Encounters with mental health care in Kenya

Roos Korste is a clinical psychologist and freelance trainer for Médecins Sans Frontières (MSF) of local counsellors and community health workers in low-resource settings. She runs a website on global mental health and possible innovative solutions for the immense treatment gap in mental health care in low-resource settings [1]. This website contains an extensive blog post about Roos’ encounters with the mental health care situation in Kenya. This article contains a number of fragments of her impressions and the challenges she met.

Mental health care situation in Kenya

The mental health care situation has been improved over the last 15 years in terms of capacity. Nowadays there are 3 national referral hospitals with 1,114 mental health beds. The total number of psychiatrists grew from 16 in 2001 to approximately 80 in 2013. However, only a few of them work in the rural areas; outside Nairobi there is 1 psychiatrist available for 3 to 5 million people. Currently 250 trained psychiatric nurses are deployed: 70 in Mathari National Hospital and 180 in the districts and provinces, resulting in less than 1 psychiatric nurse per district only. Mental health care in Kenya is predominantly government funded, but remains extremely limited in terms of infrastructure, manpower and finances [2,3]. Therefore the specialist service for nearly all regions and districts is largely delivered by extremely overstretched mental health nurses.

Users and survivors of psychiatry Kenya (USPKenya)

USPKenya is a Non-Governmental Organization (NGO) whose major objective is to promote and advocate the rights of persons with psychosocial disabilities [4]. USPKenya is 100% peer managed and peer led. They run support groups in Nairobi and a few in the rural districts.

“On a Saturday I had the opportunity to visit a two-weekly peer support group meeting of the USPKenya. Eighteen ‘experts by experience’ and caretakers came together in a hired room in the heart of the Nairobi city centre. In a quiet, gentle and respectful atmosphere they talked about their ups and downs, ways of coping with the mental problems, work, side effects of medicines, going off medication, experiences with psychiatrists, feelings of hopelessness, but also about getting to terms with their mental condition and hope.”

Mathari state hospital Nairobi

The Mathari Hospital, the only psychiatric hospital in Kenya, has a bed capacity of 700, including 200 for law offenders with a mental illness and 45 for drug and substance abusers. The hospital currently has 400 members of staff including 7 psychiatrists, 70 trained psychiatric nurses, but no clinical psychologist or psychotherapist. The hospital has huge debts, accumulated over the past years because the state subsidies are far below the real costs and patients frequently do not have health insurance coverage and are otherwise unable to pay for their treatment.

There is no psycho-therapeutic potential in the hospital and occupational therapy and rehabilitation services are very limited. They cannot offer the patients the new generation (and more costly) antidepressants (like SSRIs), anti-psychotic drugs (like Risperidon) and modern anesthetics (for ECT). Therefore patients or caretakers have to buy them elsewhere.

“When arriving at the Mathari hospital I found out that there was no electricity in the whole area, driving the pharmacist (worries about her fridge) and anesthetist (preparing an ECT treatment) to despair. In all this disorder and chaos I met psychiatrist dr. Catherine Syengo Mutisya. She didn’t seem impressed by the turmoil and took time to explain to me the current practical and treatment challenges and invited me to join her on her round this morning in the forensic department.

I really appreciated the opportunity Catherine offered to look around and write about the Mathari hospital, after a lot of negative (and one-sided) attention the hospital received in a CNN documentary ‘Locked Up and Forgotten’ [5].

In the forensic clinic 15 patients were waiting to be seen and assessed by Catherine. A few of them were there for medication, but most of them needed a report for court: were they able to plea or not? Some of them were very confused and disorientated patients. Although Catherine was running out of time, she remained patient and polite, going through all the 15 files and letters, trying to understand all the individual patients, their stories and their struggles, deciding what would be the best next step. Catherine and I discussed what could be done to improve the hospital care. Staff could try to trace more relatives who could pay for treatment.”
With improved treatment and more positive attention in the media, the hospital could be a place where people send their relatives for treatment, and not only as a last resource. This could attract more people who can pay for their treatment. Recently the hospital was appointed National Teaching and Referral Hospital and this will improve the financial allocation, which gives room for optimism.

Looking at the Mathari hospital in a broader, nationwide context, it would perhaps be better to decentralize the care to smaller facilities in every county and to have more cooperation with, and implementation of community based mental care. This would be in line with current international policies and allow people with mental disorders to live close to their relatives and prevent them from being abandoned and forgotten. [6]

Basicneeds Kenya

BasicNeeds is an international NGO with projects in low-income countries. They use an approach which is called the ‘Model for Mental Health and Development’, helping people with mental conditions and their family members to form or join self-help groups. Not only does this offer support but it facilitates income generating activities as well, like poultry and pig rearing, egg selling, farming dairy goats, soap making and the production of craft and bead products. There are currently 120 self-help support groups all over Kenya, with a cumulative impact of 12,000 affected people.

“I met Joyce King’ori, country programme manager of Basic-Needs Kenya, at the office in Nairobi West [7].The thorough and well-tested principles and methods of BasicNeeds, together with Joyce’s ‘thinking outside the box’ gives me the impression that this is what community based mental health care is all about: to do more, and reach more people, with the same budget. By building on what exists, going to the people’s homes and empowering them.

On top of Joyce’s wish list for the future is creating mental health facilities for children and youth, because there is still nothing for these groups in Kenya. They want to use the new media in targeting and involving youth. BasicNeeds Kenya is already using bulk SMS services for mothers (antenatal care) and farmers (about crops, rain, advice), but would like to have an internet-SMS platform for youth as well. Another wish is to reach very remote groups like nomads and the people in the districts not yet covered.”

Challenges for the future

It seems that a plan built on a conventional, medical western model of mental health care is prone to failure. Training enough staff with this model will take a century or more. The hope that government or international funding will increase enough to expand the mental health care as it is now, is not realistic either. One must try to reach more people with the same resources and number of mental health specialists. One must build on what is already in place and integrate mental health care, support and awareness campaigns in existing groups, communities and organizations.

Therefore, a shift in thinking seems necessary and one can see above that there are already movements in the right direction.

Acknowledgements

I would like to thank all the persons mentioned above, who took the time and effort to provide me with the necessary information. I hope, in due time, I can do something in return.

References

1. www.in2mentalhealth.com
2. Kiima D, Jenkins R. Mental health policy in Kenya – an integrated approach to scaling up equitable care for poor populations. International Journal of Mental Health Systems 2010, 4:19. doi:10.1186/1752-4458-4-19.
3. Jenkins R, Kiima D, Lock S. Integration of mental health care into primary care in Kenya. World Psychiatry 2010; 9(2):118-120.
4. www.uspkenya.com
5. www.youtube.com/watch?v=gM4meNCLYAA
6. WHO Draft comprehensive mental health action plan 2013-2020, World Health Organization, 2013 (http://www.who.int/mental_health/action_plan_2013/en/).
7. www.basicneeds.org/where-we-work/kenya