By Courtney Sabey (School of International Development and Global Studies, University of Ottawa)
“They say that mental health doesn’t kill [a] person. But if someone suffer[s] from physical disease, they respond directly. But about mental health? Oh, can wait. Everyone still thinks that mental health can wait” -Rwandan NGO representative
Mental health is gaining traction in global health policy, as evidenced by its inclusion in the United Nations Sustainable Development goals (Goal 3, target 3.4), and is currently one of the most significant and pressing issues in global public health. Despite this, physical health continues to be at the forefront of many public health policies and primary health care services while mental health remains underfunded. Notably, the World Health Organization recently reported a global shortfall in investment in mental health at a time where there is an ever-increasing need for mental health services and support. This failure by policy and decision makers to prioritize mental health sends the message that mental health needs can wait. This message is often relayed in countries that have experienced violent conflict, as rebuilding the country and taking care of physical injuries generally takes precedence. In response to this, I pose two questions: 1) Can mental health wait? and 2) Does it really need to?
Rwanda, a small landlocked country located in the Great Lakes Region of East Africa, has proven that mental health does not need to wait and that it does not need to be an “either/or” decision between physical and mental health. Rwanda experienced a devastating genocide in 1994 in parallel to a civil war that began in the early 1990s. One year following the conclusion of the genocide and the coinciding civil war, the country began implementing a national mental health policy. My recently published study researched the implementation of the country’s revised 2012 mental health policy to analyze the process of mental health reform in a post-conflict, post-genocide, and low-income country. While the research does not evaluate the results of the policy, it provides an inside look at the dynamics of mental health reform in a complex setting.
Managing an emergency in post-genocide Rwanda
Rwanda’s mental health policy was developed in response to what some local research participants referred to as a “mental health emergency”, as the extensive violence led to widespread trauma and other mental health challenges among the population. The policy was based primarily on the strategies of decentralization and integration of mental health care into the primary health care system and relied on the training of generalists.
My study found that as a result of the policy, today nearly every health centre and hospital in the country offers some degree of mental health care, with the costs of most services covered for enrolled members by the national community-based health insurance scheme. In addition, the majority of community health workers are trained in mental health and the national university has a thriving clinical psychology program. The Rwandan government also conducted a national epidemiological survey on the prevalence rates of mental illness and mental health service utilization in the country in order to inform policy implementation. These efforts are complimented by specialized hospitals, private practices, and non-governmental organizations who offer various services and programs.
Rwanda was able to reach these successes and implement integrated mental health care throughout the country without sacrificing physical health nor any of its other post-conflict development goals. However, this is not to say that this was an easy feat or that the country has not faced any challenges or criticisms throughout implementation.
Challenges of mental health policy implementation in Rwanda: Efficiency vs Efficacy
In addition to challenges such as stigma and lack of human and financial resources, my research found one of the greatest gaps to be that the implementation of the mental health policy focuses on individualized and institutionalized treatment. This was not considered suitable in a community-based culture. Stakeholders also pointed to a lack of collaboration between government implementers and those working on the ground level, with many feeing that the implementation was siloed and top-down. This finding raises questions about how to successfully implement a progressive health policy in an authoritarian country.
In many ways, authoritarianism appears to have aided implementation in that the government can quickly and efficiently enact change and carry out orders. However, that change is not always what the population wants or needs, and in the case of institutionalization, can also infringe on the basic human rights of ordinary people. Despite this, numerous non-governmental organizations appeared to be filling in a gap by providing community-based programs and advocating for more community-based care from the government side. Whether or not the government will adapt its approach based on this feedback remains to be seen.
Indeed, Rwanda has come a long way since the days where people suffering from mental health conditions were chained by their families or placed in prisons and treated as criminals – practices that still take place throughout the world. However, the country still has a long way to go, and while authoritarianism may speed up the process, it’s unlikely to produce better results. Despite this, its early successes have shown that it is possible to prioritize mental health in a complex setting, even with scarce resources and other urgent national priorities.
Previous studies have already demonstrated that addressing mental health cannot wait if we want to promote healthy and thriving societies. The case of post-genocide Rwanda, as showcased through this process tracing study, proves that it does not need to wait. The challenges Rwanda has faced, as well as its successes, can also provide many valuable lessons for other countries looking to prioritize mental health.
Image credit: Courtney Sabey