Hello all, my name is Shelley McKee, and this is my first blog of what will be a series. Presently, I am in the midst of completing my Masters of Public Health at the University of Waterloo. As the course title suggests, it is expected that this program will provide me with a broad understanding of public health issues which involves: alcohol, tobacco and drug-related harms, teen pregnancy, healthcare-associated infections, as well as food safety, maternal, nutrition, physical activity, obesity, and heart and stroke-related issues. Also, another intention of this program involves preparing learners such as myself to take on leadership roles in public health institutions; where I can utilize the knowledge and skills learned to tackle crucial public health issues actively. Currently, I work as an infection control practitioner, so my public health interests have tended to focus more on communicable diseases. However, before my current work position, I did work as a mental health nurse for around ten years. So, working on this project with Engage Africa Foundation has undoubtedly reinvigorated the passion I have for non-communicable diseases such as mental health illnesses/issues and how to address them.
However, after researching mental illnesses that impact the African population, I feel that I am beginning to view this critical public health issue from a different lens—a more global lens. For instance, as I sift through the vast literature on mental illness affecting the African population, I cannot help but notice a common thread throughout—which is, the fact that mental health resources and prevalence vastly differs within and between regions.
For instance, as indicated in the charts below—created using the World Health Organization’s (WHO) 2017 Atlas data—it can be observed that the burden of disease in terms of mental disorders (WHO official estimates) via the disability-adjusted life years (DALY) per 100,000 population for within regions ranges from 2,609.85 in the Congo (lower-middle income) to 3,853.50 in Equatorial Guinea (upper-middle income) located in Central Africa.1 The trend continues: in South Africa the DALYs range from 2,336.94 in Mozambique (low income) to 3,562.61 in Botswana (upper-middle income); 3,270.44 in Algeria (upper-middle income) to 3,684.72 in Libya (upper-middle income)—only two countries had data, in North Africa; 2,171.27 in Ethiopia (low income) to 3,537.41 in Rwanda in (low income) located in East Africa; and lastly, 1,900.00 in Guinea-Bissau (low income) to 2,705.41 in Cote d’Ivoire (lower-middle income) located in West Africa.1 As for between regions, DALYs range from 1,900.00 in West Africa (lowest) to 3,853.50 in Central Africa (highest).1
Similarly, the suicide mortality rate (SMR) per 100,000 population data also depict a range of rates, from 2.3 (Sao Tome and Principe- low income) to 16.4 (Equatorial Guinea- upper-middle income) located in Central Africa; 4.7 (Angola- upper-middle income) to 13.3 (Swaziland- low income) located in South Africa; 3.2 (Algeria- upper-middle income) to 5.2 (Libya- upper-middle income) located in North Africa; 3.2 (Kenya- lower-middle income) to 9.9 (Uganda- low income) located in East Africa; and 4.0 (Guinea-Bissau- low income) to 14.5 (Cote d’Ivoire- lower-middle income) located in West Africa.1 Between region data for SMR per 100,000 population data also ranges from 2.3 in Central Africa (lowest) to 14.5 in West Africa (highest). These rates and figures are important to acknowledge because they can help to identify where mental health resources are needed most.
DALYs and SMR Charts- compiled using WHOs 2017 Atlas data:
Other reasons for these discrepancies, I am learning, include overall healthcare worker shortages, and weak health systems that lack adequate preventative and curative healthcare services, as well as promotion programs.2-3 Also, many health systems either fail to or inadequately define health in a way that is all encompassing.4 Meaning, these health systems focus solely on the absence of disease or infirmity rather than adopting the WHOs broad definition, which encourages systems to adopt curative, preventative, promotional and rehabilitative services.4 By adopting this broad array of services, health systems can then begin to broaden their definitions of how health and wellness should be defined—which is a complete state of physical, mental, and social wellness rather than the absence of disease or infirmity.4 Likewise, by systems adopting broader, more inclusive definitions, this will result in the development of services and programs that are also more inclusive, and hence, geared toward tackling crucial public health issues such as mental illnesses.
Further, health systems that exist in developing countries also tend to suffer from insufficient financial and human resources, limited institutional capacity and infrastructure, and discrimination and inequity are unequivocally inherent, and regrettably, determine the availability and delivery of services.5-7 For instance, it is clearly evident in the table provided above, that those of low-income status, and have little or no health coverage tend to have the highest prevalence rates of total cases treated for severe mental disorder, SMR, and the lowest rates of psychiatrists and the total number of mental health professionals per 100,000 population (the graphs below further illustrate the stark differences between various income levels when it comes to the provision of mental health care/services).1
Moreover, a lack of comprehensiveness, transparency, the absence of community participation, and a dearth of accountability and capacity building management 5-7 further impede the provision of adequate mental health services, and hence, delivery of appropriate public health services.
