Bridging the mental health gap in Chad: a call to action

Abstract

Mental health remains one of the most neglected areas of healthcare in Chad, despite a high and growing burden of psychological distress driven by conflict, forced displacement, poverty and climate-related stressors. Access to modern mental health services is virtually non-existent outside the capital, N’Djamena, and the country has no functioning mental health legislation or operational national strategy. Human resource shortages are severe, with only two psychiatrists and a handful of trained professionals for a population exceeding 18 million. Cultural stigma and reliance on traditional healing approaches, while deeply rooted and often adaptive, further shape help-seeking behaviours, frequently delaying or substituting formal care. This perspective article highlights the structural, legal and sociocultural barriers to mental healthcare in Chad and presents a phased, context-specific roadmap for reform. Recommendations are categorised into short-, medium- and long-term priorities, including task-sharing to primary healthcare workers, legal reforms to protect patient rights and decriminalise suicide attempts, decentralisation of services, inclusion of essential psychotropic medications in public supply chains, and engagement with traditional and community actors to combat stigma. Drawing on WHO guidance and regional best practices, this article underscores the urgent need for political leadership and sustained investment to institutionalise mental health as a national priority. Closing Chad’s mental health gap is not only a public health imperative but also essential for social resilience, development and human rights.

SUMMARY BOX.

• Mental health in low-income and conflict-affected settings is chronically underfunded and underprioritised, with limited services, severe workforce shortages and entrenched stigma. In Chad, despite a high burden of mental illness linked to conflict, displacement, poverty and climate shocks, mental health remains marginalised, lacking an operational national strategy, legal protections and basic service infrastructure.

• This article offers the first comprehensive, policy-focused analysis of Chad’s mental health system, combining updated national and international data with structural, legal and sociocultural insights. It presents a phased, context-specific roadmap for mental health reform, grouped into short-, medium- and long-term actions, including legal reform, task-sharing, medication access, stigma reduction and the enhancement of traditional and religious actors.

• The study provides a practical framework for policymakers, donors and public health stakeholders seeking to reform Chad’s mental health. It supports immediate and long-term planning through evidence-informed, sequenced interventions and highlights the need to institutionalise mental health within broader health and development strategies. It may also inform similar reforms in other under-resourced countries confronting governance, legal, and implementation barriers.

Introduction

Chad’s health system has long neglected mental health, despite high needs.¹,³ Despite high and rising mental health needs, driven by decades of political instability, armed conflict, displacement, poverty and recurrent climate shocks, mental health remains a marginal issue in Chad’s national agenda.⁴,⁷ The WHO estimates that mental, neurological and substance use disorders account for about 14% of the global disease burden, yet up to 75% of affected people in low-income countries get no care.⁸ In Chad, one of the poorest nations, this gap is stark. Less than 0.1% of the national health budget is allocated to mental health, and services outside the capital, N’Djamena, are virtually non-existent.³

This chronic neglect has persisted even as widespread trauma and distress, fuelled by poverty, natural disasters and mass displacement continue to affect large segments of the population.⁴,⁷ Chad hosts over a million refugees and internally displaced persons (IDPs), many of whom have experienced or witnessed extreme violence.^{9 10} Yet the country had only two practicing psychiatrists as of 2020 and just one public psychiatric ward with six beds for over 18 million people.¹⁰ With no operational national mental health strategy, no mental health law and extreme shortages in trained personnel, the system remains structurally unable to respond.

This article presents a policy-focused call to action to close the mental health gap in Chad. Drawing on national and international data, it examines the structural, legal and sociocultural barriers that undermine access to care. We detail (1) the obstacles faced by duty-bearers, including weak governance and lack of accountability; (2) the coexistence of traditional healing and biomedical care; (3) the absence of legal protections and unclear status of suicide; and (4) the broader social determinants of mental health, including unemployment and displacement. We then propose a phased roadmap of interventions, categorised into short-, medium- and long-term actions, and compare our recommendations to WHO’s Mental Health Gap Action Programme (mhGAP).

