Bitta et al. Int J Ment Health Syst (2017) 11:28 DOI 10.1186/s13033-017-0135-5 International Journal of Mental Health Systems

RESEARCH Open Access An overview of mental health care system in Kilif, : results from an initial assessment using the World Health Organization’s Assessment Instrument for Mental Health Systems Mary A. Bitta1*, Symon M. Kariuki1, Eddie Chengo2 and Charles R. J. C. Newton1,3

Abstract Background: Little is known about the state of mental health systems in Kenya. In 2010, Kenya promulgated a new constitution, which devolved national government and the national health system to 47 counties including Kilif County. There is need to provide evidence from mental health systems research to identify priority areas in Kilif’s men- tal health system for informing county health sector decision making. We conducted an initial assessment of state of mental health systems in Kilif County and documented resources, policy and legislation and spectrum of mental, neurological and substance use disorders. Methods: This was a pilot study that used the brief version of the World Health Organization’s Assessment Instru- ment for Mental Health Systems Version 2.2 to collect data. Data collection was based on the year 2014. Results: Kilif county has two public psychiatric outpatient units that are part of general hospitals. There is no stan- dalone mental hospital in Kilif. There are no inpatients or community based facilities for people with mental health problems. Although the psychiatric facilities in Kilif have an essential drugs list, supply of drugs is erratic with frequent shortages. There is no psychiatrist or psychologist in Kilif with only two psychiatric nurses for a population of approxi- mately 1.2 million people. Schizophrenia was the commonest reason for visiting outpatient facilities (47.1%) while suicidal ideation was the least common (0.4%). Kenya’s mental health policy, which is being used by Kilif County, is outdated and does not cater for the current mental health needs of Kilif. There is no specifc legislation to protect the rights of people with mental health problems. No budget exists specifcally for mental health care. There have been no eforts to integrate mental health care into primary care in Kilif, and there is no empirical research work to evaluate its feasibility. Conclusion: There is an urgent need to increase resources allocated for mental health in particular infrastructure and human resource. Policy and legislations need to be established to protect the rights of people with mental illnesses, and mental health should be integrated with primary care to increase access to services. Keywords: Kilif, Kenya, Global mental health, Mental health systems, WHO-AIMS

*Correspondence: mbitta@kemri‑wellcome.org 1 KEMRI‑Wellcome Trust Research Programme, Centre for Geographic Medicine Research (Coast), P O Box 230, Kilif 80108, Kenya Full list of author information is available at the end of the article

© The Author(s) 2017. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/ publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 2 of 11

Background Methods Te 2001 World Health report by World Health Organi- Study area and population zation (WHO) [1] focussed on Mental Health and high- Tis study was conducted in Kilif County, which is lighted the dire state of mental health care globally and located on the Kenyan Coast. Kilif covers an area of the need to direct more eforts towards improving mental approximately 12,246 km2 and has a population of health care. Ten key recommendations were made which approximately 1.12 million people (2.9% of the national culminated in the formation of the WHO Assessment population), 48.3% being males [6]. Te predominant Instrument for Mental Health Systems (WHO-AIMS) inhabitants (approximately 80%) are from the Mijikenda to assess the state of mental health services especially in community (mainly the Giriama, Chonyi and Kauma). resource poor settings. Te WHO-AIMS [2] is a tool used Tere are also other groups of Swahili-Arab descendants, to collect essential information about the mental health some Indians, Europeans, mainly British, German and system of a country or region. Te aim of collecting this Italian. Te main economic activities are tourism, fshing information is to provide a basis for improving mental and subsistence farming [7]. Te prevalence of poverty health systems and for monitoring change. A brief ver- (adult equivalent poverty head count) is 78.4% compared sion of this instrument is recommended in four circum- to the national proportion of 45.9%. It is ranked 8th poor- stances: (1) for research which is limited to a single part est among 47 counties in Kenya. Climate conditions vary of the mental health system; (2) when carrying out an ini- across the year and the region, but it is generally warm tial assessment with plans of following this up with a full throughout the year [8]. Health care is structured into version; (3) if mental health resources in that country or a County referral facility, a sub-County referral facility, region are extremely limited; and (4) if the brief version is primary care facilities and community units. Te county used together with another WHO-AIMS module. executive committee is the governing authority. Health Kenya is a country in East Africa which accord- fnancing is mainly from national revenue although the ing to the World Bank is classifed as a lower middle County also receives grants and donations form charita- income country [3]. As of 2013, Kenya’s population was ble entities, raises money through taxes and licences and approximately 41.8 million (50% males) with 24% living through loans. Additionally, the County is entitled to the in urban areas. Te life expectancy is 62 years for males Equalisation fund, which is a conditional grant given by and 65 years for females. Protestants, Catholics, Mus- the national government to marginalized areas. It aims to lims, Hindu, and Traditional Beliefs are the main forms accelerate level of services to bring them up to par with of religion [4]. In 2010, a new constitution was enacted the rest of the country. in Kenya, introducing a devolved system of governance, creating 47 administrative units called counties [5]. Te Study design health care system was thus devolved to the counties. A Tis was a quantitative study which used the brief version direct impact of devolution on health care was the ineq- of the World Health Organization Assessment Instru- uitable distribution of resources, based on geographical ment for Mental Health Systems (WHO-AIMS) Version boundaries. 