Malawi.

Malawi is a country with an approximate area of 118 000 km2. Its population is estimated at 13 million and the gender ratio (men per hundred women) is 98. The proportion of the population under the age of 15 years is 47% and the proportion above the age of 60 years is 5%. The literacy rate is 75.5% for men and 48.7% for women (World Health Organization, 2005).

For administrative purposes, Malawi is divided into three regions, which are further divided into a total of 28 districts. The capital city is Lilongwe, which is situated in the central region, and the main means of travel between the capital and districts is by road.

The main languages used in Malawi are English and Chichewa. The largest ethnic group is Chewa and the other ethnic groups are Nyanja, Tumbuka, Yao, Nkhonde and Ngoni plus the Europeans, Indians and other foreign nationals. The largest religious groups are Christians followed by Muslims.

Health indicators

Malawi has high rates of infant and maternal mortality rates. The life expectancy at birth is 40 years for both males and females (National Statistical Office of Malawi).

Health services

There are very few doctors. Clinical officers, medical assistants and enrolled nurses comprise the backbone of Malawian healthcare, but there are shortages of these health personnel, especially in the rural areas, as people prefer to practise in urban areas.

The smallest health unit in Malawi is the ‘health post’, which is manned by ‘health surveillance assistants’ (who have 10 weeks’ orientation training). Each health post serves a small number of villages. Next in the referral hierarchy is the health centre, which is usually staffed by medical assistants (who have 2 years’ training) and nurses. Patients who cannot be treated at the health centre are referred to the district hospitals, which are present in all but 3 of the 28 districts. There are four general tertiary referral hospitals, distributed in all three regions of Malawi, with two in the southern region, which is the biggest.

Mental health resources and services

Zomba Mental Hospital, which is situated in the southern region, is the only government tertiary psychiatric referral hospital in Malawi. It has 333 beds and on average admits 1500 patients per year. There is a smaller psychiatric unit in the central region, in Lilongwe, with about 30 beds, and this is run as part of Kamuzu Central Hospital, which is the tertiary referral hospital in the central region. Psychiatric patients from the northern region are usually referred to a missionary hospital, St John of God in the city of Mzuzu, which has 50 in-patient beds and which runs an effective community programme. In total there are therefore just over 400 psychiatric beds for the entire population.

The commonest reasons for admission to Zomba Mental Hospital are schizophrenia, bipolar disorders, intellectual disability, epilepsy, and substance-related and HIV-related conditions (according to hospital statistics for the year 2005). Nearly all patients admitted present with severe forms of these conditions.

Mental health services in all the districts fall under the office of the district health officer and the associated expenditure is included in the district’s health budget. As with the other general tertiary hospitals, Zomba Mental Hospital has its own budget.

Public psychiatric services fall under clinical services (curative) within the Ministry of Health. The resources in terms of facilities and staffing at the different care levels are summarised in Table 1.

Table 1

Government mental health facilities at different healthcare levels

Level	Facilities	Staffing	Services offered
Tertiary	Zomba MentalHospital	One psychiatristOne psychiatric clinical officerTwenty psychiatric nursesFive general clinical workersFour general nursing workersOne occupational therapist	Long-stay careForensic servicesHospital day careAcute in-patient careCommunity servicesRehabilitation servicesOccupational therapy Out-patient care
Secondary (district hospitals)	Only two have a psychiatric ward	From one to six psychiatric nurses[1]Variable numbers of general clinical and nursing workers	Acute in-patient careOut-patient careCommunity servicesMedium-stay careOutreach clinicsReferral to Zomba Mental Hospital
Primary (district health centres)	No psychiatric wards	General nurses (sometimes enrolled psychiatric nurses)General health workers (clinical/medical officers)	Minimal out-patient careReferral to district hospitals

Psychiatric nurses are often redeployed to general medical and surgical services, resulting in diminished delivery of mental health activities in the district hospitals.

Staffing

There is only one psychiatrist for the entire population of Malawi, but since he is based in Zomba, the old capital city, the psychiatrist:population ratio is 0 for the rest of the country.

