MENTAL HEALTH SITUATION ANALYSIS IN NIGERIA
0
2012 REPORT
SUMMARY OF THE REPORT
This report represents the situation of mental health in Nigeria. It covers various aspects
of needs, availability and delivery of services and resources, policy and legislations
protecting the rights of people with mental disorders.
In Nigeria, the prevalence of mental illness is reported at 20%.Although, mental health is
a formidable public challenge which suffers serious institutional and normative neglect.
There is widespread stigmatization of mental illness and the belief that misuse of drugs
is the cause of mental illness. Poor health facilities and poverty make the care of people
with mental illness a major burden for both patients and their families. It is often
attributed to supernatural or spiritual causes.
Nigeria is classified as low income country and in regards to government expenditure as
a percentage of total expenditure on health, the Nigerian government share declined
from 29.1% in 1999 to 25.5% in 2003. There is a concern that the budgeted figures may
not be representative of the actual amount spent on health. About 3.3% of the health
budget of the federal government goes to mental health with over 90% of this going to
mental hospitals.
The majority of mental health services is provided by 10 regional psychiatric centres and
departments. The private health care sector plays a limited role in provision of mental
health services, though many people with mental illness turn to spiritual or traditional
healers for help. The specialists such as psychiatric nurses, social workers, occupational
therapists and all those who form members of mental health team are very few in
numbers, grossly inadequate.
It is estimated that roughly 50% of all drugs on sale are fake or sub- standard. Despite
this, the challenges involved in sourcing original, reliable drugs remain huge. Presently,
no legislative or financial provisions exist to protect and provide support for users.
1
Glossary
ABUTH
- ADO BAYERO UNIVERSITY TEACHING HOSPITAL
AKTH
– AMINU KANO TEACHING HOSPITAL
FMC
- FEDERAL MEDICAL CENTRE
FNPH
- FEDERAL NUERO-PSYCHIATRIC HOSPITAL
HMO
- HEALTH MAINTENANCE ORGANIZATION
JUTH
– JOS UNIVERSITY TEACHING HOSPITAL
LASUTH
–LAGOS STATE UNIVERSITY TEACHING HOSPITAL
LAUTECH
–LADOKE AKINTOLA UNIVERSITY TEACHING HOSPITAL
LUTH
-- LAGOS UNIVERSITY TEACHING HOSPITAL
NAFDAC – NATIONAL AGENCY FOR FOOD AND DRUG ADMINISTRATION AND
CONTROL
NGO
- NON GOVERNMENTAL ORGANIZATION
NHIS
- NATIONAL HEALTH INSURANCE SCHEME
OAU
- OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITAL
UCH
– UNIVERSITY COLLEGE HOSPITAL
UNADTH
– UNIVERSITY OF ADO TEACHING HOSPITAL
UNTH
– UNIVERSITY OF NIGERIA TEACHING HOSPITAL
UPTH
– UNIVERSITY OF PORTHARCOURT TEACHING HOSPITAL
WHO
– WORLD HEALTH ORGANIZATION
2
Table of Contents
1.
Introduction ……………………………………………………………
4
2.
Mental Health Needs ………………………………………………
5
3.
Mental Health Policy .……………………………………………..
6
4.
Legislation protecting the Rights of People with Mental Health ….
8
5.
Mental Health Financing ……………………………………….…
8
6.
Mental Health Services Available in the Country …….
10
7.
Human Resources for Mental Health ……………………….
12
8.
Specialist Mental Health Needs …..…………………………..
14
9.
Availability of Drugs ………………………………………………
14
10.
Organizations representing the interest of people with mental illness
………………………………………………………………………………….
15
11.
Stakeholder Views ………………………………………………..
16
12.
Relevant References/Source ……………………….………..
18
3
MENTAL HEALTH CARE IN NIGERIA: SITUATION ANALYSIS
1.
INTRODUCTION
Nigeria is a country with an approximate area of 924 thousand square kilometers and a
population of 140,003,542 million (2006 population census). The main languages used in
Nigeria are English, Hausa, Yoruba, Igbo and pidgin English. The largest ethnic groups are the
Hausa and Fulani in the north, Yoruba in the South West and Igbo in the South East. The largest
religious groups are Christians and Muslims, and other religious groups are indigenous groups.
The country is a lower income group country based on World Bank 2004 criteria.
