Increasing the Priority of Mental Health in Africa: Findings from Qualitative Research in Ghana, South Africa, Uganda and Zambia

"Our findings have indicated the importance of international information and advocacy in providing support for mental health, taking into account the information needs and social, cultural and political context. We also provide concrete evidence-based recommendations in response to calls for mental health advocacy to be informed by research on political will..."

According to the authors of this paper, despite the high prevalence of mental illness, mental health remains a low priority in Africa. Noting that there has been no investigation of the views of stakeholders in Africa on why this is and what can be done, as part of the Mental Health and Poverty Project (MHaPP), researchers undertook a comparison of the views of stakeholders in Ghana, South Africa, Uganda, and Zambia, focusing on the priority given to mental health by the government at the national and regional/province levels. The MHaPP Research Programme Consortium collaboratively developed guides for the semi-structured interviews; each country team then adapted the guides according to the local context - for example, adding and amending questions to reflect local priorities and the health system structure. Respondents included health and mental health policymakers in the Ministry of Health, politicians, health service managers, media representatives, representatives from non-health sectors, health professional unions, traditional healer unions, mental health user groups, and mental health non-governmental organisations (NGOs). Semi-structured interviews totalled 58 in Ghana, 64 in South Africa, 42 in Uganda, and 65 in Zambia. Researchers then used a 2-stage approach to analysis: framework analysis in each study country, followed by comparative analysis of the country data.

In general, mental health was largely considered a low priority at national and regional/provincial levels in all 4 countries. Why? The researchers identified 9 factors affecting the priority of mental health, which were grouped into 3 categories (beneath each category is a summary of respondents' suggestions for addressing the observed shortcomings):

1. Legitimacy of the problem - Mental health was not considered a legitimate problem due to limited appreciation of the prevalence of mental illness among decision makers. This was attributed to a lack of epidemiological research evidence on the prevalence of mental illness and a lack of routine data from the health management information system (HMIS). Data were not collected on the majority of people with mental illness in facility-based health information systems, so they remain invisible to policymakers. Some decision makers interviewed suggested that priorities should be based on mortality figures, rather than morbidity or social impact. Respondents also referred to the lack of coverage of mental health in the media, indicating that informal evidence was also important for setting priorities. Media representatives in Uganda acknowledged the prevalence and economic impact of mental ill-health, but cited the lack of mental health events and campaigns, the lack of mental health advocates, and low mortality as reasons for low media interest in mental health.
   • Respondents' suggested improving data collected on mental health prevalence and impact, including through the HMIS. Media representatives in Uganda indicated that journalists with personal experiences of mental illness were more likely to write about the topic. Likewise, politicians and policymakers with experience of mental illness were considered more likely to take up the mental health cause. Respondents in Uganda suggested a need for training for journalists to improve media coverage. Media representatives suggested a need to improve communication on mental health, hold events, and involve influential people such as politicians and celebrities to improve mental health media coverage.
2. Feasibility of response - There was some evidence that people had a lack of knowledge of appropriate interventions to prevent and treat mental illness and to promote mental health. Respondents stated that mental illness was often misunderstood among members of the general public and regarded as a spiritual, supernatural, or moral issue, rather than a disease that should be addressed by health services. "People don't think mental illness is like any other illness; you are either bewitched or it is something running strictly in your family....They think mental illness is incurable." [Media representative, Uganda]
   • "Some of the leaders don’t have the negative attitude as such but simply don't know what to do....We need massive sensitization." [NGO respondent, Uganda]
3. Support for response - Lack of funding for mental health, including government and development partner funding, was identified as a key barrier. Competing health and development priorities are described as acting as a deterrent to action for mental health. Whilst respondents felt that advocacy for mental health was vital, they noted a lack of advocacy by user groups, health workers, and managers. User groups and mental health NGOs operated in all 4 countries. However, respondents noted that there was little coordinated action to advocate for better mental health policy or implementation and service provision, in particular in South Africa.
   • Respondents frequently cited international advocacy as a driver for change. Improved national advocacy for mental health was called for by respondents in all countries; they articulated a need for coordinated advocacy movements, involving user groups, NGOs, and other organisations. The need to tackle the stigma surrounding mental illness was identified, for example through awareness-raising activities with the public. A number of respondents from Ghana, South Africa, and Uganda drew parallels between mental health and HIV, which is also a stigmatised condition. They suggested that mental health advocates should draw lessons from HIV to improve strategies to tackle stigma and increase the priority of mental health. Respondents also called for greater external funding from donors and international organisations.

Stigma was identified as an overarching problem in all countries and was a cross-cutting issue, affecting legitimacy, feasibility, and support. Stigma was found to affect not only mental health patients and their families, but also those who worked in mental health and even policymakers who took up the mental health cause. This acted as a strong deterrent to people advocating for mental health or working in a mental health field.

The paper concludes with broad suggestions to raise the priority of mental health. In brief, there is a need to:

• improve information collection, translation, and dissemination on mental health; and
• improve awareness of mental health issues among the general public and decision makers. There is a related need to develop advocacy for mental health - e.g., by supporting local and national mental health user groups to form networks, advocate effectively, and have a public voice; providing training or support to the media to improve reporting on mental health; and developing public awareness raising and education on mental health.