Mozambique – Cuamba District Mozambique—Cuamba District Project goal To integrate mental health into general health care at the primary care level, in particular through the enhancement of psychosocial support. Project objectives S To examine the needs of the local population; the socio-cultural factors influencing mental health; local definitions of mental health suffering; and traditional strategies for intervention. S To train health workers, social workers, community leaders and religious leaders in the identification of major symptoms and signs of emotional suffering. S To establish a referral system to help people with psychosocial problems. S To monitor and evaluate the programme. Implementing institutions S Ministry of Health, Maputo/Mozambique S Provincial Authorities - Lichinga/Niassa S District Health Authorities, Cuamba 11 Working with countries: mental health policy & service development projects Background Provisional results of the national cen- central hospitals in Maputo, Beira sus conducted in 1997 put the popula- and Nampula as well as two psychiatric tion of Mozambique at 15.7 million. hospitals. This is 15% lower than earlier estimates of 18 million. Primary care remains the The mental health care system in basis of the public health system in this Mozambique can be broadly divided country. The National Health Service into three sectors: (1) services based is the major provider of all health ser- within primary care facilities; (2) hospi- vices. There are four levels of care in tal services (including psychiatric in- Mozambique. patient beds and outpatient services); and (3) traditional healing. At the primary level, there are health posts, mobile services and rural health Primary health care facilities are an im- centres that carry out preventive and portant source of mental health care basic curative activities. Health posts provision. There are currently 34 psy- are staffed by semi-skilled or unskilled chiatric technicians located within personnel. The large health centres health centres throughout Mozam- bique’s 11 provinces. Their main role is to prescribe and administer psychiatric medication to patients attending the health centres. The health centres also carry out mental health awareness and educational programmes to reduce the stigma associated with mental illness and the risks associated with alcohol consumption. There are currently two psychiatric hospitals in Mozambique that cater primarily to inpatients with severe mental health problems who have been referred on by primary care psychiatric technicians. One is based in The main Provin- the City of Maputo and the other in the cial Hospital pro- have basic inpatient facilities and are northern province of Nampula. There is vides a range of services but mental staffed by nurses. also a small unit at the local rural hospi- health is not tal in Sofala. included. At the secondary level, there are rural and general hospitals. The general hos- Since many patients who suffer from pitals provide services in paediatrics, chronic mental illness are prone to re- Source: WHO obstetrics and gynaecology, general sur- lapses, one of the most important priori- gery, and medicine. Few rural hospitals ties for the Ministry of Health is to provide surgical services. monitor access to health care, and the social care patients receive once they At the tertiary level, there are provincial are discharged from hospital. There hospitals that offer diagnostic facilities was evidence to suggest that the psychi- and some specialist services. atric hospital in Maputo was a victim of the same “revolving door” phenomenon The quaternary level includes three that bedevils hospital services in many 12 Mozambique – Cuamba District developed mental health care systems. from mental health problems. Nevertheless, it was evident that provi- sions have been made with local health Mental Health is one of six sections in centres to monitor patients on discharge the Ministry of Health, alongside other and to provide general assistance to pa- community-based services and under tients and their families in the process the National Health Directorate. There of reintegration in the community. The is a National Programme Coordinator Ministry of Health has looked positively for Mental Health who is responsible upon traditional medicine because it for planning and policy decisions. In recognizes its importance to the people each province, there is a coordinator for of Mozambique. Since only 60% of the the local mental health programme. population has access to formal health There is also a mental health plan which care services, particularly in rural areas, follows closely the “Provincial Inte- healers are most often the preferred grated Plan”. port-of-call for individuals who suffer Project description The current project is located in the whom 85 specialize in the treatment of Cuamba district of the northern rural mental illness. It was deemed very province of Niassa. The project brings together government representatives, key policy-makers, and representatives of traditional healers and NGOs for the purpose of integrating mental health into the general health care system. The district was chosen as a site for the pro- ject because, among other factors, it is the most populated district of the Niassa province, it is one of the underserved areas of the country, and, during the war, most of the population of the satel- lite districts that had lost everything came to Cuamba seeking security. important therefore that they be Difficult living con- ditions compound Compared with European standards, involved in any programme of psycho- the problems of the however, formal mental health care de- social rehabilitation in the community. very poorest sectors of society and exac- livery in Mozambique is patchy and ba- erbate some of the sic and, as with the rest of the health At the XVIth Coordinating Council of mental health care system, prone to serious inequali- the Ministry of Health in 1990, decen- prolems. ties of access. But perhaps the most tralization of the Mental Health Pro- Source: WHO telling aspect of its lack of development gramme was approved. Following this and inaccessibility (particularly in rural the Niassa Provincial Directorate began regions) is the lack of clinical and social focusing on the prevention, assistance, support for people with serious mental and psychological and rehabilitation as- illnesses and their families during times pects of health. In 1997, a survey of of crisis. In the district of Cuamba, common mental health problems in the however, there are a considerable num- District of Cuamba, found that it had the ber of traditional healers (365), of largest number of mental disorders. 13 Working with countries: mental health policy & service development projects The reason given for this was the high important people in the community concentration in the district of people such as traditional healers, religious who had migrated to Cuamba from and community leaders and health other districts seeking refuge from professionals with the purpose of de- armed conflict. veloping a programme of cooperation. S Made recommendations about issues Examining the needs of the local that needed to be addressed in order population; socio-cultural factors to educate the local community and influencing mental health; local health workers about alternative definitions of mental health explanations for mental dis- suffering and traditional orders, causal factors and options strategies for intervention for treatment. A qualitative study was undertaken in order to understand local definitions and To train health workers, social grasp of mental disorders. Some 200 workers, community leaders and persons including families, community religious leaders in the identification of major symptoms and signs of emotional suffering One of the recommendations of the qualitative study was that information and education about mental health prob- lems should be undertaken in the district through discussions, debates, meetings and training seminars for health person- nel, religious leaders, community lead- ers, teachers and community health workers. To this end, the information obtained from the study was used to train com- Over 100 health leaders, heads of households, religious munity leaders, traditional healers and and mental health leaders and traditional healers were in- professionals from religious leaders. Two evaluators, all over the country terviewed. namely a project officer and a psycholo- benefited from gist from the university in Maputo, who training in interna- tional models of The results of this study were then used were familiar with the project, were in- community mental to develop a programme of psychoso- volved in planning and identifying the health care. cial support activities for the mentally relevant themes. Areas covered in- Source: WHO ill, adapted to particular social and cul- cluded: tural circumstances. In particular, the S perceptions of mental disorders; study: S causes of mental disorders; S Described local perceptions of mental S the need for psychosocial support. disorders, their causes, methods of treatment and the social rehabilitation As part of the efforts to educate the of the mentally ill. community, informal discussions were S Identified factors that might have af- also held with mothers and, using one of fected the implementation of promo- the local schools, with children. Dis- tional activities. cussions covered, among others, the ef- S Identified the local