There are no professional social workers and only one occupational therapist, at Zomba Mental Hospital. There are two clinical psychologists attached to the College of Medicine in Malawi, who teach medical students; they do not do any clinical work in the psychiatric hospitals.

The district psychiatric nurses do weekly outreach clinics, visiting different health centres and health posts within their districts; the management team from Zomba Mental Hospital visits each district twice a year to monitor mental health activities throughout the country.

World Mental Health Day

World Mental Health Day is celebrated publicly every year in a selected district. Posters, T-shirts and leaflets explaining mental health issues are distributed to the public for free at the chosen venue. The public’s response to this has always been very encouraging.

Mental health policy and legislation

The old 2000–04 policy is still being used while it is awaiting review. This policy includes the integration of psychiatric services into the primary healthcare system, the appointment of a national mental health coordinator at the Ministry of Health’s headquarters and a human resources development plan.

The Mental Treatment Act was enacted in 1959 and amended in 1968. A Mental Health Bill is awaiting review by stakeholders and later parliamentary amendment; it is anticipated that it will be passed in 2007. It compares well with legislation in countries such as South Africa and Kenya, and includes the formation of a mental health review board, which will monitor the care and treatment of psychiatric patients in hospital. It covers areas such as admissions, the rights of inpatients and the safekeeping of patients’ property.

Training

Undergraduate medical students

There is one medical school, the Malawi College of Medicine, which is part of the University of Malawi, in Blantyre. As part of their MBBS course, students in the third year have 2 weeks of psychiatry theory and in the fourth year they undergo a 5-week rotation in theory and clinical work.

Other health workers

The two main health sciences colleges offer training of paramedical staff – the clinical officers, medical assistants and enrolled nurses. Clinical officers can go for further training in specific areas and become psychiatric clinical officers, orthopaedic clinical officers and so on. Plans are being finalised to train district primary health workers in the management of common psychiatric disorders. Currently, most primary health workers lack skills in the assessment and management of psychiatric patients and end up referring all those they come across.

Postgraduate specialisation

The College of Medicine at the University of Malawi has offered postgraduate training only since 2005 in certain specialties, in conjunction with certain universities in South Africa. This does not include psychiatry, so all psychiatric training at present has to be done outside Malawi.

Psychiatric nurses

The St John of God College of Health Sciences provides a degree in psychiatric nursing for registered state nurses with a minimum of a university diploma in nursing, and the Malawi College of Health Sciences provides a certificate course in psychiatry for enrolled nurses.

Research

Mental health in Malawi has been the subject of several research projects. These have included studies in psychoactive substances, the teaching of psychiatry in the colleges and attributions for admissions to Zomba Mental Hospital (MacLachlan et al, 1995). More studies are under way or being developed by Zomba Mental Hospital on, for example:

community attitudes to and knowledge of mental illness

the prevalence of HIV and neurosyphilis among inpatients

district mental health activities in southern Malawi, including what proportions of the district budgets are allocated to mental health

common causes of relapse and readmission in patients with schizophrenia

pathways to care for psychiatric patients

neuropsychological sequalae of cerebral malaria.

At the St John of God Hospital a randomised controlled trial of carer education in schizophrenia and bipolar disorders is under way.

In general, there is not much information on mental health in the Malawian context and this provides opportunities and challenges for research.

Professional organisations

In the past there was a Mental Health Association of Malawi, but it stopped functioning, for unknown reasons, around 1999. At present, a ‘core group’ is being formed, comprising: the psychiatrist at Zomba Mental Hospital; the clinical psychologist at the Malawi College of Medicine; the chief nursing officer at Zomba Mental Hospital; and the psychiatric clinical officer at the St John of God Hospital. The main goal of this core group is to develop the preliminary constitution of a new professional association and to recruit members. Some of the functions of the association will be:

to deal with challenges in mental health

to act as an advisory body to the Medical Council of Malawi on the registration of mental health professionals

to develop, review and conduct policy for mental health professionals.

There are at present no non-governmental organisations operating in the mental health field in Malawi.

Challenges

Notable problems include a critical shortage of trained staff and frequent shortages of drugs owing to procurement problems. The referral system is not very good; neither is follow-up care, as most district psychiatric services seem to be insufficiently well developed.