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Improving the quality of primary health care and health services in Rwanda - Ubuzima Burambye (Long healthy life)

Ubuzima Burambye
> Rwanda

Integration of mental health care in primary health care to increase accessibility in Rwanda

Integration of mental health care in primary health care to increase accessibility in Rwanda

Mental health, a serious health challenge in the world

Mental health is one of the most serious health challenges in the world. Globally, 700 million people are estimated to suffer from mental and behavioural disorders and one out of four people will develop one or more of these disorders during their lifetime. Three out of four people with mental health problems live in low- and middle-income countries (LMIC) and yet up to 90% of people living with mental illness in these countries do not receive mental health services. One of the biggest reasons behind this “treatment gap” is underinvestment. Low-income countries spend less than 1% of their health budgets on mental health, while less than 1% of global development funding for health is spent on mental health. In spite of the chronic and long-term nature of some mental disorders, with the proper treatment, people suffering from mental disorders can live productive lives and be a vital part of their communities.

Mental disorders represent a huge cost to health care systems and to the global economy, and affect some of the world’s most vulnerable people, through stigma and lack understanding. In 2015 the world took a huge step forward by including mental health in the Sustainable Development Goals (SDGs), which fixed the global development agenda for the next three decades.

Mental health, priority area of intervention in Rwanda

In Rwanda, the available data show that the country faces an exceptionally large burden of mental disorders and much of the country’s burden of mental disorders can be linked to the Genocide against the Tutsi in 1994. Furthermore certain mental disorders such depression and post-traumatic stress disorder (PTSD) are described with proportions beyond international averages. One out of four people suffers from PTSD and prevalence of depression is 15.5 to 21% depending of the study. Drug abuse, particularly among young people, is a new mental health challenge in Rwanda and prevalence of epilepsy is high (5%), making mental health a serious public health problem in the country.

Mental health is clearly identified within the overall Health Sector Policy as a priority area of intervention. This policy recommends the integration of mental health services into all national health system structures, including at the community level. On the contrary to many developing countries, Rwanda is on the forefront in terms of developing a sustained and sustainable national response to the burden of disease caused by psychological and neurological disorders, as well as substance abuse. 

Mental health in Belgium Cooperation context in Rwanda

The Belgian Cooperation supports the development of mental health services in Rwanda over more than a decade and is the only bilateral donor working on this thematic.

The Mental Health intervention provides technical and financial support to decentralize mental health care into general care and integrate mental health care into primary health care. This support is mainly through capacity building, equipment, mentorship & supervision and training of health professionals to deal with mental disorders including substance abuse related issues. This intervention supports also psychological interventions during the Genocide commemoration period.  In order to ensure the success and quality of the integration of mental health care, the intervention supports the Mental Health Division of Rwanda Biomedical Center / Ministry of Health as well as the national mental health reference structures.

Key progress in the decentralisation and integration of mental health care

The officially-approved Mental Health Policy, (introduced in 1995 and reviewed in 2011) has initiated a process of decentralization and integration of mental health care as well as the creation of referral services. At the central level, there is the Mental Health Division within the Rwandan Biomedical Center in the Ministry of Health. Its main mission is to implement the Mental Health Policy through a strategic plan under the guidance of the Health Sector Strategic Plan.

Mental health is now integrated into the package of care of health centers, district hospitals, provincial hospitals and referral hospitals. Obviously, mental health services and resources were shifted from the psychiatric hospital to the community health facilities: District Hospitals (DH) and Health Centers (HC).

Mental health services are effectively decentralised. Each of the country's DH & PH (43), through the Mental Health Unit, delivers a comprehensive mental health care package according to the national standards. Within this framework, each mental health unit provides inpatient and outpatient mental health care, including analysis and diagnosis, treatment and follow-up, rehabilitative measures, counselling and interaction with families. If necessary, the patient will be referred to mental health referral settings. Mental health units are staffed by a permanent team comprising one or two psychiatric nurses and one psychologist providing a broad range of mental health services under the supervision of a physician trained in mental health care. There are 66 psychiatric nurses and 41 psychologists working in mental health units in district hospitals and at least one GP gets hands-on training. Each mental health team receives on-site formative supervision and participates in regular case review sessions led by a mental health team from the national referral structures.

General Nurses working in health centres and CHWs were trained to ensure an integrated mental health care component in health centres and at community level. CHWs serve as an important link between the community and health providers. In this context 766 General Nurses in Health Centers, more than 15000 CHWs and important number of volunteers (local NGOs & association) were trained annually. A stepped-care approach is provided: from health centres in rural areas, to district hospitals and then mental health referral settings in Kigali. Consequently, patients are treated as near as possible to their home and then receive hospital treatment only after community treatment has failed. A specific list of essential psychotropic medicines has been established for each level of the health system. These psychotropic medicines are part of the national list of essential medicines. Mental health care is integrated into the community-based health insurance (CBHI) scheme (Mutuelles de santé), which allows mentally ill people, similar to other patients, to pay at most a 10% co-payment for psychotropic medicines and services. There is no co-payment for the lowest incomes. By decentralizing mental health services and integrating mental health care into CBHI, the accessibility was increased, and the number of transfers to mental health referral structures was reduced. Data from the national health management information system (HMIS) shows that in 2016, all mental health units at DHs level received 26.060 new mental health cases and performed 201.902 outpatient consultations and 3.236 hospitalizations, with only 779 transfers to mental health referral structures.

Rwanda still lacks staff with an educational background in psychiatry. Up to 2017 there were only 7 psychiatrists in the health system. In 2013, the University of Rwanda launched a third-cycle specialization in psychiatry to increase the pool of trained psychiatrists in the country. Specialists can ensure quality of care and expand health care provision. The first 3 psychiatrists were graduated in August 2017 and 10 students are enrolled within the program in collaboration with Belgium and Switzerland universities.

In the area of prevention of drug abuse, regular awareness campaigns are conducted targeting young people. A specialized structure for the treatment of drug-related disorders has just been set up.

Integrating mental health care into Primary Health Care (PHC) is a great opportunity to intervene early and prevent chronicity. It is also an opportunity to involve communities and increase accessibility to mental health care which can be provided close to the community. 

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