The
proportion of health budget to GDP is 3.4%. The per capita total expenditure on health is
US$31, of which US$7 represented government expenditures (WHO, 2004). The health life
expectancy at birth is 41 years for males and 42 years for females.
Mental illnesses are increasingly recognized as a leading cause of disability worldwide,
with neuropsychiatric conditions accounting for 11.5% of the global disease burden (WHO,
2009). However, despite the growing burden of mental illness and the resultant level of
suffering for individuals and society, efforts to address it are unsatisfactory. This is particularly
true in developing countries due to low budgetary resources, presence of competing and
conflicting health system needs, scarcity of mental health personnel and the stigma involved in
seeking psychiatric help.
In Nigeria, the prevalence of mental illness is reported at 20%. With a population of 140
million and less than 150 psychiatrists, the ratio of psychiatrists to population is 1:1,400,000.
Although mental health is a formidable public challenge in Nigeria, it suffers from serious
institutional and normative neglect. Despite a steady growth in the number of mentally ill
patients roaming the streets and the resulting danger to the public, the government is yet to
develop any plans that might mitigate the problem. However, negative perceptions of the
causes of mental illness still abound among mentally ill and their relatives. This fact is
compounded by ignorance of existing mental health services.
Consequently, alternative
sources of care are still employed. There is a need for community health education to
demystify mental illness as well as to highlight the availability of mental health services. This
4
should create positive attitudes, correct misconceptions and encourage early specialist
consultation and better treatment outcomes.
2.
MENTAL HEALTH NEEDS
The improvement of community tolerance of people with mental illness is important for
their integration. However, there is widespread stigmatization of mental illness in the Nigerian
community. Negative attitude to mental illness may be fueled by notions of causation that
suggest that affected people are in some way responsible for their illness and by fear.
There is widespread belief that misuse of drugs is the cause of mental illness. Other
than alcohol, the most commonly used psychoactive substance in Nigeria is cannabis and
assumption is made by the public that anyone using cannabis will have a mental illness. In the
list of possible cause of mental illness, there is a belief that it could be due to possession by evil
spirits.
Almost one in ten in the community thought mental illness might be a divine
punishment.
Attitude to mental illness is consequently characterized by intolerance of even basic
social contact with people known to have such illness. In a society in which poor health
facilities and poverty make the care of people with mental illness a major burden for both
patients and their families, degree of stigma experienced by individuals with mental illness
suggest an unusual level of illness-related burden.
Amongst the public, mental illnesses are widely attributed to supernatural or spiritual
causes. Most people, regardless of social status, rely on traditional and spiritual healers and
seek orthodox treatment only as a last resort when the patient’s condition might have
deteriorated and consequently more difficult to treat. Many believed that mentally ill people
could not work in regular jobs. Some thought that people with mental illness were mentally
retarded, a public nuisance and dangerous because of their violent behavior.
5
Public Education and Awareness Campaigns on Mental Health
There is no coordinating body to oversee public education and awareness campaigns on
mental health and mental disorders. Government agencies, NGOs, professional associations,
and international agencies have promoted public education and awareness campaigns in the
last five years. These campaigns have targeted the general population, children/adolescents
and other vulnerable or minority group such as the homeless and social deviants. In addition,
there have been public education and awareness campaigns targeting professional groups
including: health care providers, teachers and other professional groups lined with the health
sector.
3.
MENTAL HEALTH POLICY
Almost 52 years as an independent nation, Nigeria is yet to have a functional mental
health policy. Although mental health is a formidable public health challenge in Nigeria, it
suffers from serious institutional and normative neglect. Despite a steady growth in the
number of mentally ill patients roaming the streets and the resulting danger to the public, the
government is yet to develop any plans that might mitigate the problem.
Nigeria’s mental health policy was first formulated in 1991 and includes the following
components: advocacy, promotion, prevention, treatment and rehabilitation.
In the
components of mental health policy, a list of essential medication is present such as
antipsychotics, anxiolytics, antidepressants, mood stabilizer and antiepileptic drugs.
The mental health plan, as contained in the 1991 policy has the following components:

Formulation of strategies for promotion, prevention, management, treatment and
rehabilitation of mental and neurological disorders and their subsequent disability
through the most appropriate approach.

Improvement of general healthcare services through facilitating the application of
mental health principles, knowledge and skills of behavioral sciences.

Enhancing the use of mental health principles to promote social health.
6

Reduction of mental health harmful effects and consequences on individuals, families
and communities.
No disaster or emergency preparedness plans for mental health exist in the country.
