community enlightenment, infrastructure im- Memiah P. (2015) End of Project Evaluation of the Capacity Building provement and capacity building of frontline pro- Within Health Care in Somaliland. Norwegian Lutheran Mission. Available at: https://www.norad.no/om-bistand/publikasjon/ngo- viders to deliver mental healthcare that is patient evaluations/2015/somaliland-capacity-building-within-healthcare- centred, evidence based and culturally aligned. cbh-final-evaluation-report/.

Funding Somaliland Ministry of Health (2012) Somaliland National Mental S.P.S. is part-funded by the National Institute for Health Research Health Policy. Republic of Somaliland. (NIHR) Collaboration for Leadership in Applied Health Research and Care WM (NIHR CLAHRC WM). Somaliland Ministry of Health (2017) The National Development Plan II. Available at: http://slministryofplanning.org/index.php/ References 10-quick-downloads/14-plans. Bradbury M., Abokor A. Y. & Yusuf H. A. (2003) Somaliland: choosing United Nations Children’s Fund (2012) Children in Somaliland. politics over violence. Review of African Political Economy, 30(97), UNICEF-Somalia. Available at: https://www.unicef.org/somalia/ – 455 478. SOM_resources_childrensomaliland.pdf. General Assistance and Volunteers Organization (2004) Baseline Survey Report on Mental Health Situation in Somaliland. GAVO. World Health Organization (2010) A Situational Analysis of Mental Health in Somalia. WHO. Available at: http://www.who.int/hac/crises/ Human Rights Watch (2015) ‘Chained Like Prisoners’: Abuses Against som/somalia_mental_health/en/. People With Psychosocial Disabilities in Somaliland. Human Rights Watch. Available at: https://www.hrw.org/news/2015/10/25/ World Health Organization (2016) Health 2015: From MDG to SDG. somaliland-people-disabilities-abused-neglected. WHO. Available at: http://www.who.int/gho/publications/mdgs-sdgs/en/.

COUNTRY Mental health in PROFILE Dawn Harris,1 Tarik Endale,2 Unn Hege Lind,3 Stephen Sevalie,4 Abdulai Jawo Bah,5 Abdul Jalloh6 and Florence Baingana7