Our central argument is clear: Chad does not need another assessment; it needs political will, policy reform and sustained investment. Without decisive leadership and coordinated implementation, millions will remain without care and dignity.

Mental health system and governance in Chad

Chad’s mental health system is marked by systemic neglect, institutional fragmentation and an almost complete absence of operational infrastructure.¹,¹⁰ While a stand-alone national mental health policy was reportedly adopted in 2016, no implementation framework, budget or accountability mechanism has followed, rendering it effectively dormant.^{3 11} Mental health remains largely absent from national health planning and public financing.^{3 10 11} The WHO Mental Health Atlas confirms that Chad allocates 0% of its national health budget to mental health.³ There is no national legislation to safeguard the rights of individuals with mental illness, regulate involuntary care or establish standards for mental health service delivery.^{3 10}

At the service delivery level, the system is severely under-resourced. As of 2020, the entire country had only 24 registered mental health professionals, including two psychiatrists, six psychiatric nurses and a small number of psychologists and social workers, equating to roughly 0.15 mental health workers per 100 000 population, among the lowest globally.^{2 3 10} The only public psychiatric facility is a six-bed ward in N’Djamena, formerly overseen by a psychiatrist.^{1 10} Since his passing, the unit has been operated by a small team of non-physician staff, including technicians and psychologists.^{1 10} There are no specialised psychiatric hospitals, inpatient facilities or community-based mental health services outside the capital.¹⁰ The Ministry of Health has taken some preliminary steps to address this gap. In 2021, a Technical Working Group on Mental Health and Psychosocial Support (MHPSS) was established, bringing together government stakeholders, United Nations (UN) agencies and national government organisation (NGOs).¹⁰ In 2022, a 12-bed psychiatric unit was opened in Sarh, a regional city, by a faith-based hospital.¹² While these initiatives signal growing awareness, they remain isolated and insufficient relative to the scale of need. In fact, nearly 1900 patients with mental disorders, with schizophrenia being the most frequent diagnosis (29% of cases), were seen at the public psychiatric facility in N’Djamena between 2019 and 2021.¹⁰ By 2023, the caseload continued to rise; over 1600 severe mental illness cases, including 487 schizophrenia and 240 depression cases, were recorded in that year alone.¹³

The broader governance context further constrains progress. Institutional capacity within the Ministry of Health to coordinate mental health programmes is limited.^{3 11} Although a National Mental Health Programme was formally established by the Ministry of Health in 1998, it remains a nominal structure with limited authority, no dedicated budget and minimal staffing.^{3 10} More than two decades later, Chad still lacks a functioning mental health directorate or national focal point with the capacity to lead, coordinate or implement mental health services.¹⁰ Weak intersectoral collaboration, particularly between health, education, justice and social protection sectors, prevents a cohesive response. Compounding this are high levels of poverty, insecurity and fragmented territorial control, which hamper the government’s ability to extend services across the country.¹⁴ The absence of a clear governance framework undermines accountability and disincentivizes investment by donors and partners. Without legal mandates, protected budget lines or national leadership, mental health efforts remain sporadic, partner-driven and unsustainable. To move forward, Chad will require both structural reform and political commitment. Specifically, a national mental health law, a revitalised policy with defined priorities and budgets, and a functioning coordination platform with decision-making authority are critical next steps to institutionalise mental health with the health system and beyond.

Legal framework and ethical issues

Chad lacks a dedicated mental law or legal framework to protect the rights of people with mental illness, regulate involuntary treatment or ensure standards of care.^{3 11} Consequently, practices such as chaining or isolating patients, often by their families or traditional healers go unregulated.¹¹ Chad’s 2017 Penal Code does not explicitly mention suicide or self-harm, but this absence likely means attempts are neither prosecuted nor decriminalised in practice.¹⁵ Advocacy trackers list Chad’s suicide-law status as ‘uncertain’.¹⁶ Given that punitive law creates stigma and may discourage people from seeking help during a crisis, we argue that any mental health law revision must explicitly decriminalise suicidal behaviour and treat it as a health issue by providing supportive mental health services.^{17 18} International best practices hold that suicide attempts should not be criminal offences; Chad should follow suit.¹⁹

