Uganda is a country with an approximate area of 241 thousand sq. km. (UNO, 2001). Its population is 26.699 million, and the sex ratio (men per hundred women) is 99 (UNO, 2004). The proportion of population under the age of 15 years is 50% (UNO, 2004), and the proportion of population above the age of 60 years is 4% (WHO, 2004). The literacy rate is 78.8% for men and 59.2% 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 5.9%. The per capita total expenditure on health is 57 international $, and the per capita government expenditure on health is 33 international $ (WHO, 2004). The main language(s) used in the country is (are) English, Swahili, Luganda, Ateso and Luo. The largest ethnic group(s) is (are) Baganda, Basoga, Iteso, Langi and Acholi Banyankole/Bakiga, and the other ethnic group(s) are (is) Banyoro/Batoro, Yo’kwekyawa and Kwekubagiza. The largest religious group(s) is (are) Christian (two-thirds), and the other religious group(s) are (is) Muslim. The life expectancy at birth is 47.9 years for males and 50.8 years for females (WHO, 2004). The healthy life expectancy at birth is 42 years for males and 44 years for females (WHO, 2004).
Kasoro et al (2002) estimated the prevalence of psychiatric disorder in one district by interviewing members of randomly selected households and key informants and through focus group discussions. The estimated prevalence of mental disorders in adults was 30.7%. Orley and Wing (1979) conducted a survey in two small rural populations using standardized tools and methods of case identification and found that 20% suffered from a probable mental disorder and a further 5% from a definite disorder. Most suffered from depression, hypomania and anxiety. Cox (1979) examined 263 pregnant and 89 non-pregnant, non-puerperal women using a semi-structured psychiatric interview. A higher frequency of psychiatric morbidity was seen in pregnant women. Separated pregnant women were particularly at risk. Wilk and Bolton (2002) used ethnographic methods, free listing and key-informant interviews, among participants from two districts to examine the folk view of psychological consequences of the HIV epidemic in a severely affected community. Participants described two independent depression-like syndromes (Yo’kwekyawa and Okwekubaziga) resulting from the HIV epidemic. No syndromes similar to posttraumatic stress disorder were detected. Peltzer et al (1999) assessed the effects of trauma on the mental health of 323 refugees settled in Ugandan camps. One-third of adults and one-fifth of children had PTSD. Ex-soldiers had significant depression. While only a fifth of those seeking help from the formal health sector had psychiatric disorders, almost two-thirds of subjects visiting traditional healers had a psychiatric disorder (PTSD: 26% and depression: 39%).
Drotar et al (1997) followed up 436 full-term infants (79 HIV-infected infants of HIV-infected mothers, 241 uninfected infants of HIV-infected mothers (seroreverters) and 116 uninfected infants of HIV-negative mothers) for 2 years. All evaluators were blinded to the HIV status of the child and family. Compared with controls, HIV-infected infants had more abnormalities in mental development at 6 and 18 months and an earlier onset of abnormalities. By 12 months, 26% of HIV-infected infants demonstrated cognitive abnormalities as compared with 6% in the other two groups. Information-processing abilities did not differ as a function of HIV infection. Home environments and infants’ interactions with caretakers were similar across groups.
MENTAL HEALTH RESOURCES
Mental Health Policy A mental health policy is present. The policy was initially formulated in 2000.
The components of the policy are advocacy, promotion, prevention, treatment and rehabilitation.
Substance Abuse Policy A substance abuse policy is absent. There is no need for a separate substance abuse policy as mental health aspects of substance abuse are covered within the mental health policy
National Mental Health Programme A national mental health programme is present. The programme was formulated in 1996. Mental health is one of the 12 key services to be provided as a part of the minimum health package at all levels of care. Intersectoral collaboration is emphasized, though it is happening only at the national level at present.
National Therapeutic Drug Policy/Essential List of Drugs A national therapeutic drug policy/essential list of drugs is present. It was formulated in 1993. The policy was reviewed in 1996 and 2001.
Mental Health Legislation The Mental Treatment Act is currently being reviewed. Enforcements of rights of patients is generally satisfactory in Government institutions. However, there is no specific body appointed to periodically review cases of involuntary admissions. The latest legislation was enacted in 1964.