2.2 to collect data [2]. We also used brief unstructured Kenya, like many other low- and middle-income coun- interviews to clarify the quantitative data where it were tries, has a very under-resourced mental health care sys- inconsistent. Te WHO-AIMS tool is designed to assess tem. Tere are 75 psychiatrists nation-wide and most of key components of a mental health system especially in them reside in or near major cities. Mathari Mental Hos- resource poor settings. It comprises 6 domains, 28 facets pital, which is the only stand-alone public teaching and and 156 items. Te six domains are: (1) policy and legis- referral mental hospital in the country, is situated in Nai- lative framework; (2) mental health services; (3) mental robi County 500 km from Kilif county. is also the health in primary care; (4) human resources; (5) public only County with tertiary teaching facilities for training education and links with other sectors; and (6) monitor- psychiatrists (the University of Nairobi). Tis leaves other ing and research. Te brief version contains 54 items that Counties such as Kilif lacking essential mental health cover key areas in each domain. services. Terefore, there is need to assess the prevailing We used the brief version because this was an ini- situation for mental health care in poor counties such as tial assessment, which will be followed by a full version Kilif. assessment and because the mental health resources in Our study aims to (1) understand the spectrum of this region are extremely limited. Data were collected mental disorders and the available resources, which will between September and November 2015 and were inform planning of mental health services; and (2) pro- based on the year 2014. Data on the spectrum of psy- vide a basis for monitoring progress in mental health care chiatric conditions were obtained both retrospectively services in light of a devolved health care system. (from records of admission in the previous year and) and Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 3 of 11

prospectively (by systematically documenting admissions outpatient facilities. Te four Key informants were pro- for at least 2-month period. Additionally, we summarised vided with instructions to independently to complete the data on suicide from Kilif’s Health and Demographic short questionnaires. Te frst author (MB) completed Surveillance System (KHDSS) because suicide has the WHO-AIMS survey instrument using data from the been linked to common mental health problems such self-administered questionnaires completed by the four as depression. Te KHDSS has been described in detail key informants. Where the data from the questionnaires elsewhere [9]. Information on the state of mental health were unclear to provide information to some items in was obtained from key informants from diferent depart- the WHO-AIMS, the frst investigator (MB) under- ments within the county department of health. took face-to-face interviews with the key informants, Purposive sampling was used to identify four key to obtain clarifcation. Where possible, data provided informants, from the Ministry of Health of the County by key informants was cross validated against publicly government of Kilif, who provided all the information available documents such as the county health budget. required to complete each of the 54 items. Te four key Te survey, data collection and data analysis was led and informants were the Chief Ofcer of Health, a psychiatric undertaken by MB, CN and SK. nurse at the Kilif County Psychiatric Outpatient Unit, a Clinical Ofcer managing a private epilepsy clinic in the Data analysis county that also occasionally serves psychiatric patients Data were entered onto standardized WHO-AIMS 2.2 and a representative from the fnance department of the Excel spreadsheet. Descriptive statistical analyses were County government of Kilif. performed following aggregation of numerical data. Fur- Four short questionnaires seeking specifc informa- ther analysis was done using Stata version 13 (Stata Corp, tion were generated from the 54 items in the brief ver- Texas, USA), to generate confdence intervals around sion of the WHO-AIMS document, targeting each of the the prevalence estimates of specifc illnesses, based on respondents. We also used data from Kilif’s Health and the binominal distribution. Te frequency of psychiatric Demographic Surveillance System. admissions according to sex and being a child/adoles- cent was compared using a Pearson’s Chi square test or Data collection Fisher’s exact test, where the entries in a cell were infre- Te tools used to collect data were provided by the quent (<5). A draft was prepared and discussed with the Department of Mental Health and Substance Abuse in-country-focal-point (the “in country focal point” is at WHO. Permission to conduct this situation analy- a well-connected senior and politically neutral person sis was sought from the Department of Health of the who leads the survey, and which is a requirement by the County government through the County Chief Ofcer WHO-AIMS), the psychiatrist nurse and the county chief of health. Te Research Ofce of the KEMRI-Wellcome ofcer of health for comments. Te fnal report on main Trust Research Programme facilitated the initial engage- fndings conforms to the reporting guidelines of WHO. ments with the County Department of Health. Several preparatory meetings attended by representatives of Results Department of Health and the investigators were held to Policy and legislative framework deliberate on the reasons and approaches for conducting Kenya’s mental health policy, which is being applied in the situation analysis on mental health. Te frst formal Kilif County, was last revised in 1989. It includes the preparatory