Challenges Encountered by Mental Health Workers in Rwanda; Current Situation and Future Needs

Introduction

The incidence of mental health disorders and psych -behavioral problems is increasing worldwide, for the first time in human history the disease burden caused by mental disorders is ranking second in the world which makes mental health a great concern of public health [1]. Even though mental health disorders occupy the 14% of the global diseases burden, it is unfortunate that it attracts a less attention of governments and policy makers of countries particularly on budget allocated to it [2]. According to World Health Organization most of Low and Middle Income Countries (LMICs) have no specific budget for mental health even those countries with specific budget, they allocate less than 2 % or even less than 1% of the total health budget and the treatment gap of mental health goes up to 90% in LMICs [3, 4].

Rwanda is one of LMIC located in Eastern Africa. In 1994, the country faced a tragedy of genocide that took approximately one million lives of people mostly from Tutsi ethnic group [5]. As consequence of the genocide, the rate of mental health burden has increased and certain mental disorders were reported to exceed the international average [6, 7]. Even several years post genocide, the rate of mental health is still high in Rwanda [7]. To address the burden of mental health disorders Rwanda has set The National Mental Health Policy. (The Rwanda National Mental Health Policy). The policy aimed to bring mental health services close to the community by decentralization of the health service delivery and training of service providers [8]. In 2017, the country has 1500 trained community health workers and at least 468 health centers across the country has more general nurse trained on mental health and psychiatric care [9]. Little is known about challenges of mental health care profession in Rwanda, as a country which has a generation post the Genocide. In this study we aimed to explore challenges that mental health professionals are facing in Rwanda.

Methodology

This study used qualitative and quantitative method in data collection and analysis. A self-administrated questionnaire was given to all participants. The questionnaire was designed containing all questions and was uploaded as online data collection system. Three phases were used for making sure on the quality of the questionnaire and the online data collection system.

The first phase consists on questions quality and adaptation on online data collection system. A few number (n=5) of participants were given the questionnaire and were asked to fill all the questions and were further requested to give comment on the questionnaire and the quality of the online data collection system. These participants were chosen based on their experience in mental health and the past experience with the first author. At the time of study participation, all of these participants were working in mental healthcare in Rwanda and proven working experience of < 5years of mental healthcare experience. Their feedback was considered for the improvement of quality of questionnaire and the online data collection system for the second phase.

The second phase consists on the of updated questionnaire and data collection system on a randomly selected sample of few mental health workers (n=8). Respondent have seen to be familiar with the data collection system and questions were approved to be familiar with the online data collection system as well as the objective of the study only the inclusion of mandatory responses was missing in the system for both the first and second phase and was included for the third phase. For the third phase questionnaire we strongly reformulated base on further literature review and recommendations of authors and the online data collection was strengthened to avoid any possible biased information or missing of information.

The used online data collection system was provided by google. The survey was immediately linked to the first author google account. The system informs the author automatically by email if there is a new response. All responses qualitative and quantitative are found in excel sheet within the system.

Questions could take around 20 minutes to be filled by study participants and submit online to be received by the first author. Data collection starts in May and ended in last week of July 2019.

The qualitative questions were open ended questions which were formulated based on study objective they gave to the participants opportunity to tell about challenges that might be present.

Discussions

Results in this study indicated that challenges encountered by mental health workers in Rwanda are quite the same as mental health care in law and middle income. As supported by literature, mental illness presents an epidemic in most parts of Africa. Despite its presence, It is unfortunate that most of countries in Africa lack inadequate health care infrastructure, insufficient number of mental health specialists and non-access to all levels of care [10, 11].

Findings indicated that mental health workers face main challenges such as challenges related to community awareness on mental health, Challenges related to less priority of mental health care, poverty of mental health seekers, challenges related to qualification and training received by mental health workers and challenges related to the structure of mental health care.

Like many other African countries Rwandan population are still in misunderstand mental health. In most parts of African continent, the awareness of mental health disorders still a big challenge. people’s attitudes toward mental illness are strongly influenced by traditional believes in supernatural causes or demons possession [12]. Consequently, these believe often leads unhelpful response to mental illness, to stigmatization of mentally ill persons and reluctance or delay in seeking appropriate mental health care. It also affect the provision of mental health care services for the needy. In some instances policy makers could have the opinion that mental illness is largely incurable or at any rate unresponsive to medical treatment [13, 14]. To raise the awareness of mental health within the community, the community itself should be involved by giving much importance to the family. It was seen that the active collaboration of the community helps in reduction of stigma and discrimination and facilitate community rehabilitation of mentally ill persons [15]. Some strategies that could work in raising the awareness of mental health in Africa include; educate the community about mental health through Newspapers, television shows performing arts, radio shows, brochures, and pamphlets these are mostly used for international events such as World mental health day (October 10th). Other suggests the creation of nongovernment organizations for mental health that could work closely with media in providing accurate information about mental health. The increase of awareness campaign is also a strategy that works [16].

