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Ghana¹

MENTAL HEALTH CARE IN GHANA

Just over 25 million people live in Ghana (WHO, 2015). Although there is a lack of reliable data regarding the prevalence of mental and neurological disorders in the country, WHO estimates that approximately 13 percent of Ghanaians suffer from a mental disorder: of those, 3 percent suffer from a severe mental disorder and the other 10 percent suffer from a moderate to mild mental disorder (WHO, 2007). Mental disorders are a leading cause of years lived with disability in Ghana, behind iron-deficient anemia (IHME, 2013a). Among patients seeking treatment for mental health issues, schizophrenia, substance abuse, and mood disorders are the top three diagnoses, although a large percentage of people receive no specific diagnosis, according to Joseph B. Asare, chair of the Mental Health Authority Board in Ghana.

The treatment gap for mental health disorders in Ghana, said Sammy Ohene, senior lecturer and head of the department of psychiatry at the University of Ghana Medical School, is estimated to be more than 98 percent (WHO, 2007). Albert Akpalu, chief of neurology at Korle Bu Teaching Hospital, offered several reasons why Ghanaians diagnosed with an MNS disorder do not receive treatment, including

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¹Many of the statistics from this chapter are drawn from Dr. Joseph B. Asare’s unpublished, informal data through his position as chairman of the Mental Health Authority Board.

• Fragmented mental health service delivery system and poor integration into primary care system;
• Poor supply of medicines;
• Poor health information systems;
• Community beliefs, attitudes, stigma, and lack of community support;
• Few financial resources allocated to MNS disorders;
• Lack of human resources and capacity for providing care;
• Lack of locally adapted, evidence-based training materials; and
• Lack of a clear referral and support system.

Policy and Legislation

In 2012, the Mental Health Act 846² was passed by Parliament, repealing the Mental Health Decree (NRCD 30) of 1972. The act seeks to accomplish several major goals, said Asare. First, the act protects the human rights of persons with mental disorders: they have the right to “humane and dignified” treatment, the right to seek education and employment, and the right to participate in leisure, recreational, cultural, and political activities (Republic of Ghana, 2012). Second, the act deemphasizes institutional care and encourages decentralization of mental health care by calling for the establishment of services and facilities at the primary, district, regional, and national levels. Third, the act calls for collaboration with providers of traditional and faith-based medicine and provides for the monitoring of care of people with mental disorders in all facilities, including those operated by traditional and faith healers.

The act also established a Mental Health Board, which is given the authority to propose and implement mental health policies in order to carry out the goals of the act. The board has already accomplished a great deal, said Asare, including drafting legislation, producing a strategic plan, and establishing regional mental health committees and coordinators. He said programs are being implemented to train non–mental health workers, and protocols are being developed for the treatment of mental health in primary care. Section 80 of the act established a Mental Health Fund to support the activities of the board; the fund is to be composed of governmental money, voluntary contributions from organizations and the private sector, grants, and gifts. However, Asare noted that no govern-

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²See http://www.refworld.org/pdfid/528f243e4.pdf (accessed August 10, 2015).

mental funds have been provided since the inauguration of the board in 2013, and that the board is relying on funding from the U.K. Department for International Development.

Asare projected that under the new Mental Health Act, a number of significant improvements will be made to mental health care in Ghana:

• Mental health care will be decentralized and refocused on care in the community;
• More inpatient and outpatient facilities will be available for mental health;
• Care will be integrated into primary care, and non–mental health workers will be given specific training in education, case detection, support, and referral;
• Treatment protocols, including appropriate psychotropic medications, will be available for use in primary care; and
• Traditional and faith healers will be given clear guidelines for practice and will be trained in regard to their obligations to human rights of patients.

Overview of Challenges and Opportunities

Ebenezer Appiah-Denkyira, director general of the Ghana Health Service, welcomed participants on behalf of the Minister of Health. Appiah-Denkyira noted that mental health care often has not been a priority of governments, but that Ghana has recently made attempts to address this neglected area. He noted that the government has taken steps to decentralize mental health care by working to downsize the three psychiatric hospitals and to move services to other facilities. He said mental health is being implemented into the curriculum for health workers, which will help address the shortage of qualified providers. He cited the passage in 2012 of the Mental Health Act as an example of the government’s dedication to improving mental health in the country, and he said the government is committed to supporting and funding the implementation of the act.