meeting was chaired by CN, and subsequent following components: (1) health promotion and illness meetings by MB. To construct a database of admissions prevention; (2) accessibility of care; (3) afordability and to the outpatient psychiatric clinics in Kilif County, sustainability of care; (4) evidence based practise; and records were reviewed retrospectively by MB (guided (5) stakeholder involvement both in the public and pri- by SK and CN) and in consultation with clinicians and vate sectors as well as families and consumers of men- nurses managing psychiatric clinics in the county. Tese tal health services. An essential medicines list exists records do not carefully document psychiatric diagno- with the following drugs being available: antipsychotics ses that prompted a prospective surveillance of admis- (haloperidol, chlorpromazine); anxiolytics (diazepam); sions over a 2-month period (September–November anti-depressants (amitriptyline); mood stabilizers (car- 2015) to accurately monitor the types of diagnosis. Pro- bamazepine, valproic acid); and antiepileptic drugs (phe- spective surveillance of psychiatric conditions over the nobarbital, phenytoin, carbamazepine and valproic acid). 2 months was done by MB who carefully documented Records for the drugs were not up-to-date and erratic the diagnosis of patients seen by the Psychiatric nurse supply of these drugs was documented. at Kilif County Hospital. Te prospective surveillance No mental health plan exists and there is no disaster/ generated frequency of psychiatric diagnoses at the emergency preparedness plan for mental health Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 4 of 11

Mental health services Table 1 Spectrum of illnesses in an outpatient facility Organization of mental health services in Kilif County over a 2-month period Te Division of Mental Health & Substance use Manage- Condition Frequency Prevalence 95% confdence (N 242) (%) interval ment Unit at the Ministry of Health is the mental health = authority to which the county department of health Anxiety 1 0.4 0.0–2.3 reports. Te Head of Mental Health & Substance use Attention defcit hyper- 2 0.8 0.1–3.0 Management Unit heads the department. Mental health activity disorder services are organized in terms of service areas namely Autism 1 0.4 0.0–2.3 Kilif county and sub-county. Bipolar disorder 20 8.3 5.1–12.5 Depression 10 4.1 2.0–7.5 Mental health outpatient facilities Epilepsy 8 3.3 1.4–6.4 Tere are three outpatient mental health facilities avail- Other seizure disorders 34 14.1 9.9–19.1 able in the County; two facilities are run by the County Post-traumatic stress 1 0.4 0.0–2.3 government and there is one private facility which is disorder run by a non-governmental organization. Additionally, Psychosis 31 12.8 8.9–17.7 there is an epilepsy research clinic run by the Neuro- Schizoafective disorder 15 6.2 3.5–10.0 science Department of the KEMRI-Wellcome Trust, Schizophrenia 114 47.1 40.7–53.6 which provides follow-up care for study participants Somatic symptom 2 0.8 0.1–3.0 with epilepsy. Tere is no facility allocated for children disorder and adolescents. Tese facilities together treat about Suicidal ideation 1 0.4 0.0–2.3 180 psychiatric patients per 100,000 populations (95% Other signifcant 2 0.8 0.1–3.0 emotional or medically CI 155–208), based on the number of outpatient visits unexplained com- only. Of all users treated in the mental health outpa- plaints tient facilities during the 2 months’ prospective surveil- lance, 58.1% (95% CI 51.7–64.4%) are females and 41.9% (95% CI 35.6–48.3%) are males. Tere was no statisti- suicide being under 20 years. Tis data only included cally signifcant diference in the frequency of men- reports which were marked as “intentional self-harm” tal disorders among males and females (p = 0.129), and so does not include relatively common category of although the small sample size and convenience sam- “indeterminate cases” some of which may include sui- pling prompts caution. Fifteen point eight percent (95% cides. Te total number of people who committed sui- CI 11.5–21.0%) of all contacts are with patients 20 years cide in the whole county is unknown, since KHDSS only or younger, 25.6% (95% CI 13.0–42.1%) of whom were represents a part of the county. Te average number of children (<14 years). contacts (an interaction e.g. an intake interview, a treat- Mental health problems treated in the health facili- ment session, a follow-up visit involving a user and a staf ties were classifed into either of the following priority member on an outpatient basis) per user is unknown. psychiatric illnesses: depression, psychosis/schizophre- Tere is no active community follow-up care for peo- nia, bipolar disorder, epilepsy, developmental disorders, ple with mental illnesses, some people report back to the behavioural/emotional disorders, dementia, alcohol and clinics when their psychiatric conditions have deterio- drug use disorders, self-harm/suicide, and other signif- rated. In terms of the available treatment, some (21–50%) cant emotional or medically unexplained complaints. Te of the outpatient facilities ofer unstructured psychoso- users treated in outpatient facilities were commonly diag- cial treatments. Sixty-seven percent of mental health out- nosed with psychosis/schizophrenia and related disor- patient facilities have at least one psychotropic medicine ders [47.1% (95% CI 40.7, 53.6)] and epilepsy [14.1% (95% of each therapeutic class (anti-psychotic, antidepressant, CI 9.9, 19.1)] (Table 1). mood stabilizer, anxiolytic, and antiepileptic medicines) Data on suicide in the KHDSS was available between available in the facility or a near-by pharmacy all year the years 2008–2016. One hundred and four people com- round. Tere are no day treatment facilities, forensic mitted suicide between the years 2008 and 2016 with 6 facilities, community residential facilities, or mental hos- committing suicide in the year 2014, the year for which pitals available in the County. outpatient estimates for other mental conditions have been provided above. Te six persons were between the Human rights and equity ages of 19 and 66 years with 5 (83.3%) being males. Tere Te status of voluntary/involuntary admission to general were no suicide reports among children (<14 years) hospitals, which serve as admission facilities for men- with only 7 (6.7%) out of the 104 people who committed tal health patients, is in general not taken into account. Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 5 of 11

