Mental health profile of Ghana.

Ghana is a West African state that attained independence from Great Britain in 1957 and became a republican state in 1960. Its population is about 22 million (2004 estimate), distributed in ten regions. The World Health Organization (WHO) has estimated that 650 000 of the population are suffering from severe mental disorder and 2 166 000 are suffering from moderate to mild mental disorder (see http://www.who.int/mental_health/policy/country/ghana/en).

Mental health activities started with the enactment of the Lunatic Asylum Ordinance in 1888 by the colonial government of the Gold Coast (as Ghana was then known). The ordinance allowed law-enforcement agencies to arrest people suspected of having a mental illness (at least those who were roaming about in towns, villages or the bush) to be confined in an abandoned prison in Accra. That facility soon became overcrowded, necessitating the provision of the Lunatic Asylum in 1906. The Asylum eventually became Accra Psychiatric Hospital (Ewusi-Mensah, 2001). Two other purpose-built psychiatric hospitals, the Ankaful Psychiatric Hospital and Pantang Hospital, were opened in 1965 and 1975, respectively. The first President of Ghana had a vision of making Pantang a pan-African mental health village for research into neuropsychiatric conditions but his vision was not realised before his overthrow in 1966.

Mental health policy and legislation

Ghana’s mental health policy was formulated in 1994, and revised in 2000 and 2004. The policy objective is to provide facilities at the tertiary, regional, district and sub-district levels for the management of psychiatric cases. In pursuit of this, each regional hospital is meant to have a psychiatric wing with 10–20 beds.

The policy of the Ministry of Health is to shift the focus of mental health treatment from institutionalised care to community care, integrated into general healthcare (according to the draft Mental Health Bill 2010). Decentralisation of mental health services has been pursued with the aim of increasing access, which has involved training more psychiatric nurses, medical officers in the district hospitals and non-mental health personnel. Ten general duty doctors were trained to head the regional wings, but only three of them could be engaged in the regions, while the others have augmented the staff at the specialist hospitals. The other policies set out in the Bill cover the formation of a technical coordinating committee, training, the rehabilitation of people who are mentally ill and periodic review of conditions of service for mental health personnel.

After the promulgation of the Lunatic Asylum Ordinance of 1888, the National Redemption Council Decree (NRCD 30) of 1972 followed. This was an institution-based law that did not address human rights adequately but was an improvement on the previous law. Unsuccessful attempts were made in 1992, 1996 and 2000 to revise the law. Since 2004, a more comprehensive Bill has been prepared with the technical assistance of the WHO and will soon be put before Parliament. The new Bill adopts an approach based on human rights, in accordance with international agreements (such as the United Nations Charter) on the health needs of people with mental disorders (WHO, 2005). The Bill applies to the private as well as the public sector. It addresses community care, which involves orthodox, traditional and spiritual practices, and the monitoring of activities in order to bring dignity to people suffering from mental illness. The Bill also ensures that standards of care and patients’ rights are adhered to in order to prevent physical and sexual abuse.

Mental health service delivery

Mental health services are provided by psychiatric hospitals, regional hospitals and some district hospitals. In-patient facilities are available at the three psychiatric hospitals, one teaching hospital, three regional hospitals and the military hospital; in addition, four of the five private facilities have in-patient psychiatric facilities. Three regional hospitals have 10–20 beds in psychiatric wings. Two substance misuse centres are available at Korlebu Teaching Hospital and Pantang Hospital, where the centre operates as a therapeutic community. The other regional hospitals admit psychiatric patients to medical wards supervised by general medical officers and assisted by community psychiatric nurses.

Community psychiatric nurses have been trained to provide aftercare to discharged patients in the community, to undertake mental health promotion, and to refer cases to regional hospitals or specialist facilities. Currently, there are 181 community psychiatric nurses, but in only 94 of the 170 districts.

There are three specialists (two on contract ) working in Accra Psychiatric Hospital, which has 1200 patients, supported by three medical officers, a resident, seven medical assistants and 248 nurses. Pantang Hospital, which has 500 patients, has two specialists, supported by three medical assist ants, one resident, 196 nurses and a clinical psychologist.

Ankaful Psychiatric Hospital has two specialists supported by two medical assistants, one clinical psychologist and 85 nurses, for a patient population of 300.

Psychiatric training

Psychiatric undergraduate training takes place at the University of Ghana Medical School at Korlebu Teaching Hospital, in Accra, where there are two lecturers (supported by eminent Ghanaian specialists living overseas) as well as two lecturers in the Department of Psychology, and at the University of Medical Sciences at Komfo Anokye Teaching Hospital, in Kumasi. Both universities offer postgraduate training programmes for the Fellowship of the West African College of Physicians and the Ghana College of Physicians and Surgeons. The West African College was established by the Anglophone West African countries; senior specialists in the region provide training and conduct examinations at approved centres. The Ghana College has a local programme that trains its students and examines them using external assessors; it was established to increase the local demand for specialists and to tackle emigration by doctors.

Psychiatric nurses are trained in two centres. The 3-year training required to become a registered mental nurse (RMN) takes place at Pantang Hospital. The 18-month post-basic RMN training for the state-registered nurse qualification takes place at Ankaful Psychiatric Hospital.

Psychiatric subspecialties and allied professions

Although some psychiatrists have expertise in the subspecialties, they end up practising as general psychiatrists as there are insufficient numbers of these. The Accra Psychiatric Hospital has a children’s ward, female and male psychogeriatric wards and male and female forensic wards. The Ministry of Education, supported by the Department of Social Welfare, is responsible for special education, including institutions for people with intellectual disability. There is one such government facility and a private facility in Accra.

There are a number of non-governmental organisations (NGOs) working in the area of mental health. Prominent among them is BasicNeeds, which both promotes mental health and provides mental health services to deprived areas in the northern and southern parts of Ghana.

Main areas of research

Ghana has been one of the four African countries involved in the Mental Health and Poverty Alleviation Project, which is sponsored by the UK Department for International Development (DfID). As a component of this project, the team has concerned itself with the development of mental health information systems; this involves development of software and the training of staff in the recording of data. There is also an ongoing project to set up a community-based mental health service at Kintampo (Akpalu et al, 2010).

Workforce issues

The mental health service in Ghana is facing many challenges. The stigma attached to the psychiatric profession deters people from joining it. The few health personnel to have been fully trained, particularly the nurses, often emigrate, which counteracts the increase in the numbers trained (each school trains 200 students a year). Most of the wards are overcrowded with long-stay patients who are not accepted at home. Ghana has 13 psychiatrists for a population of 22 million, which represents a huge treatment gap for patients who need professional psychiatric attention. Since psychiatric services are free and the hospital facilities depend on government funding (which is insufficient) and do not generate any funds, they are always under-resourced. The budget for mental health was only 2.3% of the total health budget for 2009. A large proportion of this goes on staff costs, drugs and feeding of patients. The service operates an essential drug list. Many of the patients, however, cannot afford the new-generation drugs.

Human rights

In some spiritual and traditional settings, aggressive psychiatric patients are chained or locked up. Some lose their jobs, particularly in the private sector, when employers get to know that their worker is a psychiatric patient. In the public sector, as well as in spiritual and traditional settings, patients may receive treatment against their will. Fortunately, the new Mental Health Bill seeks to address these concerns.