A panel discussion set the stage for the workshop, giving participants an overview of the mental health care system in Ghana and identifying some major issues that create challenges for people with an MNS disorder. Speakers discussed a myriad of challenges, including stigma, lack of material (e.g., beds) and human resources, shortage of medicines, lack of insurance coverage, and conflicts with traditional belief systems. Several

speakers also noted the challenge of getting the attention and necessary funding for mental health issues. Koku Awonoor Williams, regional director of the Upper East Region for Ghana Health Service, called mental health a “neglected disease.” One speaker quoted an African MoH director who said: “Although mental health is important, it is not a major killer of people. In developing countries … we place more emphasis on diseases that kill people.” Several workshop participants noted that such misconceptions often contribute to the inadequate government funding and low prioritization of MNS disorders.

In addition to identifying challenges, several participants also offered potential solutions. Integration into the primary care system was mentioned repeatedly as a way to address a number of issues, including lack of human resources and stigma. Although Ghana has a significant lack of specialists—fewer than 20 psychiatrists in the entire country—a few participants said that more specialists are not necessarily the answer (WHO, 2007). Rather than having specialty staff “in every corner of the country,” primary providers need to be trained to recognize and refer mental health patients, said Humphrey Kofie, director of the Mental Health Society of Ghana. One participant suggested that physically integrating the facilities for mental illness care into general facilities would give patients better access to both physical and mental health care, and it would help to destigmatize mental health. Several participants proposed undertaking a massive public education campaign that includes information about available services so that people know where to turn when faced with a mental health issue. A few participants also called for clarity in the National Health Insurance Scheme (NHIS) coverage for mental health, noting that while there is a perception that services and medications are free for mental health, these services and medications are often nonexistent.

Asare said a major step was taken to address some of these issues when the Mental Health Act was passed. Several speakers cautioned that the law is not well understood, even by health authorities. Many challenges remain, and full implementation of the law has not yet been achieved. However, said Ohene, passage of the act, as well as the attention it has brought to mental health care, gives many people hope for a transformation of Ghana’s mental health care system.

POTENTIAL DEMONSTRATION PROJECTS

Workshop participants discussed four challenges—lack of diagnosis and treatment, poor access to medicines, stigma, and inadequate mental health information systems—and identified opportunities for improvement in these areas. To facilitate these discussions, Julian Eaton, mental health advisor at CBM International, and Ohene developed a draft comprehensive demonstration project (see Box 3-1 for an overview; a full draft of the proposal can be found in Appendix F). Participants were encouraged to use the draft as a starting point for considering potential solutions to the challenges discussed at the workshop.

The following sections outline the goals and strategies that many participants identified as potential components of demonstration projects.

CHALLENGES AND OPPORTUNITIES
TO SUSTAINABLE MENTAL HEALTH CARE

Lack of Diagnosis and Treatment

Health care in Ghana is provided primarily by the government and administered by the MoH and the Ghana Health Service. The government health system is divided into 10 regions, each with a director and a regional hospital, and 216 districts, each with a director, a health management team, and a hospital and health centers. In addition, the government collaborates with the Christian Health Association of Ghana (CHAG), which provides services in 61 hospitals, 113 health centers, and 9 health training institutions across the country (CHAG, 2012). Private clinics and alternative medicine practitioners also provide care. About 10 million Ghanaians are covered by NHIS, which provides basic coverage for an affordable fee.³

The country has three psychiatric hospitals (Accra, Ankaful, and Pantang), as well as several regional psychiatric units and small private psychiatric facilities. Ohene noted that fewer than 20 psychiatrists are currently practicing in Ghana, and Asare said that out of the 1,887 staff working in mental health as of 2011, 38 percent are not trained to work in mental health care. Ohene said that community psychiatric nurses provide the bulk of psychiatric care in most of the country. The ratio of mental health workers to population is extremely low: there is one mental health staff person per 13,407 people, and one psychiatrist for every 1.5 million people. In comparison, European countries have one psychiatrist for every 12,000 people (WHO, 2011).

