COVID-19 impact on Mental Health in Low and Middle Income Countries: the case of Uganda

By: Dr. Benedict Akimana & Rebecca Cherop

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. According to World Health Organization (WHO), mental health is defined as a state of wellbeing in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her or his community. There are various types of mental conditions such as depression, bipolar disorders, schizophrenia, OCD amongst others.

In January 2020, the World Health Organisation (WHO) declared Covid-19 a public health emergency and for this outbreak, we know that we are not only fighting the virus but also managing stigma, fear, grief, anxiety and so much more. The different Covid-19 preventive measures such as social distancing, hand washing and above all the lockdown in most of the countries have in one way or another affected our mental health.

The mental health implications of the Corona Virus Disease (COVID-19) crisis are staggering as families across the African continent struggle to cope with financial ruin, hunger, illness, broken relationships, and isolation among others. The impact of this is more profound in most of the Low and Middle-Income Countries (LMIC) across the world. The WHO estimates that over 40% of developing countries do not have a mental health policy and over 30% have no mental health programs. As the COVID-19 crisis continues to disrupt life around the world, the toll on our mental health is enormous. At a time when there are calls for social distancing and isolation, mental health professionals and advocates continue to ensure that there is wellbeing of our mental wellness across the globe with numerous virtual events organized. We need to remain constant in our purpose to provide a solution so that everyone can lead healthy, productive and satisfying lives. Our work is more important now than ever.

Uganda is one of the LMIC and according to a WHO-AIMS research of 2010, Uganda spends 9.8% of the Gross Domestic Product (GDP) on healthcare, or US$146 annually per person. Less than 1% of this goes into mental healthcare as compared to 10% for many other countries. Uganda has made significant strides in reducing poverty over recent years and this has translated into greater investment in healthcare overall. However, funding remains low by international standards and the proportion allocated for mental healthcare disproportionately so.

National mental health services are inadequate, with little or no community care and the in-patient services which are available are insufficient to satisfy demand. According to a WHO report of 2006, 90% of the population suffering from mental illness receives no treatment. The situation is exacerbated by many skilled healthcare workers leaving Uganda to work in high-income countries (HIC), reducing what had been described as a highly skilled and motivated workforce.

Mental, neurological and substance use disorders are a public health burden in LMIC and Uganda is among the countries that have faced the challenges brought about by the devastating impact of COVID-19 on our mental health wellbeing. COVID-19 has caused disequilibrium in mental health leading to instability which is due to many issues such as uncertainty, threats to life, survival instincts kicking in and not much is known as yet such as its treatment; therefore rumours have taken over truth.

There is also transmission mode which dictates prevention of spread mode that leads to isolation and loneliness and drives social stigma. With an already low mental service user participation in health system strengthening which is reflected in the service access and approach at hand, policy development, implementation of programs and research, there are still several barriers to service user involvement in mental health system strengthening in Uganda. The COVID-19 pandemic adds more challenges to the already stretched system at hand. These challenges can be grouped into three categories: institutional, community and individual level factors. Institutional level barriers include: limited funding to form, train and develop mental health service user groups, institutional stigma and patronage by founder members of some of the user organizations. Community level barriers include: abject poverty and community stigma. Individual level barriers include low levels of awareness and presence of self-stigma.

It’s therefore recommended that more involvement of the users of the mental health services at a time as this are key since the number of victims of mental illness keeps spiking, something which is already posing a challenge to the few open mental health service centers. Mental health service user involvement could be an important strategy for advocacy and improving service delivery in this season. However, little is known about the most effective way to involve service users in mental health system strengthening during the pandemic.

Uganda is part of the 15% of countries which have mental health legislations dating back to the pre-1960s. Mental health legislation is necessary for protecting the rights of people with mental disorders, who are a very vulnerable section of society. The widespread abuse that people suffering from mental disorders frequently experience in Uganda, such as violence, stigma, and employment exploitation, appears to be at least partially symptomatic of the absence of an adequate mental health law.

Uganda’s progressive Mental Healthcare Policy of 2018 is undermined by the outdated and offensive mental health legislation. Both the pre-colonial Mental Treatment Act of 1938 and the post-colonial Mental Health Act of 1964 fail to protect and promote the human rights of people with mental disorders. Though Parliament in 2018 passed the Mental Health Act which provides for mental health treatment at primary health centers, emergency admission and treatment, involuntary admission and treatment and for voluntary and assisted admission and treatment among others, unfortunately this new law on mental health hasn’t yet come into force.

