Authors: Lamin F. M. Barrow and Ann Faerden
Publication site: Cambridge University Press
Type of publication: Article
Date of publication: 2021
Effective management of mental illnesses is a major unmet need in many low- and middle-income countries. These illnesses contribute to the costs of health and social care. They are associated with a poor quality of life, loss of employment and increased risk of disability and early mortality. The Gambia is a low-income country, the smallest within mainland Africa, with a per capita gross domestic product of about US$300 and a population of about 2 million people. Agriculture, tourism and remittances (from a re-export trade) are the main pillars of the economy. The key social challenges the country is faced with include poverty and limited access to jobs. World Bank data indicate that over 10% of the population live below the poverty line of less than US$1.9 per day. Thirty per cent of adults have not completed primary education. The unemployment rate stands at 22%, affecting mostly young people. This influences many of them to undertake a journey that leads to illegal migration into Europe, looking for greener pastures.
About 120 000 of the population are affected by mental illness, but 90% of these people do not access mental health services for their conditions
It has been estimated that about 120 000 of the population are affected by mental illness, but 90% of these people do not access mental health services for their conditions. There is just one psychiatric hospital (Tanka Tanka) and one psychiatric out-patient clinic serving the entire population. These facilities are only found in and around the capital. The only other mental health service is the community mental health team that visits health facilities outside urban areas, according to a planned schedule. Although it is the only service available to most of the rural population, a community team has recently been provided by a few health facilities in urban areas too. Nevertheless, most rural and urban areas are without any mental health service. This situation prevails even though The Gambia has a mental health policy and a strategic plan that seeks to improve access to mental healthcare for its population.
Our analysis of the interview material and issues raised by the focus groups revealed four main factors that acted as barriers to people who wished or needed to access mental health services.
First, family decision-making was of great importance. The decision to go for treatment, where to go and when to go was seen as the responsibility of the family. All the participants interviewed stated that it was primarily their family that decided whether they should seek treatment and the family decided where treatment should be sought. Such decision-making about seeking treatment is premised on a widespread belief that it is the family that should take responsibility for a sick family member.
If a family member becomes mentally ill, the family takes his responsibility, including seeking treatment for him, because he cannot make decisions and may not have the resources to pay for treatment
The second most important issue concerns common beliefs about the causes of mental illness among the interviewees. We were told that these included bad winds, evil spirits, poverty, the use of cannabis, an unmet desire to travel in Europe and childbirth. Participants who believed that mental illness is caused by bad winds and evil spirits are unlikely to come for treatment by psychiatrists whose belief system is based on biomedical foundations. Participants who believed mental illness is caused by poverty and an unmet desire to travel believed that they do not require treatment but a change of situation, although those whose mental disorder is caused by the use of cannabis can be treated by a biomedical approach. As a result of widespread beliefs about the causes of mental illness in this population, treatment seeking is often delayed.
The high cost of treatment was identified as a major hurdle by families wishing to access both traditional healers and biomedical mental health services.
Finally, most participants reported great difficulty trying to access mental health services. Access is limited by the lack of services in most areas and by the very long distances people must travel to service points. Tanka Tanka Psychiatric Hospital is the only psychiatric in-patient facility, located in the western region of the country. It was built in 2009 by a Dutch non-governmental organisation (NGO), Tanka Tanka Foundation, on land donated by the President of The Gambia. It is funded by government subvention, with the assistance of NGO donations.
Our analysis has emphasised that Gambian families are supportive, as they provide the cost of treatment and care for the mentally ill. However, we also discovered that it is the family that decides whether someone with a mental disorder goes for treatment, as well as where they go for treatment. Their decision is often premised on their belief about the putative cause of the illness. There was a plurality of beliefs about the causes of mental illnesses among participants, some of which were in line with modern scientific beliefs, whereas others were not.
Access is limited by the lack of services in most areas
Family decision-making about the perceived cause of mental illness is problematic as it can either delay care seeking or lead to no care being provided at all, because of an assumption that the condition will go away spontaneously. The scarcity of mental health services in the Gambia hinders individuals from accessing services, as they would either have to travel to the city or use alternative services that are traditional in character. The scarcity of modern mental health services contributes to the continuing use of traditional and alternative healers, which is a common phenomenon in other African countries too.
A further problem is the high cost of both traditional and biomedical services. That cost deters the mentally ill from accessing services. In a country where a typical salary per year is just US$1000 after tax, our informants reported that traditional healers are reported to charge up to US$187 for treatment, and biomedical daily medication and injection cost about US$9–12, depending on the geographic location.
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