Mozambique: Policy Project

Mozambique: policy project

Project objectives

• To increase the technical capacity of Mozambique in mental health policy-making and planning. • To assist the Ministry of Health of Mozambique to draft a mental health policy and update and improve its mental health programme. • To build the capacity of mental health professionals to provide community-based care.

Project strategies

• Ensuring the harmonization of the mental health plan with the overall health plan. • Strengthening the technical expertise and skills of local mental health professionals especially in the area of community care.

• Paying particular attention to the development of community-based services in the planning

process. • Ensuring the involvement of non-governmental or ganizations, especially traditional healers, in the area of training. • Actively encouraging the involvement of a range of ministries, other than the Ministry of Health, in the policy-making process.

Implementing institutions

• Ministry of Health, Maputo • Provincial Health Authorities

diagnostic facilities and some Background specialist services. The quaternary level includes the three

Provisional results of the national central hospitals in Maputo, Beira and census conducted in 1997 put the Nampula. population of Mozambique at nearly The mental health care system in 15.7 million inhabitants. This is Mozambique can be broadly divided approximately 15% lower than earlier into three sectors: estimates of 18 million. Primary care 1) Services found in primary care remains the basis for the public health facilities system in this country. The National Primary health care facilities are an Health Service is the major provider of important source of mental health care all health services. delivery. There are currently 34 psychiatric technicians located in There are four levels of care in health centres throughout Mozambique’s 10 provinces. At the Mozambique’s 10 provinces. Their primary level, there are health posts, main roles are to prescribe and mobile services, and rural health administer psychiatric medication to centres that carry out preventive and patients attending the health centres basic curative activities. Health posts and to provide psychosocial are staffed by semi-skilled or unskilled rehabilitation. The health centres also personnel. The large health centres engage in mental health awareness and have basic inpatient facilities and are educational programmes in an attempt staffed by nurses. to reduce the stigma associated with mental illness and to highlight the risks associated with alcohol consumption. Mental health care Medication can also be administered by staff in health posts. These are At the secondary level, there are rural generally smaller than health centres. and general hospitals. The general 2) Mental hospital services and hospitals provide services in psychiatric beds provided by general paediatrics, obstetrics and hospitals where outpatient services are gynaecology, general surgery and also available medicine. Few rural hospitals provide Psychiatric facilities within general surgical services. hospitals are very limited. They are available in Maputo from the Central Hospital and in the province of Sofala where there is a small unit in the local rural hospital. There are currently two psychiatric hospitals in Mozambique. They cater primarily to inpatients with severe mental health problems who have been referred by primary care psychiatric technicians. One is based

in the city of Maputo and the other in A rural hospital in the north the northern province of Nampula. 3) Traditional healing At the tertiary level, there are The Ministry of Health has looked provincial hospitals that offer positively upon traditional medicine because it recognizes its importance to

18 the people of Mozambique. Given that In November 1996, a national mental only 60% of the population has access health programme was outlined for the to formal health care services, first time. This programme identified particularly in rural areas, healers are several areas of importance for most often the preferred port-of-call Mozambique that needed to be for individuals who suffer from health addressed to improve mental health and mental health problems. facilities. These included:

Since many patients who suffer from • The failure to prioritize mental chronic mental illness are prone to health services. relapses, one of the most important • The dominance of a custodial priorities for the Ministry of Health has system of psychiatric care, which been to monitor patients’ access to perpetuates stigma against persons health and social care services once with mental health problems. they have been discharged from the • The lack of epidemiological hospital. There is evidence to suggest information on mental illness. that the psychiatric hospital in Maputo has been a victim of the same “revolving door” phenomenon that bedevils hospital services in many developed mental health care systems. Nevertheless, it is evident that some arrangements have been made with local health centres to monitor patients on discharge and provide general assistance to them and their families in the process of re-integration into the There is a need to incorporate mental health community. care into general health care.

