www.jogh.org • College ofArtsandSocialSciences,AdiKeih, Fikrejesus Amahazion steps forward A briefoverviewandpossible Mental healthinEritrea: JOGH ©2021ISGH © 2021THEAUTHOR(S) The onlineversionofthisarticlecontainssupplementarymaterial. Electronic material: supplementary mortality. causes ofdisability, comorbidity, and tal illnesses are among the leading health problemsinEritrea,andmen There isarisingfrequencyofmental doi: 10.7189/jogh.11.03018 ties includeaddressingmaternalandchildhealth,aswell controllingcommunicablediseases.Healthser at anaffordablecost.Priori Eritrea’s nationalhealthpolicyaimstoensureequityandaccess tohealthservices GENERAL HEALTHCARESTRUCTURE Table 1. and aprevalenceofstigmadiscriminationtowardthosewithmentalillness[ treatment gapprevails[ Across Africa,healthsystemshavenotadequatelyrespondedtothe burden of mental disorders,anda large health anddevelopmentpolicyagenda,whiletherehasbeenlittleresearchintomentalproblems[ M Mental healthworkers Mental hospitalbeds Suicide mortalityrate Burden associatedwithmentaldisorders (disability-adjustedlife-years) Children withintellectualdisabilities Mental disorderprevalence Patient-Doctor ratio GDP percapita Population Eritrea mentalhealthstatistics es [ grown, withsignificantimpactsonhealthandmajorsocial,humanrights,economicconsequenc ental health is an integral component of health. Recently, the global burden of mental disorders has 1

, 2

]. Despiteitssignificance,however, mentalhealthhashistoricallybeenneglectedonAfrica’s 4 - 6 ]. There is also widespread ignorance about the extent of mental health problems ]. Thereisalsowidespreadignoranceabouttheextentofmentalhealthproblems - have beenfewstudiesonthetopic. bor [ rainfall andpotentialfordrought,foodsecurity,shortageofskilledla lenges, including regional conflict, poverty, socio-political challenges, erratic of majordiseases[ pectancy, maternal, infant, and , immunization, and control has madeconsiderableprogresswithinthehealthsector, includinginlifeex is arisingproblem( In Eritrea,adevelopingcountrylocatedinNortheastAfrica,mentalhealth 9 - 12 ]. Additionally, mental health is a growing issue, although there ]. Additionally,mentalhealthisagrowingissue,althoughthere 1

9 Table 1 - 12 ]. However, thecountryalsofacessignificantchal ). Since winning independence in 1991, Eritrea ). Sincewinningindependencein1991,Eritrea 2.48 per100 4.13 per100 7.9 per100 2704.61 per100 30-40 000 14.5% 0.5:10 000 US$780 3 500000 and possible steps forward. JGlobHealth2021;11:03018. and possiblestepsforward. Cite as: AmahazionF. MentalhealthinEritrea:Abriefoverview 000 population 000 population 000 population 000 population 7 , 8 ].

