Introduction
Uganda, officially known as the Republic of Uganda, is a landlocked low-income country in East Africa with a population of around 46 million, 8.5 million of which live in the capital Kampala.
Like most African countries, Uganda has been plagued by a history of instability, corruption and violent conflicts, including an eight-year-long military dictatorship led by Idi Amin, one of the most brutal authoritarian leaders of modern history from 1971 to 1979. The current president of Uganda, Yoweri Kaguta Museveni, has been in power since January 1986 following a protracted six-year-long guerilla war.
The Mental Health Situation in Uganda
Uganda is ranked among the top six countries in Africa with high rates of depressive disorders. Recent studies estimate that 4.6% of the population live with depressive disorders [1], while 2.9% live with anxiety disorders [2].
Those suffering from mental, neurological, and substance abuse disorders place a significant burden on public health resources. In 2017, out of Uganda’s £127 GDP annual spend per capita on healthcare, only 1% of that budget was used for mental healthcare (compared to the 10% (£2989)) spent in the UK per capita in the same year) [3].
A significant proportion of the country’s national mental health funding goes directly to Butabika Hospital (the national mental health referral hospital established in 1955), with little investment directed towards community-based mental health treatment services in more remote areas. Even with this funding, Uganda’s mental health services have been regarded as inadequate and unable to meet demand. It is estimated that 90% of people with mental illness receive no treatment [4]. The situation has worsened as the otherwise motivated and highly regarded healthcare workers leave the country to work in more stable, high-income countries.
A rising number of Ugandans suffer from mental health disorders due to the country’s history of conflict, political turmoil, and ongoing civil unrest. Like many countries across Africa, traditional beliefs around causation have deterred Ugandans from seeking professional help and led them to seek the services of traditional healers. Traditional healing can be patient-centered and caring; however, it often includes chaining or tying individuals for prolonged periods to ward “evil spirits” off. It is reported that 80% of those admitted to Uganda’s psychiatric hospitals have previously been to a traditional healer [3].
In 2014, the Mental Disability Advocacy Centre (MDAC) released a critical report on the services at Butabika National Referral Hospital. A 500-bed facility with frequent overcrowding (and approximately 430 staff) [5].
The hospital was found to have no reserved areas for children, and there is no data regarding the average length of stay or the diagnostic mix of patients.
There is significant concern about the conditions at the Butabika facility, including the detention of visitors without assessment, the prolonged and dehumanising use of seclusion, and the low levels of staff with mental healthcare training. Many of the seclusion rooms have no toilets, forcing patients to lie and sleep, often naked, on the same floor where they defecate and urinate. There is also a heavy reliance on medication for treatment, often leaving patients with severe side effects such as epilepsy [6].
There are 28 outpatient treatment facilities that are severely underfunded and disproportionately concentrated around the capital, Kampala. In a survey in 2006, only 57% of the clinics had just one psychotropic medication in each class [4].
Stigma is a crucial driver worldwide, and the evidence points towards this as a prevalent barrier inhibiting the development of Uganda’s mental healthcare system and for people seeking treatment.
The effects of poverty are also significant. People presenting with mental health disorders are often not offered employment or able to seek credit for land, livestock, or state assistance. There are many cases where they cannot afford to travel to the clinics or for medication; well-situated treatment facilities could address these problems. Families are affected as work is often disrupted to care for the relative in need, sometimes leaving some families to abandon them as a lost cause.
References
[1] Miller, A. P., Kintu. M., and Kiene, S. M. (2020). Challenges in measuring depression among Ugandan fisherfolk: a psychometric assessment of the Luganda version of the Center for Epidemiologic Studies Depression Scale (CES-D). BMC Psychiatry, 20(45)
[2] WHO report (2019). Mental disorders. World Health Organization (WHO), Geneva, Switzerland. (https://www.who.int/news-room/fact-sheets/detail/mental-disorders)
[3] Molodynski, A., Cusack, C., and Nixon, J. (2017). Mental healthcare in Uganda: Desperate challenges but real opportunities. BJPsych International, 14(4).
[4] World Health Organization (2006) WHO-AIMS Report on Mental Health System in Uganda, WHO and Ministry of Health, Kampala, Uganda.
[5] Emerald Project (2016) Butabika National Mental Health Hospital.
[6] Mental Disability Advocacy Centre (2014) Psychiatric Hospitals in Uganda: A Human Rights Investigation. MDAC.