Chad’s Constitution, specifically Article 17, recognises the right to life. While the constitution does not explicitly use the term ‘right to health’, it does guarantee the right to a ‘clean, healthy and sustainable environment’.²⁰ However, its enforcement is weak. Allegations of mental health human rights abuses, including forced treatment and use of faith restraints, are likely uncounted.¹¹ Proposed legal reforms, which have been discussed by NGOs and health actors, include drafting a modern Mental Health Act to recognise mental illness, require consent for treatment and establish oversight bodies.¹⁰ We strongly endorse such reforms. Aligning law with international standards, including UN conventions on disability, would provide a strong foundation for funding and accountability. In the absence of these reforms, Chad risks lagging behind its neighbours. As illustrated in figure 1, Chad is among several African countries, including Cameroon, Niger and the Central African Republic (CAR) that currently lack both a dedicated mental health law and a comprehensive national policy.²¹ In contrast, Nigeria has made progress, enacting a National Mental Health Act in January 2023 and establishing a national policy framework.²² Even Sudan, despite protracted conflict, has adopted both a national mental health policy in 2009 and a mental health law in 2016.²¹ However, Sudan’s example demonstrates that the existence of legal frameworks and policies alone does not guarantee service delivery.^{23 24} Without adequate resources, trained personnel and implementation mechanisms, mental health services remain inaccessible or undeveloped, particularly in fragile and conflict-affected contexts.²⁵ This growing regional contrast underscores the urgency for Chad to act, not only by passing legislation, but also by ensuring its operationalisation through sustained investment and oversight.

Figure 1. Status of mental health laws and policies in Chad and neighbouring countries. Notes: This map categorises countries based on the presence of a national mental health law, policy, both or neither. Sources: WHO Mental Health Atlas (2020) for Cameroon, Chad, Libya, Niger, Nigeria, South Sudan and Sudan and WHO Mental Health Atlas (2017) for Central African Republic.

Cultural context: traditional and biomedical care

Any policy must grapple with the deep-rooted of traditional and faith healers in Chad’s mental health landscape.^{13 26} Mental health problems are often interpreted through spiritual and social lenses.^{11 27} Some families initially seek help from marabouts (traditional healers), clerics or relatives rather than hospitals.¹¹²⁶,³⁰ Importantly, research shows that in Chad and in the wider Sub-Saharan Africa, all three modes of care, including home/family support, traditional healing and biomedical services, coexist and even complement each other, rather than simply competing.²⁹,³² People often cycle through these approaches since stigma and fear of psychiatric ‘institutionalisation’ lead many to try traditional remedies first.^{33 34} Traditional medicine is viewed as ‘socially acceptable’ because it externalises causes such as curses, spirit possession or divine punishment rather than blaming the individual.^{11 35} Only if these fail, or if an acute crisis occurs, will families turn to clinical care.^{11 36}

We reject any simplistic call to ‘eradicate’ traditional healing. Instead, integration is key.^{37 38} Chad’s roadmap should acknowledge medical pluralism.³¹ For example, traditional healers can be engaged as community partners. They can be trained to recognise red flags, provide basic support and refer complex cases. Similar models in Africa have shown mutual respect can improve coverage.^{28 39} A successful reform will not force a false dichotomy between tradition and biomedicine; it will leverage local understandings of illness.^{38 40} Our roadmap therefore includes community outreach (short-term) and training of non-specialists using WHO’s mhGAP guidelines so that biomedical workers can respectfully liaise with healers.⁴¹ For instance, education campaigns led by both healers and clinicians can reduce the notion that ‘mental illness is a curse’, while also strengthening trust in clinics. By building on cultural norms of communal care and resilience, Chad can expand access in a culturally congruent way.