Ghanaians also seek mental health care from primary providers and traditional healers in addition to the psychiatric hospitals and the few mental health specialists. However, fewer than 20 percent of physician-based primary health care clinics have assessments and treatment protocols for mental health conditions, said Asare. In addition, primary care physicians in Ghana receive little training in mental health—only about 3 percent of their training, according to Akpalu. Traditional or faith healers are a common first option for those suffering from MNS disorders because the origin of mental health issues is generally seen as spiritual, said

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³This section draws on a commissioned paper, “Providing Sustainable Mental Health Care in Ghana: A Demonstration Project,” by Julian Eaton and Sammy Ohene (see Appendix F).

Eaton. These healers often practice in “prayer camps” where patients are sometimes subjected to shackling, beating, sexual abuse, and forced fasting.

Goals and Potential Strategies Forward

Several workshop participants identified a number of goals in the areas of diagnosis and treatment, and they developed specific strategies to address each of these goals as part of a mental health demonstration project. The suggestions ranged from garnering support and assistance both from the top levels of government and from local community and faith leaders, to improving treatment through enhanced training and use of protocols.

Political and leadership involvement

Gaining active commitment from leadership in Ghana: It would be important to get Ghanaian leadership to commit to mental health improvement in the country, according to several participants. Specifically, they noted that the government should commit to providing leadership on the issue, supervising the transformation of the mental health system, and performing monitoring and evaluation activities. Eaton noted that the MHAP was signed by every Minister of Health from the 194 member states; therefore, he urged participants to hold the leadership accountable to this commitment. A few participants suggested using a leadership opinion survey to measure success and noted that key stakeholders would be the MoH, Parliament, NGOs and civil society, and health care service providers.

Disseminating information to targeted groups: To involve leadership in mental health transformation, several participants said it was critical to give both governmental and nongovernmental organizations accurate, targeted information about the burden of mental health and how it can be treated. This effort would require resources such as technical expertise, graphic materials, and documents, and the media could be a key partner in disseminating information, several participants noted.

Addressing specific government concerns: Many participants noted that the government manages competing priorities and may have specific concerns about some of the changes proposed in the health care system. They suggested performing a survey of government officials or depart-

ments in order to determine what these concerns are and to begin to address them. One participant suggested that aligning the Ghanaian mental health system with international norms and approaches could be persuasive; one example would be aligning system goals with the MDGs.

Improving protocols and guidelines, training and supervision

Refining and simplifying the mhGAP protocols to align with the Ghana health system: In order to address the lack of treatment protocols, Eaton suggested adapting WHO’s mhGAP guidelines, which are designed for non-specialist health settings and provide protocols for clinical decision making, including psychosocial treatment. He emphasized that the mhGAP protocols required government buy-in to implement. Several participants suggested the protocols be adapted for specific levels of the health workforce so that the appropriate amount and scope of information was being shared with providers at each level, with monitoring and supervision. A few participants said that aligning these guidelines with the Ghanaian system would require technical advisors, a team of Ghanaian clinicians for validation, and the assistance of the MoH, the Mental Health Authority, and health providers at all levels.

Identifying core competencies and train existing staff to build workforce capacity: Although many participants generally agreed that having more mental health specialists would be optimal, several participants suggested that existing staff could be used more effectively if they received ongoing training in key skills. First, a list of core competencies should be developed, as well as a comprehensive list of current providers and their skills. Next, expert local trainers and supervisors should be identified and health workers at every level should receive training and ongoing supervision to ensure that they are competent in key skills of mental health care. Several participants noted that this program would require the assistance of the ministry, the Mental Health Authority, and health providers at all levels. Many participants recognized a need to improve training in medical schools and to support mental health care education through increased time spent in neurology and psychiatry rotations. In some programs, Akpalu noted, only 1 week is spent in the neurology rotation and approximately 2 hours are spent in psychiatry. According to several participants, engaging institutional leadership will be important to ensure a more comprehensive mental health education.

Engaging traditional healers, community, and family to aid diagnosis and treatment

Creating an alliance between the Ghana health system and traditional and faith healers: Several participants suggested a number of ways that the Ghana health system could engage with traditional and faith healers, such as undertaking trainings of nonorthodox health providers, creating official affiliations between mental health facilities and faith-based facilities, and creating a system for referrals from faith-based healers to mental health providers. The resources needed to facilitate this alliance would include a pictorial diagnostic manual, personnel to provide training, and facilitators to assist with aligning the two groups, a few participants said.