Emergency or disaster agencies have no specific mental health work. Other than indirect
references to mental illness in some areas of the nation’s criminal codes, no comprehensive
mental health legislation currently exists in the country. A bill to that effect is currently under
consideration in the National Assembly, the country’s legislature.
‘Movement for reform’ may not be the best term to describe the largely unheeded calls
for change in Nigeria’s mental health law. Despite prominent voices making calls for reform, no
movement in the direction of change has materialized. The draft of a new law drawn up in
2003 is yet to be passed by the National Assembly.
Current Status of Mental Health Policy
Recently, the Federal government has reviewed the 1999 mental health policy
responsible for regulating the practice and management of mental health in Nigeria. The
review would enhance the provision of access and appropriate care for people who have
mental disorders in Nigeria and also make adequate provisions for its implementation in the
national health budget.
7
4.
LEGISLATION PROTECTING THE RIGHTS OF PEOPLE WITH MENTAL ILLNESS
A national human rights review commission established by an act in 1995 does exist in
the country. However, it has no specific monitoring activities for mental health but conduct
visits to prisons. No mental hospitals, community-based inpatient psychiatric units or
community residential facilities have review or inspection of human rights protection of
patients at anytime.
Fourteen percent of mental hospitals staff and twenty percent of inpatient psychiatric
units and community residential facilities staff have had at least one day training, meeting, or
other type of working session on human rights protection of patients in the year of assessment.
A workshop on human rights was conducted in one of the mental hospitals with attendees from
the other hospitals. Presently no legislative or financial provisions exist to protect and provide
support for users.
5.
MENTAL HEALTH FINANCING
According to UNDP, government expenditure on health as a percentage of GDP was 1.3%
in 2003, a decline from 2.2% in 2000. In regard to government expenditure as a percentage of
total expenditure on health, the Nigerian government share declined from 29.1% in 1999 to
25.5% in 2003, lagging behind many other African countries, even those similarly classified by
the World Bank as low income economies. In per capita terms, public spending on health
stands at less than $5, and in some parts of the country can be as low as $2, far short of the $34
recommended by WHO for low income countries within the Macroeconomics Commission
Report. Apparently, this level of spending will make it extremely difficult to provide even the
most basic of services. In addition, there is a concern that the budgeted figures may not be
representative of the actual amount spent on health as there continues to be a gap between
the two figures. Moreover, it is not even clear whether the budgetary allocations were actually
spent on health services or wound up in private hands.(WHO,2007)
8
Financing of Mental Health Services
About 3.3% of the health budget of the Federal government goes to mental health, with
over 90% of this going to mental hospitals.
Graph 1.1: Health expenditure toward mental health
Of all the expenditures spent on mental health, 91% is directed towards mental hospitals
(Graph 1.1).
Graph 1.2: Mental health expenditure toward mental hospitals.
9
Thirty three percent of the population has free access (at least 80%) to essential psychotropic
medicines. The cost of antipsychotic medication for a day is N42 (7% of the daily minimum
wage of N18,000) and antidepressant medication is N30 (5% of the daily minimum wage of
N18,000 per month), the sum of N600 being one day minimum wage in the local currency. The
duration of treatment in many cases is a maximum of 21 days.
The National Health Insurance Scheme (NHIS) Act, promulgated in 1999, seeks to bring
changes to this system of health care financing by reducing the cost burden on individuals and
improving the quality, availability and affordability of services. The Act provides for the
creation of Health Maintenance Organizations (HMOs) which, in turn, are authorized to
contract with health care providers for services to insured individuals. Each insured person is
entitled to choose a health center with which he wishes to register, with payment made to the
health center on monthly capitation basis. While universal coverage is intended by the NHIS,
beneficiaries have been limited to employees of the Federal Government and large
corporations. Given this limitation, most people continue to pay for health care directly out of
pocket, and this has significant access implications.
6.
MENTAL HEALTH SERVICES AVAILABLE IN NIGERIA
Mental health services are predominantly government provided through dedicated
psychiatric hospitals, psychiatric units and clinics. The majority of mental health services is
provided by 10 regional psychiatric centres and psychiatric departments. The private health
care sector plays a limited role in provision of mental health services, although many people
with mental illness turn to spiritual or traditional healers for help.
There are no social programmes specifically targeting the needs of mentally ill patients,
with the result that except for the few who are able to afford the cost of treatment and provide
for themselves, the vast majority are left to their fate. Many die on the streets. In view of the
few numbers, mental health facilities tend to provide service to patients coming from very
distant locations with the resultant negative effect on continuity of service.