Mental Health Financing There are budget allocations for mental health. The country spends 0.7% 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. Funding for health is mainly from economic aid and does not favour mental health. People with mental illness might spend on an average $57 per year on mental health care, a large amount given that the per capita income is $89. Most families and consumers report a worsening of their economic situation and productivity as a result of their contribution to patient care. NGOs are increasingly getting involved in funding of primary health care. The country does not have disability benefits for persons with mental disorders. Disability benefits are low and even lower for mental health.
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. Treatment for severe mental disorders are available only at the 10 regional referral centres and the National Mental Referral Hospital. Mental health is an integral part of primary health care policy.
Regular training of primary care professionals is carried out in the field of mental health. Though training facilities for the primary care workers are not present, there is a training manual which can be obtained for purpose of training staff. There has been an effort to instil basic knowledge about mental disorders and its treatment among medical students so that they are able to identify the disorders and manage them in primary care level. Community-based programmes which combine the services of traditional medical practitioners with modern medical services in providing sustainable rural health care have been supported. Such clinics are staffed by a trained nurse and a pharmaceutical technician and visited by doctors. Traditional herbalists may refer patients to mental health care staff at these clinics. These clinics also provide community health education, which emphasizes hygiene and the appropriate use of local medicinal resources. Traditional health practitioners care for the emotional and spiritual as well as the physical well-being of their patients.
There are community care facilities for patients with mental disorders. All community health departments at all health units provide some form of community based care but it is still in its infancy. Secondary mental health services can be found at 10 regional referral hospitals where services are run by a resident psychiatrist who are supervised through visits by a psychiatrist on a quarterly basis. There is a provision of a psychiatrist at this level once adequate numbers are trained and are available.
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
- 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
Out of the 55 other staff, 25 are psychiatric clinical officers. The bed strength in the Butabika National Mental Referral Hospital was reduced from 1000 to 450. With support of an ADB loan of USD 48 million, the Government has refurbished the Butabika National Mental Referral Hospital and constructed 6 Regional Mental Health Units with 35 beds each. There are 100 forensic beds, 50 beds for children and adolescents, 20 beds for psychologically traumatized patients and 10 beds for the treatment of drug abusers. Most health facilities try to segregate male and female patients. All qualified health workers are required to renew their registration – doctors every year and nurses every 3 years. All professionals are now prescribed minimum hours of exposure to continuing medical education for their reaccreditations, but the process is new and enforcement not particularly strict. There are few mental health professionals in the private sector, all of them are in the capital city. Trained specialists are found only in urban centres.
Non-Governmental Organizations NGOs are involved with mental health in the country. They are mainly involved in advocacy, promotion, prevention, treatment and rehabilitation. There is some increase in NGO participation in capacity building and primary mental health care provision. Consumer support groups for mental health are also emerging. They are involved particularly with psychosocial care to war-afflicted populations. NGOs are also carrying out research in mental health.
Information Gathering System There is mental health reporting system in the country. They are mentioned broadly as ‘mental illness’ without the break-up into different disorders. The country has data collection system or epidemiological study on mental health. Monthly and quarterly reports are received from referral hospitals and NGOs. Some key psychiatric and monitoring items have been developed (including diagnoses) to collect data. Routine health management information forms list just 2 items under mental health, mental illness and epilepsy. Guidelines for monitoring mental health have been developed but have to be disseminated.
Programmes for Special Population The country has specific programmes for mental health for refugees, disaster affected population and children. There are psychosocial support programmes in war affected areas. Limited services are available for children, elderly and those in prisons. There is an initiative to set up a substance abuse and trauma centre at the national hospital.
Therapeutic Drugs The following therapeutic drugs are generally available at the primary health care level of the country: carbamazepine, phenobarbital, phenytoin sodium, chlorpromazine, diazepam, haloperidol, lithium. Some of the other drugs are available at referral centres only.
Other Information Academic psychiatry was started in the late 1960s when the Makerere University Department of Psychiatry was founded. Psychiatry suffered during the Amin regime, but over the years, there has been a lot of improvement. However, problems remain; there is a lack of resources and the legislation needs to be upgraded. HIV and PTSD place an added burden on Ugandan psychiatry.