1Mental Health Coordinator, literacy, 78% Muslim) (UNFPA, 2018). The country King’s Sierra Leone Partnership, Sierra Leone is a West African country with a is divided into 16 districts, of which the Western King’s Global Health Partnerships, population of just over 7 million. Many Sierra King’s Centre for Global Health Area Urban District (Freetown) is the most popu- Leoneans lived through the psychologically and Health Partnerships, School lous with 1.1 million people. Sierra Leone has 20 of Population and Environmental distressing events of the civil war (1991–2002), Sciences, King’s College London, local dialects, with distinct cultural beliefs and prac- the 2014 Ebola outbreak and frequent floods. Sierra Leone. Email: dawn.harris@ tices. More than half (52.9%) of Sierra Leoneans live kcl.ac.uk Traditionally, mental health services have been 2 below the poverty line (UNFPA, 2018). Mental Health Volunteer, King’s delivered at the oldest mental health hospital Sierra Leone Partnership, King’s Many Sierra Leoneans have experienced trau- ’ in sub-Saharan Africa, with no services Global Health Partnerships, King s matic events that are associated with negative men- Centre for Global Health and available anywhere else in the country. Mental Health Partnerships, School of tal health outcomes (Betancourt et al, 2015). These illness remains highly stigmatised. Recent Population and Environmental include a decade-long civil war which ended in Sciences, King’s College London, advances include revision of the Mental Health Sierra Leone 2002, the 2014 Ebola outbreak (Jalloh et al, 2018), Policy and Strategic Plan and the strengthening 3Mental Health Volunteer, King’s and recurrent floods which in August 2017 caused of mental health governance and district Sierra Leone Partnership, King’s a deadly mudslide that left an estimated 1141 dead Global Health Partnerships, King’s services. Many challenges lie ahead, with the or missing (The World Bank, 2017). Additionally, Centre for Global Health and crucial next steps including securing a national Health Partnerships, School of alcohol use is significantly higher than the regional Population and Environmental budget line for mental health, reviewing mental ’ average (WHO, 2014) and substance misuse, espe- Sciences, King s College London, health legislation, systematising training of Sierra Leone cially of marijuana and tramadol, are of increasing mental health specialists and prioritising the 4Commanding Officer, Joint concern (Shackman & Price, 2013). Medical Unit, Republic of Sierra procurement of psychotropic medications. Leone Armed Forces, Sierra Leone National and international commitment must 5 Lecturer, Department of be made to reduce the treatment gap and Pharmacology, College of Systematic issues facing mental health Medicine and Allied Sciences, provide quality care for people with mental services University of Sierra Leone, Sierra illness in Sierra Leone. Leone Sierra Leone is a low-income country with a gross 6Specalist Psychiatrist, Hospital domestic product (GDP) per capita of $653 and a Care Manager, Sierra Leone Human Development Index ranking of 181 out Psychiatric Teaching Hospital; and Lecturer, College of Medicine of 188 countries. Approximately 21.7% of the and Allied Health Sciences, Sierra Leone is situated on the west coast of Africa, GDP is spent on health, which amounts to $160 University of Sierra Leone, Sierra fl anked by the Atlantic Ocean and bordered by per capita. However, only 7.3% of that expend- Leone Liberia and Guinea. The country has a young and 7Independent Consultant, Sierra iture comes from the government, with the rest Leone rapidly growing population of 7 092 113 people coming from out-of-pocket expenditures (33%), (50.8% female, 40.8% <15 years, 41% urban, 51% donor funding (46.9%) and non-governmental