However, it is estimated that the majority of admissions Prescription in primary health care are involuntary. Te proportion of patients who were Nurses and non-doctor/non nurse primary health care restrained or secluded at least once within the last year workers are not allowed to prescribe psychotropic medi- in all facilities is unknown. Most violent patients visiting cations in any circumstance. However, primary health psychiatric outpatient units are chained by caregivers, care doctors are allowed to prescribe psychotropic but it is difcult to precisely know for how long this hap- medications without restrictions. As for availability of pens before hospitalisation. However, reports from our psychotropic medicines, few physician-based PHC clin- community feldworkers suggest that the patients are iso- ics and non-physician based PHC clinics have at least lated and tethered at home for sustained periods. one psychotropic medicine of each therapeutic category Tere are no beds allocated for psychiatry within the (anti-psychotic, antidepressant, mood stabilizer, anxio- County, not even in Kilif County Hospital, the only refer- lytic, and antiepileptic). Te records of the drugs are usu- ral hospital in the region. Tis greatly limits access to ally not up-to date and erratic supply of these drugs is care as admission is dependent upon availability of beds common. in the general hospital. Tere is equity of access to mental health services for other minority users (e.g., linguistic, Human resources ethnic, religious minorities) within the County. Human resources in mental health care Te total number of health care professionals work- Mental health in primary health care ing in public mental health facilities is 11.1 per 100,000 Training in mental health care for primary care staf population. Te total number of professionals in private Te proportion of primary health care doctors and nurses facilities is unknown. Te only personnel available at who have received at least two days of training in mental the mental health outpatient facilities are mental health health is unknown. Both physician based primary health nurses, social workers and occupational therapists. Tere care (PHC) and non-physician based PHC clinics are pre- are no psychiatrists, psychologists or other mental health sent in the County. Neither the physician based PHC nor workers. Te breakdown according of professions per non-physician based PHC clinics have assessment and 100,000 population is summarized in Table 2. treatment protocols for key mental health conditions. Figures provided are best estimates based on ofcial None of the physician-based PHC clinics makes at least registration and data from professional associations. All one monthly referral to a mental health professional. Tis the estimates provided refer to human resource in the is also true for non-physician-based PHC clinics. How- outpatient mental health facilities, which are the only ever, there are two non-governmental clinics for peo- mental health facilities in the County. ple with epilepsy in the County. One is a research based clinic for care of people with epilepsy and neurodevelop- Training professionals in mental health mental disorders runs twice a week under the auspice of Te number of professional graduates from Kilif County Kilif County Hospital and KEMRI-Wellcome Research in the last academic year is unknown. No mental health Programme and the other is managed by the Foundation care staf in Kilif County attended refresher training for People with Epilepsy, a non-governmental organiza- on the rational use of psychotropic drugs, psychosocial tion, and is run on weekdays. Tis former clinic focuses interventions, or child/adolescent mental health issues. on follow-up care for research participants of neuro- Documentation of these numbers is not a priority of the logical and mental health studies and does not have the County department of health. capacity to ofer services to all residents of Kilif County. As for professional interaction between primary health care staf and other care providers, all or almost Table 2 Human resource per 100,000 population all (81–100%) primary health care doctors interacted with a mental health professional at least monthly in the Human resource Number per 100,000 population last year often in informal meetings. None of physician- based PHC facilities, non-physician-based PHC clinics, Psychiatrists 0.0 or mental health facilities interacted with a complemen- Nurses 0.2 tary/alternative/traditional practitioner. Traditional heal- Psychologists 0.0 ers are frst point of care for people with mental health Social workers 0.2 persons in this county and have expressed willingness Occupational therapists and other health or 0.4 a to refer mental health patients to biomedical facilities if mental health workers­ proper referral frameworks are put in place (unpublished a This includes auxiliary staf, non-doctor/non-physician primary health care work). workers, health assistants, medical assistants, professional and paraprofessional psychosocial counsellors Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 6 of 11

