Community-based vs. hospital-based mental health care: the case of Africa

Traditional methods of treating mental illness within communities prevailed in all cultures until the 19th century, when building asylums and isolating mentally ill persons from the rest of the society boomed in the economically developed countries. I believe this style of treating mental illness crossed to Africa in the era of colonialism and still prevails in many countries of the continent.

Mental health service reform in Europe came about because of national initiatives and policies (1), whereas there are no mental health policies or mental health legislations in many African countries (2). This clearly indicates that African governments have very little commitment for mental health services.

Moreover, because of poor economy and brain drain, Africa suffers from shortage of material and human resources for social services in general and mental health services in particular. In Europe, the average number of psychiatrists per population ranges from 5.5 to 20/100,000, and 5 to 10% of health care funding goes to psychiatric services (1), while in Africa the average number of psychiatrists is 0.05/100,000 population (3) and the funding for mental health services is much less than one per cent of the general health budget (4).

Because of other competing priorities and attitudinal problems, mental health care in the developing countries gets the least in the priority setting compared to other areas of health care. The burden of caring for the mentally ill in most African countries is left to the families. When one family member gets ill with a mental disorder, traditional healing sites are the places which are tried first. Having tried and failed all other alternatives, modern mental health care centers are very often the last places where help is sought (1,5). Vagrancy in a disheveled state and malnutrition are very common phenomena for patients with chronic mental disorders. Such patients get admission to the traditional hospitals/asylums for assessment only when they get some kind of involvement with the law (6). In these hospitals they get food and shelter on a regular basis. One then wonders whether such patients are better off in asylums where at least they could get basic necessities for survival. This is not to suggest that asylums are good enough for African patients, but just to throw some thoughts on the discrepancy between economically developed countries and the lowincome countries with regards to care provision to the mentally ill.

Until the early 1980s, the idea of expansion of mental health care for many African countries meant duplicating the existing traditional mental hospitals. One good example of this is a blue print of a design to build a huge mental hospital at the outskirt of Addis Ababa, Ethiopia around 1984. Before this plan of building the hospital materialized, the Director of the Mental Health Division of the World Health Organization paid a working visit to Ethiopia. Consistent with the new trend of the time, he advised the Ministry of Health against building the hospital, but rather to decentralize the service to the regions by training midlevel health workers. Following that advice, the plan to build the hospital was cancelled and training of psychiatric nurses was started. Now the service that was limited to one traditional mental hospital in Addis Ababa has spread out to 36 regional and district hospitals where units for mental health care have been established. Two psychiatric nurses each run these units. This service is now expanding to lower health facilities and has become relatively more accessible to those who need it and to their families. There is a good system of referral between the mental hospital in Addis Ababa and these centers. Given the shortage of resources in Africa, can one take this as a kind of counterpart to the mental health care reform or balanced care in Europe? In a country where there are only nine psychiatrists for a population of 65 million, forming a community mental health team of which psychiatrist is a member would be very far from reality, to say the least. Therefore, the current trend will remain in place for years to come and the prevailing socio-economic situation in the region forces us to accept it as a reasonable system of care for many African countries.