2021 •Vol. 11 • 03018 3 ]. ]. ------

VIEWPOINTS VIEWPOINTS 2021 •Vol. 11 • 03018 wiki/File:LocationEritrea.svg). Photo: Eritrea geographicsetting(Imagecredit: https://commons.wikimedia.org/ in communicableandpreventabledis concomitant withsignificantreductions As healthandlivingstandardsimprove, burden ofdisease. of disability,andcontributiontooverall challenge, intermsofprevalence,cause also will likely continue to grow as a Eritrea. Mentalillnessesanddisorders toward non-communicablediseasesin eases, thereisagradualshiftinburden common conditionsinEritreaincludeschizophrenia,bipolaraffectivedisorder, neurotic,stress,andmood es ofdepressivedisorders(4.3%thepopulation)and156 common mentaldisorderprevalencerateofabout14.5%[ Eritreahasa causes ofdisability,comorbidity,andmortality.Accordingtoa2014localmentalhealthsurvey, There isarisingfrequencyofmentalhealthproblemsinEritrea,andillnessesareamongtheleading MENTAL HEALTHINERITREA patient ratio(approximately0.5per10 ble diseases(NCDs).Furthermore,healthcareworkersoftenhaveaheavyworkloadrelatedtolowdoctor Mary’s onlyasmallproportionofthose needingcare. Neuro-Psychiatric Hospital,whichserves 4.13 mentalhospitalbedsper 100 community-based facilityisalso locatedinAsmaraandhostsseveralhundredbeds.Nationally, thereareabout This those with relatively stable and chronic mental disorders not requiringintensivemedicalinterventions. Aswell,there isacommunityresidentialcarefacilitywhichserves beds andalsooffersoutpatient services. Builtin1971andlocated , thecapital,itisequippedwithseveralhundred stay residentialservices. The country’s solementalhospital,St.Mary’s Neuro-PsychiatricHospital, provides inpatientcare and long- water, hunger, sanitation,andcommunicable diseases. get. Thisislargely duetothefactthatcountryhasprioritizedpublichealthfundamentals,suchasclean low-income countriesmentalhealthhastraditionallycomprised asmallproportionofthenationalhealthbud policy, itdoesnothavementalhealthlegislation.Moreover, althoughcurrentdataareunavailable,likemost WhileEritreahasanationalmental health try hasalimitednetworkofmentalhealthfacilitiesandservices. werefirstintroducedinEritreaduringtheperiodofItaliancolonization.Today, coun Psychiatric services CARING FORTHEMENTALLYILL significant issuesincludepoverty,unemploymentandunderemployment,single-headedhouseholds. placement, manyEritreanshavesufferedheavilyfromdepressionandposttraumaticstressdisorder. Other

- 000 population[ associated withmentalillness.Duetowar, regionalinstability,anddis Eritrea ischaracterizedbyseveralsocio-politicalandeconomicfactors agnosed. able thatmanymentalillnessesanddisordersareundetectedormisdi human resourceconstraintsandalackofspecializedskills,itisprob ity rate(per100 tal disorders alsocontributeto premature mortality; thesuicide mortal of anxietydisordersis14 (constituting 8.2% of total years lived with disability), while the burden burden ofdepressivedisordersisabout40 justed life-yearsisapproximately2704.61per100 in Eritrea.Theburdenassociatedwithmentaldisordersdisability-ad Mental disordersleadtoconsiderablelossesinhealthandfunctioning children areestimatedtohaveintellectualdisabilities. disorders, epilepsy,anddementia.Notably,approximately30-40 000 people). 2

