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An innovative approach expands mental health care in Africa

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Richard Okidi’s vision is weak. He stopped attending school when his vision loss kept him from seeing the writing on the blackboard. Left behind as his peers moved on with their studies, he began to lose all hope.

“I would ask myself that if I cannot see well at this age, then by the age of 40, I might fail to see at all,” says Okidi, who resides in the Agago District of Uganda.

Because of this, Okidi contemplated suicide. Instead, he met with a counselor.

“He talked to me in regard to my condition, and so I listened to him,” Okidi says in a video made by the nongovernmental organization Finemind. “His support helped me overcome” thoughts of suicide, he says.

Okidi’s treatment may seem relatively straightforward, but it was remarkable that a counselor was available. Uganda has fewer than three mental health workers per 100,000 people, and as of 2020 had 42 psychiatrists to serve a population of more than 44 million.

Thanks to a Rotary Foundation global grant, Okidi had someone to talk to. Rotary members worked with Finemind to expand mental health care services in the Agago District. By training nurses and other health workers to address mental health issues, the Rotary grant aims to provide care to people who would otherwise go untreated. That’s particularly crucial in a country where years of civil war have left many people traumatized. Beginning in the late 1980s and continuing for decades, an insurgent group called the Lord’s Resistance Army brutalized the populace in its attempt to overthrow the government.

“Some people really underwent a lot of trauma, seeing their close relatives – family, parents – being slaughtered by these rebels,” says Specioza Kiwanuka, a member of the Rotary Club of Kampala Munyonyo, Uganda, which co-sponsored the Rotary grant. The insurgency also displaced many people, she adds. The Agago District was particularly affected.

“People had to run away and stay away from home in settlement camps for a long time,” Kiwanuka says. “There is a lot of poverty, and people have taken to drugs. There is a lot of anger and many mental health issues in the community.”

Thirty-five percent of Ugandans experience some form of mental illness, according to a 2016 report. Facing that level of need, Finemind doesn’t attempt to provide the years of training required for mental health professionals in some other countries. Instead, it recruits people with experience providing care, such as nurses and social workers, and offers a short course for them to learn the fundamentals of mental health care. Its counselors spend just six days learning how to listen and provide support to people suffering from depression and anxiety.

“We spend a considerable amount of time talking about effective principles of counseling. In counseling, you’re not giving advice or interrogating. You’re trying to invite reflection,” says Pavel Reppo, Finemind’s co-founder and executive director.

Finemind’s counselors administer a basic level of care. They listen empathetically, document the patient’s condition with a questionnaire, and provide referrals for more advanced interventions when necessary. Finemind’s patients receive an average of four counseling sessions.

“I really feel I’ve helped many people. Some of them come back to me and tell me, ‘You have really saved my life,’” says Roseline Lamwaka, a Finemind counselor in the Agago District. She has a diploma in social work and previously worked at a local hospital counseling HIV-positive patients. Since beginning her association with Finemind in September 2021, she’s counseled 174 people.

From left: Finemind counselor Charles Anywar, Finemind counselor Roseline Lamwaka, Finemind counselor Margaret Ayaa, Finemind counselor Kenneth Ocan. Photos courtesy of Khullood Rahman.

“There was one mother who was drinking every day. She didn’t care about her family, about her life – she just wanted to drink and die,” Lamwaka says. “After my counseling sessions with her, she came back and testified to me, ‘My life has improved so much.’ So I feel that I’ve really supported patients in the community.”

Finemind uses an approach called “task sharing,” an increasingly common way to provide health care in areas with few medical professionals. Tasks usually undertaken by a doctor are transferred to nonspecialist health workers, such as those recruited by Finemind. Citing the “crippling health workforce shortages” in many countries, former World Health Organization Director-General Margaret Chan has called task sharing “the vanguard for the renaissance of primary health care.”

Finemind modeled its program on one in India, and similar programs are being tried in Kenya, Pakistan, Zimbabwe, and other countries. Task sharing may be unconventional, but studies have shown that it can work.

“The evidence suggests that lay health workers are effective,” says Melanie Abas, a professor of global mental health at King’s College London, England. “They’re definitely able to provide counseling for a proportion of people with depression if they stick to the protocol and don’t start talking about themselves too much or being judgmental. They’re able to build a therapeutic alliance with the client, so the client leaves at the end of the session and thinks, ‘I felt understood. I felt listened to.’”

With the Rotary grant, Finemind trained, equipped, and supported 10 health workers, ultimately providing counseling to more than 1,500 people who otherwise would have gone untreated. Rotary members reviewed the training and referral procedures and followed up with counselors.

In addition to the shortage of providers in Uganda, there’s also powerful social pressure against seeking help for depression and anxiety. To address this, the grant funded a weekly radio talk show about mental health. Besides offering advice and explaining how to find services, the show hosts a panel of counselors who answer call-in questions.

To further build community trust, the program works in partnership with a local hospital. Many of Finemind’s counselors are recruited from the hospital’s staff, and the counselors refer patients there when more advanced treatment is needed.

“This integration with physical medical services is very powerful,” says Diane Messamore, a member of the Rotary Club of Denver Mile High, Colorado, USA, which co-sponsored the global grant. “When you walk in and it says ‘Medical’ across the top of the door, or ‘Physical Health,’ it’s much less stigma than if it says ‘Mental Health Services.’”

Kiwanuka notes that NGOs don’t commonly address mental health issues in Africa. With this grant, Rotary members are focusing on problems that people don’t usually talk about, much less fund.

“We realized that something can be done to improve these people’s lives,” Kiwanuka says. “We can have an impact on people who would otherwise become victims of suicide.”

- January 2024