10
Types of Service/Institution
Number
1.Psychiatric hospitals
10(including state owned)
2.General hospitals with psychiatric departments
24
3.Community-based mental health service
3
4.NGOs/Family group working in mental health area
8
Few NGOs work directly on mental health, but a large number provide mental health services
as part of other programmes, for example counseling in HIV programmes.
No desk exists in the ministries at any level for mental health. Mental health issues are often
supervised by officials with other primary duties. Health services in general are not provided on
a defined catchment basis and this often leads to uncoordinated delivery of service. In view of
their few numbers, mental health facilities tend to provide service to patients coming from very
distant locations with the resultant negative effect on continuity of services (WHO,2006).
Priority Problems and Positions of Mental Health
The availability of mental health resources in most developing countries is poor due to
scarcity of resources, competing health problems and the low priority given to mental health
issues. In Nigeria, modern psychiatric care is developing, but as yet most people have no access
to it because they cannot afford the treatment. Moreover, treatment facilities are mainly
concentrated in large urban centres (Klecha et al,2004).
11
7.
HUMAN RESOURCES FOR MENTAL HEALTH
It has been estimated that at least, about 90 percent of people with clear cut mental health
syndromes do not even get any treatment at all in Nigeria. That is an atrocious figure and
everybody knows the issue.
The specialists, such as psychiatric nurses, social workers,
occupational therapists and all those who form members of mental health team are very few in
numbers, grossly inadequate.
Mental Health Professionals in Nigeria:
Profession
Number
1. Psychiatric nurses
1460
2. Psychiatrists
149
3. Psychologists
69
4. Occupational Therapists
35
5. Social Workers
114
Material Resources
Facilities
Beds
1. Psychiatric hospital, Yaba
500
2. FNPH, Aro, Abeokuta
526
3. FNPH, Calabar
201
4. FNPH, Enugu
150
5. FNPH, Maiduguri
200
6. FNPH, Kaduna
136
7. FNPH, Sokoto
122
8. Psychiatric hospital, Uselu, Benin City
267
12
9. Psychiatric hospital, Akure
60
10. FMC, Abraka
14
11. FMC, Iddo-Ekiti
35
12. FMC, Makurdi
36
13. FMC, Umuahia
5
14. FMC, Yola
40
15. Specialist hospital, Irrua
12
16. LUTH, Lagos
28
17. LASUTH, Lagos
15
18. UITH, Ilorin
20
19. JUTH, Jos
38
20. OAUTH, Ile Ife, Osun State
23
21. LAUTECH, Osogbo, Osun State
20
22. ABUTH, Zaria
28
23. UPTH, Port Harcourt
100
24. Psychiatric hospital, Rumnigbo, P.H.
128
25. ASPH, Nawfia
28
26. Central hospital, Agbor
8
27. UNTH, Enugu
10
28. UNADTH, Ado Ekiti
20
29. UCH, Ibadan
62
30. AKTH, Kano
24
_______
2,856
______
13
The total number of beds at the time of writing this report is 2,856. There is a misuse of
skill atimes because poor attention is given to mental health, the specialists are
deployed to other department or unit.
8.
SPECIALIST MENTAL HEALTH SERVICES
Child and adolescent psychiatry is an under-developed specialty in Nigeria, relegated by
more entrenched cultural systems, such as traditional healers and syncretic churches, to merely
an auxiliary role in child mental health care. Little is therefore known about the epidemiology
of childhood disorders as encountered in psychiatric settings. Child and adolescent mental
health services are available in 4 psychiatric facilities. However, no facility has in-patient
service appropriate for children and adolescents.
There are twenty-two beds in mental health facilities for persons with mental disdorders
in forensic inpatient units and eighty-five in six other residential facilities such as homes for
persons with mental retardation, detoxification inpatient facilities, homes for the destitute, etc.
In forensic inpatient units no patient spend less than one year.(WHO-AIMS,2006)
9.
AVAILABILITY OF DRUGS
One of the biggest challenges to providing services for the mentally ill wing community
services in Nigeria is that of ensuring a regular, adequate supply of appropriate, safe and
affordable medication.
In Nigeria, it is estimated that roughly 50% of all drugs on sale are fake or sub-standard.