14 BJPSYCH INTERNATIONAL VOLUME 17 NUMBER 1 FEBRUARY 2020 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 12:50:56, subject to the Cambridge Core terms of use. Conflict of interest: None. organisations (11.8%). There is no official budget was established within the Ministry of Health line allocated to mental health (Sierra Leone and Sanitation (MoHS) to coordinate services Keywords. Low- and middle- Ministry of Health and Sanitation, 2017). and oversee partner mental health activities. income countries; Sierra Leone; global mental health; mental Government investment in human resources The Directorate is in the process of drafting new health system; human rights. for health has been limited, with few doctors in mental health legislation with the hope of protect- training and poor retention. Almost 50% of the ing the human rights of people with mental ill- First received 23 Jul 2018 Final revision 23 Mar 2019 health workforce has not been absorbed onto nesses. District focal persons are soon to be Accepted 7 Jun 2019 the payroll (Sierra Leone Ministry of Health and appointed to act as advocates for mental health Sanitation, 2017), resulting in informal payments in their local area. doi:10.1192/bji.2019.17 or reliance on other sources of income (Wurie © The Authors 2019. This is an et al, 2016). Mental health workforce Open Access article, distributed Sierra Leone has an estimated treatment gap under the terms of the Creative A cohort of twenty-one mental health nurses com- Commons Attribution licence of 98% for severe mental illness (Alemu et al, fi (http://creativecommons.org/ 2012). Historically, mental healthcare was deliv- pleted either certi cate- or diploma-level courses licenses/by/4.0/), which permits in 2012/13 at the College of Medicine and Allied unrestricted re-use, distribution, ered at ‘Kissy Lunatic Asylum’ which opened in and reproduction in any medium, 1820 and was the oldest asylum in sub-Saharan Health Sciences (COMAHS) in Freetown. provided the original work is Unfortunately, two nurses passed away, leaving properly cited. Africa (Akyeampong et al, 2015). Now referred to as the Sierra Leone Psychiatric Hospital nineteen in clinical practice. Two further mental (SLPH), it remains the country’s only in-patient health nurses have trained abroad. A second facility, treating up to 150 patients at a time. cohort of eight nurses started their training with SLPH is highly stigmatised and suffers from COMAHS in January 2019. Additionally, eight chronic underfunding, limited human resources, healthcare professionals have completed an MSc a lack of basic facilities and frequent interruptions in child and adolescent mental health (CAMH) to medication supplies. This often results in in Nigeria, but only one nurse continues to prac- restricted treatment options and the chaining of tice solely as a CAMH specialist. The University of patients; however, this dire situation is now start- is currently running a diploma in coun- ing to improve with support from international selling psychology. partners. Sierra Leone continues to use the out- Two Sierra Leonean psychiatrists returned to dated Lunacy Act of 1902 which is highly the country following completion of specialist discriminatory. training in 2016: one is the medical director at fi Stigma towards mental illness is a major issue SLPH and the other is the commanding of cer and mental health literacy is extremely low. of military medical services. Additionally, there Mental illness is viewed as something that is is a semi-retired psychiatrist who previously ran brought upon oneself or as the result of supernat- SLPH. There are no clinical psychologists or psy- ural activity (Alemu et al, 2012). A person exhibit- chiatric social workers in public service. ing symptoms of mental illness may be called The scarcity of educational opportunities and crezman or ful ful (pejorative terms indicating senior staff for training and supervision is a chal- that the person is crazy or a fool). By the time lenge. Sierra Leone lacks the capacity and infra- patients present to formal mental health services structure to conduct specialist training of it is usually after considerable investment at additional psychiatrists. Furthermore, many of fi home or with one of the 37 000 traditional healers those who completed the certi cate/diploma in the country (Alemu et al, 2012). A 2005 assess- course are yet to be professionally recognised ment suggested that up to 88% of people with and remunerated as mental health nurses. A cur- mental disorders had seen a traditional healer riculum is in development for specialist commu- fi before accessing psychiatric care (Jones et al, nity health of cers (CHOs) but training has not 2009). Although there is evidence of potential begun. CHOs run most of the primary health ser- psychosocial benefits of traditional healing in vices and are vital for planning the future mental Sierra Leone (Stark, 2006), these healing methods health workforce. are varied and unregulated, leaving great poten- tial for abuse such as prolonged chaining, beating, Service delivery confinement and deprivation of food and water. Mental health services remain highly centralised. There are no mental health in-patient beds out- side of SLPH. At the secondary care level, mental Major developments and future health treatment is delivered by mental health challenges nurses. They operate out-patient units at district Mental health governance and leadership hospitals, as well as a national CAMH service at In 2012 a national Mental Health Policy was Ola During Children’s Hospital. launched, with an updated Mental Health Policy There is limited integration of mental health and Strategic Plan in the process of finalisation into services such as primary care, maternal and for 2019. Mental health is included in the Basic child health or HIV clinics. At the peripheral Package of Essential Health Services and various health unit level and below, there are no desig- other national strategic policies and plans. nated mental health workers. Training on the use In December 2016 a Directorate for of the World Health Organization’sMental Noncommunicable Diseases and Mental Health Health Gap Action Programme (mhGAP) has