health workforcenecessaryforcombatingnoncommunica and medical information systems, while lacking a skilled deficits infinancing,accessto basic technologies, medicines, Eritrea facesnumerouschallengeswithinhealthcare.Ithas ers [ of apartnershipbetweentheGovernmentandhealthwork private practicewithingovernmenthealthfacilitiesbyway no privatehealthfacilitiesinthecountry,there is asystemof ry-level facilities(nationalreferralhospitals).Whilethereare sub-zone hospitalsandzonalreferralhospitals)tertia health centres),secondary-levelfacilities(firstcontactor tiers, comprisingprimary-levelfacilities(healthstationsand vices aredeliveredutilizingareferralsystembasedonthree 17 ]. The majority of spending on mental health goes to St. ]. Themajorityofspendingon mentalhealthgoestoSt. 12 000 population)inEritreaisabout7.9[ - 14 15 599 casesofanxietydisorders(3.1%)[ ]. ]. In2015,therewereanestimated219 474 yearslivedwithdisability(2.9%).Men www.jogh.org • 426 years lived with disability 426 yearslivedwithdisability 000 population. The 000 population.The doi: 10.7189/jogh.11.03018 16 - 18 16 ]. Due to ]. Dueto 549 cas ]. Other ]. Other 000 000 ------www.jogh.org • doi: 10.7189/jogh.11.03018 many patientsarepoor. Additionally,someindividualswithmentalillnessesreceivemedicationsandother whichisimportantsince in someareas.Patientsdonotpayforpsychotropicmedicines(orcareandservices), be limited,especiallywithgeographicaldistancefromhealthcareprovidersnegativelyimpactingaccessibility Essential psychotropicmedicinesareavailablewithinmanyhealthfacilities.However, distributioncanoften sent abroadfortraininginpsychiatry.Generally,thesefiguresallfallbelowglobalaverages[ nurses per100 tion. Additionally,Eritreahasapproximately0.08psychologists,0.04socialworkers,and2.17mentalhealth is scarcity of mental health professionals.Thereareabout2.48mental health workersper100 Anotherconstraint urban areas.Consequently,patientsfromruralareashavereducedaccessibilitytoservices. withmostlocatedin There isahighdisparityinurban-ruraldistributionofmentalhealthworkersandservices, level healthcarefacilitiesprovidedoutpatientorinpatientmentalservices. the countryhaveatleastonepsychiatricnurse.In2017,about23%ofcountry’s secondaryandtertiary In addition,thereare10psychiatricunitsattachedtogeneralhospitals,whileallsixadministrativezonesof overall burden of disease. More and methodologically rigorous population-based studies and data collection overall burdenofdisease.More andmethodologicallyrigorouspopulation-basedstudies and datacollection also willlikelycontinuetogrow asachallenge,intermsofprevalence,causedisability, and contributionto ventable diseases,thereisagradual shiftin burden towardNCDs in Eritrea.Mentalillnessesanddisorders As healthandlivingstandards improve,concomitantwithsignificantreductionsincommunicable andpre andawarenessMore information MOVING FORWARD port forstatehousingandsubsidizedhousing. articles ondiscriminationrelatedtoemployment,termination ordismissal,andwages,aswellsocialsup cess, andparticipationinallaspectsoflifeforpeoplewithmental illnessesanddisabilities.Theseincludelegal There arelegislativemeasuresinplacetohelprectifydiscrimination andensureequalityofopportunity,ac reducing thelikelihoodofseekingtreatment. afraid abouthowotherpeoplewillviewortreatthemifknowledge oftheirconditionbecomespublic,thus edging theconditionorseekinghelp.Forexample,manypatients andtheirfamiliesareoftenconcernedor as abarriertotreatment,inhibitingboththementally ill and their families from acknowl Stigma oftenserves common forfamilymembersofmentallyillpersonstoalsoexperiencestigmathemselves. or blame,andarefrequentlyconsidereddangerous,dependent,unfitformarriagework.Itisnotun great shame.Moreover, peoplewithmentalillnessoftenencounterisolationorexclusion,experienceridicule the resultofwitchcraft,sorcery,orpossessionbyevilspirits(eg,“evileye”),contagious,andasource Mental illnessinEritreaisstigmatizedandpoorlyunderstood.ItoftenviewedasapunishmentfromGod, STIGMA ANDDISCRIMINATION tation withalternativepractitionersmaydelayaccesstocareandexacerbatethecourseoroutcomeofillnesses. practices havesoundempiricaldatabasestosuggesttheireffectivenessandsafety.Furthermore,initialconsul Although alternativepractitionerscanprovideimportantsupport,veryfewtraditionalortreatment areconcentratedinurbanareas. a predominantlyagriculturalcountryandmosthealthfacilitiesservices priate. Moreover, traditionalhealersorreligiousadvisersareoftenmoregeographically accessible;Eritreais families) turntotraditionalhealersorreligiousleadersfortreatmentastheyareperceivedculturallyappro religion-boundsociety,manypeoplewithmentalillness(ortheir With Eritreabeingatraditional,conservative, A large proportionofpeoplewithmentalillnessconsultalternativepractitioners formentalhealthtreatment. ALTERNATIVE TREATMENT financial challenges,andhealthproblems. associated withcarecanleadcaregiverstoexperiencesignificantphysicaloremotionalstress,employment the resourcesorspecializedskillstoprovidepropercare.Furthermore,addedresponsibilitiesandcosts Families andcaregiversfrequentlyplayanimportantroleinthecareofmentallyill.However, manylack support fromrelativesabroad. 000 population. There is one psychiatrist in the country, although several doctors have been 000 population.Thereisonepsychiatristinthecountry,althoughseveraldoctorshavebeen

