Providing Sustainable Mental Health Care in Ghana: A Demonstration Project

A commissioned paper prepared for the April 28–29, 2015, workshop on Providing Sustainable Mental Health Care in Ghana, hosted by the National Academies of Sciences, Engineering, and Medicine’s Forum on Neuroscience and Nervous System Disorders and Board on Global Health. The authors are responsible for the content of this article, which does not necessarily represent the views of the National Academies of Sciences, Engineering, and Medicine.

The first section of the report provides a summary of the context in which the project will run, and the considerations made in development of the project. The second section contains the proposal for the demonstration project itself, made up of a project narrative and logical framework for its successful implementation.

This document sets out to propose a model for a project that will build on these considerable achievements, and bring together relevant aspects of evidence-based practice that would make a good fit for the needs of the situation in Ghana. The Institute of Medicine (IOM) has convened several activities related to strengthening the capacity for delivering quality mental health services in low- and middle-income countries (LMICs, a designation by the World Health Organization, or WHO) over many years. The landmark publication Neurological, Psychiatric and Developmental Disorder: Meeting the Needs in the Developing World 1 was an early driver of the growth of global mental health as a discipline. In recent years, three key workshops have been held, bringing together international and local experts to explore sustainable solutions to service development challenges, including addressing the treatment gap and improving quality of care, human resource development, and access to appropriate medication.

Ghana has experienced a positive trend in its economic development over the past two decades, and seen a gradual strengthening of its democracy in recent years. This has led to its reclassification (by the World Bank) as a lower middle-income country, and it is on track to meet the Millennium Development Goal of halving extreme poverty by the year 2015. This positive overall picture hides persistent inequity. Infrastructure of basic services, including health, is far from meeting the needs of the population. This is particularly the case in mental health, where many years of neglect have left services even farther behind. This is now beginning to change. Ghana recently adopted a progressive Mental Health Act (2012), a reflection of the substantial efforts made by a growing civil society sector interested in mental health. These efforts, over the past decade, have also seen the emergence of one of the strongest service user movements in Africa, new cadres of trained personnel, and a greater awareness of mental health issues in the country.

SECTION 1: BACKGROUND AND SITUATION ANALYSIS

General Development Indexes

Ghana is a West African country with a population of approximately 25.3
million people (2012) (see ). About 45 percent of the population are below age 18
(2012), and there is an annual increase in population of 2.5 percent.
The population is generally denser in the southern part of the country,
and there is a rapid growth in urban populations (currently 52.8 percent
of the total population), especially in Accra.

TABLE F-1

Main Development Indicators (Health, Education,
Economy).

Although there is a strong growth in the economy (7.1 percent in 2013),
28 percent of the population still live on less than $1.23 USD per day,
with greater levels of poverty and worse health and development indexes
in the northern part of the country.

Health Services

Despite good progress since the 1990s, as shown by infant and under-5
mortality rates that have halved between 1980 and 2012 and an increasing
life expectancy (see ), provision of health services is generally weak and
inconsistent in quality across the country.

FIGURE F-1

Contribution of human development index (HDI) domains to
gradual improvement in HDI and gross national income (GNI) in
Ghana (1980−2012).

The Ministry of Health (MoH) provides policy direction for all
health-related issues in Ghana, and the Ghana Health Service (GHS) is
responsible for provision of public health services. The system is
functionally divided into the 216 administrative districts covering the
10 regions of the country. Each district has a District Health
Management Team headed by a district director, who reports to the
regional director. Every region has a regional hospital, and each
district should have a district hospital, although the facilities
available in some are limited. Subdistricts are served by health centers
(see ).

TABLE F-2

Current Health Facilities and Human Resources.

The smallest unit of health care in the Ghanaian public health system is
the Community-based Health Planning and Service Compounds (CHPS)
compound, providing the most basic health care. Most communities have
CHPS compounds, but the nearest health center or district hospital may
be quite a distance away, especially in the northern parts of the
country. Access is also further limited by the poor transportation
network in many rural areas, and the high costs of transport.

A number of faith-based health facilities provide services in Ghana. Most
are organized under the ambit of the Christian Health Association of
Ghana (CHAG). Their facilities are controlled by the churches, while the
Ghana government pays the salaries of the nurses and doctors who work
there. CHAG runs 58 hospitals and 121 health centers. Their facilities
are responsible for 20 percent of outpatient visits and 30 percent of
hospital admissions.

