Africa stares at severe child, adolescent mental health services gap

Mental health care has long been neglected in Africa with many countries lacking basic services while others, where the services are available, the outlook remains bleak. This neglect is manifest in the inadequate attention from the general public, the healthcare system, and policymakers. This has resulted in far-reaching consequences for the affected individuals and their communities.

Compounding the problem is the under-appreciation of the disease burden, exacerbated by the lack of research and data on mental health in health management systems. This prevents policymakers from fully understanding the scale of the problem, leading to insufficient allocation of resources.

In fact, according to the World Health Organisation (WHO), most African governments allocate less than 1 percent of their health budget to mental health, leaving an estimated 85 percent of people with depression without access to effective treatment.

On average, African governments allocate less than 50 US cents per capita to mental health, well below the recommended $2 per capita for low-income countries. Inadequate financing and low government investment in mental health care in many African countries contributes to poor access to services.

Also, despite efforts to develop training programmes for mental health professionals (psychiatrists, psychologists, mental health officers, and nurses), there is a severe shortage of these professionals on the African continent. The WHO reports that there are only 1.4 mental health professionals per 100,000 population in Africa, compared with the global average of 9 per 100,000 population, further limiting access to mental health care.

Yet, the percentage of health workers at the primary care level receiving training on the management of mental health conditions is also lowest in Africa. This lack of training and expertise at the primary care level means that people at the community and primary care levels are left largely underserved.

Universal human right

The concentration of resources in large psychiatric institutions in urban areas exacerbates the problem, as it leaves people at community level with limited access to mental health care. In 2020, the annual mental health outpatient visits in Africa were only 94 per 100,000 population, compared with the global average of 2001 per 100,000 population.

This dire situation suggests that even if governments make financial commitments and take action based on their policy declarations, they are likely to fall short of achieving the desired level of mental health care provision. The WHO’s 2022 Mental Health Report emphasizes that maintaining the status quo in mental health care is insufficient and calls for significant changes to be made.

“The right to mental health is a necessity not a luxury in Africa,” said the Unicef Regional Director in West and Central Africa, Felicité Tchibindat on this year’s World Mental Health Day on October 10, 2023, which celebrates mental health as a universal human right.

“The only way we can enable greater realisation of this right is through more significant investment in mental health and psychosocial support. This includes better policies and systems, including in the community, and integration of mental health services into education, protection and health interventions.”

Even worse, despite a large population of children and adolescents, there is a severe shortage of child and adolescent mental health services in the continent. According to the WHO Mental Health ATLAS 2020 Report, only 11 out of the 47 countries of the WHO African Region provided information on child and adolescent mental health policies, and only three of these countries reported that they have such policies. Further, less than 50 percent of the mental health policies and plans in the Region comply with human rights standards.

According to the WHO, there is a link to the number of harms children face, the huge gap in services and poor mental health outcomes. These harms include, child marriage, female genital mutilation, sexual and physical violence (both male and female), intimate partner violence, child labour and violent discipline. To achieve tangible progress towards achieving the SDGs, efforts to protect children from harm need to be doubled, as well as treatment for both physical and mental impacts of such harms.

This lack of focus on child and adolescent mental health is deeply troubling, as it has a direct impact on the well-being of young people in the region.

“We cannot afford to ignore the concerning number of children and young people across the region who experience mental health challenges, exacerbated by multiple shocks, violence and humanitarian crises, with devastating impacts on their well-being and on communities as a whole,” said Etleva Kadilli, Unicef Regional Director for Eastern and Southern Africa.

“Now is the time to increase investment in mental health services and provide children and young people with the essential tools and resources for them to develop to their full potential. Change is long overdue, and no child should have to carry invisible scars alone.”

SDG targets

The lack of mental health policies and plans in Africa is a significant barrier to improving mental health care, with only 21 percent of Member States having mental health policies or plans that are fully compliant with human rights instruments, causing a significant deferment on the 2030 global target of 80 percent. The Africa region has the lowest percentage, with only 4 percent of all Member States meeting this criterion.

