: Developed by those who will use the system, from future users of the services to key decision makers whose buy-in at an early stage will facilitate future support.
• Sustainable: Considering the economic context of the country, and able to show good value for investment by potential donors.

• Replicable and scalable: Able to be replicated and adapted in other communities, and scaled up to a countrywide program.
• Able to be evaluated: Including a plan to evaluate the project, with metrics for success that can be collected in a methodologically sound way.

The following report summarizes the presentations and discussions by the expert speakers and individual participants. Chapters 2 and 3 are focused respectively on the Kenya and Ghana workshops, covering country-specific challenges, opportunities, and potential demonstration project components that were identified at each workshop. Chapter 4 summarizes the lessons learned from the case studies presented and discussed. The report ends with a road map for moving forward in Chapter 5, including a summary of key themes and practical considerations for implementing a demonstration project.

CHALLENGES TO SUSTAINABLE MENTAL AND
NEUROLOGICAL HEALTH CARE IN SSA

Although Ghana and Kenya differ in many important ways, the challenges they face in the care of people with MNS disorders are similar. Both workshops focused on the same four challenges—lack of diagnosis and treatment, poor access to medicines, stigma, and inadequate mental health information systems—and asked participants to identify country-specific strategies to address these challenges.

Lack of Diagnosis and Treatment

The treatment gap for MNS disorders in SSA—that is, the percentage of people who need treatment but do not get it—is more than 80 percent and often higher in many countries (WHO, 2011). The reasons for this gap are myriad, many workshop participants said, including lack of human resources, particularly specialists; the effect of stigma and traditional beliefs on seeking treatment; poor access to medicines; and a lack of awareness and knowledge about MNS disorders among both the community and health care workers. The shortage of human resources is significant. The United States has more psychiatrists than China, India, and all of the countries of the African continent combined (Patel and Thornicroft, 2009). Several workshop participants suggested that in order

to fill this gap, primary care providers must be trained and given the tools to diagnose, treat, and refer MNS patients. Current providers receive little training in mental health, and they have poor access to treatment guidelines and protocols. Several participants said that any effort to improve mental health care in Ghana and Kenya must include training for providers, both during school and through continuing education, and better guidelines for treatment, diagnosis, and referral. As Sodzi Sodzi-Tettey, director at Project Fives Alive!, said at the workshop in Ghana, “We need to get to the point where every provider thinks of himself as a mental health provider.”

Poor Access to Medicines

WHO recommends that a combination of psychosocial and pharmacological therapy is the best way to treat mental health disorders (WHO, 2009). Unfortunately in countries like Ghana and Kenya, several participants said that many people lack access to essential psychotropic medications and psychosocial treatment. A few participants noted that on the supply side, drugs are unavailable due to challenges such as unstable supply chains, poor forecasting of drug needs, and a lack of reliable financing, while on the demand side, barriers include the resistance of providers to new medications, a lack of treatment guidelines for providers, and the inability of patients to pay for medicines. Several workshop participants said a critical first step to improving access to medicines is performing a comprehensive needs assessment so that the drug needs of the community can be understood and forecasting can be improved. Many also suggested the use of a community revolving drug fund, in which proceeds from the sale of drugs are used to purchase more drugs, creating a sustainable supply of medicines.

Stigma

Stigma against mental health issues exists on all levels and has a significant impact on patient care, noted several workshop participants. Particularly in the community, stigma prevents people from seeking treatment when they need it, family members may shun patients with MNS disorders, and patients may have difficulty reintegrating into the community. From a workforce perspective, stigma can deter health care providers from choosing to work in mental health, and those who do specialize in mental health are often looked down on by other providers.

Stigma among government officials and policy makers can result in less attention and funding for mental health care. Several workshop participants stressed the need for more education about MNS disorders on all levels—in primary schools, community settings, medical schools, and for government officials. Many participants noted that one of the most effective destigmatization strategies is direct engagement with people who have struggled with MNS disorders, and demonstrating that treatment works—and that patients can lead normal lives—can reduce stigma significantly.

Inadequate Mental Health Information Systems

One pervasive theme at both workshops was a lack of data about mental health in the country: that is, information on the burden of mental health, on how MNS disorders are treated, or on patient outcomes is generally unavailable, said several participants. A robust MHIS could significantly increase available data and improve care, according to several participants. WHO defines an MHIS as “a system for collecting, processing, analyzing, disseminating, and using information about a mental health service and the mental health needs of the population it serves” and notes that an MHIS is also a “system for action” that can help guide decision making in all aspects of the mental health system (WHO, 2005, p. 1). Both Ghana and Kenya have some components of an MHIS in place, but a few participants stressed that improvement in data collection through training and understanding its usefulness for providers and decision makers is needed.

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