The mental health awareness should be part of prioritizing mental health. Prioritizing mental health is crucial to improving patient care as adequate spending and infrastructure. Prioritizing start with implementing mental health policy that will formulate and coordinate comprehensive and integrated care in local community [17]. Rwanda is one of few African countries which have mental health policy [18]. As per WHO recommendation, improving healthcare in general goes together with integrating mental health into primary healthcare [19]. By following this recommendation as well as implementing mental health policy, Rwanda has introduced mental health care into primary health care. A package of Mental health services are available in most health centers within the country, community health workers were trained on providing basic mental health assistance in general community [8]. However, this program is an ongoing program, it is clear that the program might still face challenges in its implementation process. According to Rwanda health strategic plan, Mental health services will be available up to community level by the year 2024 as per defined service package at all level [20]. In addition to this, the policy must include mental health infrastructures yet in most Middle- and Low-Income Countries the budget of mental health still low. On the average most of African countries spend less than 1% of their budget on mental health [21]. Few is known about mental health total budget in Rwanda some numbers show the financing of specific projects of mental health without providing a full information of total budget.

The matter of trained mental health professionals In Rwanda is also seen in the literature as a matter of a big concern. The World Health Organization (WHO) stated that there are few qualified and trained staff in mental health services in Rwanda [22]. The shortage of well-trained mental health might have a negatively impact on the quality of services provided and outcome of treatments. According to Rwandan statistical year book by 2015 Rwanda counts 208 psychiatric nurses and 103 psychologists who work in public institutions and few is known on registered mental health professionals working in other institutions [23]. As mentioned in previous paragraphs, Rwanda proves its commitment in increasing the number and availability of qualified mental health workers, for instance more psychiatrists are being trained at the University of Rwanda to be deployed to district referral hospitals. The number of trained psychiatrists has increased from 1 to 7 psychiatrists. These ones are rotated in different referral hospitals like Centre Hospitalier Universitaire de Butare (CHUB), Centre Hospitalier Universitaire de Kigali (CHUK), Ruhengeri and Ndera Hospital. In addition to this, the Ministry of Health through Rwanda Biomedical Centre has trained more than 15.000 community health workers who are attached to health centres. These community health workers are not professionals but simply trained basic mental on mental illness, how to identify and with symptoms of mental illness in their areas. These ones are added to each two general nurses and one general practitioner that is trained on psychiatric cares each year since 2014. Currently a total of 468 health centers across the country have more general nurses trained in mental health [9].

The poverty of mental health seekers was seen as a matter of concern by respondents the poverty would affect not only a mental health seeker as individual but also the mental health practitioner. According to the WHO, poverty and mental disorders relate negatively as those with mental disorders have limited employment opportunities, which will increase deprivation and delays health care seeking due to lack of financial means [24]. In dealing with this matter the government of Rwanda has introduced psychotic drugs into national list of drugs so that people can access drugs at affordable price mental health services is being also introduced into Mituelles de santé insurance [9].

Conclusion

The finding of this study shows that mental health practice in Rwanda still face challenges that interfere with its strengthening strategies. Challenges are in some cases caused by other preventable challenges whether other might have long-term causes. For instance, the lack of finance in mental health affects the number of mental health practitioners and the low quality of service. Similarly, the lack of quality of training of mental health practitioners also affect the quality of provided service. There is a lack of mental health awareness which can be associated with low resources for financing mental health awareness programmes and lack of involvement of private sector in the field of mental health care. The mental health structure claimed in the study and other issues such as training to mental health workers and poverty of mental health care seekers all turn around financial matter which need the collaboration of authorities the local and international NGOs and the private sector.

The findings in this study are quite similar to challenges faced by mental health care profession in most of African countries. However, Rwanda has its unique history of genocide which has affected most of its sectors including health sector in addition the high rate of mental health burden caused by the genocide has its role in the challenges. Furthermore, unless these challenges there are a political will of authorities in dealing with some of challenges. If mental health practitioners are consulted their added value in strategies and policies development and implementation could help in strengthen and sustain the mental healthcare in Rwanda thereby avoiding frequent challenges in mental healthcare in general and challenges within mental health workers in particular.