Ethiopia is a country with an approximate area of 1104 thousand sq. km. (UNO, 2001). Its population is 72.42 million, and the sex ratio (men per hundred women) is 99 (UNO, 2004). The proportion of population under the age of 15 years is 45% (UNO, 2004), and the proportion of population above the age of 60 years is 5% (WHO, 2004). The literacy rate is 49.2% for men and 33.8% 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 3.6%. The per capita total expenditure on health is 14 international $, and the per capita government expenditure on health is 6 international $ (WHO, 2004). The main language(s) used in the country is (are) Amharic, Oromo and Tigrinya. The largest ethnic group(s) is (are) Oromo and Amhara, and the other ethnic group(s) are (is) Tigre, Somale and Walayta. The largest religious group(s) is (are) Muslim, and the other religious group(s) are (is) Ethiopian Orthodox Christian. The life expectancy at birth is 46.8 years for males and 49.4 years for females (WHO, 2004). The healthy life expectancy at birth is 41 years for males and 42 years for females (WHO, 2004).
Alem et al (1999d) assessed 10 468 subjects from a rural and semi-urban community with the Self Reporting Questionnaire (SRQ). Psychiatric morbidity was found in 17% of the respondents (cut-off – 10/11). The rate was higher among women probably because they were more likely to be older, illiterate and widowed/divorced. Tafari et al (1991) used the SRQ (cut-off – 10/11, for psychotic symptoms – 2/3) and the Holmes-Rahe Social Readjustment Scale in another rural sample (n=2000) and found the prevalence of mental illness to be 17.2% (neurotic: 11.2% and psychotic: 6.0%). Prevalence of mental disorders was significantly associated with stress, family history of mental illness and with marital status (divorced, separated or widowed). Awas et al (1999) used the Ahmaric version of the CIDI (ICD-10 criteria) for assessing 501 respondents selected from a predominantly rural district by stratified random sampling. They found a lifetime prevalence rate of 31.8% (26.7% when substance dependence was not included). The most frequent specific diagnoses were: dissociative disorders (6.3%), mood disorders (6.2%), somatoform disorders (5.9%) and anxiety disorders (5.7%). Female gender was associated with increased risk of mood disorders and somatoform disorders. Cognitive and mood disorders were more common among the elderly. Kebede et al (1999) examined a sample from an urban community (n=10 203). They reported a probable diagnosis of psychosis in 5% of the sample (positive response to 2 out of 4 items of the SRQ) and of common mental disorders in 11.7% (using a cut-off of 6 out of 20 SRQ items). Age, female sex, lower educational level, unemployment, small family size and family history of mental illness were associated with high prevalence rates. Kebede and Alem (1999c, d, e) conducted a survey on a randomly selected urban community sample of 1420 individuals using the Ahmaric version of CIDI. Lifetime prevalence for severe cognitive deficits, schizophrenia, schizoaffective disorder, affective disorders, neurotic and somatoform disorders were 2.6%, 0.4%, 0.5%, 5.0% (overall: women 7.7% and men 3.2%, bipolar disorders: 0.3%, depressive episodes: 2.7%, recurrent depressive episodes: 0.2% and persistent mood disorders: 1.6%), 10.8% (phobic disorder: 4.8%, somatoform disorders: 2.7%, dissociative disorders: 0.8% and other anxiety disorders: 2.7%). The one month prevalence of schizophrenia, schizoaffective disorder, affective disorders, phobic anxiety disorders, other anxiety disorders, dissociative disorders, and somatoform disorders were 0.3%, 0.4%, 3.8% (women 5.9% and men 2.3%), 4.4%, 1.2%, 0.4% and 2.5%, respectively. Alem et al (1999b) and Kebede and Alem (1999b) reported that the overall prevalence of problem drinking (meeting 2 criteria on the CAGE questionnaire) was 3.7% in a rural (n=10 468) and 2.7% in an urban (n=10 203) sample. Age, gender (male), education (low), employment status (low), religion (Christian), ethnicity (non-Gurage) and smoking were associated with problem drinking in both sexes. Marital status, mental distress and income were associated with problem drinking only in men. Kebede et al (1999) reported that use of CIDI yielded a lifetime and one-month prevalence of alcohol dependence in 1.0% and 0.8% of the urban sample, respectively. Alcohol dependence was reported almost exclusively in males. Almost one third of the Ethiopean adult population uses or has used Khat. Alem et al (1999a) reported that 17.4% of subjects from a rural sample (n=19 468) used it daily. Habitual use was associated with gender (male), age (15-34 years), religion (Muslim), smoking, educational level (high), family functioning (better) and mental distress. De Jong et al (2001) assessed randomly selected post-conflict survivors in four countries – Algeria, Cambodia, Ethiopia (n=1200) and Gaza using the CIDI and Life Events and Social History Questionnaire. The prevalence rate of PTSD was 15.8% in Ethiopia. Conflict-related trauma after age 12 years, torture, psychiatric history and current illness were associated with PTSD in Ethiopia. Alem et al (1999c) and Kebede and Alem (1999a) reported the rate of suicide attempts to be 3.2% and 0.95% in rural (n=10 468) and urban (n=10 203) samples, respectively. In both studies hanging (among men) and poisoning (among women) were the preferred methods of attempting suicide. Suicide attempts were associated with young age (15-24 years), religion (Christianity), psychiatric morbidity and problem drinking. Kebede and Ketsela (1993) evaluated a representative sample of all high-school students in a city. Almost 14.3% of