Underfunding remains a challenge

Mental health is still significantly underfunded in most LMIC. In Uganda, only about 1% of health care expenditures by the government are directed towards mental health. Consequently, like many other African countries, the mental health care sector relies heavily on donor-funding. Although the level of financing generated through this mechanism appears to be relatively high in Uganda, there are many dangers involved with an over-reliance on donor-funding, including it being unreliable, unsustainable and sporadic in nature as well as the frequently attached conditionalities. In addition, 55% of the funds that are dedicated to mental health are directed towards the National Mental Hospital, resulting in a continued over-reliance on hospital-based, institutionalized care.

The predominant form of inpatient mental health service provision continues to be based in mental hospitals, with for example, no beds available in some community residential facilities.

In addition to the above, there is a widespread inequality between urban and rural areas in the resources available for mental health care, including staffing and inpatient beds as reported in the WHO research of 2010. Like in many other low-income countries, the availability of psychiatric care is significantly skewed in favour of the urban city centers, with an inequitable geographical spread of services. It’s further revealed that 62.4% of the psychiatric beds in the country are located in Uganda’s capital city, Kampala, with limited access for rural users. Even with the decentralization of mental health treatment, it’s majorly skewed to the regional referral hospitals located in urban areas majorly but now turned into COVID-19 quarantine centers. This is frustrating access to some of the key medications needed for serious mental complications.

This situation is further complicated by absence of reliable, routinely collected data that can be used to plan for services and redress current inequalities. In a WHO-AIMS research of 2010, High Income Countries (HIC) had adopted effective systems and approaches to mental health through rigorous studies. However, unlike Low and Middle Income Countries (LMIC), HIC have the resources and logistics to achieve this. Several LMIC have made attempts to address mental health system from different perspectives. In Brazil for example, efforts have been made to develop a mental health system to promote respect for the rights of people with mental disorders, gradually replacing psychiatric beds with community-based and primary healthcare mental health services, and also promoting training and financial support to change the mental health care paradigm.

In South East Asia, seven out of the 11 countries have made use of the WHO-AIMS project for an initial assessment of their mental health systems which is a significant regional effort where 25% of the world population lives.

In the African setting, there have been calls for action to develop appropriate polices, efforts to change community attitudes towards mental illness, provision and delivery of health and social services and access to medication and community care in Nigeria, Ethiopia, Kenya, South Africa and Uganda.

Furthermore, there is absence of specialized child and adolescent mental health services in place, with children and adolescents being treated in the same facilities as adults, a common problem in most developing countries. This is despite the fact that children and adolescents constitute over 50% of the country’s population, and 16% of all new users of mental health outpatient facilities are children and adolescents. The lack of attention afforded to child and adolescent mental health is somewhat surprising, given that the mental health needs of children and adolescents are specifically mentioned in Uganda’s mental health policy 2018. The Ugandan government has signed and ratified the Convention on the Rights of the Child, which obliges the government to ensure the maximum possible development and best health care for children.

In Uganda, the lockdown and the ensuing restrictions have had unprecedented impact on the livelihoods of citizens. There are cases of domestic violence in Uganda as a result of the COVID-19 pandemic. Generally, all national newspapers have reported an upsurge in domestic violence as reported to Police stations across the country, and most of the victims are women.

The rise of domestic violence has been attributed to the economic pressures exerted on families as a result of the lockdown. In addition, many people who were previously living under abusive relationships now have no escape from their abusers because of the nationwide lockdown. People are undergoing stress, fatigue and depression due to insecurity and income worries which have fueled the domestic violence. According to the New Vision of 27th April 2020, it’s reported that from March 31st to April 14th, 328 cases of domestic violence were reported to the police nationwide. In one week from 20th April -27th April, the police in Kampala received 297 cases of domestic violence including 35 cases of home desertion by husbands who have run away after failing to provide food to their families. Similar cases of desertions and violence have been reported across the country, but the unreported cases could be much higher especially in rural areas where most people are either unaware of their rights or are far away from protective services.

In the Daily Monitor of 22^nd April 2020, it was reported that a 53-year-old man in Sironko district was allegedly beaten to death by his 27-year-old son over Shs. 6,000 (0.5 US dollars) which he had borrowed from the son but had failed to pay back. Bukedde TV in the week starting 22nd April aired a story of a woman from a suburb of Kampala whose head was hit by her husband, when she asked for money to buy food. In the Daily Monitor of 5^th May 2020, it’s reported that in one township in Western Uganda, a woman reportedly poured hot porridge on her 35-year-old husband, accusing him of failing to provide food for the family. The couple had just stayed in marriage for only two months.

