Kenya is a country with an approximate area of 580 thousand sq. km. (UNO, 2001). Its population is 32.42 million, and the sex ratio (men per hundred women) is 98 (UNO, 2004). The proportion of population under the age of 15 years is 41% (UNO, 2004), and the proportion of population above the age of 60 years is 4% (WHO, 2004). The literacy rate is 90% for men and 78.5% 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 7.8%. The per capita total expenditure on health is 114 international $, and the per capita government expenditure on health is 24 international $ (WHO, 2004). The main language(s) used in the country is (are) English (official) and Swahili (national). The largest ethnic group(s) is (are) African (Kikuyu, Luhya, Luo, Kalenjin and Kamba tribes are most populous), and the other ethnic group(s) are (is) Asian and European. The largest religious group(s) is (are) Christian (more than three-fourths), and the other religious group(s) are (is) Muslim, Hindu and indigenous groups. The life expectancy at birth is 49.8 years for males and 51.9 years for females (WHO, 2004). The healthy life expectancy at birth is 44 years for males and 45 years for females (WHO, 2004).
Ndetei and Muhangi (1979) studied 140 rural medical walk-in-clinic patients and found that 20% suffered from psychiatric illnesses, especially depression and anxiety. Sebit (1996) assessed 186 patients attending primary care facilities using the Self Rating Questionnaire (SRQ), the Clinical Interview Schedule/Revised (CIS-R) and the WHO Audit Instrument for Alcohol abuse. The diagnosis of a psychiatric disorder was made according to DSM-III-R criteria. The overall prevalence rate of psychiatric disorder was only 0.43% with an incidence of 0.43 per 1000 persons. In a cross-sectional survey involving 15 324 household heads who reported on a population of 68 487 people in a district. Some (1994) found that there was at least one person who regularly used drugs in 44.3% of the households. The prevalence of regular drug use was 6.4% for alcohol, 2.7% for cigarette smoking, 0.6% for marijuana and 0.2% for non-prescribed medicines. Significant social, financial, occupational/academic, legal, health and injury related complications were noted. Odek-Ogunde and Pande-Leak (1999) assessed 558 undergraduates with a questionnaire on drug use. The lifetime prevalence of commonly used substances was tobacco (54.7%), alcohol (84.2%), cannabis (19.7%) and inhalants (7.2%). The lifetime prevalence of hard drugs (heroin, cocaine, mandrax, amphetamines and LSD) was low (< 5%). Substance use was commoner in males. Rates for regular use (> 20 days/month) were high for tobacco (24.7%) and alcohol (11.5%). More than half of the subjects started using drugs at upper primary and secondary levels but nearly one fifth started substance use in lower primary school. Kuria (1996) interviewed 547 urban and 405 rural students with the WHO youth survey questionnaire. Alcohol was the most commonly abused drug (15% and 14% in urban and rural schools, respectively). Tobacco, cannabis and inhalants followed in that order.
Male students abused drugs more often than female students. ‘Hard’ drugs were used more often in the rural schools. Ayaya et al (2001) found features of tobacco dependence in 37.6% of street children (n=191) who also frequently used other drugs. Saunders et al (1993) evaluated 1888 subjects in 6 countries. After non-drinkers and known alcoholics had been excluded, 18% of subjects had a hazardous level of alcohol intake and 23% had experienced at least one alcohol-related problem in the previous year. Intercountry variations were noted. Omolo and Dhadphale (1987) found a high prevalence of Khat chewing among patients attending a primary health clinic (n=100). Dhadphale et al (1989) used a two-stage screening procedure to diagnose depression according to ICD-9 descriptions in a primary care sample of 881 patients. The prevalence of depressive disorders was 9.2%, with about a third having moderate to severe depression. Maj et al (1994) conducted a multi-country (including Kenya) WHO Neuropsychiatric AIDS Study. The mean global score on the Montgomery-Asberg Depression Rating Scale was significantly higher in symptomatic seropositive individuals than in matched seronegative controls in all centres. Sebit (1995) reported similar results in a study done in Kenya and Zaire (n=408). Maj (1996) also reported that in contexts where social rejection of HIV-seropositive subjects was harsh, symptomatic stages of HIV infection were associated with a greater prevalence of syndromal depression. Weisz et al (1993) interviewed parents of 11-15 year old children living in different societies – Embu in Kenya, Thai, African-American and Caucasian-American. Caucasian-Americans were rated particularly high on under-controlled problems (e.g. arguing, disobedient at home, cruel to others).