Consumer and family associations Psychiatric conditions admitted to hospital Tere are no consumer associations or family associa- Verbal reports from the nurses managing psychiatric tions in Kilif County. Te government does not provide facilities in Kilif indicate that over 2000 people were economic support for either consumer or family asso- diagnosed with a psychiatric condition in 2014, translat- ciations. Only one non-governmental organization called ing to 180 per 100,000 population (95% CI 155–204). Tis Afya Research Africa is formally known to be involved in data is not reliable and may be is a gross underestimate of individual assistance activities such as counselling, hous- the true burden of mental health conditions in the com- ing, or support groups. munity as it likely represents severe patients, who access the hospital, and those without animistic beliefs about Public education and links with other sectors biomedical treatment. Psychosis and seizures were the Data on public education and links with other sectors commonest diagnosis, which is unsurprising since the could not be collected using the brief version of the long-standing studies on epilepsy and other seizure dis- WHO-AIMs assessment instrument. orders in this area may have sensitised the community [10], while psychosis has overt symptoms easily identif- Monitoring and research able for referral for treatment. Te few cases of depres- No formally defned list of individual data items that sion may suggest that this condition is under-recognised ought to be collected by all mental health facilities in the community due to its internalising symptoms or exists. Te government health department received is considered less debilitating than psychosis or epilepsy, data from all the three mental health outpatient facili- calling for the need to train primary health to identify ties. However, no report was produced using the data the condition or to conduct awareness and epidemio- transmitted to the government health department. Te logical studies to sensitise the community. Suicide within data were not detailed and included a few items as fol- the KHDSS was documented as “intentional self-harm”. lows: all three facilities provided data on the number of Tere reports of suicide from verbal autopsies within users treated and the diagnosis of each patient, two of the KHDSS were fewer than those of “indeterminate the three facilities provided data on the number of users cases” [14]. Tis could be due to under-reporting of sui- restrained and no facility provided data on the user con- cide cases, probably because of the stigma and isolation tacts in the facility. Research in Kilif County is focused that family members of people who die by suicide face in on epidemiological surveys of the burden of mental dis- many African communities. Indeed a study by Kizza et al. orders often conducted by researchers from KEMRI- [15] from Uganda indicated that suicidality was associ- Wellcome Trust Programme. However so far, these ated with “loss of masculinity” and such stereotypes may studies have only been based on a few mental health interfere with reporting of suicide cases, leading to gross problems such as behavioural disorders in young chil- under-estimation of these cases. Also, the preponderance dren and epilepsy in all ages [10, 11]. Te research con- of male suicides in our report is consistent with other sists of monographs, theses and publications in indexed studies [15, 16]. Further studies are required to under- journals. stand the reasons for males killing themselves more than females. Suicide cases may be a refection of the devastat- Discussion ing efects of unaddressed depression among the casual- Te fndings of this study reveal a fragile mental health ties. Few children presented to outpatients clinics with system in Kilif County. Most conspicuously is the lack neurodevelopmental and behavioural/emotional prob- of mental health care facilities (e.g. no admission beds lems, probably because most parents cannot identify for mental health patients in the county referral hospi- symptoms for these conditions in their children and they tal) and the limited human resource allocated to men- have a misperception that their children will outgrow the tal health care (e.g. low physician/patient ratio and lack disorders. While the numbers provided in this study only of qualifed psychiatrists). Tere are no legislation and represents a proportion of the true burden in the com- policy frameworks on mental health care in the county munity, they are expected to exert an enormous burden and rights of people with mental illnesses are violated on the County Health System [17], which appeared ill- (e.g. being restrained). Te frequency of psychiatric equipped to address mental health problems as discussed conditions treated at the outpatient facilities shows in subsequent sections below. that conditions such as depression may be under- recognised in this community as in other low income Policy and legislative framework settings [12, 13]. Tis study also sheds light on the chal- Kenya promulgated a new constitution in 2010, but Men- lenges posed by a devolved system of health care and tal Health Acts were given little attention in the new dis- outdated legislation. pensation. In fact, the Mental Health Act was last revised Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 7 of 11

in 1989. Tis act is outdated and does not address the away and was the provincial headquarters) for essential current needs of people with mental illnesses and the mental health services; (2) there has been no data on the unprecedented challenges of a devolved system of health prevalence of mental, neurological and substance used care, which was inaugurated with the new constitution. disorders for informing policy and resource allocation; For instance, the District Mental Health Board, which is (3) most people with mental, neurological and substance supposed to be the mental health authority at the lowest used disorders visit traditional healers as their frst point level of administration, is not functional in Kilif County of care due to misconceptions, stigma and discrimina- and there is no County Mental Health Authority [18]. tion associated with mental illnesses and therefore the Also, there is no mental hospital in Kilif County despite enormous burden of mental, neurological and substance the substantial burden of people with mental and neuro- used disorders is unappreciated by biomedical facili- logical disorders [19]. Because of lack of appropriate leg- ties (unpublished work); and (4) meagre fnancial budget islations and policy frameworks, the rights of people with towards mental health care and training of health staf mental illnesses are violated (e.g. being restrained and at higher institutions of learning. It is worth empha- isolated), little resources are allocated to