Addressing Child and Adolescent Mental Health (CAMH) in Uganda

Mental health nurse Emma Gilbert has spent nine months volunteering in Kampala, Uganda, within the Child and Adolescent Mental Health (CAHM) project implemented by the East London NHS Foundation and the Butabika Hospital. What follows is the account of her experience in Uganda. 

With a background in anthropology and a career in radio, my interest for global health only developed at a later stage of my life. I qualified as a mental health nurse and from the beginning I found the idea of working in global health very appealing. When, in 2015, the East London NHS Foundation was looking for a mental health nurse for their health partnership in Uganda, I jumped at the opportunity.

Understandably, the first question that my family and friends asked was: Why are you going?

The answer was pretty easy: when the project was launched there were, I think, only five child psychiatrists in Uganda, a country where 60% of the population is under 16. The lack of specialised human resources was appalling, so in implementing a training course for CAMH the partnership was trying to address a very obvious need.

The training course was designed by Dr Allison Hall, from East London, in collaboration with Dr Godfred Jokundo and Dr Joyce Naluja, the two psychiatrists from Butabika Hospital who run the course in Kampala. The programme promotes a multidisciplinary approach, to foster better integration of services, a real problem in a country where child healthcare often falls under primary care and there is a lack of specialist services. Therefore the training attracted a really interesting mix of health professionals, not only psychiatric clinical officers, but also paediatricians, nurses, social workers, psychiatrists and medical doctors. The enthusiasm of the people I was teaching was probably one of the best things of the job. They took time out of their formative jobs, and travelled from all over the country to take part in incredibly long teaching days. At the end of these, at 6 or 7 pm, we usually had a question session. I did not expect anybody to have the energy to keep going. I was wrong. The dedication - the interest was great. And because CAMH is a relatively new area, you could really feel their hunger for leadership, for pioneering the field.

At the hospital we saw the broad spectrum of mental health disorders. Sometimes that would also include severe learning disabilities or episodes of psychosis and issues linked to trauma or abuse. If a person had emotional behaviour difficulties, which wouldn’t necessarily be classified with a mental health diagnosis, they would still come to Butabika. There were all these factors in play which meant that diagnosis, although important, wasn’t always the first thing that we addressed. In many cases we were operating almost like a children’s home

The majority of our cases, however, were epilepsy. The child’s family often believed that epilepsy was contagious or that the child was bewitched. In many instances we saw evidence of violence on epileptic children. They were often brought to traditional healers and went through all sorts of ceremonies.

There is still stigma attached to mental health in general and by extension to the Butabika hospital, which means that the hospital is often the last resource. I saw a lot of brain injuries that could have being avoided if they had come to us sooner. The work that has been done with the trainees is also helping to overcome and challenge the wrong beliefs, but it is a slow process.

The training has been instrumental in developing CAMH services. It has generated the interest of the Ministry of Health, which we have tried to engage from Day 1. We also have university accreditation which was extremely important in order to attract new students. Before the very few CAMH specialists were operating individually with lack of support, supervision or platforms to share any kind of clinical knowledge, a network for collaboration and discussion has been established. Finally, we collaborated with the Ministry to write policy guidelines on CAMH services. I feel very proud of what the course achieved.

On a more personal level, I also learnt a lot, being forced out of my comfort zone and in the end almost running a clinic where you see fifty patients a day. In the UK, you’d be seeing maybe four patients daily, here it’s more 30 to 40, so my clinical knowledge improved significantly. I 100% feel that I am a better nurse after this experience. The ability I developed to work with different people, and to be open and flexible is extremely valuable back in London where I work with patients from diverse backgrounds.

I now consider myself a strong advocate for health partnerships. I have already encouraged other colleagues within the NHS who want to work overseas that this is the best way to do it. A lot of nurses feel the appeal of working with organisations like MSF, which is of course a very valuable frontline aid service. But health partnerships are amazing because they enable sustainable service transformation.

Emma Gilbert 

Mental Health Nurse

East London NHS 

Strengthening Global Mental Health partnerships - #LetsTalk Depression

A new mental health collaborative was inspired to come together after the Health Partnership Symposium, Petty and Randy explain why sharing knowledge and practice across country borders is so crucial in the battle to improve mental health care. 

“Seeing mental health and substance misuse patients suffering, neglected by the community, families and other healthcare workers; motivated me to work with mental health. Working as a health Administrator and a Project Coordinator at a Tanzania National Mental Health Hospital, I found I could help these individuals so that they can be provided with an environment that will allow them to recover from their illnesses, reduce relapses and lead a normal life.”

