Zimbabwe is a country with an approximate area of 391 thousand sq. km. (UNO, 2001). Its population is 12.932 million, and the sex ratio (men per hundred women) is 99 (UNO, 2004). The proportion of population under the age of 15 years is 42% (UNO, 2004), and the proportion of population above the age of 60 years is 5% (WHO, 2004). The literacy rate is 93.8% for men and 86.3% for women (UNESCO/MoH, 2004).
The country is a low income group country (based on World Bank 2004 criteria). The proportion of health budget to GDP is 6.2%. The per capita total expenditure on health is 142 international $, and the per capita government expenditure on health is 64 international $ (WHO, 2004). The main language(s) used in the country is (are) English, Ndebele and Shona. The largest religious group(s) is (are) Christian, and the other religious group(s) are (is) indigenous groups. The life expectancy at birth is 37.7 years for males and 38 years for females (WHO, 2004). The healthy life expectancy at birth is 34 years for males and 33 years for females (WHO, 2004).
Patel et al (1997, 1998) and Todd et al (1999) developed the Shona Symptom Questionnaire to measure prevalence of common mental disorders (CMD) among African populations. In an unmatched case-control study, they assessed a cohort of 199 cases with CMD recruited from primary health care facilities, traditional practitioners, general practitioners and 197 controls. CMD was significantly associated with female gender, older age, chronicity of illness, number of presenting complaints, beliefs in ‘thinking too much’ and witchcraft as a causal model, economic impoverishment, infertility, recent unemployment, an unhappy childhood for females, disability, and consultations with traditional medical practitioners and religious priests. The cohort was reassessed after 2 and 12 month. Of the 134 subjects interviewed at both follow-up points, 49% had recovered by 2 months and remained well at 12 months while 28% were persistent cases at both 2 and 12 months. Higher scores on the instrument, a psychological illness model, bereavement and disability predicted a poor outcome at both times. Poorer outcome at 2 month follow-up was associated with belief in witch-craft and an unhappy childhood. Caseness at follow-up was associated with disability and economic deprivation. Onset of new episodes of CMD was recorded in 16% at 2 and 12 months. Higher psychological morbidity scores at recruitment, death of a first-degree relative and disability predicted the onset of CMD at both follow-up points. While female gender and economic difficulties predicted onset at 2 months, belief in supernatural causation was strongly predictive of CMD at 12 months. Caseness at both follow-up points was associated with economic problems and disability. Patel et al (1999) reanalysed five epidemiological data sets from four low to middle income countries (India, Zimbabwe, Chile and Brazil). In all five studies, female gender, low education and poverty were strongly associated with common mental disorders. Broadhead and Abas (1998) found depression and anxiety in 30.8% of 172 randomly selected women in a township. Assessment with the Zimbabwean modification of the Bedford College Life Events and Difficulties Schedule revealed that events like humiliation, entrapment in an ongoing difficult situation and bereavement, which are known to be more depressogenic, were reported much more commonly in this sample compared to a sample in London. Reeler and Immerman (1994) examined the prevalence and factors associated with psychological disorders in Mozambican refugees in Zimbabwe using the SRQ-20. They found that 62% of refugees suffered from psychological disorders. They had multiple somatic complaints and a high suicidal risk. Acuda and Eide (1994) conducted a survey on 2783 secondary school students from randomly selected schools in rural and urban areas using a self-report questionnaire. Drug use was prevalent among the students. The main drugs involved, in descending order, were: alcohol, tobacco, inhalants (solvents), amphetamines and cannabis. Drug use increased with age and involved both sexes, the problem being more acute in the urban schools. Eide et al (1997 a, b) assessed 3061 secondary school children in Zimbabwe, selected by means of a two-stage sample design (first schools and then students registered with them were selected randomly). Standardized procedures were used by trained researchers to collect data. Sensation-seeking, addictive
behaviour of significant others (social factors) and global and local cultural orientation (based on choice of media, language and music) explained 29.7% of the variance in dependent drug use. Social variables and global cultural orientation were significantly associated with increased use of cannabis and inhalants.
MENTAL HEALTH RESOURCES
Mental Health Policy A mental health policy is absent. The mental health policy was developed over a three-year period and it will be officially launched in December 2004.
Substance Abuse Policy A substance abuse policy is absent. The initial formulation of the Zimbabwe National Drug Control Master Plan (substance abuse policy) was in 1999, and it is currently in the Parliament awaiting ratification.
National Mental Health Programme A national mental health programme is present. The programme was formulated in 1984. The national mental health programme was updated in 1996 and is known as National Health Strategic Plan 1997-2007.
National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It was formulated in 1995. The first essential drug list was published in 1985. The current list was published in the year 2000. The Zimbabwe National Drug Policy was published in 1995.
Mental Health Legislation There are two recent laws. The Mental Health Act 1996 and the Mental Health Regulation 1999. The latest legislation was enacted in 1996.
Mental Health Financing There are no budget allocations for mental health. Details about expenditure on mental health are not available. The primary source of mental health financing is tax based. The mentally ill are entitled to free health services.
The country has disability benefits for persons with mental disorders. Mental illness falls under the category that qualifies for tax credits.
Mental Health Facilities Mental health is a part of primary health care system. Actual treatment of severe mental disorders is available at the primary level. Primary health care workers have the capacity to handle patients with severe psychosis and refer only those that they feel require specialized services. Most of the rural and district hospitals do not have facilities for inpatient care and only 17 district, provincial and central hospitals have primary care teams. Regular training of primary care professionals is carried out in the field of mental health. In the last two years, about 2000 personnel were provided training. There are training facilities for nurses, occupational therapists, rehabilitation workers and social workers. All student nurses are supposed to go through a period of training in mental health (4 weeks of theory and 8 weeks of practical experience).
Training workshops for mental health are also organized from time to time at the district and provincial level. However, the
programme has significant limitations. A system of supervision, referral and back referral has been established in some regions. There are community care facilities for patients with mental disorders. There is a shortage of material and staff to sustain community care programme.
Psychiatric Beds and Professionals
Total psychiatric beds per 10 000 population
Psychiatric beds in mental hospitals per 10 000 population
Psychiatric beds in general hospitals per 10 000 population
Psychiatric beds in other settings per 10 000 population
Number of psychiatrists per 100 000 population
Number of neurosurgeons per 100 000 population
Number of psychiatric nurses per 100 000 population
Number of neurologists per 100 000 population
Number of psychologists per 100 000 population
Number of social workers per 100 000 population
There are 221 physiotherapists and 243 rehabilitation technicians who help in mental health. There are 71 occupational therapists.
Non-Governmental Organizations NGOs are involved with mental health in the country. They are mainly involved in advocacy, promotion, prevention, treatment and rehabilitation. NGOs also provide training.
Information Gathering System There is mental health reporting system in the country. Although there is no mention of mental health in the secretaries’ annual report, mental health is included in the National Health Profile Annual Report. The country has data collection system or epidemiological study on mental health. Plans are under way to make the data collection form more user friendly.
Programmes for Special Population There are no special services for these populations. Mental health is integrated into other services and so all types of people benefit.
Therapeutic Drugs The following therapeutic drugs are generally available at the primary health care level of the country: carbamazepine, phenobarbital, phenytoin sodium, amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, biperiden, carbidopa, levodopa. Benzhexol (5mg) is present. There is a shortage of drugs due to the lack of foreign currency.
Other Information In Zimbabwe, traditional healers have been allowed to form an association of their own through an Act of the Parliament. The national training programme for registered nurses has been decentralized. In addition to the central hospitals, few rural district hospitals were selected for training, provided they had a separate ward for the care of psychiatric patients.