Within the ministerial hierarchy, • The lack of human and financial mental health is one of six sections that resources and facilities. together make up the Division of • The lack of awareness among Family Health. The Division of health staff and the community as a Family Health comes under the whole about mental health Department of Community Health, problems. which has its own National Deputy • The lack of systematic knowledge Director. A National Programme about the influence of social and Coordinator for Mental Health is cultural factors on Mozambique’s responsible for planning and policy mental health problems. decisions. In each province, there is a • The absence of an agency to coordinator for the local mental health organize, promote, coordinate and programme. The coordinator is supervise action in the mental usually a psychiatric technician, except health sphere. in two provinces where the work is • The lack of continuity in action carried out by psychiatrists. A two- undertaken. This can be attributed year strategic plan for mental health to lack of resources and heavy was drawn up but has only been reliance on international cooperat- partially implemented. It is related to ion. the National Integrated • A highly centralized structure and a Plan/Community Health 2001. lack of intersectoral collaboration.

The lack of epidemiological information Each issue is discussed in turn, below. on mental illness For the first time as part of this The low priority given to mental health project, WHO has funded the services undertaking of a pilot epidemiological This continues to be the case in study to provide an evidence base for Mozambique largely because of the mental health policy. limited financial resources and the pressing needs created by communic- The Ministry of Health has outlined able diseases. the benefits of the pilot epidemiological study as follows: The dominance of a custodial system of • Increase the availability of reliable psychiatric care, which perpetuates epidemiological information on stigma against persons with mental mental health in Mozambique. health problems • Begin the integration of mental There has been a noticeable health epidemiological information improvement in the conditions of into the general health information patients in the psychiatric hospital and system (statistics). in their management. Therapeutic • Improve, monitor and supervise the work, in the form of agricultural effectiveness of mental health projects, has been developed on land interventions on the basis of the surrounding the hospital in conjunction initial evidence. with members of the local community. • Monitor the changes and trends in mental and neurological disorders. These are a major cause of disability in Mozambique, a country undergoing rapid and severe social, political and economic changes with serious impacts on the population. • Work towards reducing the incidence and prevalence of mental and neurological disturbances with better information systems.

WHO is encouraging joint-working between mental The lack of human and financial health workers and traditional healers resources and facilities Owing to the work of Italian These continue to be a big challenge to Cooperation, the management of the the provision of mental health service hospital has been improved and work particularly in the community. Until in the community has been encouraged 2002 there were only five psychiatrists and promoted. Italian Cooperation has in Mozambique, (none of whom are also had an input into the training of Mozambican). Three Mozambican psychologists, nurses and psychiatric doctors have been trained as technicians through the Central psychiatrists, but their location and the Hospital in Maputo. A new project to duration of their stay in Mozambique further develop community activities in the future cannot be predicted with will shortly begin. Community any degree of certainty. In addition, projects have also been developed and because of the shrinking pool from implemented by the Italians in Manica which to draw nurses for training as and Sofala and by WHO in Niassa. psychiatric technicians, no new