mental health sising that these reasons alone cannot fully justify the care (e.g. no budget of staf training) and there is lack conspicuous lack of resource allocation towards mental of will to use available research fndings to change poli- health, given that some reasonable resources are spent on cies on mental health care. Fortunately, there were pro- other health problems particularly control of infectious posed amendments to improve the Mental Health Act in diseases such as malaria and HIV, and Expanded Pro- 2014, but this bill is yet to become law. Tis is indicative grammes on Immunizations. of lack of efective advocacy for mental health in parlia- Due to the under-resourced mental health care, Kilif ment. Tere has been a positive step towards improv- County relies on two psychiatric nurses who serve at the ing mental health policy with the launch of Kenya’s frst only two public psychiatric outpatient facilities. Te low mental health policy in May 2016. Tis was however staf patient ratio for mental health poses a risk of poor not captured in our study as data was collected in 2015. quality of mental health services, especially diagnosis Although the new policy brings with it a lot of promise and management of common mental illnesses. Because for improved mental health care, the challenge lies in of the enormous burden on the health care system, it is implementing it, especially in remote resource limited likely that only severe psychiatric cases will visit the out- settings such as Kilif. patient clinics, perhaps explaining the few cases of com- mon mental, neurological and substance used disorders Mental health services resources and fnancing reported in the County. For instance only 4% of patients Data collected with the brief version of the WHO-AIMS who seek care in these facilities are diagnosed with suggests that the current budgeting system is not pro- depression, which may be misperceived as a less severe gram based; making it difcult to directly determine the condition than psychosis; depression contributes to the exact amount of funds allocated to mental health ser- largest disability adjusted life years for all illnesses in vices. Although the County budget is a publicly accessi- Kenya (2.3%) and worldwide [22]. ble document, the implementation process is not, making accountability for resources spent on mental health care Human rights and equity difcult, unlike in other countries such as Uganda, Stigma and discrimination towards people with mental where budgetary allocation to mental health is quanti- illness is ubiquitous [23]. Although WHO-AIMS could fed (approximately 4%) [20]. It is possible that the lack of not assess the extent of human rights violations, it helped quantifcation of exact mental health needs in the county highlight a notable absence of bodies that oversee human makes planning for mental health services difcult. We rights of persons with mental illnesses in facilities. Tis hope that our eforts to conduct this situation analy- situation is not unique for Kilif and can be compared to sis will identify exact mental health needs in the county Uganda [20] although human rights review bodies exist that may inform objective fnancial allocation on mental in some sub-Saharan countries like Ghana [24]. Future health care. studies are required to systematically document the Tere is no mental hospital or mental health facil- extent of discrimination and human rights violations ity allocated to child or adolescent mental health care among mental health patients in this area, using stand- despite the substantial burden of mental and neuro- ardised methods. logical disorders particularly in older children [21]. Tis lack of resources could be due to a number of reasons: Mental health in primary health care (1) until recently, Kilif as an administrative unit was Kilif County and indeed Kenya in general is still lagging dependent on county (which is located 60 km behind as far as integrating mental health into primary Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 8 of 11

health care is concerned compared to other countries in mental illnesses [26]. As such, refresher training should sub-Saharan Africa [20, 24]. In Kilf, care is still ofered perhaps be done routinely if any long-term benefts are in outpatient facilities only. Anecdotal evidence sug- to be realised. Fortunately, these training initiatives gests that most primary health care providers are willing could be sustained through the existing training pro- to be involved in providing mental health care but they grammes run by the Kenyan ministry of health, which require refresher training and guidance to be able to ofer trains health workers from rural health centres. Tis pro- this care adequately. Introducing a mental health train- gram uses curriculum developed through a partnership ing intervention for primary health care workers may be with WHO. Te training covers core concepts of mental a useful way of improving this situation. health, common mental and neurological disorders and health system issues including policies and legislations, Limitations but it is yet to be rolled out to the county hospitals in Tere are a number of limitations of this study. Te prin- the current devolved system of governance. An evalu- cipal investigator in this pilot study (MB) had spent very ation of the impact of the frst 1000 trainers showed a little time with the respondents prior to collecting this 35% mean improvement in knowledge among those who data and may not have built enough trust to get accu- were trained [27], yet the training initiative has not been rate responses from the respondents. Client records for applied in many rural county and sub-county hospitals in mental health services were scanty and poorly recorded Kenya. Health stakeholders of a region initiate the pro- which made the verifcation of quantitative data virtually cess of training and as such, the County chief ofcer of impossible. Te possible areas of action suggested by the health in Kilif should initiate this process. authors were based solely on the evidence generated by Te County government should also initiate talks with this study with no consultation