Ellen VAN HIMBERGEN | 07/05/2018
Mental health, a serious health challenge in the
worldMental health is one of the most serious health challenges in the world. Globally, 700 million people are estimated to suffer from mental and behavioural disorders
and one out of four people will develop one or more of these disorders during
their lifetime. Three out of four people with
mental health problems live in low- and middle-income
countries (LMIC) and yet up to 90%
of people living with mental illness in these countries do not receive mental
health services. One of the biggest reasons behind this “treatment
gap” is underinvestment. Low-income countries spend less than 1% of their
health budgets on mental health, while less than 1% of global development
funding for health is spent on mental health. In spite of the chronic and long-term nature of some
mental disorders, with the proper treatment, people suffering from mental
disorders can live productive lives and be a vital part of their communities.
Mental disorders represent a huge
cost to health care systems and to the global economy, and affect some of the
world’s most vulnerable people, through stigma and lack understanding. In 2015
the world took a huge step forward by including mental health in the Sustainable Development Goals (SDGs),
which fixed the global development agenda for the next three decades.Mental health, priority area of intervention in
RwandaIn Rwanda, the available data show that the country
faces an exceptionally large burden of mental disorders and much of the
country’s burden of mental disorders can be linked to the Genocide against the
Tutsi in 1994. Furthermore certain mental disorders such depression and
post-traumatic stress disorder (PTSD) are described with proportions beyond
international averages. One out of four people suffers from PTSD and prevalence
of depression is 15.5 to 21% depending of the study. Drug abuse, particularly
among young people, is a new mental health challenge in Rwanda and prevalence
of epilepsy is high (5%), making mental health a serious public health problem
in the country.
Mental health is clearly identified within the overall
Health Sector Policy as a priority area of intervention. This policy recommends
the integration of mental health services into all national health system
structures, including at the community level. On the contrary to many
developing countries, Rwanda is on the forefront in terms of developing a
sustained and sustainable national response to the burden of disease caused by
psychological and neurological disorders, as well as substance abuse. Mental health in Belgium Cooperation context in RwandaThe Belgian Cooperation supports the development of
mental health services in Rwanda over more than a decade and is the only
bilateral donor working on this thematic.
The Mental Health intervention provides technical and
financial support to decentralize mental health care into general care and integrate
mental health care into primary health care. This support is mainly through
capacity building, equipment, mentorship & supervision and training of
health professionals to deal with mental disorders including substance abuse
related issues. This
intervention supports also psychological interventions during the Genocide
commemoration period. In order to
ensure the success and quality of the integration of mental health care, the
intervention supports the Mental Health Division of Rwanda Biomedical Center /
Ministry of Health as well as the national mental health reference structures.Key progress in the decentralisation and integration
of mental health careThe officially-approved Mental Health Policy,
(introduced in 1995 and reviewed in 2011) has initiated a process of decentralization
and integration of mental
health care as well as the creation of referral services. At the central
level, there is the Mental Health Division within the Rwandan Biomedical Center
in the Ministry of Health. Its main mission is to implement the Mental Health
Policy through a strategic plan under the guidance of the Health Sector
Strategic Plan.
Mental health is now integrated into the package of
care of health centers, district hospitals, provincial hospitals and referral
hospitals. Obviously, mental health services and resources were shifted from
the psychiatric hospital to the community health facilities: District Hospitals
(DH) and Health Centers
(HC).Mental health services are effectively decentralised.
Each of the country's DH & PH (43), through the Mental Health Unit,
delivers a comprehensive mental health care package according to the national
standards. Within this framework, each mental health unit provides inpatient
and outpatient mental health care, including analysis and diagnosis, treatment
and follow-up, rehabilitative measures, counselling and interaction with
families. If necessary, the patient will be referred to mental health referral
settings. Mental health units are staffed by a permanent team comprising one or
two psychiatric nurses and one psychologist providing a broad range of mental
health services under the supervision of a physician trained in mental health
care. There are 66 psychiatric nurses and 41 psychologists working in mental
health units in district hospitals and at least one GP gets hands-on training.
Each mental health team receives on-site formative supervision and participates
in regular case review sessions led by a mental health team from the national
referral structures.
General Nurses working in health centres and CHWs were trained to ensure
an integrated mental health care component in health centres and at community
level. CHWs serve as an important link between the community and health
providers. In this context 766 General Nurses in Health Centers, more than
15000 CHWs and important number of volunteers (local NGOs & association) were
trained annually. A stepped-care
approach is provided: from health centres in rural areas, to district
hospitals and then mental health referral settings in Kigali. Consequently,
patients are treated as near as possible to their home and then receive
hospital treatment only after community treatment has failed.
A specific list of essential psychotropic medicines has been established
for each level of the health system. These psychotropic medicines are part of
the national list of essential medicines.
Mental health care is integrated into the community-based health
insurance (CBHI) scheme (Mutuelles de santé), which allows mentally ill people,
similar to other patients, to pay at most a 10% co-payment for psychotropic
medicines and services. There is no co-payment for the lowest incomes.
By decentralizing mental health services and integrating mental health
care into CBHI, the accessibility was increased, and the number of transfers to
mental health referral structures was reduced. Data from the national health
management information system (HMIS) shows that in 2016, all mental health units at DHs level received 26.060
new mental health cases and performed 201.902 outpatient consultations and 3.236
hospitalizations, with only 779 transfers to mental health referral structures.
Rwanda still lacks staff with an educational background in psychiatry. Up
to 2017 there were only 7 psychiatrists in the health system. In 2013, the
University of Rwanda launched a third-cycle specialization in psychiatry to
increase the pool of trained psychiatrists in the country. Specialists can
ensure quality of care and expand health care provision. The first 3
psychiatrists were graduated in August 2017 and 10 students are enrolled within
the program in collaboration with Belgium and Switzerland universities.
In the area of prevention of drug abuse, regular
awareness campaigns are conducted targeting young people. A specialized
structure for the treatment of drug-related disorders has just been set up.
Integrating mental health care into Primary Health
Care (PHC) is a great opportunity to intervene early and prevent chronicity. It
is also an opportunity to involve communities and increase accessibility to
mental health care which can be provided close to the community.
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