Private clinics are available in parts of the country, and provide an
important first point of contact with services for many people,
especially in urban areas, but their services are generally more
expensive.

The National Health Insurance Scheme (NHIS) introduced in 2007 provides
coverage for most common disease conditions. It is available upon
payment of an annual premium of GHS20.00 or $6.00, which is about 3 days
of the minimum wage and considered affordable. Registration by an adult
parent gives automatic coverage to all offspring below age 16. The
poorest members of communities can register for free. About 10 million
of the estimated 25 million population is currently covered. The low
level of state funding has an impact on the quality of these services.
For example, many service providers complain that they are not
reimbursed for services provided in a reasonable time. Nevertheless, the
plan is still widely used and serves to lessen considerably the strain
on families. Perinatal care and delivery, including caesarean sections,
in public facilities is free.

Mental Health Services

Mental health services are provided in three large psychiatric hospitals,
all located in the coastal south, and in smaller psychiatric units in
five regional hospitals (see Appendix 1). Three teaching hospitals, one each in the south
(Accra), central (Kumasi), and northern (Tamale) parts of the country,
provide services on a relatively small scale. Each has at least one
psychiatrist, with services consisting of inpatient and busy outpatient
departments.

Large parts of the country receive psychiatric services from community
psychiatric nurses (CPNs), who can be found in 159 of the 216 districts.
These CPNs work in the communities, but operate from district hospitals.
There are four community-based mental health services, which are
nongovernmental or faith based and mainly based in the middle and south
of the country. In the Upper East and Upper West Regions, there are
community-based rehabilitation (CBR) programs, again faith based, which
link clients to GHS CPNs.

Since the Mental Health Act was enacted in 2012, a new Mental Health
Authority has been charged with managing mental health issues, though it
is still in its formative stages. The governing body of the Mental
Health Authority is an 11-member board with a number of committees under
it. There is an acting chief executive officer responsible for daily
operations of the Authority. Legislative instrument and the law
governing the source of mental health funding has yet to be passed, and
funding streams for its activities have not been determined.

The psychiatric hospitals and CPNs provide the majority of psychiatric
services in the country. The level of knowledge and standard of care
offered to people with mental disorders by general practitioners and
primary care services is generally poor. Most general practitioners
avoid seeing people with psychiatric problems, preferring to refer them
to the few mental health care providers. There are many reasons for the
low level of interest in mental health. It is stigmatized and is not
seen as an income-generating field or a positive career choice.
Therefore, the area has been generally neglected by professionals and
the health service sector, including international development
agencies.

There are few non-health-oriented services, though a small number of CBRs
interact with GHS-based nurses to provide a more comprehensive model of
care in the north of the country. A few nongovernmental organizations
(NGOs) provide community-based services, especially for substance abuse
and in a few, for people with mental disorders.

Two special schools for children with intellectual disabilities, one
private, and another funded by the government, exist in Accra. Every
regional capital has a school for intellectual disabilities. A few small
facilities for the care of children with autistic spectrum disorders
have been set up by individuals. Professional psychiatric social work
services are virtually non-existent and social services receive
negligible funding from the state. There is no dedicated forensic
psychiatric facility in Ghana, and the mentally ill who violate the law
are often kept in the Accra Psychiatric Hospital, some indefinitely.
Prisons have high rates of mental illness, with inadequate care
provided.

Given this lack of services, particularly in more rural areas, it is not
surprising that there is a large treatment gap. In nearby Nigeria, which
has better resources, this gap was found to be 90 percent (as defined by
those with DSM IV, or Diagnostic and Statistical
Manual
, version 4, disorders not receiving any treatment within
the previous 12 months).3 The treatment gap for mental health disorders in
Ghana is estimated at more than 98 percent.

The Informal Sector

Most people who start exhibiting signs of mental illness (especially in
the rural communities) will first be taken to a traditional healer,
herbalist, or religious leader, such as a Christian Pastor or Muslim
Imam. This is because mental health problems are generally perceived as
spiritual, and often seen as punishment for doing wrong. The treatment
offered, particularly for people with severe and enduring mental
disorders like schizophrenia, can be very abusive and often makes the
problem worse.4
Engaging faith leaders is important given their position of authority in
communities in health care. Some efforts have been made to work
constructively, but this remains a challenge due to the high levels of
human rights abuse in some areas, and the fact that provision of modern
mental health services can sometimes be unwelcome because it challenges
authority and competes for their source of income.5

System Factors Impacting on Mental Health Services

Progressive change in mental health services cannot happen in a vacuum
and is dependent on the existing health infrastructure, particularly if
there is a commitment to investing in sustainable change through
integration in mainstream structures. Comprehensive mental health
services must provide access to biological, psychological, and social
interventions (or facilitate access to such services for those who need
them).

