The Mental Health System In Ghana

The mental health system in Ghana 2011 / 2012Executive SummaryThe World Health Organisation AssessmentInstrument for Mental Health Systems (WHOAIMS) was used to collect information on themental health system in Ghana for the year 2011 andto prepare a preliminary report. Discussions withsenior stakeholders enhanced data quality and aidedinterpretation of the findings to produce this full incountry detailed report. A small amount of extra datawas added for the year 2012 where this was relevant(eg the passing of the Mental Health Act). All 216 districts in Ghana were surveyed. All data is for 2011 unless stated otherwise.1: Policy, legislativeframework, financingand human rightsPolicy and plansA mental health policy (1996) and plan (2007-2011)existed. Emergency and disaster plans for mentalhealth did not exist.LegislationA new Mental Health Act 846 2012 was passed in2012 and was awaiting Government to establish theMental Health Board.Financing of mental health servicesMental health had a ring-fenced budget of 1.4% oftotal governmental health expenditure.Monitoring of human rightsA national human rights review body existed and allthree national mental hospitals had been inspected8/9in 2011. Staff refresher training in human rights wasvery sparse.Access to psychotropic medicinesEveryone had free access to essential psychotropicmedicines from hospitals / pharmacies when theywere available. A one day supply of the cheapestantipsychotic or antidepressant was costing 30% ofthe daily minimum wage and phenobarbitone forepilepsy was 16% of the daily minimum wage.Social insurance schemesMental disorders were not covered by socialinsurance schemesLegislative and financial provisions for personswith mental disordersVery little protection was available2: Mental health servicesOrganisation of mental health servicesThere was no national or regional mental healthbody to provide advice to the government onmental health policies and legislation. There was noorganisation of services into catchment / serviceareas.Although there was no national organizational bodyfor mental health, the responsibility for nationalorganization of mental health services was vestedin the Chief Psychiatrist as the national head whoalso served to directly advise the Minister for Healthon mental health. There was also a focal personfor mental health located in the Institutional CareDivision of the Ghana Health Service, to coordinatemental health care in the Ghana Health Serviceinstitutions. The Chief Psychiatrist also coordinated

www.thekintampoproject.orgplanning and organization of mental health activitiesat the national level. At the regional and districtlevels the Regional and District Coordinators ofCommunity Psychiatric Nursing served as thecoordinators.Psychoactive substance relateddisordersDisorders of adult personality andbehaviourOthers or no diagnosis madeOutpatient servicesThere were 123 outpatient units and one daytreatment unit. In terms of number of services (notsize of service), Upper West Region had the mostoutpatient services per 100,000 of its population andAshanti Region had the fewest.Day treatment servicesThere was one day treatment service (DamienHouse in Western Region).23 days (figurebased on 1hospital only)3 mental hospitals7 inpatient unitsWomen and childrenWomen comprised 32-54% of those treated andchildren around 1-10%. Mental hospitals had wardssegregated by sex. There were 15 beds reservedsolely for children.16 days4 community residential units365 daysForensic servicesThere were 79 dedicated inpatient beds for forensicpatients but there was serious overcrowding.Diagnoses across the facilitiesThe range of diagnoses across all facilities was:Neurotic and stress related disorders10 – 58%Average length of stay in 2011The average length of stay in hospital beds was:Inpatient servicesThe summary details of all the inpatient services canbe seen in Table A.Mood disorders0 – 1%Availability of medicationAt least one psychotropic medicine of eachtherapeutic class (anti-psychotic, antidepressant,mood stabilizer, anxiolytic, and antiepileptic) wasavailable all year long in 40% of outpatient facilities,57% of hospital inpatient units and 100% of themental hospitals.The total number of outpatients treated in 2011 was57,404.Schizophrenia, schizotypal anddelusional disorders7 – 26%Human rights and equityIn 2011, 2-8% of in-patients were detained on a legalorder and 10-20% of in-patients were restrained(mechanical and/or non-mechanical) or secluded.Greater Accra Region had 7.23 times more beds,4.28 times more psychiatrists and 4.44 times morenurses than the rest of the country despite only 16%of the 24.2 million population living in that Region.Most services were in or near large cities.21 – 32%6 – 19%0 – 8%TABLE AInpatient services in Ghana in 2011No of beds*% of all bedsbeds / 100,000population1,32285.1%5.427 inpatient units (in generalhospitals and clinics)1207.7%0.494 community residential units1127.2%0.451,554100%6.363 mental hospitalsTOTAL*In this report we have referred to the number of ‘beds’ available in the various facilities rather than actual spaces available for patients,which is often a higher number than the number of beds. We refer to beds because the results we report are based on the WHO-AIMSsurvey we conducted in 2011 and the WHO-AIMS specifically looks at physical beds, not actual ward / hospital occupancy. So it isimportant to acknowledge that in this report ‘bed’ just means physical beds and ‘bed’ does not reflect the capacity (which is the number ofpatients originally allotted to be accommodated in the ward) or the actual number of patients being treated at any time.