the adolescents reported having attempted suicide. Suicide attempts were strongly and linearly associated with hopelessness, grade and heavy alcohol intake. Mulatu (1995) interviewed mothers using the Child Behavior Problem Questionnaire to assess 611 randomly selected children from an urban community. They found that 21.5% of boys and 25.2% of girls had some behavioural problems. Tadesse et al (1999) used the Amharic version of the Reporting Questionnaire for Children in a community survey and found behavioural disorders in 17.7% of children. Childhood mental disorder was significantly associated with the subjects’ own age (higher), gender, and parents’ age (younger), marital status (not currently married) and psychopathology (neurosis in mothers). Ashenafi et al (2001) used an Amharic version of a Diagnostic Instrument for Children and Adolescents to interview parents in a rural community (n=1477) and found that 3.5% had at least one mental or behavioral disorder. The most frequent diagnoses were anxiety disorders (1.6%), attention deficit hyperactivity disorder (1.5%), disruptive behaviour disorders (1.5%), mood disorders (1%) and elimination disorders (0.8%).
MENTAL HEALTH RESOURCES
Mental Health Policy A mental health policy is absent. A team of mental health professionals was assigned the task of drafting a mental health policy in 2004. The draft is expected to be submitted for approval in the same year.
Substance Abuse Policy A substance abuse policy is absent.
National Mental Health Programme A national mental health programme is absent.
National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. Details about the year of formulation are not available. Shortage of essential drugs is a problem.
Mental Health Legislation There is no mental health legislation in the country. Currently, individual rights are seen in unison with the family. Involuntary treatment only requires informed consent from the escorts. Though a draft legislation was submitted for approval several years back, it has not yet been enacted. In 2004, the team working on mental health policy is also reviewing the draft legislation for re-submission.
Mental Health Financing There are budget allocations for mental health. Details about expenditure on mental health are not available. 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 grants. The country has disability benefits for persons with mental disorders. Pension and transfer are allowed on the basis of psychiatric certification.
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. Mental health has become part of primary health care in 42 units spread throughout the country. The number is gradually increasing as trained professionals are assigned to new sites every year. Thus, actual treatment of severe mental disorders at the primary level is steadily expanding. Regular training of primary care professionals is carried out in the field of mental health. In the last two years, about 277 personnel were provided training. In the last two years, about 45 personnel were provided basic training, 160 primary mental health professionals participated in yearly refresher seminars and 72 on-the-job training programmes were conducted for those working at the different units in the country. 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
There are different medical assistants for other fields, around 10 000, but not for psychiatry. There are 36 regional and district mental health units besides the mental hospital in Addis Ababa. These hospitals are each staffed by at least 2 psychiatric nurses who are supervised by psychiatrists periodically. A system of referral and back-referral has been established. In some regional hospitals the psychiatric nurses admit and provide inpatient service to their cases in the medical wards when it is necessary. A postgraduate programme in psychiatry was started in Addis Ababa University with an initial intake of 7 residents in 2003.
Non-Governmental Organizations NGOs are not involved with mental health in the country. One indigenous NGO named
‘Mental Health Society of Ethiopia’ was established in 2004. The association is currently working on building up its membership but is already involved in supporting the only rehabilitation centre for mental health near Addis Ababa.
Information Gathering System There is mental health reporting system in the country. Hospitals send annual report to the Ministry of Health. The country has data collection system or epidemiological study on mental health. The training and research division of the Amanvel
Mental hospital has been established recently for this purpose.
Programmes for Special Population There are no programmes for special population. Psychiatric services have been introduced to some police and army hospitals, one prison clinic, and some university and school clinics. Two substance abuse treatment units were opened in the capital city in 2004.
Therapeutic Drugs The following therapeutic drugs are generally available at the primary health care level of the country: carbamazepine, ethosuximide, phenobarbital, phenytoin sodium, sodium valproate, amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, lithium, carbidopa, levodopa. The essential list of drugs was revised recently. Some other medicines like cloimipramine and fluoxetine are also a part of the list. All drugs in the essential list are available in major cities of the country but not in all areas at the primary health care level.
Other Information Traditional healers play a major role in the treatment of mental health; in one study (Alem et al 1999) it was found that 85% of emotionally disturbed people sought help from traditional healers.