Another factor to consider is that of global climate change. For instance, because global climate changes result in higher temperatures and increased rainfall, this inevitably, not only leads to more natural disasters, but it is also the primary cause of crop failure. These are important considerations when it comes to health-related impacts because they are a leading cause of health issues such as malnutrition, mental illnesses, premature mortality, injuries, the development and spread of water and food-borne illnesses, an increased prevalence of water and food insecurity, and last but not least, limited access to healthcare services.8 It is important to acknowledge the impact global climate change has on the exacerbation of such health-related issues because these are health issues that also disproportionately impact resource-poor countries. For example, take mental illness and global climate change, there has been a growing amount of literature to suggest that both direct and indirect causal pathways impact the development of this critical public health issue.8 This is in part due to the psychological consequence of such disasters, as well as economic losses (i.e., a drought may be the precipitant of a farmer's suicide; migration and forced displacement along with physical impairments/illnesses can cause populations to experience severe mental anguish leading to the development of mental health issues overtime).8 Low-and-middle-income countries also tend to be more vulnerable to the effects of global climate change because as mentioned and identified in the graphs above, they tend to lack adequate availability of essential services and/or have weak health systems already insitu. This ultimately, exacerbates social, economic and demographic inequalities, further straining health systems.
Additionally, another common thread throughout the African continent is the fact that it tends to score lower than other continents when it comes to mental health resources. For example, when it comes to mental health expenditure per capita in US dollars, Africa scores the lowest of all other continents at 0,1, whereas the Americas is 11.8 and Europe is 21.7, respectively.1 Also, when considering the source(s) of payment for mental health services, Africa is almost a 50/50 split between the percentage of countries where persons pay mostly or entirely out of pocket versus percentage of countries where persons pay nothing or at least 20 percent towards the cost of mental health services.1 Additionally, Africa has the lowest median number of mental health workers per 100,000 population, at 0.9 versus 50 in Europe, or 10.9 in the Americas.1
Thus, the aforementioned certainly highlights some of the inherent disparities that exist when it comes to mental health service and public health care delivery in the African population, but given this, where do we begin to ‘Tackle this Serious Public Health Issue in Resource-Poor Countries?’
The following quote was taken directly from my school’s homepage, “Public health is the science and practice of preventing disease, improving the quality and length of human life, and reducing health inequalities by improving the organized efforts and informed choices of societies” (Winslow, 2002). This quote particularly resonates with me at this time because I feel it offers guidance on how one can utilize public health knowledge to tackle such essential health issues, especially when vulnerable populations lack distinct, clear-cut discourses/strategies.
To conclude, it is my profound hope that throughout the development of this report I will get answers to the current question I seek, which is; why do mental health resources differ so significantly within and between regions? And hopefully, these answers will be in the form of distinct, clear-cut strategies on how to address this critical public health issue affecting this particularly vulnerable population.
So, please stay tuned. For the unravelling of answers to further pressing questions pertaining to the tackling of this important public health issue in resource-poor/developing countries.
- World Health Organization (WHO). (2017). Mental health Atlas- 2017 country profiles. Retrieved from https://www.who.int/mental_health/evidence/atlas/profiles-2017/en/
- Pfeiffer, J., Johnson, W., & Fort, M.,…(2008). Strengthening health systems in poor countries: a Code of Conduct for nongovernmental organizations. Strengthening health systems in poor countries: do we need an NGO code of conduct? AJPH, 98(12). pp. 2134–2140.
- Chen, L., Evans, T., & Anand, S.,…(2004). Human resources for health: overcoming the crisis. Lancet, 364(9449). pp. 1984–1990.
- American Public Health Association [APHA]. (2008). Strengthening health systems in developing countries. Retrieved from https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/23/09/09/strengthening-health-systems-in-developing-countries
- Travis, P., Bennett, S., & Haines, A.,... (2004). Overcoming health-systems constraints to achieve the Millennium Development Goals. Lancet, 364(9437). pp. 900–906.
- Institute of Medicine. (2007). PEPFAR Implementation: Progress and Promise. Washington, DC: National Academies Press.
- Ooms, G., Van Damme, W., & Temmerman, M. (2007). Medicines without doctors: why the Global Fund must fund salaries of health workers to expand AIDS treatment. PLoS Med, 4(4):e128.
- The World Bank. (2019). Climate change and health: Understanding poverty. Retrieved from https://www.worldbank.org/en/topic/climatechangeandhealth