In August 2022, African health ministers gathering for the 72nd Session of the WHO Regional Committee for Africa — the region’s flagship health meeting — endorsed a new strategy to reinforce mental health care and set 2030 targets: all countries to have a policy or legislation on mental health and set aside a budget for mental health services.

Guidelines for integrating mental health into primary health care are lacking. This further hampers the delivery of mental health services at the primary care level, where a significant portion of the population seeks healthcare.

High suicide rates

Inadequate collaboration between the mental health care system and the social affairs and social welfare sector is another challenge. Many patients are left without proper care due to this lack of collaboration. Efforts to improve collaboration and coordination between these sectors are crucial for ensuring holistic care for individuals with mental health conditions.

The absence or non-functioning of authorities or bodies assessing the compliance of mental health legislation with international human rights instruments is another concerning issue. The African and South-East Asia regions have the highest percentages of countries reporting such absence or non-functioning, indicating a lack of oversight and accountability in mental health legislation.

Insurance coverage for mental health patients in Africa is poor, with a significant percentage having to pay out of pocket for mental health services and psychotropic medicines.

In Africa, a significant percentage of mental health patients, (41 percent), pay mostly or entirely out of pocket for mental health services, and 49 percent have to do the same for psychotropic medicines. This situation is particularly prevalent among low-income countries.

The high cost of treatment often leaves young people in Sub-Saharan Africa with no choice but to live with untreated mental disorders or seek treatment from traditional or religious leaders, leading to a significant treatment gap in the region.

Yet the high suicide rates in Africa add to the urgency of addressing mental health care in the region. Africa, home to six of the top 10 countries with the highest suicide rates worldwide, has one of the highest suicide rate globally, with approximately 11 out of every 100,000 people dying by suicide annually. This is higher than the global average of 9 per 100,000 people. Moreover, studies have shown that for every completed suicide in Africa, there are approximately 20 attempted suicides.

In Kenya, Nigeria, and Egypt, depression and suicide rates continue to rise, highlighting the urgent need for action. South Africa reported a suicide crisis in 2022, joining other African countries with high suicide rates such as Lesotho, Eswatini, Zimbabwe, Mozambique, and the Central African Republic. Mental health problems contribute significantly to the risk factors associated with suicide, underscoring the need for comprehensive mental health care and suicide prevention programs.

For instance, in Kenya, young people aged 10-24 years make up 60 percent of the population, and 10 percent of these young individuals suffer from mental health difficulties. The suicide rate in Kenya is also concerning, with seven people out of every 100,000 dying by suicide.

Dr Matshidiso Moeti, WHO Regional Director for Africa, emphasized the need for radical change to make mental health care a public health priority in the African region and ensure that people in need receive the necessary support and treatment.

“Suicide is a major public health problem and every death by suicide is a tragedy. Unfortunately, suicide prevention is rarely a priority in national health programmes,” she said. “Significant investment must be made to tackle Africa’s growing burden of chronic diseases and non-infectious conditions such as mental disorders that can contribute to suicide.”

“The severe shortage of professionals is among the major barriers to adequate mental health services in our region. To address this challenge, we are supporting countries to enhance mental health worker training, including at the lowest level of care. We are also supporting the efforts to improve availability of essential psychotropic medicines as well as promote and protect the rights of people with mental health conditions,” said Dr Matshidiso Moeti, WHO Regional Director for Africa.

To address the gaps in mental health care, some countries in Africa, like Nigeria, have turned to online counselling and psychosocial support.

Online therapy has helped destigmatize mental care and encouraged more young people to seek treatment for depression, stress, and anxiety.

Breaking the stigma surrounding mental health is crucial, and initiatives that educate young people about mental well-being and encourage open conversations can play a significant role in normalizing discussions about mental health.