between the authors and traditional healers, who are involved in the diagnosis and the stakeholders regarding their views on priority areas treatment of patients with mental health problems [28], for action. Tis limits the extent to which these recom- to encourage them to refer people with mental health mendations are acceptable and replicable. problems to health facilities. Traditional healers are frst point of contact for people with mental illnesses, and Possible areas for action they have expressed willingness to cooperate if such an Based on the fndings of this study, we provide recom- initiative was put in place. mendations using two criteria. We consider the evidence base from this study, other studies within the country and Advocacy and awareness campaigns the opportunities provided by the current devolved sys- Te County government together with stakeholders in tem of government and of healthcare. Tese actions rely mental health should cooperate in initiating and sustain- on cooperation and collaboration between Kilif, neigh- ing routine awareness campaigns to create knowledge bouring counties and with the national government, and of the causes and symptoms of common mental health are informed by results of studies done within the coun- problems. Currently, the national government and non- try, as referenced in each section. governmental organizations organize such campaigns. Tey are held in major cities only on days relevant to Short term areas for action mental health such as Te World Mental Health Day Service development priorities and International Epilepsy day. A starting point should Primary health care workers should receive refresher be conducting these campaigns at the county level and training on mental health. Some topics for this training encouraging consumers of mental health services and should include identifcation and management of depres- their families to share their experiences with the com- sion, psychosis, suicide, child and adolescent issues, alco- munity during such campaigns. Tese campaigns should hol abuse, anxiety disorders and patients with chronic encourage help seeking and better coping strategies for complaints. Jenkins and colleagues in their study on the people with mental health problems. In future, these experiences and perspectives of trained primary health advocacy and awareness campaigns should also target care workers in Nyanza Kenya, found that even in the the communities where people with mental illnesses presence of a weak health system and inadequate medi- live by supporting and strengthening existing self-help cine supply, providing mental health training had a posi- groups [29]. tive impact on the quality of life of their clients [25]. However, as shown in a randomized control trial of a Policy and legislation priorities mental health training intervention of primary health Although there was no mental health policy during the workers in three districts in Kenya, short term training time of data collection for this study, a new national pol- improved patients’ outcomes, but not ability to diagnose icy is now in place. Te County Department of Health Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 9 of 11

should organize workshops to sensitize health care pro- health workers in Kilif by psychiatrists from Nairobi. A viders on the contents of this policy and to encourage systematic review on the use of information communica- them to be part of the implementation process. If imple- tion technology (ICT) in health initiatives in Kenya found mented, this policy will improve the quality of services that of the 14 marginalized counties in Kenya [33], Kilif provided to people with mental health problems. had the highest number of initiatives [34]. Although none of these initiatives were specifcally for mental health, Medium/long term areas for action this review indicates that Kilif has the capacity to utilize Research priorities ICT in health. Epidemiological studies on the spectrum of common Investment in mobile outpatient assistance teams will mental disorders should be conducted on persons of all help cover distant areas and improve access to services age groups to provide reliable data on the burden of men- hence avoid hospitalization. Mobile teams could also tal, neurological and substance use disorders in Kilif. Te backup local primary health care services assisting men- results of such studies will be useful in two ways. Firstly, tal patients. Mental health clinics and wards in health people identifed with these mental disorders will receive facilities should also be established. Tese will decongest follow up care through the ministries of health in col- the outpatient facilities. laboration with the research centres involved. Secondly, Lastly, providing community care for patients (and stakeholders can use reliable data generated from these their families) will avoid the costs of hospitalization and studies to support advocacy for increased budgetary allo- promote integration, as well as reduce stigma associated cation towards mental health services. Additionally, as with institutionalized care. with any epidemiological studies, there may be increased community awareness because of the research activities. Advocacy and awareness campaigns Tis should however be complemented with active and Stakeholders in mental health care i.e. consumers and consistent awareness campaigns. families should be encouraged to form associations through which they can be involved in processes aimed Service development priorities at improving care. Tere should be integration of mental health care into primary care, a model which has been shown to be Policy and legislation priorities efective in Kenya [30] and other resource poor settings Legislation should be updated to protect the rights of [31]. Tis can be done by providing training on WHO’s people with mental health problems such as equitable mental health Gap Action Program Intervention Guide access to care, protection from inhuman treatment and (mhGAP-IG). However, contextualizing the available evi- involuntary admissions. Tis requires more consistent dence is paramount. advocacy eforts from all mental health