On July 2, 2020 it was reported in the Daily Monitor, one Hussein Walugembe came to the end of his life’s journey. On the fateful day, the 20-year-old entered Masaka Central Police Station in Masaka City, which is 130km from Kampala City and doused himself with petrol that he had carried in a small jerry can, before setting himself on fire. Walugembe was protesting the seizure of his motorcycle. Two days earlier, a police officer had impounded Walugembe’s motorcycle for violating presidential directives barring movement of motorcycles after 5pm. This is one of the measures instituted by the government of Uganda to stop the spread of COVID-19.

There has been a rise in domestic violence in homes, teenage pregnancies, suicide, increased substance use and such incidents might seem isolated and forgotten but they are an indication of the increasing number of people grappling with mental health challenges as they deal with the upheaval caused by the lockdown that was imposed in Uganda due to COVID-19.

In the WHO report of 2006, it is assessed that the treatment gap for mental disorders is at 85%. This implies 15% of those with emotional well-being challenges who need clinical consideration don’t get it. Likewise, numerous individuals managing mental difficulties are not even mindful of what they are encountering. With the current COVID-19 pandemic, many people are now facing anxiety problems, stress and depression amongst others leading many into suicide. Many people, who suddenly had a lot of time on their hands because they could not go to work, resorted to alcohol and drugs. Undoubtedly, the number of alcohol and substance abuse cases have doubled in this COVID-19 period.

Uganda has 13 regional referral mental health treatment units but since March, the government gazetted these units for the treatment of COVID-19 patients. We contend that turning the units into COVID-19 treatment centers was a big blow to the services offered to mental health patients in the different referral hospitals around Uganda.

The kind of care given by these mental health units are for chronic care and for some people treatment takes about three to four weeks, or longer. Others have to visit for drug refills, admissions and the sudden turn of these units into COVID-19 treatment centers has meant that people can’t access them, yet there is no alternative provided. A few individuals who can manage to travel to Kampala for treatment have spent more and this has increased the number of patients that the National Mental Referral Hospital has to handle.

No longer at ease: People cannot cope

The challenge of coping up has also further weighed down heavily on the population. Before the episode of COVID-19, there were numerous components accessible to the populace. Be that as it may, a portion of these alternatives are not there any longer. A few people adapt to issues by associating at different gatherings, bars and visiting companions and family members. For the past few months since March, those choices have not been accessible to them and yet more human and money related assets were required. Coping during the COVID-19 pandemic is important in keeping our mental wellbeing.

The way forward: In our view

Compared to many other low-income countries, Uganda’s mental health care sector has made significant strides forward. The formulation of a new progressive mental health policy and the implementation of numerous service reforms within the country are testimony to Uganda’s increased commitment to meeting the health care needs of the country. Despite these reforms, and the consequent strengthening and improvement of mental health services, Uganda’s mental health system still possesses a number of shortcomings. In this light, a number of activities, policy and service development initiatives are required.

There is need to review the outdated mental health legislation to bring it up to date with current International Standards. The law should provide a legal framework for protecting the rights of the mentally ill and addressing critical issues such as the community integration of persons with mental disorders, the provision of care of high quality, the improvement of access to care, the protection of civil rights and the protection and promotion of rights in other critical areas such as housing, education and employment.

A nationally agreed minimum data set needs to be put in place and an information system established, in order to consistently monitor mental health service delivery at district and national levels.

There is need to expand our support and expertise to include other mental health issues brought about by the pandemic such as anxiety, stress and other mental conditions.

In such a time as this where social distancing has been advised, there is a high need to deploy mobile, print and radio messages to reach a large audience by broadcasting information about the signs and symptoms of depression, stress and anxiety as well as simple coping strategies that can be done at home.

There is also a need to check in by phone with respective former patients by mental health professionals to gauge their mental health, to remind them to use the coping strategies they learnt in therapy groups and to encourage them to share these strategies with loved ones. As we continue to fight the corona virus, providing support and technical guidance to Non-Governmental Organizations and government health workers on how to address mental health needs and to incorporate this in their response to the pandemic will be instrumental in how LMICs deal with mental health issues.

There is growing interest in the involvement of service users in health systems development. Although this is still a recent innovation in many of the service delivery systems around the world due to the COVID-19 outbreak, we believe that collaboration with users provides key inputs into the health system to deliver integrated and quality services that meet the needs of the populations they are designed to serve. For example, service users can share their lived experience (for instance, with mental conditions, stigma, service seeking and the attitudes of service providers towards people with mental illness) and this information can be used to improve health reforms and service delivery.

There is need to comprehend the psychological viewpoints of COVID-19 and potential measures to adapt to the pandemic for their viable administration.