  • Access to biological treatments: Having
    professionals in the right place with the right skills to
    prescribe appropriate medications is important, but cannot be
    done without a reliable supply of medications. This is
    particularly the case for severe mental disorders such as
    schizophrenia, bipolar affective disorder, moderate and severe
    depression, and epilepsy. Such evidence-based medical
    interventions are advised in the mhGAP Intervention
    Guide
    , a publication by the WHO Mental Health Gap
    Action Program (mhGAP).

    The government policy on mental health care has always been and
    remains to provide psychiatric treatment, including admissions
    and all medications, for free. In the face of a very small
    budget, the range and quantities of medications provided is
    often grossly inadequate. There is a turnaround time of around 2
    years in the public procurement cycle, and in practice most
    medications are only accessible in the specialist public
    psychiatric facilities, which often procure them from private
    pharmacies (or through private donations). In less urban areas,
    most pharmacies do not find it cost-effective to stock
    psychopharmacological agents beyond the most basic (and usually
    inappropriately used) benzodiazepines. The overall result is
    long periods of shortages of medication, which can lead to
    relapse of illness, and in the case of epilepsy, dangerous
    recurrence of seizures.

    Costs are generally affordable for the few drugs made available
    through the state system, but most patients are unable to afford
    medication, even if they can be obtained from private sources.
    The real challenge is making an appropriate range of medications
    easily available at all times to patients within the policy of
    free care.

  • Access to psychological treatments: In general,
    there has been a tendency for mental health services to mainly
    focus on biological treatments. There are a number of reasons
    for this: training is biologically focused, and there are few
    trained psychologists; patients expect and value medication;
    availability of appropriate, practical talking therapies has
    been limited even in international guidelines; and it is
    logistically more complex and expensive to provide talking
    treatments. Despite this, the evidence is growing for
    low-intensity, often group or peer, models of therapy, which is
    an important intervention in many disorders where the evidence
    implies talking therapies are equally or more effective than
    medications. Clinical psychologists are nearly absent from
    Ghana. There are only 16 clinical psychologists in public
    service in Ghana. This means any solution would require lay
    providers of simple psychological interventions.

  • Access to social interventions: In general,
    there is inadequate intersectoral collaboration in providing the
    broad care that many people with mental health problems need.
    Apart from the few CBR programs, health, education, social
    welfare, and livelihood services do not engage well together.
    The emergence of organizations engaged in mental health advocacy
    made up of multiple stakeholders is a positive development that
    may help to break down some of the traditional vertical siloes
    in which different sectors work. The Mental Health Act has seen
    some collaborative work across agencies.

Health Management Information Systems

Recent years have seen a significant investment in improving the way that
information is gathered and managed, both for recordkeeping and data
collections for individual patients, and for service-level information.
Unfortunately, as is often the case, mental health/psychiatry services
are often not sufficiently integrated into these mainstream systems, and
must either develop their own or attempt to advocate for inclusion
later.

With the stronger emphasis on mental health by international bodies such
as the WHO, standard indicators are now being developed that can guide
what data should be gathered for local and national planning, and for
providing a means of comparison internationally. The indicators in the
WHO Comprehensive Mental Health Action Plan6 are a good example.

Health Promotion, Prevention of Ill Health, and Surveillance

In general, health surveillance is strongest in child and maternal health
services that have been a focus of government health efforts, largely
driven by the Millennium Development Goals. Within mental health work,
awareness-raising activities have been a part in some comprehensive
programs. In general though, the capacity to identify people in need
early to reduce unnecessary morbidity has been poor, and duration of
untreated illness is usually very long, with patients presenting to
services very late. Knowledge about mental ill health among first-line
clinicians is poor, and referral routes unclear or non-existent outside
of major cities.

Human Resources for Mental Health Services

A lack of human resources is often cited as a major barrier to scaling up
services in LMICs, and this is a major challenge to delivery of adequate
care in Ghana (see ). The number of psychiatric nurses was estimated at 2.47 per
100,000 in 2011,7
but this is probably an overestimate, particularly as only a proportion
of this number work effectively in mental health settings, and the
majority are not in the community or in rural areas. This reflects a
general concentration of services in cities.