stakeholders. Tere is need to increase capacity for managing men- Advocates of people with mental health problems should tal health problems. Tis requires both an increase in work together towards the same goal. Indeed lack of infrastructure and in human resource. Kilif can utilise cooperation among stakeholders has been an obstacle in the National Health Sector Human Resource Strategy the eforts to improve mental health services in resource 2014–2018 [32] which clearly outlines the implementa- poor settings [35]. Campaigns such as those started by tion process for increasing human resource in health in the National Department of Mental Health services to every County. It describes the recruitment targets per decriminalize suicide should be made into laws, to pro- annum in general and specialized areas including men- tect people with suicidal ideations and encourage them tal health. It also outlines the resources required to train to seek help. Currently, mental health governance is still these personnel and the sources of funding for coun- centralized. Tis limits the extent to which counties can ties to implement this strategy. It also lays emphasis on independently plan and implement mental health activi- the importance of cooperation between Counties. Kilif ties. Devolution of mental health services should be County has two facilities currently training medical per- hastened to enable each county respond to the specifc sonnel and many more in the neighbouring Mombasa mental health needs of their regions. County. Mental health facilities in Mombasa have quali- fed psychiatric staf, capable of providing training in the Conclusions teaching facilities in Kilif. It is therefore feasible to cre- Mental health care system in Kilif Kenya is under ate a coordinated framework where mental health train- resourced and should be improved through several ing can be ofered in Kilif by personnel from Mombasa approaches and strategies. Tere is an urgent need to and other neighbouring counties. Tere is also need to increase resources allocated for mental health. Infra- explore if telehealth could be used to ofer training to structure and human resource should be increased. Bitta et al. Int J Ment Health Syst (2017) 11:28 Page 10 of 11

Policy and legislations need to be put in place to protect 2. WHO: World Health Organization Assessment Instrument for Mental Health Systems (WHO-AIMS). World Health Organization Assessment the rights of people with mental illnesses. Mental health Instrument for Mental Health Systems (WHO-AIMS). Geneva: World should be integrated with a strengthened primary care to Health Organization; 2005. increase access to services. 3. Bank TW: New country classifcations. In New country classifcations, 07/02/2015 edition. World Bank Group; 2015. Authors’ contributions 4. KNBS: Population and Housing Census 2009. Population and Housing MB is the principal investigator and the corresponding author for this study. Census 2009. Kenya National Bureau of Statistics; 2015. MB contributed to the design of the study, collected data, aggregated it and 5. NCLR: The Kenyan Constitution. In The Kenyan Constitution. National wrote the frst draft of this report. CN and SK designed the study and assisted Council for Law Reporting; 2016. in writing this report.EC was involved at diferent stages of data collection and 6. WorldBank: Country classifcation of economies. Country classifcation of assisted with the writing of this report. All authors read and approved the fnal economies, 2013 edition. The World Bank; 2013. manuscript. 7. KC: Kilif County Government: Demographics. Kilif County Government: Demographics. Kilif County Government; 2016. Author details 8. KIRA: Kilif secondary data review. In: Kilif secondary data review, 1 KEMRI‑Wellcome Trust Research Programme, Centre for Geographic Medi- 02/04/2014 edition. Kenya Interagency Rapid Assessment; 2014. cine Research (Coast), P O Box 230, Kilif 80108, Kenya. 2 Ubuntu Afya Clinic 9. Scott JA, Bauni E, Moisi JC, Ojal J, Gatakaa H, Nyundo C, Molyneux CS, for People with Epilepsy, Malindi, Kenya. 3 Department of Psychiatry, University Kombe F, Tsofa B, Marsh K, et al. 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Research Programme, Professor Philip Bejon and the centre director, Benjamin Lancet Psychiatry. 2017;4:136–45. Tsofa for assisting with initial engagements with the department of health of 12. Abas M, Baingana F, Broadhead J, Iacoponi E, Vanderpyl J. Common the county government of Kilif. We acknowledge Ms. Cynthia Mauncho and mental disorders and primary health care: current practice in low-income Ms Zainab Mwanjirani for assisting with planning and logistics for the face countries. Harv Rev Psychiatry. 2003;11:166–73. to face interviews. We acknowledge members of the fnance department of 13. Greenhalgh T. WHO/WONCA report—integrating mental health in primary the County government of Kilif for their help in retrieving information for the care: a global perspective. Lond J Prim Care (Abingdon). 2009;2:81–2. fnancial year 2014. 14. Ndila C, Bauni E, Mochamah G, Nyirongo V, Makazi A, Kosgei P, Tsofa B, Nyutu G, Etyang A, Byass P, Williams TN. Causes of death among persons of all ages within the Kilif Health and Demographic Surveillance System, Members of the Department of Health of the County Government of Kenya, determined from verbal autopsies interpreted using the InterVA-4 Kilif. Dr. Timothy Malingi—Chief Ofcer of Health, County Government of model. Glob Health Action. 2014;7:25593. Kilif. Mr. Leonard Nasoro—Psychiatric nurse in charge of the Kilif Psychiatric 15. Kizza D, Knizek BL, Kinyanda E, Hjelmeland H. Men in despair: a qualitative Outpatient Unit. Mrs. Margaret Kabibu—The Chief nursing ofcer Kilif County psychological autopsy study of suicide in northern Uganda. Transcult Hospital. Finance Ofce of the County government of Kilif. Psychiatry. 2012;49:696–717. 16. Kanchan T, Menon A, Menezes RG. Methods of choice in completed Competing interests suicides: gender diferences and review of literature. J Forensic Sci. The authors declare that they have no competing interests. 2009;54:938–42. 17. 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