Belgian Platform for International Health ENG | FR
When trying to ‘summarise’ this conference we have to start by emphasising the impressive ingenuity and commitment of the many participants involved in mental health and psychosocial support in sub-Saharan Africa: despite the limited means at their disposal and the many challenges they face on a daily basis. The testimonies gathered throughout this conference provided a sound basis for experiences to share and give hope for future improvements.
On the basis of two half days of rich exchanges about the challenges of mental health in French-speaking sub-Saharan Africa, Jaak LE ROY and Willem VAN DE PUT identified several cross-cutting themes and put into perspective both the tensions they generate as well as the projects they suggest.
Accessibility of care
Proactivity
Effectiveness and sustainability of mental health interventions
The broad definition of “mental health and psychosocial well-being”
Diversity
L’Accessibility of care is a central issue. To help people access services it is important to reduce the stigma surrounding mental health. Therefore awareness raising and preventive activities are needed both in and with the community. At the same time, increasing the quality and effectiveness of services and psychosocial support programmes will help to convince people to use them. Specifically when it comes to implementation, there is tension and the right balance must be found between giving beneficiaries, users and their representatives their say on the one hand, and implementing international, standardised protocols and/or approaches adopted by (inter)national public health systems in defining health care services on the other hand.
Proactivity was regularly mentioned in the discussions. Effective governance and sufficient resources are essential for effectively integrating mental health care and psychosocial support into the different levels of the public services pyramid (from districts to health zones, regions, provinces, country). This includes all aspects of the public service system: from training for health, social and community workers to financial means and essential materials. Governments should not put off tackling challenges until a major crisis such as climate disaster, genocide, war or pandemic occurs. Tension can be found between emphasising governmental responsibilities or emphasising the importance of local initiatives from civil society. Authorities may expect grassroots actors to be enterprising, but often do not take into account these initiatives in the community when planning care.
The view on effectiveness and sustainability of mental health interventions has shifted with new insights gathered over the last few decades. Psychiatric hospitals have existed since colonisation in some African countries, but mental health and psychosocial well-being have only entered modern public health care policy following interventions linked to humanitarian crises and emergencies or with vulnerable groups (AIDS, violence, trauma, Covid 19, gender-based violence). Based on the criteria of accessibility, effectiveness and sustainability, the place, role and tasks of health care structures as well as the types of interventions need to be redefined. Tensions arise when stakeholders in the care pyramid want to respond to the needs of the patients and call for a new care policy that is more ambulatory than hospital-based care, and work closer with the community. As Florence BAINGANA pointed out, in most countries in sub-Saharan Africa an average of 80% (and often 100%) of resources for mental health are allocated to psychiatric hospitals. Tension arises when financial resources have to be redistributed from psychiatric hospitals to primary health care structures in order to decentralise and implement mental health care close to where the population lives.
The broad definition of “mental health and psychosocial well-being” came up again during this conference. The range of medical conditions (including severe mental disorders but also chronic psychosomatic complaints, epilepsy, and substance abuse) and the effects of stress that people and communities experience due to poverty, conflict, climate change and other socio-economic determinants of health cover an enormous diversity of issues, which play out in different contexts and socio-cultural settings. Tensions are recognised in the search for a harmonious mix of a medical and social perspective, finding complementarity between health and social care, valuing person-centred care but also community and group interventions, and linking with other sectors altogether to address underlying causes of psychological suffering (education, income, security).
Diversity: this relates closely to various definitions of helpers, users, caregivers, and all the different actors in the field of complete health. Caregivers can be lay people, health professionals, teachers, religious leaders, so-called ‘traditional healers’ that represent the local knowledge and local contextual understanding of problems. To what extent and in what way can these different skills be combined? Who has a mandate to ‘negotiate’ between different views and beliefs that caretakers and beneficiaries integrate into the care pathway? How can a long-term care pathway and personalised psychosocial support be developed in socio-economic conditions of social breakdown? Tensions are known to exist between care-givers of different identities, professionals and users with different beliefs and convictions, and also between advocates of different sectors such as health, protection and social work. The conference showed that exchanging views and sharing examples of collaboration seemed to be the best way forward.
Finally, the importance of enhanced cooperation between mental health projects and psychosocial support in different sub-Saharan African countries was a recurring theme during the conference. There are differences between countries related to culturally-defined values and norms and to colonial and post-colonial events and patterns. The organisation of meetings and exchanges via a “community of practice” between French, English and Portuguese speaking actors and countries can contribute to the development of dialogue and contributions beyond cultural, linguistic and historical differences.