This is particularly high for certain products such as anti-malaria drugs and common over-thecounter products such as paracetamol. The National Agency for Food and Drug Administration
and Control (NAFDAC) has a high profile, matched by some success in prosecuting those
14
involved in the trade. Despite this, the challenges involved in sourcing original, reliable drugs
remain huge.
Prescription
Given the lack of suitably qualified medical staff (general and specialist doctors), many
services providing community psychiatric services make arrangement for other health
professionals (usually s specialist nurses or medical officers) to perform front-line clinical duties
such as prescribing drugs.
In many projects, psychiatric nurses prescribe where they are part of a team in a
programme with adequate training and supervision. The provision of drugs is an essential
component of a community-based psychiatric service where local supplies cannot be relied
upon. A well-managed, affordable supply system is an asset to a service, and may attract clients
to that service. Availability of drugs enable patients with mental illness to obtain relief from the
worst of their symptoms so as to have the best chance of reintegrating back into society.
10. Organizations representing the interest of people with mental illness
No organization of nationwide function or spread exists. Some NGOs and family support groups exist at
the local level. They include the following active and not so active organizations:
. Mental Health Foundation, Lagos (Registered)
. Lifecare Trust Initiative, Osogbo, Osun state (Registered)
. Health and Restoration Centre for Psychiatric Illness, Agboko, Otukpo, Benue State (Registered)
. Allahs Megaphone Foundation, Ibadan Oyo State (Unregistered)
. Foundation for Mental Health Law, Rights and Restoration, Ibadan Oyo State (Registered)
.Family Support Group, UCH, Ibadan Oyo State (Unregistered).
The oldest of these organizations was established less than 5 years ago. Others are recent in set-up.
15
11. STAKEHOLDERS VIEWS
As part of the general assessment of the state of mental health care in Nigeria, key
informant interviews were conducted to find out what relevant stakeholders, including mental
health professionals, general practitioners, activists, ministry officials and the general public
think of mental health care in the country. Below is the summary of the public perceptions:

Low priority to mental health: most of the respondents were of the opinion that mental
health care is receiving little or no priority by the Ministry of Health, especially in the
area of budgetary allocation. According to most of the respondents, the ministry is more
interested in HIV/AIDS, malaria and child and maternal health.

Awareness and adequacy of mental health policy: Very few of the people interviewed
claimed to be aware of the mental health policy in the country, of these numbers, only
very few seem to be conversant with the letters of the mental health policy.

Assessment of the state of mental health care delivery: Opinion varies among the
respondents on the state of mental health care delivery in the country. While some are
of the opinion that there has been a marked improvement in some areas, others are of
the opinion that mental health care delivery is nothing to write home about in Nigeria.
INTERVIEW WITH THE KEY INFORMANTS
KEY INFORMANTS
NUMBERS
Consultant psychiatrists
4
General practitioners
2
Psychiatric nurses
3
Occupational therapists
2
University lecturer
1
Ministry officials
2
User/caregivers
2
Social worker
1
NGO founder
1
16
Links with Other Sectors
The primary health care agency at the national level has at times involved psychiatrists
in the development of training programmes. In terms of support for child and adolescent
health, it is unknown if any primary or secondary schools have either a part-time or full-time
mental health professional. However, a few primary and secondary schools (less than 20%)
have school-based activities to promote mental health and prevent mental disorders.
As for training, less than 20% of policy officers, judges and lawyers have participated in
educational activities on mental health in the last five years. In terms of financial support for
users, many mental health facilities (51-80%) have access to programs outside the mental
health facility that provide outside employment for users with severe mental disorders. Finally,
no persons receive social welfare benefits for a mental disability.
17
RELEVANT REFERENCES/SOURCE
Klecha D., Barke A., Gureje O.; Mental health care in developing countries: the example of
Nigeria. Nervenarzt 2004, Nov. 75(11):1118-22.
Shekhar S., Gureje O.:WHO-AIMS Report on Mental Health System in Nigeria, WHO and
Ministry of Health Ibadan, Nigeria,2006. Pg15.
WHO, World Health Statistics 2007(Geneva:WHO,2007) 68.
WHO,’’Health
Financing
and
Social
htpp://www.who.int/countries/nga/areas/health
Protection’’
financing/en/index.html
available
accessed
at
20
August,2007.
UNDP,Human Development Report 2006(Geneva:Palgrave Macmillan/UNDP,2006) 303.
Act 35 of 1999, Laws of the Federation of Nigeria, Part 2, S.5.
18