Recognizing, upgrading, and capitalizing on the existing skills of traditional and faith healers: Several participants recognized that traditional and faith healers have skills that could be built on to improve mental health care. They suggested holding focus groups to identify these skills and then building on these skills with training sessions. Progress could be measured by developing metrics based on tracking trends on the number of faith healers who adhere to protocols; the amount of increased, accurate referrals to health care facilities; the overall number of functioning nonorthodox health care facilities; and observing the proportion of traditional and faith healers to mental health care workers, according to a few participants.

Supporting families at home to look after affected relatives once discharged from service: Integrating patients back into their homes is a critical part of recovery, said many participants, and families need support to do this successfully. They suggested having nurses perform home visits, providing information and education to families, and starting mental health support groups in the community. Ohene discussed the lackluster availability of the workforce in this field, noting that the MoH only employed one occupational therapist, and there were no trained psychiatric social workers. He explained that of the limited cadre of social workers who worked in Ghana, very few want to be involved in working with psychiatric patients. Eaton likewise advocated the need for comprehensive psychological services and proven social interventions that were important in recovery for both patients and their families throughout the entire treatment cycle.

Poor Access to Medicines

More than a third of the world’s population lacks access to essential medicines, including psychotropic medicines, and the majority of the people who lack access live in the poorest parts of Africa and Asia, said Gyansa-Lutterodt of the Ghana MoH (Medecins Sans Frontieres, 2015). Asare reported on the availability of psychotropic medicines in Ghanaian facilities in 2011. He said at least one psychotropic of each therapeutic class (antipsychotic, antidepressant, mood stabilizer, anxiolytic, and antiepileptic) was available all year long in 40 percent of outpatient facilities, 57 percent of hospital inpatient units, and 100 percent of mental hospitals, and more than 80 percent of physician-based primary clinics had access to at least one medicine of each category. However, he noted that since 2014 there has been an erratic psychotropic drug supply.

The Ghana National Drugs Programme (GNDP) was established by the MoH to develop, manage, and coordinate the national drug policy, said Gyansa-Lutterodt. GNDP has developed an essential medicines list⁴ and standard treatment guidelines (STGs) to assist providers in deciding on appropriate treatments for clinical problems (Republic of Ghana, 2010). The essential medicines list and STG are evidence-based and are reviewed regularly by GNDP to ensure continued accuracy. The most recent STG, from 2010, includes, among other conditions, epilepsy, attention deficit hyperactivity disorder, depression, schizophrenia, bipolar disorders, and anxiety disorders (Republic of Ghana, 2010). The 31 psychotropic medicines on the essential medicines list (which is aligned with STG) are covered by NHIS, said Gyansa-Lutterodt.

Although Ghana has taken some steps to control the price of essential medicines, such as exempting some pharmaceuticals from the value-added tax, Gyansa-Lutterodt said the absence of a drug pricing policy is a barrier to access. Other barriers she discussed included

• Weak supply system for psychotropics and limited capacity for local production of medicines;
• High cost of newer medications;

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⁴See http://www.moh-ghana.org/UploadFiles/Publications/eml2010140204051145.pdf (accessed October 29, 2015).

• Inadequate funding to support cost of medicines, and no dedicated budget for psychotropic medicines; and
• Lack of a Logistics Management and Information System (LMIS) to forecast needs and prevent stock-outs.

Goals and Potential Strategies Forward

Several workshop participants identified a number of goals in the area of access to medications, and they developed specific strategies to address each of these goals as part of a mental health demonstration project. The discussion focused on improving funding and the procurement process, and on ensuring the safety and quality of drugs once they are on the market.

Improving funding for essential medicines

Clarifying reimbursement policies: Several participants noted that there is a perception in Ghana that mental health medications are free. Unfortunately, this perception results in reduced access to the medications because pharmacies are reluctant to stock products that are not likely to be profitable for them. Participants said these medications are, in fact, reimbursable under NHIS, but this is widely unknown. They suggested that the reimbursement policy needs to be clarified to improve access.

Mobilizing resources internally and externally: One major barrier to access, a few participants said, is simply that funds are not always readily available to purchase medications. Several participants suggested numerous ways to address this: a dedicated budget for MNS medications; a revolving drug fund (in which the drug supply is replenished using money from the sales of drugs); and removing barriers that prevent private pharmacies from purchasing psychotropic medications.