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VIEWPOINTS VIEWPOINTS 2021 •Vol. 11 • 03018 sulted during the planning and implementation of these programs. As well, alternative practitioners, such as sulted during theplanning and implementation of these programs. As well, alternative practitioners, such as management of people with mental illnesses. Experts and trainers from international organizations can be con gramme, whichcanbeusedtobuildcapacityamongnon-specialisthealthcareprovidersinassessmentand specialized care.Onecost-effectiveoptionistheWorldHealthOrganization’s MentalHealthGapActionPro necessary skills to screen, diagnose, and manage common mental health conditions or to refer patients for viders. Specifically,primarycarephysicians,nurses,andgeneralhealthprofessionalsshouldbetrainedinthe This willrequireatask-sharingortask-shiftingapproach,involvingtheuseofnon-specialisthealthcarepro associated withseekingspecialistcareindistantlocations. well asareductionintheworkloadofprimarycareworkers.Itcanalsohelpreduceindirectcostsforpatients and treatmentofpatientswithmentaldisordersatprimarycarelevelscanleadtoconsiderablecostsavingsas can beexploredtoidentifylessons.Importantly,foralow-incomecountrylikeEritrea,thecorrectdiagnosis The experiencesofmentalhealthsystemsinothercountrieswithsimilarsocio-culturaloreconomiccontexts disorders andpromotegoodmentalhealththroughdirectprovisionreferralstomorespecializedservices. integrationcanachieveearlyidentificationofmental first pointofcontactbetweenpeopleandhealthservices, andreducethetreatmentgap.Withprimaryhealthcare toimproveaccessservices ary healthservices shouldbedecentralizedandintegratedintogeneralprimarysecond Additionally, mentalhealthservices health-related educationaldepartments. nities. International experts and organizations can support the development and expansion of local mental should beestablishedwithforeignprogramstoprovidemorescholarships,fellowships,andotheropportu reduce disability,morbidity,andmortality,improvefunctioning,decreasehospitalization.Partnerships cially psychiatrists and psychologists, should be trained. Increasing psychotherapy in the country can also help The scarcityofmentalhealthprofessionalsremainsamajorchallenge.Morespecialists,espe Improved andprofessional services development in designanddissemination. used withinthecountry,whilevariouscommunities,elders,andotherrespectedfiguresshouldbeinvolved is ethno-linguisticallydiverse,educationalandawarenessmaterialsshouldbemadeavailableinalllanguages Moreover, these campaigns can involve public workshops and seminars or utilize local media. Since Eritrea be linkedtoexistinggovernmentandcommunity-basedprogramsfocusedongeneralhealthrightsissues. There isaconsiderableneedtoincreasepublicawarenessaboutmentalhealthandreducestigma.Effortsmay tion forgovernment,policymakers,andhealthcareprofessionals. are necessary to estimate theprevalence, burden, andimpactofmentalillnessprovide relevant informa there arenumerous possibilitiesforfutureresearch. Forinstance,workmay exploresignificantfactorsor con Mental healthisagrowingchallenge inEritrea.Withtheissuenothavingreceivedgreat attention todate, CONCLUSION nesses areaffordedprotection andreceiveimprovedtreatmentcare. latory frameworkforaddressingcriticalmentalhealthissues andhelpensurethosesufferingfrommentalill mental illnesses,andhelpchangenegativeattitudesbeliefs. Furthermore,legislationcanprovidearegu demonstrate high-levelprioritizationofmentalhealth,increase awareness,promotetherightsofpeoplewith sive mentalhealthlegislationinlinewithinternationalnorms andstandards.RatificationoftheUNCRPDcan ratify the ership. Althoughtheexistenceofamentalhealthpolicyispositive andencouraging,thegovernmentshould requirescontinuedhigh-levelpolitical commitmentandlead Improvement ofmentalhealthcareandservices Continued high-levelcommitment able toreachpsychiatricservice. improving psychotherapeutic skills in general workers can help ease psychic pain in people un health careprovidersinappropriateprescriptionanddispensation.Notably,moreemphasisondevelopingor availability ofessentialmedicinesatalllevelsthehealthcaresystemandtrainingnursesnon-specialist care, mustbeimproved,especiallyinremoteandruralareas.Thiscanencouragedthroughensuringthe The availabilityanddistributionofpsychotropicmedicines,whichareanessentialcomponentmentalhealth in ordertoreachmorepeoplesufferingfrommentaldisorders. social capitalandlocallegitimacy),canbeintegratedintothetreatmentprocessthroughoutreachtraining traditional healersandreligiousleaders(whoareknowledgeable about culturalnormsand possess significant

United NationsConventionontheRightsofPersonswithDisabilities 4

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There arenosourcesoffundingtodeclare. of Interest: . UpdatedApril2018.Accessed20November2019. contributions:

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[email protected] Eritrea Adi Keih College ofArtsandSocialSciences Dr. FikrejesusAmahazion Correspondence to: https://www.who.int/news-room/fact-

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