It is estimated that 80% of people with mental health conditions come from low- and middle-income countries[1]. The degree to which they are disabled depends on the barriers that they face in society, but many people with psychosocial disabilities grapple with living in poverty, poor physical health and human rights violations. They often face deeply entrenched taboos and cultural beliefs, resulting in negative stigma and discrimination. Lack of awareness regarding psychosocial disabilities can lead to harmful practices and extreme violations of human rights. As an added challenge, in communities of all income levels, many people don’t like to talk about mental health.

The Mental Health Leadership and Advocacy Program (mhLAP) is a regional initiative working to train, build change and advocate for mental health reform in five countries of West Africa. Supported by CBM and funded by the Australian Government through the Australian NGO Cooperation Program, the program works to promote mental health and well-being for all by improving mental health services. Changes have happened at the local level, where mhLAP works with traditional healers to change practices and develop livelihood opportunities, through to the national level, where new mental health plans and policies are in place.

This article highlights how mhLAP’s work contributes to implementing SDG targets 3.4 and 3.c. Under SDG 3 (Ensure healthy lives and promote well-being for all at all ages) target 3.4 calls to: “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.” Target 3.c calls to “Substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing States.”

Mental health in West Africa and mhLAP

Mental health researchers have confirmed that developing countries in Africa (as well as other regions) have “insufficient human resources for mental health, poor funding, a high unmet need for services and a low prioritisation of mental health”[2].

The mhLAP initiative aims to address this in five countries across West Africa: The Gambia, Ghana, Liberia, Nigeria and Sierra Leone. The program was developed by the Department of Psychiatry at the University of Ibadan, Nigeria in partnership with CBM International and the University of Melbourne in 2010 and is now in its second phase. mhLAP has been influential in its work engaging with government. Key people with an interest in mental health from each country participated in leadership and advocacy training, and then continued support once they return to work in their own countries. Motivated by the training, the participants used their skills and knowledge to form stakeholder councils in each country. The councils have become effective organizations in the five countries, playing a central role in advocating for improved mental health services, working with government bodies to develop new policy, and improving the availability and quality of mental health services. This has led to high level progress in how mental health is prioritized in all five countries. Notably, the Mental Health Society of Ghana was instrumental in influencing the adoption of new mental health legislation.

From these achievements, the program has now extended its focus beyond high level awareness-raising to the broader community, conducting initiatives such as:

• Training selected senior clinicians in the use of the World Health Organization (WHO) Mental Health Gap Action Program (mhGAP), so they can train others in their own countries. This program provides an effective way of enabling primary health care workers to recognize mental conditions, provide support and refer people with complex needs for advanced care.

• Addressing human rights violations such as physical restraint and isolation currently experienced by people with mental conditions in these countries. This will be achieved through health workers using the WHO Quality Rights Toolkit (originally developed with support from CBM), which provides guidance on assessing and improving quality of care, including human rights standards in mental health services.

• Addressing widespread negative attitudes towards those with mental health issues, which can deepen their and their families’ experience of exclusion.

Addressing attitudes and human rights in The Gambia

An example of how the program works to address attitudes and human rights violations at a local level can be seen in The Gambia. The country facilitator for mhLAP work in The Gambia, Dawda Samba, has described some of the local and national achievements. He notes that in The Gambia, most people with mental health issues go to a traditional healer, whose treatment often involves chaining and caning people to “drive out the devil.” This led to the initiation of the Drop the Chain and Cane Campaign. Dawda explained that, “…we aim not to openly condemn their practices, but to converse with them and influence change of the human rights abuses and promote the positive things they do, especially in counselling”. This approach has seen strong success. In Japinneh, one of the communities involved, the use of the chain and cane by traditional healers has reduced. Previously, this approach was used with approximately one third of people with mental health issues who were brought to traditional healers. A recent survey indicated the practice is now used with approximately five per cent of people presenting.

A further success of the program in The Gambia has been the establishment of a national mental health policy and strategic plan. Currently efforts are underway in reviewing the so-called Lunatic Detention Act of 1917 into a progressive Mental Health Law aligned to human rights legislation like the Convention on the Rights of Persons with Disabilities.

To ensure healthy lives and the promotion of well-being, including mental health, for all at all ages, change must happen at all levels – from changing negative attitudes at a community level through to establishing inclusive national policies. The mhLAP programme demonstrates that collaboration between stakeholders in countries, with support from the international community and experts in Africa, can result in significant progress.

[1] Seth Mnookin, World Bank Group and World Health Organization, 2016. Out of the shadows: Making Mental Health a Global Development Priority.

[2] Abdulmalik et al, 2014. The Mental Health Leadership and Advocacy Program (mhLAP): a pioneering response to the neglect of mental health in Anglophone West Africa. International Journal of Mental Health Systems, 8:5.