Shortening the procurement cycle

Performing a needs assessment of drug usage: To procure the appropriate drugs in a timely manner, the community’s drug needs must be understood, several participants noted. They suggested performing a comprehensive needs assessment so that planners, pharmacists, and health care providers can be better prepared.

Using an LMIS to improve procurement: A few participants discussed how an LMIS could increase the efficiency of procurement by forecasting drug needs and preventing stock-outs. They suggested that the software be integrated into a more robust general MHIS and that workers be trained in order for the system to operate to its potential.

Ensuring drug quality

Performing postsupply monitoring of drug quality: Several participants stated that in addition to making drugs more accessible, ensuring the quality and safety of the drug supply is important. One participant gave an example of a drug that was tested and found to contain only a small percentage of the claimed active ingredients. Many participants suggested several ways to ensure postmarket quality, including: enabling users to report quality concerns; requiring the Food and Drug Authority to perform postmarket surveillance; encouraging providers to report side effects; and empowering drug and therapeutic committees in the health facilities to monitor drug quality and adverse events.

Stigma

Stigma is a major barrier to care and treatment of MNS disorders in Ghana, stated many participants. Asare said that stigma affects not just the patients themselves but also the family and friends of affected persons. Stigma is a barrier to training and recruiting mental health personnel, Asare said, adding that mental health services may receive less funding because of stigma. Several participants noted that stigma and a lack of understanding of MNS disorders prevents people from seeking care, and it may cause friends or family to turn away from people diagnosed with a disorder. Many participants also observed that there is significant stigma against health care workers who treat mental health: primary providers are reluctant to take on psychiatric patients, and providers who specialize in mental health are considered “among the least valuable” providers in the profession. One participant brought up the role that traditional and faith healers play, noting that labeling patients as “witches” or ostracizing them in prayer camps can exacerbate the stigma that already exists,

Goals and Potential Strategies Forward

Several workshop participants identified a number of goals to reduce stigma, and they developed specific strategies to address each of these goals as part of a mental health demonstration project. Several participants discussed reducing stigma through dissemination of information, integration of patients back into the community, and improving mental health facilities.

Improving information and education surrounding mental health disorders

Strengthening professional development training for health care workers and staff: Several participants observed that providers receive little education about mental health, and that some of the most acute stigma against people with mental health disorders is within the health profession. To this end, many participants suggested a comprehensive professional development program for providers that is designed to increase knowledge, improve skills, and boost compassion among health care workers. To assess the efficacy of such a program, surveys could be conducted that measure providers’ knowledge and attitudes, and client satisfaction with their care could be a proxy for measuring provider skills and compassion.

Implementing mental health education in primary and secondary schools: Some participants suggested implementing mental health education in schools, in the hope that early education would prevent stigmatizing attitudes and that the knowledge and compassion gained would “trickle up” to the community.

Incorporating effective rehabilitation and reintegration in treatment plans

Integrating people with MNS disorders into community-based vocational and educational training: One participant said that employment and education are a crucial component of patients’ recovery and can contribute to “getting their dignity back.” Several participants suggested implementing vocational and educational training that supports mental health patients and gives them the skills necessary to become employed. It was noted that such a program would require buy-in and cooperation from

multiple sectors, including the government and health care providers, families, schools and vocational centers, NGOs, and employers. Reintegration of patients into the workforce can lessen stigmatization by showing that recovery is possible and that patients can lead productive lives, as reported by Stephanie Smith, Abundance Fellow in Global Mental Health at Harvard Medical School and health and policy advisor for mental health for Partners In Health.

Improving psychiatric facilities

Renovating or building mental health facilities that are safe and hygienic to facilitate effective care and recovery: Many participants observed that the physical condition of current mental health facilities is less than ideal; this can contribute to stigma, they said, because patients are often treated as “less than human,” and friends and family are reluctant to visit. Participants had many suggestions for improvement of facilities, including beds for every client, pleasant outdoor areas for recreation, recreational opportunities, functioning toilets, and safety features such as alarm bells by each bed. To accomplish this goal, several participants said, necessary steps would include organizing stakeholders and securing resource commitments, documenting the baseline conditions, and establishing a facilities monitoring system to ensure continuous improvement. Funds would be needed for building and maintenance, and stakeholders from the MoH to community leaders would need to be involved, according to several participants. Kwadwo Obeng, psychiatry resident at Accra Psychiatric Hospital, noted that perhaps this suggestion was duplicative, as the government has already pledged to improve psychiatric facilities, but Pringle answered that a fast-moving demonstration project could provide a model for renovation that the government could use.