The mental health system in Ghana 2011 / 2012Number of patients treated in 2011The number of patients treated across all availablefacilities was:123 outpatient units57,4041 day treatment unit187 inpatient units2,2553 mental hospitals7,9934 community residential unitsTOTAL12267,792Greater Accra had the most staff and treated themost outpatients per 100,000 of their populationwhereas Ashanti had the fewest and treated thefewest patients (per 100,000). Upper East andUpper West were not well supplied with staff butboth treated a high proportion of their populations,particularly Upper East suggesting high efficiencyand productivity in these regions.3: Mental health inprimary health careTraining in mental health care forprimary care staffMental health accounted for the following percentages of various training courses:Medical students3%Nurse students10%Community health workers trained atthe College of Health and Well Being inKintampo14%No primary health care staff received mental healthrefresher training in 2011.Mental health service provision inprimary health careLess than 20% of physician-based primary healthcare clinics had assessment and treatment protocolsavailable for key mental health conditions. Therewas no data available on referral rates from PHC tomental health staff.Informal primary health careTen faith-based and 10 traditional practitionerstreating 1,253 and 749 mentally ill people respectivelywere sampled. The practitioners identified somepatients as having diagnoses similar to thosefound in the western practitioner samples. Fifty sixper cent of faith based practitioners administeredmedications. Restraint (mechanical and/or nonmechanical) was used on 41-57% of patients. Somefacilities referred cases to psychiatric services.Prescription in primary health careOver 80% of physician-based PHC clinics had accessto at least one psychotropic medicine of eachtherapeutic category.TABLE BThe number of staff in mental health care in 2011Mental health trained staffMental health nurses (RMNs)1,068Community Mental Health 177Staff working in mental health but not specifically trained in mental healthOthers eg. Medical Assistants, auxiliaries, paraprofessional counsellors, non-doctorprimary health care workers, health assistants etc474Other nurses (SRN, ENs)180Other medical doctors31Social workers21Occupational therapists (VSO)SubtotalGrand TOTAL10 / 1147101,887

www.thekintampoproject.org4: Human resources7: Comparison of Ghanawith other low and middleincome countriesStaff working in mental health servicesSee Table B: the number of staff in mental healthcare in 2011.There were 1,887 staff working in mental healthservices. Sixty two per cent (1,177) of the 1,887were specifically trained in mental health and 710(38%) were staff working in mental health but notspecifically trained in mental health.Training mental health practitionersIn 2011 the following professionals trained in mentalhealth:Nurses with 1 year training in mentalhealth careCommunity Mental health Officers (1 yeardiploma in Community Mental Health)33472Psychologists with 1 year training inmental health care5Psychiatrists1Social workers 1 year training in mentalhealth care0Occupational therapists 1 year training inmental health care0Consumer and family associationsThere were some consumer associations but nofamily associations.In 2011 Ghana was a lower-middle income country(LMIC) so LMICs are the comparator. However,LMICs as a group do not have good mental healthservices so their levels of service are probably nota good target to aim for. Upper-middle incomecountries UMICs have better services and shouldprobably be the long term target to aim for whichmeans gauging the best trajectory to set in order toachieve these longer term goals.Spending on mental healthSpending on mental health was less than half that ofother LMICs. To reach median levels for UMICs a 35fold increase will be needed.Outpatient treatment ratesTreatment rates were one third (33%) that of LMICs.The rates were similar to that of low incomecountries (LICs).Patients treated in psychiatric day servicesDay treatment rates were very low. To reach medianLMIC levels a 92 fold increase is needed.Psychiatric beds in hospitals and clinicsProvision was nearer that of LIC countries thanLMICs. To reach LMIC level, beds must be increasedfrom 120 to 278, ie average 28 per region. UMIClevels would be 220 beds per region.5: Public education andlinks with other sectorsAdmissions to psychiatric beds in hospitals andclinicsGhana admits fewer patients per 100,000 populationthan LICs even though Ghana was a LMIC in 2011.Between 1-20% of schools were actively promotinggood mental health. Less than 2% of prisoners hadcontact with a mental health professional. There wasno mental health training for police, lawyers, judges.The balance of nursing to non-nursing staff inhospital and clinic inpatient unitsIn Ghana this service provision is dominated bynurses far more than for most other countries asthere are not enough specialists.6: Monitoring and researchThere was a mental health information system. Oneper cent of health related research was on mentalhealth.Beds in mental hospitalsGhana has almost the same number of mentalhospital beds per 100,000 population as other LMICs.There is a trend upwards as countries becomemore prosperous so Ghana should redistribute bedsacross the country but be careful about any overallreduction. UMICs have three times more mentalhospital beds than Ghana. The trend continuesupwards for HICs.The balance of nursing to non-nursing staff inmental hospitals and the ratios of staff to bedsGhana has more than one nurse for every two bedsin the mental hospitals which is far more than other