BJPSYCH INTERNATIONAL VOLUME 17 NUMBER 1 FEBRUARY 2020 15 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 12:50:56, subject to the Cambridge Core terms of use. been conducted for over 100 CHOs, however most are also key. The launch of the national Strategic are yet to receive any supervision or refresher train- Plan and Policy will be vital to guide the improve- ing and the impact is still to be evaluated. ment of services. Programmes to increase mental health literacy among the population are also Health management information systems and needed. This will require the involvement of stake- research holders both within and outside of the formal There has been a dearth of mental health health system, such as traditional/faith healers. research in Sierra Leone, with the last systematic Together, these steps will help pave the way for epidemiological study dating back to a 2002 the future delivery of high-quality, universal mental MoHS survey (Alemu et al, 2012). Subsequent healthcare in Sierra Leone. mental health research has largely focused on the civil war and Ebola. Currently, MoHS routine data collection has Acknowledgements been relegated to a single box labelled ‘mental We thank all the mental health nurses in Sierra Leone who have contributed to running mental health services in their districts disorder,’ which is rarely completed. This lack of and assisted in collecting data. The development of this article disaggregated mental health data limits useful- has been supported by United States Agency for International ness for service planning and policy action. Development (USAID) through the Advancing Partners & Partners have worked with mental health nurses Communities project, implemented by JSI Research & Training to strengthen monitoring and evaluation systems Institute, in collaboration with FHI 360 under cooperative agree- through the collection of routine clinic data. ment number AID-OAA-A-12-00047. The opinions herein are fl Although there are concerns about accuracy, the those of the authors and do not necessarily re ect the views of USAID. data provides some insight into service utilisation and diagnosis. From 2015 to 2017, epilepsy accounted for almost half of the diagnoses, with References psychosis appearing almost twice as frequently Akyeampong E. K., Hill A. G. & Kleinman A (editors). (2015) The as depression or alcohol and substance misuse. Culture of Mental Illness and Psychiatric Practice in Africa: 349. Indiana University Press. fi Health nancing and medical products Alemu W., Funk M., Gakurah T., et al (2012) WHO proMIND: Profiles At present, there is no specific mental health bud- on Mental Health in Development Sierra Leone. World Health get line at the level of the MoHS or the District Organization. Health Management Teams. Psychotropics are Betancourt T. S., McBain R. K., Newnham E. A., et al (2015) The included on the list of essential medications but intergenerational impact of war: Longitudinal relationships between have rarely been procured by the MoHS; most caregiver and child mental health in postconflict Sierra Leone. The psychotropics in the country are donations. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 56, 1101–1107. lack of mental health funding and a severe short- age of psychotropics at the district level are major Jalloh M. F., Li W., Bunnell R. E., et al (2018) Impact of Ebola barriers for accessing treatment. Limited options experiences and risk perceptions on mental health in Sierra Leone, July 2015. BMJ Global Health, 3, e000471. at all levels hinder the provision of quality services and the retention and motivation of mental Jones L., Asare J. B., El Masri M., et al (2009) Severe mental disorders – health workers. in complex emergencies. Lancet, 374, 654 661. Shackman J. & Price B. K. (2013) Mental health capacity building in Conclusions northern Sierra Leone: lessons learned and issues raised. Intervention, – There is a long way to go before inhumane prac- 11, 261 275. tices are put to an end and minimum standards of Sierra Leone Ministry of Health and Sanitation (2017) Annual treatment are reached, but the establishment of a Health Sector Performance Report 2016. Sierra Leone Ministry of Directorate for Noncommunicable Diseases and Health and Sanitation. Mental Health demonstrates a growing commit- Stark L. (2006) Cleansing the wounds of war: an examination of ment to the cause. Although mental health is traditional healing, psychosocial health and reintegration in Sierra – included in the Minimum Package of Essential Leone. Intervention, 4, 206 218. Health Services and the Health Policy and The World Bank (2017) Sierra Leone - Rapid Damage and Loss Strategic Plan, this has not translated into adequate Assessment of August 14th, 2017 Landslides and Floods in the – investment towards the strengthening of the men- Western Area:1 118. The World Bank. tal health system. Efforts to improve research and United Nations Population Fund (UNFPA) (2018) Sierra Leone 2015 health information systems are crucial to future Population and Housing Census National Analytical Report. UNFPA. fi planning. It will also take signi cant investment World Health Organization (WHO) (2014) Global Status Report on in human resources, with training of additional Alcohol and Health 2014. WHO.

psychiatrists and the development of a local Wurie H. R., Samai M. & Witter S. (2016) Retention of health workers in Mental Health BSc for nurses and CHOs. rural Sierra Leone: findings from life histories. Human Resources for Further efforts to decentralise mental healthcare Health, 14,3.

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