The 2012 passage of the Mental Health Act in Ghana coupled with the nation’s recent ratification of the United Nations Convention on the Rights of Persons with Disabilities certainly marks a huge forward leap towards providing improved conditions for persons suffering from mental disabilities.
But many are already questioning the preparedness of the nation to move beyond the public declaration to practical demonstration that will make real the provisions of the law to save the over 2 million Ghanaians languishing with various mental health conditions as well as salvage the country’s dented international mental health image.
Interestingly however, even before serious national efforts backed by needed resources are brought to bear on the core tenets of the eight years “battle-Born” mental health law, some public health institutions are already several miles way into the operationalization of aspects of the law which promotes early identification and prompt treatment of mental disorder in primary health care facilities and referral hospitals. One of such institutions is the Bongo District Hospital in the Upper East region.
Authorities of the hospital have not only defied all odds to set up and run a psychiatric unit but have also rolled out an intensive district-wide community outreach programme on mental health.
With just a skeletal staff of four personnel made up of two fully trained psychiatric nurses and two internship psychiatric medical assistants, the unit provides mental health services daily including weekends and run scheduled routine services in all six sub-districts. Home visits to clients are conducted to give treatment and counseling to patients whose conditions does not permit them to move to the facilities. Those who default in their treatment regime are traced and supported at the community level.
According to the Medical Superintendent of the Bongo district hospital Dr. William Gudu, the hospital’s vision to expand mental health service began on a small note a few years ago with daily education at the Outpatient Department. This was after authorities realised an increase in the number of persons reporting daily at the facility with various mental health conditions. The initiative was therefore to increase awareness on the importance and need for support for mental health and to reduce the associated stigma. This idea, Dr Gudu said worked well as the number of cases increased steadily.
He said as time went on, the hospital realised it could better attend to clients and gain adequate support from families and relatives for them if services are decentralised through the normal system. Authorities therefore deployed an outreach programme and followed it up with home visits. He emphasized that in all the avenues for providing services particularly at homes the providers employ education to try to demystify mental health as conditions caused by bodily functional disorders like any other health condition so as to reduce the abuse victims suffer.
Asked on the range of mental health conditions and trends in the district Dr. Gudu pulled out staggering figures. The statistics indicated that between July and October, 2012, a total of 1038 mental health cases were recorded at the Psychiatric Unit. 221 of the recorded cases were psychosis, 72 for depression, and 9 for substance abuse. Epilepsy topped the list with 441cases with other conditions being 295. He said the hospital has over the past two years ensured constant supply of all basic drugs and treatment for most cases while following through with families to refer patients who required high levels of care to the appropriate facilities.
Dr. Gudu pointed out that his biggest motivation in the few years of expanded services for mental health patients is the increase in community acceptance and the commitment of staff working in the unit. He revealed that the hospital has taken upon itself to give all student nurses who come on internship to have an experience working at the psychiatric unit. This measure Dr Gudu hinted is to expose students to real mental health service environment so as to reduce the poor perception of mental illness among health workers. “It is part of our policy here; any nurse who passes through this hospital must run a schedule at the psychiatric unit”. On his impression about the attitude of students nurses towards the policy the Medical Superintendent said the practices has been received well by all and is working perfectly.
To say authorities of the Bongo District Hospital are living the dreams of “Diehard” advocates of mental health might be the least: as Dr. Akwesi Osei Ghana’s Chief advocate for mental health and other like-minded fellows have long held, it is only by shifting focus of mental health treatment from institutionalised care to one of integration at each level in the health system that Ghana can redefine rights and dignity for all persons including persons who suffer mental illness.
The Bongo District Hospital mental health initiative is therefore an insightful experience that lends credence to the quest for mental health mainstreaming policy. This point received emphasis when the Regional Director of Health Services Dr John Koku Awoonor-Williams was contacted to ascertain a broader picture of mental health situation in the region. Dr Awoonor-Williams said even though the Upper East region is not well supplied with staff, the region has over the years made efforts to provide support and treatment for high proportion of the population who suffer various forms of mental illness. The director of health expressed delight at the reforms the news mental health law contains and said the Upper East Region is poised to give strong backing for training of more community mental health officers and strengthening other health systems that give focus to the involvement of patients and families, strong advocacy and health promotion as well as quality and equity of access to services across different groups.
But if there is anything that the Bongo hospital initiative has helped to bring to the fore in the mental health mainstreaming front, it is the extent of backing, resources and other wise needed for operationalization of the new reforms in mental health in Ghana. As it came out later in my interaction with Dr Gudu, integrating mental health into the core general healthcare services come with a lot of challenges. In the case of Bongo, the paucity of logistics forms the biggest threat to the very existence of the unit. It is disheartening to see the accommodation space in which the unit operates. In the words of the Medical Superintendent the psychiatric unit operates in an “unimaginably too small office space” which could hardly accommodate the few staff let alone clients.
So, the integration argument which is to do away with the inhuman environment identified with mental health service in Ghana turn to give little hope as patients stay in the open at the mercy of the weather for hours, waiting for their turn to access service. Certainly this cannot be the new phase of mental health system which Dr. Osei and others want to see.
Transport was another grave concern of the psychiatric unit at the Bongo Hospital. Not only is the community service programme severely constrained by the poor state of the old motor bike at their disposal but also the lack of funds for fuel and its maintenance. Apart from that with NHIS not covering mental health all other costs with the exception of drugs which is mostly donated have no source of funding and the hospital must find the funds wherever it may to foot the bills.
It is worth ruminating the impact and effect of the burden of cost on facilities if upon the coming into force of the mental health law government as has been advocated does not make direct budgetary allocation for the sector.
“Staffing is also a challenge”, Dr Gudu stated. “There are only two staff that must cover the entire Bongo district, and even though they are able to do it by sheer hard work it is obvious they cannot continue like that for long”, he lamented. The two Staff deployed to provide services in 134 communities with a population of 86, 586 people as noted in Bongo tells the depth of the staffing problem with regards to mental health in Ghana. Currently while over two million people are known to suffer from various mental disabilities in the country; there are only 14 psychiatrists, 600 psychiatry nurses, 8 Medical Assistants in psychiatry, and 3 Clinical Psychologists in Public Health Service in the country.
But whilst we are all concerned and anxious for the take off of the “better days train” of Ghana’s mental health, the intervention at the Bongo hospital more than provides a test case for assessing the value of the new law viz a-viz factors that could impede any meaningful implementation of the community based service approach envisaged.
In answering a question on how mainstreaming can deal with the case of shrines and prayer camps; one of the ugliest spot of Ghana’s mental health care, Dr Gudu indicated that under the community base approach as underlines the Bongo initiative, residents who are known to be receiving treatment and spiritual healing from shrines and men of God are also provided with services concurrently. But Bongo might be a place not known for popular spiritual centers for mental health as according to Dr Gudu he did not know of any such centers in the district where residents are chained or highly restrained.
As I sat down listening to Dr William Gudu on the Bongo story, I thought and believe share the view; better days for mental healthcare in Ghana are just at the corner; the new mental health law is the best thing that has ever happened to the country but the government and all who matter this must act without delays to meet all the provisions of the new law. Mainstreaming mental health is feasible and impactful and the entire nation can draw inspiration and lessons from Bongo District Hospital regarding rolling out community-based mental health programme. But I cannot forget to add that authorities at the Bongo District hospital are holding out a hand for dire resources to maintain and sustain the flagship programme.
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