Inadequate Mental Health Information Systems

Lily Kpobi, assistant lecturer in the department of psychiatry at the University of Ghana School of Medicine and Dentistry, said that data on mental health needs in Ghana are often inconsistent and sometimes inaccurate, and she noted that this was partly due to outdated and inadequate record keeping and patient management systems. She said that in 2012, a new MHIS was developed for the three psychiatric hospitals in Ghana. This system is partially computer based and uses the uniform diagnostic system of WHO’s International Classification of Diseases (ICD). Kpobi

noted that the information that a robust MHIS can provide has multiple benefits, including improving the care of patients and the management of the hospital and increasing the availability of information for policy makers and advocates. She also noted that accurate information about the prevalence and treatment of MNS disorders can help educate communities and reduce stigma.

Kpobi said barriers to implementing an effective MHIS exist on many levels. First, the data must be properly collected, processed, and analyzed; these steps require training of all of the users of a system. Second, sufficient resources—both human and technological—must be available for the system to operate to its full potential. Finally, the data must be disseminated and used in an appropriate way. Kpobi stated that barriers specific to Ghana include a lack of privacy policies and security of data, poor Internet connectivity or electricity, lack of resources allocated to MHIS, and data that are entered inaccurately, late, or not at all.

Goals and Potential Strategies Forward

Several workshop participants identified a number of goals to develop and strengthen MHISs, and they developed specific strategies to address each of these goals as part of a mental health demonstration project. Participants focused their discussions on improving the data collection process and creating a system that is flexible and helpful for users.

Improving and standardizing data collection process

Training data managers to enter data correctly: Many participants noted that a major challenge in the implementation of a robust MHIS is accurate and timely entry of standardized data. They said that anyone who enters data—from nurses to administrative staff—should be trained in both the technical aspects of inputting data as well as WHO’s ICD in order to ensure that data entered are standard and correct. Several participants suggested that data should be entered on a daily basis and forwarded to the district on a monthly basis, with a maximum 1-week backlog, ensuring that the necessary data is accessible at most 1 week after the end of each month. Resources necessary for this strategy include funds for sufficient computers and technical experts and facilitators to carry out the trainings.

Training clinicians, providers, and institutions in ICD: For data to accurately describe the burden of disease or the efficacy of treatment, provid-

ers must use a standardized system to diagnose patients that is incorporated into their training. Several participants suggested that providers be trained in the most recent version of WHO’s ICD, and they suggested that a goal should be for at least 70 percent of cases to be diagnosed accurately under this system. This number, a few participants emphasized, should increase as clinicians and training institutions become better-versed in using the most recent version of ICD.

Provider awareness and support of MHIS: Many participants observed that if providers are not “on board” with the MHIS system, it will not be successful. Several participants suggested that a survey be performed to assess provider knowledge of and attitudes toward MHIS and that knowledge and attitudes could be improved through training, continuing medical education, and involvement of providers in the system development.

Developing a system that meets the needs of patients and providers

Identifying and using appropriate indicators for mental health planning, monitoring, and evaluation: The indicators included for mental health issues must be appropriate not just for clinical use but also for community- or nationwide planning, monitoring, and evaluation, said several participants. They suggested using experts to develop and continually review the set of indicators and noted that the indicators must be easily computable through the District Health Information Software that Ghana currently uses. Several participants stated that engaging all involved parties in the implementation process ensures a widely used, interoperable system.

Developing a flexible, electronic system: The current health information system is only partially electronic, and does not allow for certain functions that providers and patients need, said several participants. They suggested developing a system that is fully electronic and that is flexible, allowing for functions such as collection and usage of comorbidity data, patient tracking, and the use of unique patient identification numbers. Several participants said that data access should be easy, yet secure, and user-friendly for all providers and all purposes. They stressed that a privacy and security policy is necessary to regulate access and usage of data, and they suggested using an independent information technology firm to manage the system.

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