TABLE F-3

Mental Health Facilities and Human Resources.

The country has 16 psychiatrists (around 1 per 1.5 million population),
but they are mainly based in specialist hospitals in Accra. Many newly
trained specialists leave the country to work abroad, where there is
also often a shortage of psychiatric nurses and psychiatrists. In fact,
there are more Ghanaian psychiatrists working abroad than in Ghana,
mainly in the United States and the United Kingdom. Specialist
psychiatrists from the diaspora occasionally come to provide teaching in
Ghana.8
Within the country, many trained mental health nurses are posted to
inappropriate placements in other branches of medicine, so they are
inefficiently used.

It is generally accepted that if the challenge of closing the gap in
human resources is to be met, this will be done through a task-sharing
model, where greater clinical responsibility will be given to less
senior personnel than has traditionally been the case. Most recent
major, evidence-based global initiatives have followed this principle,
but in order to result in safe and quality care, there need to be
clearly establish roles and tasks, adequate training, ongoing
supervision and support, and in some cases changes in policy and schemes
of service. Some work has recently been carried out to establish
candidate core competencies for different cadres, for example, by the
IOM,10
and the West African Health Organization has recently finalized a
process for harmonizing training for doctors, nurses, psychiatrists, and
psychiatric nurses in the region. At present mental health/psychiatry
training is not prioritized in medical and nursing schools, and many
curricula are outdated.

The Kintampo College of Health, which specializes in training personnel
for rural communities, has since 2011 been running a diploma program for
community mental health officers, degrees for clinical psychiatric
officers, and a diploma for medical assistants, specialized in
psychiatry. This has started to fill an important gap in mid-level
professionals at the community level. There is not a single psychiatric
social worker active in the country.

Clinical psychologists number around 100, but fewer than 20 work in the
public sector and are accessible mostly to people living in the two
biggest cities. Several projects encourage development of self-help
groups and peer support, an important source of care, not only in
low-income contexts. The Mental Health Society of Ghana works to support
these groups, not only for the potential therapeutic benefit, but for
advocacy purposes.

Financing

At the individual and family levels, a chronic mental illness can have a
catastrophic effect on financial security. The cyclical relationship
between poverty and mental illness is well demonstrated, but there is
increasing evidence to support intervention both in the “social
drift” direction (mental ill health leads to poverty) and the
“social causation” direction (social factors like poverty
lead to mental ill health).11

Mental health services in the public sector of Ghana are, in principle at
least, free as a matter of policy. This includes consultation, all
medication, and admission, including food. Many people still spend large
amounts on transportation and other opportunity costs to access
services. The fact that services should be free can act as a barrier to
internally generated revenue as an option for sustaining services.

NHIS is currently not designed for psychiatric services. Some
psychotropic medications, however, are covered by NHIS when prescribed
in general practice, and people with mental illness may access other
NHIS services if they are registered.

In Ghana in the year 2012, total health expenditure as a percentage of
gross domestic product was 5.2 percent—the agreed target is 15
percent.d
In 2010, 1.3 percent of this figure was spent on mental health, very low
when compared to the (global) estimate of 13 percent of total burden of
disease attributable to mental, neurological, and substance use
disorders (see ).

FIGURE F-2

Comparison between need (burden of disease, or
disability-adjusted life years, for mental, neurological, and
substance use disorders) and resource allocation (percentage of
health budget for mental health) in Ghana.

With the recent increase in interest in mental health at the government
level, and creation of the Mental Health Authority, it is hoped there
will be a greater allocation of resources to mental health. Major donors
such as the U.K. Department for International Development and the
European Union have already invested in significant mental health
program, in part because of the leadership shown by government and the
positive framework for action that the Mental Health Act provides.

Lived Experience, Human Rights, and Social Inclusion

As well as the heavy cost to the individual and family from having a
psychosocial disability, the stigma associated with these problems often
leads to social exclusion, rejection from the community, and even to
physical abuse. Holding people against their will is common when someone
has destructive or aggressive behaviors, and traditional and religious
treatments can involve beating, burning, and forced fasting, which can
last for months at a time. Containment in a prison is common as a
“solution” when families are unable to access the care
they need for their relatives whose behavior they cannot manage, and
women with severe mental illness are vulnerable to sexual abuse. Human
Rights Watch published a comprehensive report on human rights in the
formal and traditional sectors in 20124 that gained wide international
attention. The new Mental Health Act provides some powers to the Mental
Health Authority to enforce rights, and it will be interesting to see to
what extent it will impact the experience of people being subject to
human rights abuse in institutions and communities across the
country.