The mental health system in Ghana 2011 / 2012countries. This, rather than indicating better service,is because many wards do not have the requisitenumber of beds that the ward can contain, andthere are patients on the floor. As countries becomemore prosperous there is a downward trend instaff:bed ratios. Other LMICs have more mentalhospital psychiatrists and ‘psychosocial staff’ thanGhana.Long stay (‘residential’) facilitiesIn 2011 Ghana treated 112 patients in long stayservices which is fewer than LICs. To reach LMIClevels Ghana needs to treat 224 such patients / yearand to reach UMIC levels means treating 1020 / year.Length of stay in UMICs is four times longer than inGhana in 2011.Beds in other residential servicesGhana is far behind on this, compared to othercountries, and needs to start a very steep trajectoryto increase beds in these services. The numberof beds Ghana would expect for a population of24.2 million if it was a UMIC would be a staggering19,185. These services are a hallmark of UMICs andhigh income country services, representing servicediversity and high levels of care and support forvulnerable and disabled members of the population.The cost of medicationMedication in Ghana is more costly than in othercountries.The total number of mental health workersIn 2011 Ghana had fewer mental health trainedstaff per 100,000 population than other LMICs. Todraw even with other LMICs Ghana needs 377 moremental health trained staff (based on 2011 figures)but any aim to reach UMIC levels will need 7,226more.The number of psychiatrists needed for 24.2million peopleGhana had 18 psychiatrists which is LIC level. LMIClevel would be 130 and a trajectory to reach UMIClevel would require 491 psychiatrists in all for apopulation of 24.2 million.The number of other staff needed for 24.2 millionpeopleIn all cases apart from nursing, Ghana lags a longway behind the projected numbers that would beexpected.Refresher trainingGhana’s levels of refresher training for mental healthstaff are considerably less than even LICs.Patients treatedThe number of patients treated in Ghana in 2011 waslower than found in LICs. To reach LMIC level treatmentrates need to be 2.2 times higher and the trajectory toeventually reach UMIC levels is even steeper.12 / 13

www.thekintampoproject.orgIntroductionGhana is a tropical country situated on thewest coast of Africa. It shares boundarieswith Togo to the east, La Cote D’Ivoire tothe west, Burkina Faso to the north and the Gulf ofGuinea to the south. The country covers 238,533square kilometres. The population in 2010 was24,392,000 with 51% living in urban areas.1 Figureswere not available for 2011 at the time this reportwas published.Ghana is one of the leading world exporters ofcocoa and is a significant exporter of other valuablecommodities including gold and timber. A recentdiscovery of oil in the Gulf of Guinea could makeGhana an important oil producer and exporter in thenext few years.In 2010, 37.3% of the population was less than 15years old, 6.7% was above age 60 and 4.1% wasabove age 64. The life expectancy was 57 years formales and 64 years for females.2 The literacy ratewas 67.3%.3English is the official language of Ghana and isuniversally used in schools in addition to nine otherlocal languages. The most widely spoken locallanguages are Akan, Ewe, Ga, Dagomba.4Traditional religions accounts for two-fifths of thepopulation. The Christian population also accountsfor two-fifths of the total population and includesRoman Catholics, Baptist, Protestants, etc. TheMuslim population (12% of the total) is locatedmainly in the northern part of the country.4Health care delivery in Ghana is provided byboth public and private sectors. The Ministry ofHealth exercises control over the whole systemincluding policy formulation, monitoring andevaluation. Under the public health system, theservice delivery is undertaken largely by GhanaHealth Service, teaching hospitals and the ChristianHealth Association of Ghana (CHAG). In addition tothat, other quasi- and non-government institutions,religion-based and statutory bodies are also involvedin health service delivery. Total health expenditurein 2011 was 7.8% of GDP. Per capita expenditure onhealth was US 114.Ghana’s mental health sector is funded primarily bygovernment and is supplemented to a small extentby internally generated funds and donations.The history of Ghana’s GNI can be seen in Table Cbelow (Ghana rebased in 2010 and the table reflectsthe figures after rebasing). In 2011, Ghana officiallybecame a low middle income country as per theWorld Bank definitions in Table D.TABLE DWorld Bank definitions of country incomeGross National Incomeper capitaCategorylow income 1,025lower middle income 1,026 - 4,0352upper middle income 4,036 - 12,475high income 12,476TABLE CThe history of Ghana’s per-capita Gross National Income (GNI) 520042005200620072008200920102011 390 460 600 810 1,160 1,190 1,250 1,410

