- Zarina Geloo - Zambia & Angela Tufvesson - Hong Kong
How Africa heals as community-led mental health care makes inroads
Mental health conditions remain untreated in large parts of Africa. Community-led initiatives are bridging the gap by training lay workers to deliver innovative treatments and support.
Teddy Kyolaba was a university student living in Kampala when she was diagnosed with bipolar disorder. She was admitted to Butabika National Referral Mental Hospital, the only referral psychiatric hospital in Uganda. “Getting the diagnosis for bipolar brought me relief,” Kyolaba says, as she could finally understand what she was going through and why.
But the relief was short-lived as Kyolaba’s path to recovery proved long and complex. After a one-month stay in the hospital, which included electroconvulsive therapy (ECT), Kyolaba’s condition stabilised, then worsened—a pattern that repeated for many years, including during the three years she lived in Kenya without medication. Access to healthcare was often patchy and the stigma associated with mental illness a major barrier to seeking treatment.
Most African governments spend less than 1% of their health budget on mental illness and, across the region, there are just 1.4 mental health workers per 100,000 people – compared with a global average of 9 per 100,000.
Eventually, Kyolaba was referred to HeartSounds, a peer support service that trains lay workers to deliver at-home outpatient care for people with mental health conditions. The experience was transformative. “My brother took me there and they helped me,” she says. “Since then, I haven’t been back to hospital.”
Kyolaba is now a peer support worker for Peer Nation, the latest iteration of HeartSounds, which trains lay workers with lived experience of mental health challenges to fill the human resource gap in community mental health care.
“When people are discharged [from hospital], peer support workers support them in their homes,” she says. “We make sure they take their medication and follow medical advice, and we act as role models. I look after them, and doing this work also helps me look after my mental health.”
Grassroots initiatives like Peer Nation that share the management of mental health conditions with specialists and community workers—a process known as ‘task shifting’—are helping a greater number of Africans access care.
Most African governments spend less than 1% of their health budget on mental illness and, across the region, there are just 1.4 mental health workers per 100,000 people – compared with a global average of 9 per 100,000. Coupled with competing and conflicting health system needs, a shortage of mental health personnel, and the stigma involved in seeking psychiatric help, the situation is often bleak for people in need of treatment; very few Africans receive care for mental health problems.
While not a substitute for specialised mental health workers, community-led programmes offer the promise of better outcomes and a brighter future.
Leveraging lived experience
Lived experience of mental health conditions is an important factor in the success of Peer Nation, explains founder and CEO Edward Nkurunungi. Nearly 60% on the board of directors have a lived experience of mental health challenges.
He says the organisation has trained 82 peer support workers across Uganda and offered support to more than 1,500 clients. Most of the peer support workers, like Kyolaba, are themselves recipients of Peer Nation’s services.
"We almost always manage to have success with helping people get over their depression using this method"
A recent evaluation by Peer Nation found the benefits are two-fold. “Recipients of peer work showed an increased sense of hope, inspiration and encouragement, and there were also positive changes in family relationships and related stigma,” Nkurunungi says.
“Peer support workers benefited by regaining their sense of identity, self-esteem, confidence, physical health, social networks, hope and self-care behaviours.” He says they also reported feeling proud of their ability to offer hope to others and of being able to better fight stigma and discrimination.
Strong Minds employs a similar approach to treat depression in Uganda and Zambia. Women with depression are treated through group interpersonal psychotherapy (IPT-G) delivered by lay counsellors.
The talk therapy model, which is recommended by the World Health Organization (WHO) as a first-line depression intervention in resource-poor settings, emphasises relationships as the root cause of, and source of recovery for depression. Since 2014, Strong Minds has treated more than 100,000 women and adolescents.
Mental health supervisor Michael Manda says the organisation trains volunteer community workers, most of whom have themselves recovered from depression, and they form therapy groups in local neighbourhoods. "We almost always manage to have success with helping people get over their depression using this method" says Michael Manda from Strong Minds, adding they want to replicate it everywhere.
With the support of Zambia’s Ministry of Health, Strong Minds aims to scale up its services and introduce community workers at health centres around the country. “We do not want to recreate the wheel—we want to use what is already available and strengthen it,” Manda says.