Social determinants of mental health

Chad’s social landscape deeply influences mental health. More than one-third of Chadians live in extreme poverty, and 3.4 million people faced acute food insecurity in 2024.⁴² Chronic poverty, unemployment and underemployment, especially among youth are rampant.⁴²,⁴⁴ These hardships heighten stress, trauma, and suicide risk.^{2 45 46} Moreover, Chad has long been a host to mass displacement. As of mid-2025, over 1.2 million Sudanese refugees have crossed into Chad due to the Darfur conflict, up from 409 000 before 2023.⁴⁷ Including refugees from CAR and IDPs, Chad now shelters more than one million forcibly displaced people.^{6 9} Such crises bring violence, loss and uncertainty. The United Nations Refugee Agency (UNHCR) reports that over 70% of recent arrivals fled atrocities, including killing and rape.⁴⁸ The psychological tool is immense.⁴⁹ We note that humanitarian agencies have called for ‘urgent expansion of mental health support’ for these populations, yet funding is dangerously low.⁵⁰

While our focus is national policy, these social factors mean mental health action cannot be siloed. Programmes must coordinate with sectors tackling poverty and education.^{51 52} For example, short-term crisis centres in refugee camps with NGO support can run psychosocial activities and trauma counselling, but long-term stability will require integrating mental health into livelihoods and schooling programmes.¹¹⁵³,⁵⁶ We urge that Chad’s Ministry of Health work with other sectors, including education, labour and social welfare to address drivers such as unemployment. This may include vocational training, cash-transfer pilot projects for vulnerable families and mental health literacy in schools. Aligning with the UN’s 2030 Agenda, effective mental health strategy must recognise these determinants.⁵⁷ By citing sources like the The International Monetary Fund and Sustainable Development Goals reports, we underline that mental health cannot improve in isolation from socio-economic development.

A phased roadmap of recommendations

We distill our analysis into a roadmap of interventions (table 1), grouped as short-term (1–2 years), medium-term (3–5 years) and long-term (>5 years) priorities. Each recommendation is placed in logical sequence with dependencies noted. The overarching goal is sustainable system building as immediate relief and capacity building pave the way for deeper reforms.

Table 1. Prioritised roadmap for Chad’s mental health system.

Action/intervention	Timeframe	Dependencies/notes
Formalise national Mental Health and Psychosocial Support coordination structure (ministry-led task force)	Short term	Builds on 2021 Technical Working Group (TWG) Requires ministerial mandate and some funding
Official national mental health plan with budget	Short term	Dependent on coordination group Require political approval
Rapid mhGAP training for general health workers	Short term	Uses WHO mhGAP-Intervention Guide (IG) Initial trainers secured by NGOs/WHO support
Ensure continuous supply of key psychotropic medications	Short term	Needs initial procurement Logistic channels must be arranged
Launch stigma reduction and awareness campaigns (mass media, schools)	Short term	Partnerships with civil society and traditional leaders
Engage traditional and faith leaders in referral networks	Short term	Requires outreach and respect for local practices
Establish mental health units/teams in major regional hospitals	Medium term	Depends on trained personnel and facility allocation
Conduct national mental health and psychosocial needs assessment	Medium term	Provides baseline Informs planning and indicators
Enact dedicated mental health law, revise Penal Code re: suicide	Medium term	Legislative process Could draw on WHO model legislation
Scale community-based psychosocial programmes, especially in refugee camps	Medium term	Coordinate with UNHCR/NGOs Build on pilot projects and short-term training
Introduce school-based mental health education and screening	Medium term	Work with the Ministry of Education Depends on public awareness traction
Allocate dedicated budget for mental health	Medium term	Requires budget negotiations linked to new policy
Integrate mental health into universal health coverage schemes	Long term	Follow enactment of law Long-term financing stable
Develop specialist services, including regional psychiatric centres	Long term	After workforce pipeline and infrastructure growth
Link mental health programmes to social welfare	Long term	Requires intersectoral policy (labour, finance) Builds on poverty reduction plans
Monitor and evaluate progress with indicators	Long term	Relies on data systems Ensures accountability

mhGAP, Mental Health Gap Action Programme; NGOs, national government organisations.

