Abstract
Within the continent of Africa, mental health services are relatively undeveloped. In the sub-Saharan countries of Malawi, Kenya and Nigeria, similar problems are faced by dedicated psychiatrists who are struggling to create and sustain an educational, management and political structure for psychiatry.
Malawi exemplifies some of the most pressing issues. As Dr Kauye recounts, this is a country with an excessively low gross domestic product (GDP) per capita, even by African standards. Moreover, the overly centralised administrative structure for medical services militates against the provision of adequate community care. There are very few trained psychiatrists, and in most out-patient and in-patient settings nurses take on major responsibilities for the everyday care of patients. However, the shortage of nursing staff means that many psychiatric nurses end up doing general nursing duties. A further issue, pertinent to the need to retain appropriately trained staff, concerns medical staff who are so poorly paid that retention of their services is often linked to private sponsorship. This provides a temporary supplement to their meagre salaries. The supply chain for medication is especially vulnerable to disruption, and procurement at a national level is less secure than it should be, especially for psychiatric treatments. Ways of tackling this continuing concern are discussed by Dr Kauye.
Kenya and Nigeria are wealthier countries than Malawi, but they experience similar problems. Professor Ndetei describes how difficult it has been to retain psychiatrists in Kenya over the past decade, despite the country having made a tremendous effort to train them. Unfortunately, they migrate in ever greater numbers. As in Malawi, trained psychiatric nurses are often redeployed in order to provide general nursing duties, and at a community level there are few appropriately trained staff to deliver services to individuals with mental health disorders. We have discussed in previous issues the potential benefits of using native healers to supplement conventional psychiatric services; this is an issue discussed by Professor Ndetei with approval. As in Malawi, a lack of epidemiological research has meant that relatively little is known about the nature and scale of disorders at the level of community mental health, and there is an associated danger that research expertise is unduly centralised and remote.
Finally, Dr Olugbile and colleagues discuss the issue of mental health education in Nigeria. They provide a relatively structured account of the current state of knowledge about mental health issues in two surveys, the first concerning primary healthcare workers and the second specifically targeted at general practitioners. The authors discuss, first, a survey they conducted with a national sample of primary healthcare centres. Remarkably, none of the centres surveyed had any psychotropic drugs available in their pharmacies, nor were there any medically trained practitioners working in them. The survey was therefore focused mainly upon nurses and community health workers (without specific psychiatric training). In all categories, knowledge about mental health problems was regarded as poor. It is perhaps more surprising that similar results were obtained in a further survey of general practitioners (the vast majority of whom were seeing psychiatric patients).
Taken together, this set of papers emphasises the remarkable work being done by psychiatrists in some of the poorest countries in the world to provide better care for psychiatric patients, and stresses how important it is that they are supported in their endeavours by links with centres of excellence in the UK and elsewhere.