Closing the gap

Published on 08 July 2020 Go back to The ACU Review
Wellcome Trust Image (Cropped)

In the face of stigma and underfunding, a project in west Africa is empowering patients, caregivers, and health workers to change the way their countries approach mental healthcare.

By Oye Gureje, University of Ibadan, Nigeria

Mental health is one of the most neglected of global health issues, and this is particularly true in low and middle income parts of the world. An estimated three-quarters of those suffering from mental illness live in low and middle income countries, yet as many as 90% will be unable to get the right help and treatment for their needs. In sub-Saharan Africa, less than 1% of already small health budgets is spent on mental health, while policies and legislation to protect and improve the lives of those suffering are inadequate or non-existent. This neglect is reflected in the desperate shortage of trained mental health professionals: many countries in the region have only one psychiatrist per million people; some have none at all.

Mental health problems are responsible for much suffering globally. Indeed, the World Health Organization estimates that more than 264 million people worldwide are affected by depression alone. Many mental health conditions take hold early, particularly in adolescence and early adulthood, leaving those affected unable to achieve important milestones such as completing their education, building a career, or forging lasting relationships.

Yet it is invariably the case that physical wellbeing is prioritised at the expense of mental health. In most parts of the world, the budgets apportioned to mental illness are grossly inadequate, and even more so in low and middle income countries. An even more fundamental sign of neglect is the absence of formal policies on mental health or a failure to implement those that exist. Without such policies and legislation to protect the rights of people with mental illness, there are no benchmarks to hold governments to account over what they should be doing to advance and protect the mental health of their nations.

In sub-Saharan Africa, a glaring symptom of this neglect is a dire shortage of resources and trained professionals for mental healthcare. The number of mental health beds, for example, is just 2.5 per 100,000 in the African region compared to a global median of 16.4 – and most of those available are in stand-alone mental institutions, rather than in general healthcare settings close to the community. Human resources are equally scarce: as mentioned earlier, the ratio of psychiatrists to the population in many sub-Saharan African countries is about or less than one to a million, while psychologists, mental health nurses, and social workers are often scarcer still.

Reform is about more than resources

But changing the mental health landscape is about more than just improved resources. It’s about changing mindsets. Despite the fact that mental health conditions share similar genetic, social, and environmental risk factors to many physical disorders, there is a tendency to treat them differently and pay less attention to the needs of those affected. In many parts of the world, people with mental health issues also face discrimination and stigma.

This pervasive negative attitude towards mental health is often driven by poor knowledge, particularly about the causes and treatability of mental illness. In some parts of the world, there remains a widespread belief in supernatural causes, including a belief that those affected may have done things to invite the wrath of ancestors or local deities.

A consequence – both of these shortages and misconceptions – is that many people with mental health conditions do not get the treatment that is appropriate for them. When treatment is received, particularly for more severe conditions, it is commonly from traditional and faith healers who may not always be able to deliver safe treatment or interventions that are respectful of a patient’s dignity. Abuse of human rights is rampant and degrading practices, such as shackling and coercion, are not uncommon. Even in the formal health sector, a shortage of vital expertise and resources means that inhumane practices – the use of force, constraints, or physical abuse – may continue.

Having conducted epidemiological studies over several decades and taken part in efforts to generate greater political interest in mental health, it was clear to me that mental health reform in Nigeria would require a multifaceted approach. There needed to be far greater public understanding of mental health in order to reduce the stigma surrounding it. Policymakers would need to be educated and service users empowered to know what good mental healthcare looks like and how to demand it. Civil society would need to be energised to drive mental health service reform by advocating for change in policy and legislation. And a critical mass of voices was needed to demand improvements to mental healthcare.

Empowering stakeholders

In response to these challenges, the Mental Health Leadership and Advocacy Programme (mhLAP) was launched at the University of Ibadan, Nigeria, in 2010. With funding from CBM Australia, the project works across five English-speaking African nations: Ghana, Liberia, Nigeria, Sierra Leone, and the Gambia. Our aim is to strengthen mental health systems in the region in two overlapping ways: first by building skills and knowledge in mental health leadership and advocacy. And second, by establishing groups of stakeholders in each country who can identify and drive improvements to mental health services.