20 psychiatric technicians were being This has been overcome to some extent trained. Most of the psychiatric by the appointment of a National technicians who provide the bulk of Programme Coordinator for mental psychosocial rehabilitation and are health based in the Ministry of Health. trained to administer medication, are However, this programme is only due to retire shortly (two-thirds) or are managed by two people and the planning to change careers. Training Coordinator also has clinical of new technicians was not envisaged responsibilities. Some progress has because of the lack of financial been made to coordinate action in the resources in the Ministry of Health to mental health sphere by giving people absorb staff at this level. The issue of in the province (mainly psychiatric training is therefore a crucial one and technicians) responsibilities for mental is addressed in the mental health health. However, whether or not a policy. mental health programme is implemented remains the responsibility The lack of awareness about mental of the provincial director of health. health problems among health staff and the community as a whole The lack of continuity in action The first training sessions given to undertaken, attributable to the lack of mental health personnel in June 2000, resources and heavy reliance on have been continued in a limited way international cooperation with general health staff at some health This continues to be the case except in centres, in particular in Cuamba where a few provinces where community there was another WHO community- services have been established. based mental health project. A highly centralized structure and lack The lack of systematic knowledge of intersectoral collaboration about the influence of social and At the regional and provincial levels, cultural factors on Mozambique’s there has been some decentralization of mental health problems services, and regional and provincial While anecdotal knowledge exists, no officials responsible for mental health systematic research has been carried have been appointed. out on a national scale. However, a study was carried out as part of the preparation of another WHO-funded Project description project in the province of Niassa in the north of the country. Beliefs about the Mozambique faces many problems and causes, the types of treatment and challenges due to the lack of human where treatment is sought, were and financial resources in the field of recorded. The study also gathered mental health. There is a need to information about local names given to address all of these issues in a mental health problems. As part of an systematic and practical manner. epidemiological study, a comparison Because of the scale of communicable was made between these and ICD-9 diseases in Mozambique, that are classifications. exacerbated by periods of flooding and drought, the health sector in general is The absence of an agency to organize, under considerable pressure. The promote, coordinate and supervise project therefore set out to address the action in the mental health sphere objectives spelt out at the beginning of this document.

people in primary care and general hospitals. Increasing the technical capacity The training given by WHO as part of of Mozambique in mental health the pilot epidemiological study has policy making and planning been part of a capacity-building exercise to enable the Department of Epidemiology within the Ministry of Health to begin to integrate some information into its routine statistics and for record-keeping purposes.

Strengthening the technical

expertise and skills of local

mental health professionals

especially in the area of

community care International training seminar for health professionals in Maputo, June 2000 In June 2000, approximately 90 mental WHO has assisted the government of health professionals and Mozambique to develop and write a representatives of non-governmental mental health policy. The policy has organizations from all 10 provinces of addressed inter alia, a number of key Mozambique were trained in best areas. Among them areas such as: the practices in community mental health. organization of mental health services; The training also included persons human resource development; the from the statutory and non-statutory provision of psychopharmacological sectors. drugs at all levels of the health system; intersectoral collaboration; the role of the traditional practitioners; and, the need for adequate epidemiological information to support the planning process.

The policy-making process was achieved through joint collaboration and planning between officers responsible for mental health in the Participants at the international meeting in Ministry and consultants hired by Maputo, June 2000 WHO to collaborate with the Ministry An international meeting of experts and guide it through the process. and local mental health policy-makers

and practitioners was also convened in As previously mentioned, a pilot June 2000. epidemiological study has been

undertaken and has provided a base for policy-making and planning. It was conducted in one rural and one urban province and included a sample of people in the community, as well as

22 that runs across the whole of the health sector and affects the provision of The following received training as community services. part of the project: Existing community services were • Clinical psychologists visited and discussions held with • Psychiatric technicians workers and international NGOs, where • General practitioners they existed, in order to evaluate the • Psychiatris ts impact on community service provision. • Traditional healers • Technician s in preventive Actively encouraging the

medicine involvement of a range of

• Nurses ministries other than the

• Nursing tutors Ministry of Health in the policy-

• Heads/representatives of nine making process NGOs • Chiefs of provincial community mental health services This process of building intersectoral collaboration where none has previously • Senior primary health care staff existed was initiated with the Ministry of • National Programme Co- Social Action and the Ministry of ordinator for Mental Health Labour. It was then extended to cover a • Psychiatric technician based in range of other ministries who were the Ministry of Health consulted to contribute recommendations on the way forward. Paying attention to the developmen t of community- Other areas that need to be addressed as part based services within the policy of the policy-making process affecting and planning process community care include:

• Ιntegrating mental health into existing community It has already been recognized that this health programmes within the Ministry of Health is a fundamental part of the process of (such as the Infant and Maternal Health strengthening the role of mental health Programme (UNFPA), and the Integrated Management of Childhood Illnesses Programme in primary health care. Discussions with (WHO/UNICEF)). Ministry and clinical staff indicated a high rate of re-admission. It was • Introducing/strengthening the training and use of primary health care staff such as health agents and recognized that there is a need for social agents. This is aimed at improving care in greater follow-up in the community. the community as part of a national programme of This is a problem because of the training by the Ministry of Health. insufficient numbers of trained staff. • Ensuring the adequate provision of Given the size of the country and psychopharmaceutical drugs at each of the four logistical problems in servicing levels of distribution and ensuring the introduction communities with poor infrastructure, of the necessary psychopharmaceutical drugs into the provision of mental health services is the “kit system” at the PHC level. greatly limited. There are however • Rationalizing the work of psychiatric technicians successes in a few provinces where with the roles of health agents, recently trained psychiatrists and social action agents from the international aid is being injected into Ministry of Social Action, with particular reference the community by Italian Cooperation. Overall however, the issue of staff to roles and responsibilities, and career structures. training, support and retention is one

As far as future collaboration is concerned, the involvement of the The following consultations and Department of Mental Health in the visits have been made: training of “social agents” who work in Ministry of Health the community has been discussed • Deputy Minister of Health with the Ministry of Social Action as • National Director of Community Health part of this project. This is seen as a • Head of School and Adolescent Health fruitful area for cooperation. Future • National Director of Human Resources collaboration also includes further and Training • Deputy National Director of Medical work with the Directorate for Women Assistance within the Ministry of Social Action. • Head of Pharmaceutical Department This is because domestic violence is an • Meeting with Restricted Consultative area of concern. Group (a Maputo-based group with For the Ministry of Labour, recent representatives from the Ministry of labour legislation has been drawn up Health, the Military Hospital, the but still needs to be implemented psychiatric hospital, the central through various regulations. Input (General) hospital and NGOs). Psychiatric Hospital - Infulene from the Department of Mental Health in drawing up regulations for workers • Meeting with the Psychiatric Hospital Director followed by a tour of the who have mental health problems has hospital. been welcomed. Ministry of Social Action

• National Director of Women and Social A series of consultations were held Action with other Ministries during the course • National Director of the Institute of of the project. These are outlined Social Action (INAS) below. Consultations and visits covered • Chief of Programmes – INAS all of the 10 provinces. Ministry of Labour • Permanent Secretary

• Head of “Gabinete de Estudos” (Study

Some of the chief aims of the Cabinet) activities that have taken place NGOs included: • Italian Cooperation • Executive Director of Reconstruindo • understanding the problems and Esperanca (Reconstructing Hope) – issues of mental health; children and adolescents • understanding how health/mental • Mahotas (adults) health services were organized at Focal points for mental health in all of all levels; the provinces

• discussing recommendations on the • Relevant local health personnel key areas that need to be addressed • Provincial authorities in the policy document and • International NGOs suggestions on how to address the

current problems in mental health; • Local NGOs

• getting a better idea of the role and • Traditional healers • Ministry of Education contribution of the traditional sector; • Ministry of Youth and Sports • agreeing on the nature and scope • Ministry of Justice of collaboration with other • Ministry of Internal Affairs ministries in order to optimize • Ministry of Finance limited human and financial • The City Health Board resources.

Key results

The formulation of a national mental health policy.

This was achieved through a process of:

• Political commitment and collaboration with senior personnel in the Ministry of Health. • Training of mental health professionals in the area of community mental health. • Undertaking an initial situational analysis of mental health issues and problems.

• Drawing up a clear and costed plan-of-action. • Engaging in widespread consultations and discussions at the central and provincial levels (75 meetings involving over 250 persons). • Ensuring consensus on areas to be included in the policy through a national

meeting. • Underpinning the policy with an evidence base by undertaking a pilot epidemiological study. • Building in-country capacity for undertaking epidemiological research.

• Disseminating the final policy document for comments. • Holding a final meeting before submission for formal adoption by the Council of Ministers.