Perpetua Mwambingu- Tanzania Link Project Coordinator

“In Ghana mental illness is often attributed to spiritual causes and people who suffer from mental illness do not get the help that they need. Stigma and discrimination is high and people who suffer from mental illness lose their dignity, respect and self-worth. My passion for awareness creation and advocacy and my belief that someday Ghana will appreciate the importance of mental health motivates me even during moments of burnout”

Randy Agbodo- Project Lead for Ghana - Zambia - NHS Highlands Partnership

The Story Remains the Same

According to the World Health Organization, for every four people, one will be affected by a mental or neurological disorder in their lifetime. The magnitude of mental health burden is not matched by the size and effectiveness of the response it demands. Currently, more than 33% of countries allocate less than 1% of their total health budget to mental health[1].

Sadly, in Tanzania and Ghana where Randy and I are working, the story remains the same, mental health services are underfunded, and most of the donor funded programs go to communicable diseases. There is inadequate human resource and insufficient supply of medications. Stigma and discrimination towards persons with mental disorders is still prominent and effective mental health prevention and promotion programs are woefully inadequate.

 No Health without Mental Health

Depression is ranked first in the list of top ten leading causes of years lived with disability (YLDs)[2]. Globally, an estimated 350 million people of all ages suffer from depression[3]. At its worst depression can lead to suicide and close to 800,000 people die due to suicide every year[4].

This is why it is so vital that World Health Day this year is addressing depression, bringing it to the fore of global health discussions. It gives health managers and policy advisers the opportunity to appreciate that depression affects productivity and therefore prioritizing and investing heavily in mental health would, in the long run, culminate in populations with healthy outcomes, respect for human rights and stronger economies.

The Health Partnership Symposium ‘effect’

In order to make this a reality, we believe that collaboration and the sharing of approaches is key and at the recent Health Partnership Symposium, organized by THET, we found we were not alone in this thinking.

Our passion for working in mental health was further cemented at the event where a certain chemistry brought colleagues from Ghana, India, Kenya, Nepal, Scotland, Tanzania, Uganda and Zambia together to form the ‘Mental Health group’.

We all wanted to come together to tackle and develop our learning on different mental health issues.  Ultimately we wanted LMIC’s to start collaborating and to share experiences which can strengthen the partnerships we work in. That’s when a luncheon ‘chat’ was called, then a dinner ‘talk’ happened and then we came to form a WhatsApp group, a way for us to easily reach out to each other.

The world is facing many challenges; political unrest, war, economic hardship, unemployment, etc., all are contributing factors to depression. This must be a wake-up call for the global community, the need to re-think, and re-act to this global crises, now is the time to re-set our priorities with regards to mental health and to act together through partnerships and shared learning. After all there is no health without mental health.

Perpetua Mwambingu

Tanzania Link Project Coordinator,

Tanzania

Randy Agbodo

Project Lead for Ghana - Zambia - NHS Highlands Partnership,

Ghana

[1] http://www.who.int/whr/2001/media_centre/press_release/en/

[2] http://www.who.int/mediacentre/factsheets/fs369/en/

[3] Ibid

[4] Ibid

Together We Can Overcome - #LetsTalk Depression

The grief and grievances for those suffering from mental health problems are largely overlooked by both health and social sectors.

In every street, in every corner, we find those suffering from neuropsychiatric disorders. They are silent victims of neglect and abuse experiencing human rights violations across the globe. Those we called our friends, fathers, mothers, sisters, brothers, sons and daughters in the past, today have become our enemies without committing any crime.

Depression is the most commonly diagnosed mental illness in Zambia[1], alongside other neuropsychiatric disorders such as those relating to drug and alcohol abuse. Stigma attached to mental illness, the prevalence of HIV, high unemployment and socio-economic difficulties all significantly increase the risk of mortality[2]. At a global level, over 300 million people are estimated to suffer from depression, equivalent to 4.4% of the world’s population[3].

Although mental health constitutes a large number of disease burdens in developing countries, it is largely overlooked and given inadequate attention.

It is in this context that THET is working hard to help those facing mental health challenges, among other global health issues. As part of their work they have provided funding for the Mental Health Literacy and Improved Patients Safety Empowering Communities Project run by the NHS Highlands – Chipata General Hospital Partnership.

Located in the eastern part of Zambia is Chipata Central Hospital. The hospital is the biggest referral Centre in the province and is well known for its specialized treatment of mental health services. Like any other hospital in low income countries, Chipata Central Hospital suffers from huge medical demand with limited financial resources that put mental health in the periphery of priorities.

People can recover from mental illness but traditional beliefs and cultural practices have led to a persistent belief that mental conditions are untreatable, and this in turn has led to the marginalization of the issue in the public domain. The stigma and limited public knowledge diminishes grassroots demands for mental health policy and service developments which are weak and poorly implemented. As a result traditional medicine and spiritual management are the most common forms of treatment. Thus the need for the project is apparent.

