Backgrounder No. 39
Psychiatric Hospital, Accra, Ghana (Berry Fine/Flickr)
In the World Health Organization’s (WHO) latest report on the global burden of disease, mental disorders have been recognized as a leading worldwide concern. Women and the poor are particularly vulnerable to mental problems as their disorders are exasperated by social and cultural vulnerability (Ofori-Atta et al., 2010: 589-97). Despite the significant global prevalence of mental disorders, however, there is a recognized gap in funding for treatment, especially in developing countries where patients are left on their own and face social stigmatization (WHO, 2001: 3). In general, developing countries tend to allocate minimal resources towards mental health, prioritizing initiatives that target infectious disease and reproductive health instead (Prince et al., 2007: 860).
Despite its other progressive health policies, Ghana is no exception to this trend. The WHO reports that there are currently over 2 million Ghanaians suffering from moderate to mild mental disorders, and 650,000 of which are suffering from severe illnesses (WHO, 2011). It is further estimated that Ghana’s treatment gap (defined as the number of people whose illness goes untreated) stands at 98 percent (WHO, 2011). This backgrounder explores the shortcomings of Ghana’s mental health policies, and highlights the implications and outcomes for the country’s population.
Given Ghana’s limited infrastructure and support for mental health, the above figures should not be surprising. Out of the country’s entire 2009 health budget, just over one percent of funds were allocated to mental health. Even this small proportion was a drop from previous annual budgets, reflecting the recent lack of recognition for mental health initiatives (Raja et al., 2010: 10).
In Ghana the primary sources of mental health treatment are three psychiatric hospitals, all located in the southern part of the country (Raja et al., 2010: 11). Altogether, the entire country has only 14 practicing psychiatrists, all of whom are also based in the south, making for a care ratio of 1:1.7 million (GNA, 2009). Thanks to the concentration in the south, the northern areas are significantly underserved and lack adequate access to treatment. As a result, those in need of long-term care or intense treatment often have to travel across the country in search of it (Antwi-Bekoe and Mensah, 2009: 5).
Further, while consuming the entire mental health budget, the care given at Ghana’s three psychiatric hospitals is not ideal for the majority of mental health issues. Almost 83,000 patients attended one of the hospitals in 2002, the majority of whom were diagnosed with schizophrenia (Owusu-Daaku et al, 2011: 1). The hospitals are often congested, unorganized and consistently short on beds for patients (Antwi-Bekoe and Mensah, 2009: 5).
A variety of reasons account for the lack of support for mental health in Ghana. Stigma surrounding mental illnesses is chief among them. There is also a lack of funding from international donors that has kept it a low political priority within the government. Progress in mental health policy also suffers from inadequate research and, in the rare cases that policies are enacted, they are poorly implemented (Omar et al, 2010: 7-9). The resulting deficit of mental health professionals, shortages of psychiatric medicines and poor infrastructure only works to further isolate the afflicted and engrain social stigma surrounding mental illness (Antwi-Bekoe and Mensah, 2009: 1).
Since the majority of Ghanaians suffering from mental illness will never come in contact with a psychiatrist or mental institution, would-be patients are seeking assistance in other ways. Much of the official care burden falls on other health professionals. As Ghana makes significant strides toward enrolling the population its universal national health insurance program (see: Dixon, 2011: 1-6), a large proportion of people can access free health care. Health professionals such as community nurses and pharmacists become the first, and often only, point of contact with those suffering from mental illness, though their preparation for this type of care is minimal (Antwi-Bekoe and Mensah, 2009: 5).
There is also widespread appeal for traditional healers to treat mental illness. For the most part this can be traced to the availability and affordability of the healers, most notably in rural areas of the country. Practices by healers have been a source of much controversy, however, and include human rights and safety concerns, in addition to skepticism surrounding the effectiveness of conventional treatments (Ae-Ngibise et al., 2010: 558—67; Read et al., 2009: 2-3). Influenced by the spiritual and controversial understanding of mental illness as ‘madness’ in some communities, chaining and beatings have been a regular component of treatments initiated by healers (Read et al., 2009: 8). These actions represent an attempt to maintain the care of the severely ill in the absence of other forms of support. These practices are also rooted within historically and culturally accepted responses and typically do not evoke questions of human rights abuses in Ghana (Read et al., 2009: 14). Some evidence also suggests that in areas where traditional healers have fallen out of favour, those suffering from mental health problems are likely to seek help from religious counselors before turning to the formal health care system (Appiah-Poku et al., 2004: 209—11).
As Ghana’s policy makers struggle to allocate health care resources most effectively, questions arise as to why mental illness deserves special attention. The WHO’s director-general writes: “WHO is making a simple statement: mental health — neglected for far too long — is crucial to the overall well-being of individuals, societies and countries and must be universally regarded in a new light” (WHO, 2001: ix). Mental and behaviour disorders involve a complex intertwining of biological, psychological and social factors. These disorders are similar to many physical illnesses in both their complexity of treatment and impact on the lives of those affected (WHO, 2001: 10).
