Modern Mental Health Services

in Ethiopia

Like all scientific knowledge and skills, the development of modern mental health services in Ethiopia also followed the level of influence of Western civilization in the c o u n t r y. In this aspect, it can be said that there have so far been four relatively distinct phases:

Phase 1, 19 30s - 19 60 s .

Phase of introduction into the country of scientific knowledge
This phase is identified by the introduction into the country of scientific knowledge about the brain and psychological phenomena. This phase started following the invasion of Ethiopia by Fascist Italy, which lasted for five years.

Ethiopia, an ancient country in the horn of Africa, has had a rich history of experiencing its own unique traditional ways of handling people’s mental illnesses. The country had accepted both Christianity and Islam earlier, and, within the boundaries of each religion, developed over the centuries its own nomenclature of mental illnesses and prescriptions for the various types of identified psychological problems. Although modern theories about the psychological phenomena and psychopathology had been introduced during the above period via higher education, the deep- rooted traditional perceptions regarding psychological phenomena could not be displaced by the new concept. Because of this fact, people were not utilizing the country’s mental hospital, Amanuel hospital, which was established in 1948. The public attitude towards this hospital had been negative during this period.

Phase 2

Phase of introduction of mental health workers
This period extends from the 1960s to end of 1970s. Before that time, the mental health services at Amanuel hospital was provided by general practitioners, nurses and other low-level health workers. Psychiatrists from different European countries entered Ethiopia during this phase. A Dutch team led by Dr Robert Giel, who was the founder and head of the Psychiatry Department in Addis Ababa University in the 1960s, exerted the most important influence of this phase.

In addition to providing mental health services in Addis Ababa, these health workers conducted several researches in the field in different parts of the country. By rendering more effective professional services and by the dissemination among professionals of their research findings, Dr Giel et al were able to significantly change the negative attitude of the public. Consequently, the public was now coming to Amanuel hospital as a last resort after failing with traditional practices.

Ph a s e 3

Phase of producing Ethiopian mental health workers
This phase was in place from end of the 1970s to the end of the 80s. It can be said that this period played the most important role in the modernization of the service in the c o u n t r y. The main factors that influenced the positive changes were;

1 – Training of Ethiopian medical doctors were in psychiatry indifferent European countries;
2 – Training of Psychiatric nurses was started at Amanuel Hospital. These two schemes were initiated by the sponsorship of the WHO;

The availability of indigenous staff enabled the interview of patients and families by health workers who speak the same languages and who know the cultural meanings of verbal and bodily expressions of feelings and other related culturally important issues. This was a crucial factor in increasing public awareness about the scientific concepts of mental illness and the modern way of their management. Moreover, psychiatric units were established in hospitals outside of Addis Ababa during this phase. Graduate psychiatric nurses staffed these units. Thus started the decentralization of the service. People who were unable to afford to travel to Addis Ababa from distant rural areas started using the mental health services that was made available in their vicinities;
3 – Effective psychotropic drugs were availed in the country. Previous to this phase, people were discouraged from seeking help from modern services, even when there is the positive attitude, by the lack of supply of psychotropic drugs. The improvement in the supply during this phase played a significant role in the increased number of people coming to psychiatric units.

Although the training of mental health workers was a significant advance, the number of trained staff was much less than the demand. During previous phases, the public under- utilized the available few staff because of negative attitude and refusal to use the service. This situation was reversed during and after this phase. The staff shortage made it impossible for the service to meet the growing demand. The main reason for the lack of trained staff was that the country was, because political instability and other priorities, unable to start post graduate training for doctors locally.

Phase 4

Phase of Reopen ness. This is the ongoing phase, which started in the 90s
This period is characterized by the resumption of free communications between local and foreign professionals and the normalization of relationships between the North and Ethiopia.

The country still struggles to stand on its own to feed its people. The recurring natural and man made disasters have foiled the possibility to effect uninterrupted development programs. Notwithstanding this, the progress in mental health care improvement has been advancing, albeit slowly.

The driving forces in the sustenance of the growth of services during this phase are:

The ongoing psychiatric nursing program. This has enabled the country to fill the void created by the lack of high-level professionals. The number of psychiatric units throughout the regional states has now grown to 43, each staffed with one or more psychiatric nurses. Psychiatrists and senior psychiatric nurses visit these units annually from Addis Ababa. The visiting senior assists and discusses with the practicing nurse regarding problems cases, and discusses with the health managers and the administrators of the area about administrative problems. Amanuel Hospital also organizes two workshops annually for practicing psychiatric nurses and general practitioners where by experience sharing and problem- solving discussions are taking place. The annual supervisions and seminars help in updating the knowledge and skills of the psychiatric nurses. These schemes sponsored by WHO, are now paying off. It has now become possible to reduce the referral of psychiatric cases to Addis Ababa from the regions by over 50%. In addition more people are using the services because of accessibility of the latter. It now costs many rural people less as they don’t have to travel long distances to Addis Ababa (which they had to travel with much discomfort due to lack of modern transportation).

Growing collaboration in research between foreign and local institutions.

A number of researches have been undertaken in the field of mental health in Ethiopia lately. There are several ongoing research activities. These activities were or are being carried out by teams of professionals from Ethiopia and from countries like Sweden, The US, Holland and The UK. Collaborative research helped and is helping to improve the clinical and research capacity of local staff.

Recognition by the government of mental health care of the people as a p r i o r i t y.

The Health policy of the current government acknowledges the importance of mental health service for the welfare of the public. The Health Sector Development Program (HSDP) of the Ethiopian government, which is now in its 2n d 5-year plan, incorporates the provision of mental health care at the different levels of the health care system in the country. As part of this program, postgraduate training in psychiatry for medical doctors will start in Addis Ababa University at the beginning of
2003.

Growing public awareness

The public is now more than ever aware of the importance of mental health. Families now do not need much agitation to seek medical help for their mentally ill members. The level of awareness has grown to such a stage now that a body by the name ‘Society of Mental Health Ethiopia’ (SMHE) is under formation. Families of mentally ill persons initiated the formation and a large number of people has already requested for membership. The program of this society, among other things, includes education regarding prevention of mental illness and supporting patients and their families.

These four phases show the development of modern psychiatric services in Ethiopia. The country is still among severe economic crisis and depends on donation from the North for improving the coverage of its modern health care. Besides, there are killing infectious conditions that are rampant throughout the land and that absorb much of the health budget.

Because the impacts of mental illnesses are not as acute and dramatic as infectious conditions, the policy makers have, until recently, been lenient with the meager psychiatric services. Although the government has now realized the significance of the impact of mental disorders in the overall development process, the national economy seems too limited to bring about the desired expansion work.

Being the third most populous country in Africa and with high birth rate, the health problems are expected to rise in the future unless the North enhances its technical and financial support to the health-care system. Without the North’s organized assistance, it will be impossible to bring about a systematic incorporation of mental health in the ongoing Health Sector Development Program.