Access to good health care is an important first step toward inclusion in
community life, and acceptance into social structures. The human rights
messages in the awareness activities will reinforce this, with direct
messages about social inclusion and reintegration after people have
experienced discrimination while unwell.

Policy and Legislative Framework

The Mental Health Act 2012 (Act 846) is the current law that governs the
practice of mental health in Ghana. It replaced the previous law, NRC
Decree 30, of 1972, which focused largely on custodial care. It is the
result of an 8-year collaboration among the WHO, civil society
organizations including user groups, and Ghanaian mental health
officials. Its eventual passage into law by the legislature was greatly
facilitated by intense public advocacy and lobbying, which assumed an
international dimension. The new law has been seen as a model for reform
of mental health legislation in other parts of Africa. It is
particularly strong in recognizing and upholding human rights of people
with mental illness and emphasizes community care. Perhaps its greatest
shortcoming is the absence of specific provisions recognizing suicide
attempts as a sign of mental illness because Ghana still maintains
suicide as an offense in its criminal code.

A novel feature of the Act is that it covers the operations of
traditional and faith healers. The Mental Health Act also provides for
setting up a mental health fund to provide a dedicated source of funds
for mental health activities. This has yet to be made available for full
roll-out of the provisions of the Act.

There are plans to build a forensic psychiatric facility, have a
psychiatric hospital in each region, and have dedicated beds for
psychiatric patients in every district and regional hospital. Day
hospitals and rehabilitation centers in the community are all included
in the vision of the new Mental Health Authority. None of these have
actually taken off yet, however.

The latest mental health policy in Ghana dates from 1996 (revised in
2000), but was never implemented. In 2006 Ghana passed its Disability
Rights Act (Act 715). Ghana is a signatory and has ratified the United
Nations Convention on the Rights of People with Disabilities (in March
2007 and July 2012, respectively).12

Civil Society in Mental Health

Ghana can boast strong civil society organizations and established
networks in mental health. This includes strong service user
organizations, which is rare in Africa. It is generally recognized that
they, alongside professionals, have played an important part in
advocating for, drafting, and now implementing the new mental health
legislation. International NGOs have played an important supportive role
in this, with BasicNeeds standing out as having a particularly important
long-term role in supporting civil society to promote change in Ghana.
BasicNeeds mobilized the advocacy group that carried out a widespread
and effective campaign that expedited the passing of a new mental health
law in 2012. It has continued to support meetings to draft legislative
instruments to actualize the law.

User associations of people with mental illness have been formed in many
regions, which also helps with rehabilitation and even occasionally the
supply of medications to affected individuals. Many have become
economically independent through such activities. The Mental Health
Society of Ghana has been formed, again through the support of
BasicNeeds, to bring together various civil society organizations
interested in mental health and thus bring sustainability to their
activities. See Appendix
2 for a list of civil society organizations working in mental
health. However, interest in mental health by general health and
development organizations is less than ideal. For example, the Ghana
Federation of the Disabled does not have strong mental health
representation.

Research

Ghana has a strong history of research in mental health, going back many
decades.13 Well-established local research institutions like
the University of Ghana and the Kintampo Project have participated in
important international collaborations such as the Mental Health and
Poverty Project. International NGOs such as BasicNeeds and CBM
International have a strong philosophy of evaluation and research within
their projects, and have published examples of good practice.14,15 The WHO is collaborating on an
important demonstration project related specifically to improving
services in the field of epilepsy using the evidence base of mhGAP.

Summary

Quality community-based services improve access to care by the poorest,
most rural populations, who are usually excluded from hospital services.
Unfortunately, despite evidence of their efficacy, and government policy
officially stating that they should be available, such services are rare
beyond the existence of psychiatric nurses at decentralized locations.
The development of accessible community-based services in Ghana will
considerably increase the chances of people receiving the care they
need. Experience shows that even if services are available, it is only
with efforts to increase community awareness that the services are well
used. Therefore it is important to deliver simple awareness messages,
including basic human rights messages, positive messages about mental
health issues (e.g., treatability), and advice on how to access care in
the community.

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