Embu children were rated particularly high on over-controlled problems (e.g. fears, feels guilty, somatic concerns), largely because of the numerous somatic problems reported. Geissler et al (1998) identified geophagy in 73% of 285 school children. The prevalence decreased with age until age 15 and then stabilized for girls till age 18 but continued to decrease for boys.
MENTAL HEALTH RESOURCES
Mental Health Policy A mental health policy is absent. In 1982, Kenya adopted mental health as the ninth essential element of its primary health care provision.
Substance Abuse Policy A substance abuse policy is absent.
National Mental Health Programme A national mental health programme is present. The programme was formulated in 1996. The main emphasis is on decentralization of mental health services, integration into general health care provision and establishment of community mental health services. Multidisciplinary and intersectoral collaboration are a central feature. The implementation of this programme has been slow due to inadequate resources, especially human resources.
National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It was formulated in 1994.
Mental Health Legislation There is a Mental Health Act. The new act of 1989, provides for voluntary and involuntary treatment of people with mental illness and creates a regulatory board to oversee its implementation (The Act was implemented in May 1991). The latest legislation was enacted in 1989.
Mental Health Financing There are budget allocations for mental health. The country spends 0.01% of the total health budget on mental health. The primary sources of mental health financing in descending order are tax based, out of pocket expenditure by the patient or family, private insurances and social insurance. The National Hospital Insurance Fund is a contributory fund for people in employment. It mainly covers bed charges. About 4.8% of Kenyans have health insurance, but the insurance does not cover mental illness. The Ministry of Health is working on a broader national social health insurance scheme. The country does not have disability benefits for persons with mental disorders.
Mental Health Facilities Mental health is a part of primary health care system. Actual treatment of severe mental disorders is not available at the primary level. Regular training of primary care professionals is not carried out in the field of mental health. Health care guidelines for primary health care workers are being developed. Only limited training facilities for training are available. However, a system of referral and back-referral exists and some outreach services have been established. More than 70 traditional health practitioners have been identified and are currently being trained in mental health to improve their intervention skills. There are no community care facilities for patients with mental disorders.
Psychiatric Beds and Professionals
psychiatric beds per 10 000 population
beds in mental hospitals per 10 000 population
beds in general hospitals per 10 000 population
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
One-third of the total psychiatrists work in the public sector. Mathari is the national referral and teaching hospital. Most of the patients admitted in this hospital are referred by the criminal justice system for assessment. As a result of the new legislation psychiatric wards were set up in general hospitals. The provincial units are 22-bed units. Seven out of 70 district units have also been set up. Nearly half of the psychiatrists are practicing in Nairobi. The provincial and district psychiatric units are under-staffed. Psychiatric nurses and medical officers are involved in mental health care.
Non-Governmental Organizations NGOs are involved with mental health in the country. They are mainly involved in advocacy and rehabilitation.
Information Gathering System There is no mental health reporting system in the country. The country has no data collection system or epidemiological study on mental health. The national tally sheets contain only one section relating to mental disorders. A proposal for the inclusion of 8 categories has been submitted as a part of health sector reforms.
Programmes for Special Population Special clinics for children and adolescents are run.
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.
Other Information Initially, Kenya had a system of psychiatric practice that was dependent on traditional practices. The first western style system developed in 1912 when a smallpox unit was transformed into a centre where ‘mad’ people used to be locked up. Today, Mathare Hospital is the mental health referral and training centre. The Government is in the process of legislating to regulate the practice of traditional practitioners and incorporate it into the health sector.