The mental health system in Ghana 2011 / 2012The basic WHO-AIMS data in this report has alsobeen used to produce a shorter WHO-AIMS Ghanareport which forms part of the international WHOAIMS country series and is available on the WorldHealth Organisation website. Head of each general hospital with aninpatient psychiatric service Head of each private psychiatric service Head of each community residential serviceThis WHO-AIMS follows on from a previous survey ofthe Ghana mental health system for the year 20056.The earlier survey used WHO-AIMS methods but waslimited in scope and the findings generalised, so the2005 survey is not generally compared with the 2011survey findings. Chief Pharmacist Head of Finance at Ghana Health Service /mental hospitals Director of Family / Public Health at GHS Head of Nursing and Midwifery Council /Medical and Dental Council / Directors ofNursing / Medical Schools Director of Policy, Planning, Monitoring andEvaluation at MoH Officer in Charge of Ghana School HealthEducation Programme Director of Health, Ghana Police Service Officer in Charge of Statistics, Ghana PrisonServiceNotesRates in this report that are expressed as ratesper 100,000 of the population refer to all agegroups (birth to death) and both sexes ie the wholepopulation.Regional population figures for 2011 are not available,so 2010 census figures are used.Data collectionThe WHO-AIMS was used to collect, analyse, andreport data on the mental health system andservices for all districts of the ten regions of Ghana.Data was collected in 2012, based on the year 2011.The data collection phase was May-June 2012.Where a one-off event happened in 2012 before orduring the data collection which had a significantimpact on the mental health system, such as thepassing of the Mental Health Act 846 2012, it wasincluded, but otherwise all data is for 2011.3. Ten pairs of data collectors (one pair for eachregion) were formed. Each pair consisted ofone CoHK preceptor Community PsychiatricNurse (CPN) and one Community Mental HealthOfficer (CMHO). The pairs were all then trainedto assist in the WHO-AIMS data collection fortheir region.4.Interviews were scheduled with each of theaforementioned respondents and conducted byLead Researcher, Research Assistant or CPN /CMHO data collector pairs.5.Data was entered into the WHO-AIMS 2.2 Excelspread sheet and discussed with the in-countryFocal Point.Process1.The need to conduct the WHO-AIMS in Ghanawas identified by the Ministry of Health andleaders of the Kintampo Project. Officialsanction to conduct the survey was given by theMinister of Health.2.The WHO-AIMS was used and the questions in itwere divided into thirteen separate surveys, eachtargeting specific respondents. The item number,characteristic, and salient content of thequestions were maintained. Each questionnairetargeted one of the following respondents: Chief Psychiatrist Director / Nurse Manager / Principal NursingOfficer of each mental hospital Director / Nurse Manager / Principal NursingOfficer of each outpatient service14 / 156. The lead Researcher prepared and circulateddraft reports to the in-country Focal Point, UKProject Coordinator and Chief Psychiatrist forcomments.7.Where information is lacking the Delphitechnique was used.8.Once the initial draft WHO-AIMS report wasready, findings and further analyses weredisseminated to key stakeholders in Ghana forconsultation, refinement and contextualisation.

www.thekintampoproject.orgResults

The mental health system in Ghana 2011 / 20121Policy, legislativeframework, financingand human rightsOverviewPolicy and plansThis section covers:Well-defined mental health policies and plans helpin the implementation and maintenance of goodgovernance and leadership. Thus, the existence ofa clear mental health policy and plan are importantfor improving the organisation and quality of mentalhealth services. Poli

A mental health policy (1996) and plan (2007-2011) existed. Emergency and disaster plans for mental health did not exist. Legislation A new Mental Health Act 846 2012 was passed in 2012 and was awaiting Government to establish the Mental Health Board. Financing of mental health services Mental health had a ring-fenced budget of 1.4% of