Mental disorders have also been found to impact the incidence of other health conditions. For example, those suffering from depression have a heightened chance of contracting HIV/AIDS (Prince et al., 2007: 864). As well, mental disorders may be a symptom of other serious medical problems or may impact the treatment and final outcomes of patients suffering other health conditions. For example, patients may delay seeking treatment or have difficulty following medical guidelines for treatments of other illnesses (Prince et al., 2007: 862-70).
Mental illness impacts are far reaching and go beyond the patient. Given that many communities in Ghana have tightly interwoven social networks, one person’s illness impacts an entire community. Families in Ghana, in both urban and rural settings, provide the main source of care for the ill, which has been found to lead to financial burden, emotional strain and social stigma (Quinn, 2007: 33). A mother’s mental state also has huge implications for the well being of her child. Maternal schizophrenia is associated with preterm delivery and low birth weight, and maternal depression is associated with lower cognitive development in children (Prince et al., 2007: 867—8).
Treating mentally illness should be understood as a public good as the benefits of effective mental health policy are evident in non-health forms. Incidences of reduced motor vehicle accidents, lower rates of substance abuse and reduced poverty levels are just a few examples of the upside linked to properly treating mental illness (WHO, 2001: 93).
Through a series of workshops and consultations with key national stakeholders, Ghana has developed what the WHO considers to be a “comprehensive Mental Health Bill, which protects the rights of people with mental disorders and promotes mental health care in the community in accordance with international human rights standards” (WHO, 2011). The Mental Health Bill supports adequate provision of resources across the country, and calls for a board, review tribunal and recognized rights for persons undergoing care. The bill would also shift financing away from institutional care and place mental health coverage within the national health insurance plan (GNA, 2009). While receiving broad support from the international medical community, the bill (originally drafted in 2004) has stalled at Ghana’s Ministry of Health. At the time of writing, in 2012, the bill was being presented in Parliament.
Mental illness in Ghana is a poorly understood and funded element of health that stands to benefit greatly from government support. Ghana’s proposed mental health legislation would serve to address many of the issues raised in this backgrounder.
Ae-Ngibise, K., S. Cooper, E. Adiibokah, B. Akpalu, C. Lund and V. Doku (2010). “‘Whether you like it or not people with mental problems are going to go to them’: A qualitative exploration into the widespread use of traditional and faith healers in the provision of mental health care in Ghana,” International Review of Psychiatry. Vol. 22, No. 6: 558—67.
Antwi-Bekoe, T. and E. Mensah (2009). Financing Mental Health Care in Ghana. BasicNeeds. Available at: http://www.basicneeds.org/html/Publications_BasicNeeds_Research.htm.
Appiah-Poku, J., R. Laugharne, E. Mensah, Y. Osei and T. Burns (2004). “Previous help sought by patients presenting to mental health services in Kumasi, Ghana,” Soc Psychiatry Psychiatr Epidemiol. Vol. 39: 208—11.
Dixon, J (2011). “Financing National Health Insurance in Ghana,” Africa Portal: Backgrounder. Available at: http://www.africaportal.org/articles/2011/07/13/financing-national-healt....
GNA. “Mental Health System on the verge of collapse - Dr Osei,” GhanaWeb. May 10. Available at http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=181770.
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Owusu-Daaku, F., A. Marfo and E. Boateng (2011). “The contribution of Ghanaian pharmacists to mental healthcare: current practice and barriers,” International Journal of Mental Health Systems. Vol. 4, No. 14.
Prince, M., V. Patel, S. Saxena, M. Maj, J. Maselko, M. Phillips and A. Rahman (2007). “No health without mental health,” Lancet. Vol. 370: 859—77.
Quinn, N (2007). “Beliefs and Community Responses to Mental Illness in Ghana: The Experiences of Family Carers,” International Journal of Social Psychiatry. Vol. 53, No. 2: 175—88.
Raja, S., S. Wood, V. de Menil and S. Mannarath (2010). “Mapping mental health finances in Ghana, Uganda, Sri Lanka, India and Lao PDR,” International Journal of Mental Health Systems. Vol. 4, No. 11.
Read, U., E. Adiibokah and S. Nyame (2009). “Local suffering and the global discourse of mental health and human rights: An ethnographic study of responses to mental illness in rural Ghana,” Globalization and Health. Vol.5, No. 3.
WHO (2001). The World Health Report 2001: Mental Health: New Understanding, New Hope. Geneva. Available at: http://www.who.int/whr/2001/en/.
_____ (2003). Mental Health Financing. Geneva. Available at: http://www.who.int/mental_health/resources/en/Financing.pdf.
_____ (2008). Global Burden of Disease 2004 Update. Geneva: World Health Organization.
_____ (2011). Mental Health: Ghana. Geneva. Available at: http://www.who.int/mental_health/policy/country/ghana/en/.
Jenna Dixon is a Ph.D. candidate in the Department of Geography at The University of Western Ontario. Her doctoral research draws on a foundation of health and developmental geography to focus on the roles of gender and poverty in achieving access to health care in Ghana.