The mental-physical link
Treating mental health conditions at a community level has flow-on effects for physical health. Tiny Kamvura is a Zimbabwean researcher focusing on health systems in low- and middle-income countries (LMICs). He sees a strong correlation between poor mental health and other non-communicable diseases (NCDs) like hypertension, diabetes and cancer—projected to become the leading cause of disability and mortality in sub-Saharan Africa by 2030—even as people struggle to get the care they need.
“As much as 50% to 90% of those in need of diabetes care or evidence-based mental healthcare will not get it,” he says.
Friendship Bench is an evidence-based mental health intervention delivered by thousands of trained community grandmothers through basic cognitive behavioural therapy—a talking therapy used to treat depression, anxiety and other mental health conditions—and peer-led group support. Since 2005, more than 40,000 Zimbabweans have accessed treatment and the programme is now available at 72 clinics across the country.
Kamvura, a project coordinator, says Friendship Bench is investigating strategies to integrate diabetes and hypertension care into the existing mental health framework after anecdotal evidence of clients presenting with a combination of depression, diabetes and hypertension. Researchers highlighted the need for people with lived experience of the conditions to promote patient-centred care and bolster the Friendship Bench method.
Merging traditional and Western medicine
That community-based interventions can benefit both mental and physical health is evident elsewhere in the country, too. Roydah Ndlovu is a Zimbabwean nurse at Parirenyatwa General Hospital who suffered a tragic bereavement. She sought help from a volunteer counsellor at a small clinic in her local church after realising that, while she was “functional” and seemingly managing her grief, she had developed a cough and was breathless “out of the blue” without any other accompanying symptoms. "My counsellor immediately recognised I was depressed and linked it to the sudden asthma-like attack. Since I started therapy for depression, the attacks have subsided," she says.
Ndlovu, now a volunteer counsellor herself at the Young Women Christian Association (YWCA) of Zimbabwe, says far too many people experience serious consequences from illnesses caused by poor mental health. This problem is often compounded by traditional belief frameworks.
"People still believe that mental health issues do not exist in African society,” Ndlovu says. “Because they cannot pinpoint why they are feeling out of sorts, they immediately think [of] witchcraft and seek traditional healers or prophets rather than medical help, sometimes with tragic results.”
"My counsellor immediately recognised I was depressed and linked it to the sudden asthma-like attack. Since I started therapy for the depression, the attacks have subsided"
However, she acknowledges that a significant proportion of the Zimbabwean population, especially in rural areas, consult traditional healers as their primary healthcare providers. As traditional healers are part of communities and more affordable because they are often paid in kind, Ndlovu suggests recruiting them into counselling programmes through basic mental health training.
“It will serve a dual purpose by merging traditional and Western [approaches],” she says. “Those comfortable with their service provider will likely adhere to the treatments or protocols that are scientifically based. The traditional healers, too, will be empowered with the knowledge of how to treat their patients successfully.”
Upskilling for better care
Back in Uganda, the heightened focus on community-led mental health care is driving efforts to upskill primary healthcare providers. Dr Emmanual Ssekidde, a psychologist at Hill Side Recovery Home, says cases of poor mental health are increasing with the rapid changes in lifestyle. The extended family system, in which uncles, aunties and grandparents provided counselling and a support system, has largely disappeared, leaving many without an anchor.
“As people urbanise and move away from their extended families, they become isolated, their lifestyle and eating habits change—not necessarily for the better,” Ssekidde says.
He says the introduction of an intermediary course in mental health care at diploma level puts the country “a few miles” ahead of other nations in east and central Africa. Ideally, such training of intermediaries will ensure that every health centre has at least one psychiatric clinical officer.
“We can now ideally have diploma-level clinical officers operate some of these clinics, providing critical care for people with a mental health condition,” Ssekidde says.
For Teddy Kyolaba, access to critical care at the hospital and, in particular, ongoing mental health support from Peer Nation has had life-changing impact. Besides enabling her role as a peer support worker, Peer Nation has also supported her in setting up a small book-binding business, which helps to support her family.
“My mental health is now stable,” Kyolaba says. “I am happy that last year I had Holy marriage with my partner, and we are happy with our three children.”