At the heart of the programme is its training component. Our mental health leadership and advocacy course is delivered by local, as well as international, experts in global mental health, with input from a multidisciplinary team from areas such as public health, communication, and economics. The training is geared towards a range of stakeholders, including NGO and hospital leaders, policy and law makers, mental health service users, and caregivers. Module topics range from the stigma and social determinants of mental health to the principles and practice of health promotion, as well as communication and leadership skills.

The second of project’s key objectives is to build coalitions – known as councils – of stakeholders in each of the five countries to identify and lead country-specific mental health reform. A country facilitator – a graduate of mhLAP training – is engaged full-time to coordinate the council’s activities in each country. Members, including patients and caregivers, set their own national goals, such as specific public engagement activities or policy change.

In all five countries, the councils have grown in influence. Some have become partners in government mental health departments; council members have been invited to serve on government committees set up to draft new policies or legislation. Each council has also been able to register and become a self-sustaining charitable organisation.

A major activity for each council is public awareness – countering the stigma and pervasive negative attitudes around mental health. School outreach programmes are a common approach, but councils also work with journalists and other media practitioners to reduce derogatory and stigmatising characterisations of mental illness in the media.

mhLAP stakeholders take to the streets to raise awareness of mental health Gureje Image 2 (Credit Mhlap) (1)

Another important focus of the programme is to urge governments to expand mental health services using existing resources. The central argument of this advocacy work is that, despite a shortage of trained professionals, mental health services can be scaled-up by shifting some assessment and management tasks from specialist to non-specialist healthcare workers. For example, allocating tasks usually undertaken by staff with specialist psychiatric training to non-specialist doctors and nurses, as well as to lay community health workers who are trained and supervised to provide such a service. This approach is espoused by the World Health Organization through its Mental Health Gap Action Programme – a global initiative to close the gap in mental health provision in low and middle income countries.

Voices for change

In the ten years since it began, the Mental Health Leadership and Advocacy Programme has had a significant impact. Many of those who’ve taken part in our training have become important and active voices for change in their countries. Many have gone on to establish NGOs dedicated to mental health service improvement and patients’ rights. Prior to the programme’s launch, Nigeria had only three identifiable NGOs focused on mental health issues. By 2019, the number had grown to at least 12, with each making active contributions to the development of mental health services. Meanwhile, our stakeholder councils in Ghana, Liberia, and Sierra Leone are actively involved in the development of new national legislation and policies for mental health.

In almost all countries involved, it was the first time that stakeholders – such as patients, caregivers, and mental health professionals - had an opportunity to inform the national mental health agenda in a systematic and evidence-based manner.

One important lesson from the project is the need to build vocal partnerships and coalitions to ensure that mental healthcare is not overlooked by government and policymakers. While this holds true in almost every country the world over, it is particularly pressing in settings with a deep-rooted negative attitude to mental illness and those affected by it. The stigma surrounding mental health extends across the community and into the policymaking sectors of government, meaning it cannot be tackled except through a concerted effort to challenge these attitudes more widely.

By drawing on their research and teaching expertise, universities can play a vital role in improving mental healthcare in their nations. The design and implementation of mhLAP was derived largely from the cumulative experience of staff at the University of Ibadan, who had long been involved in work to improve mental health systems in low and middle income settings. Through quality training, universities can empower stakeholders, giving them the skills and knowledge they need to make a difference and ensure their voices are heard. And by bringing these stakeholders together, universities can build partnerships for action and change in mental healthcare.


Professor Oye Gureje is Director of the WHO Collaborating Centre for Research and Training in Mental Health, Neuroscience and Substance Abuse at the University of Ibadan, Nigeria.

To learn more about the Mental Health Leadership and Advocacy Programme, visit www.mhlap.org

Images (from top): Artist’s impression of neuronal organisation in the brain, courtesy of Professor Bill Harris / the Wellcome Collection, and licensed under CC BY 40. Stakeholders raising awareness , courtesy of mhLAP.