The main aim of our partnership is to empower communities and patients to take action for better and safer mental health by creating positive change in:

• Perception, attitudes and understanding of mental illness,

• Improving levels of safety and support by health institutions and local communities

• Providing relevant mental health educational materials delivered appropriately and creatively to communities deprived of contemporary communication channels

We also acquired bicycles to be used by community volunteers and as a social enterprise, to provide greater access to creative Arts, explaining mental health and helping to disseminate more accurate information to communities regarding mental health.

I have met so many people through the partnership and have seen the positive impact that reaching out and empowering communities on mental health literacy can have. It is increasingly clear that supporting such projects in any way possible can help overcome the challenges mental health is facing.

People with mental health problems, deserve your attention. Together we can overcome.

Pearson Moyo

Project Coordinator - Zambia

Mental Health Literacy and Patient Safety: Empowering communities.

[1] http://www.commonwealthhealth.org/africa/zambia/mental_health_in_zambia/

[2] Ibid

[3] http://apps.who.int/iris/bitstream/10665/254610/1/WHO-MSD-MER-2017.2-eng.pdf?ua=1

Zambia: training health workers to make a difference

Sophie Pinder, Evaluation and Learning Officer at THET in London, shares her impressions following a recent monitoring visit to health partnership projects in Zambia which are funded through the DFID/THET Health Partnership Scheme (HPS).

In May 2016, my colleagues Pippa, Viki and I visited five health partnership projects in Zambia working on different health themes in major hospitals across the country. The week-long monitoring visit involved meeting local leads and stakeholders at the sites where these projects are being implemented.

Beyond the monitoring purpose of the trip, this was an excellent opportunity for me to gain a deeper understanding of the local context these partnerships are working in, of the perspectives of local stakeholders and which direction they want to take their projects – aspects that can often be difficult to grasp just by reading project reports when sitting at my desk in London.

One of these projects is being implemented by the Zambian Union of Nurses Organisation (ZUNO) and the Royal College of Nursing in the UK. They established their partnership in 2012. Their project aims to build ZUNO’s capacity to influence nursing policy and improve nursing practice in Zambia. 
At the ZUNO offices in Lusaka, Jennifer Munsaka, Director of Programmes and Professional Affairs and lead for this project along with Rita Mutale, Programmes Officer, explained to us how the partnership has trained twelve staff members at the University Teaching Hospital (UTH) in Lusaka in advocacy skills and supported them to become champions for the implementation of the WHO safe surgery checklist, enabling them to build their advocacy skills in practice. Not only did the champions go on to train 164 members of theatre staff to implement the checklist, they now form a strong collective voice to bring issues and needs, backed by evidence, to the attention of hospital management and advocate for improvements. Their work has also improved interdisciplinary team work and raised the profile of ZUNO at the University Teaching Hospital, the largest hospital in the country. 
The partnership now plans to train the regional directors of ZUNO in advocacy so that they can influence national policy. This expansion has the full support of ZUNO’s new General Secretary, Michelo Fray, who stressed how this project is in line with ZUNO’s strategy of empowering nurses and midwives and protecting and promoting their interests.

In the Eastern Province, Chipata General Hospital has been working in partnership with NHS Highlands since early 2014. The objective of their current HPS project is to empower communities to address mental issues through an improved understanding of mental ill health and how to provide a safe and supportive environment. Communications lead, Pearson Moyo and professional lead, Marron Mugala, introduced us to the hospital staff who are volunteering to deliver messages on mental health in 20 communities around Chipata. We participated in one of the mental health education sessions organised by the volunteers and I found that the community members were very active in the discussion and their answers reflected their awareness of how to deal with mental health issues. At the end of the session, they even told us that they hope this project would be extended to other communities in the region so that volunteers could continue to raise awareness on mental health. The volunteers come from different specialities and wards across the hospital and some of them live nearby or in the communities themselves. As such, I had the feeling that the entire hospital was mobilizing itself for this project and that this could raise the profile of psychiatry and mental health as a speciality with the hospital.

After every project we visited, I felt a real sense of commitment of those engaged, from the UK volunteers delivering training to hospital staff to health workers volunteering their time to drive the projects forward. All have the ambition to expand their work at regional or national level, despite the challenging environment and obstacles they face along the way. On a number of occasions, projects mentioned the lack of resources and workload, hospital budget cuts that are putting a clear strain on already over-stretched services and health workforce.

On a personal level, this visit has broadened my understanding of health partnership work on the ground. It has also inspired me and my colleagues to think more deeply about how THET can support health partnerships working in the same geographical area to collaborate with each other and how this can enable them to become stronger catalysts for change at national level. In light of this visit and others to come, my team and I are discussing how we can support partnerships to connect with each other and deepen their influence and impact.