Short-term priorities focus on creating an enabling environment. We propose formalising the existing MHPSS group into a National Mental Health Coordination Body with a budget line and developing an official Mental Health Strategic Plan. Simultaneously, key actions include (1) training general health workers in WHO’s mhGAP interventions so that primary care can begin to treat depression, psychosis, epilepsy, etc.; (2) ensuring supply of essential psychiatric medicines in clinics; (3) launching public awareness campaigns to reduce stigma; and (4) working with traditional healers and religious leaders to build referral pathways. Many of these steps can be taken with minimal new infrastructure but require government commitment of modest funds and strong collaboration with NGOs/UN (who have some emergency funding).

In the medium term, the roadmap emphasises institutional and legal reforms. This includes passing a mental health law to formalise patient rights, consent and decriminalise suicide and enacting regulations to ensure its implementation. We recommend expanding services beyond N’Djamena. For example, establishing mental health teams in regional hospitals and integrating mental health into community health posts. This depends on the short-term training and cadre development. We also prioritise data systems such as conducting a national mental health survey and improving routine reporting so that progress can be monitored. Scaling up psychosocial support for refugees and conflict-affected areas is another medium-term goal, contingent on initial capacity building. Importantly, we advise that midterm financing increases.

Long-term priorities aim for sustainability, including integrating mental health into universal health coverage through insurance or free basic packages, ensuring ongoing funding. We envision establishing a network of community psychosocial centres and rehabilitation programmes across Chad, made possible after workforce development and infrastructure growth. Addressing social determinants becomes more feasible over time such as linking mental health to employment initiatives, poverty reduction strategies and education reforms. The highest-level goal is to embed mental health into all relevant policies. We note that many long-term goals like reducing national suicide rates or achieving fully decentralised services depend on earlier stages, including laws, training and pilot programmes, hence the sequencing in table 1.

This roadmap shares many elements with the mhGAP.⁴¹ In particular, like mhGAP, we emphasise task-sharing and primary care integration, which includes training general clinicians to treat priority conditions, and community-level psychosocial support. Both approaches recognise that with limited psychiatrists, non-specialists must deliver care. We also align with mhGAP’s goal of expanding access even in low-resource settings. However, our roadmap extends beyond mhGAP’s clinical focus. We explicitly incorporate legal reforms (a mental health law, decriminalisation), governance (coordination bodies) and social interventions (poverty alleviation, education) which mhGAP does not cover. In this sense, our plan is broader. It uses mhGAP as one tool within a larger policy framework. Finally, whereas mhGAP guidance assumes international funding, our recommendations emphasise national ownership and domestic resource mobilisation. In light of declining external aid flows, Chad must transition from donor-driven initiatives toward a sustainable, government-led mental health system anchored in national priorities and financing.

Conclusion

Chad’s mental health gap is glaring and unjust. Decades of underinvestment, combined with a humanitarian crisis on its border, have left millions without care. This commentary calls on Chad’s government, and its partners, to treat mental health as a policy priority. We have outlined the tough realities duty-bearers face, from collapsed infrastructure to cultural barriers to make our recommendations realistic. At the same time, we take a strong stance: further delay is indefensible. The phased roadmap presented here offers a realistic and actionable pathway foreword. It begins with achievable short-term interventions and builds toward the structural reforms needed for long-term sustainability. None of this will be possible without bold political leadership, cross-sector collaboration and a shift toward nationally driven systems less reliant on declining external aid. The reward is profound, including healthier families, more productive citizens and a society better able to recover from trauma and conflict. We urge the Ministry of Health to take the lead in adopting these reforms, with oversight and support from the presidency, Parliament, and international partners. It is time for Chad to move beyond symbolic policies and pilot programmes. What is needed now is a coherent, well-financed and rights-based mental health system, one that ensures no one is left inviable, uncounted or uncared for.

Data availability statement

All data relevant to the study are included in the article.