In 2009, the Spanish Agency for International Development Cooperation funded a study to conduct an assessment of Equatorial Guinea's mental health care system. The study's findings were not all too surprising: while primary health practitioners realized the need for the provision of mental health services, the resources to make it happen simply are not there.
With that in mind, the NGO Sanitary Religious ederation (FRS, Federacion de Religiosos Sanitarios) was tasked with conducting the situational analysis. While it is not surprising that physical health morbidity rates overshadow mental health disparities in terms of attention, what is not so obvious is the impact the current primary healthcare infrastructure will have on the country's ability to provide adequate mental health services. According to Morón-Nozaleda, de Tojeiro, Cobos-Muñoz, & Fernández-Liria (2011), Equatorial Guinea's primary healthcare system is largely centralized with three doctors and five nurses for every 10,000 inhabitants. The authors emphasized that most of the doctors in the healthcare workforce (who represent just 10% of healthcare staff in the primary care system) are foreigners, and that 76% of them live in major cities with only 39% of the population. That is not terribly surprising given that there is currently no medical school in Equatorial Guinea. The remaining 24% of doctors in the workforce are distributed among provincial hospitals, district hospitals, health centres and health posts.
The centralization of primary health services is an important factor to consider when starting to conceptualize the integration of mental health services into the primary healthcare system. Even if the services were made available, how would people access the services on a regular basis? In general, many people turn to traditional medicine for support. The authors note that while no legal framework or schools exist for traditional medicine, the practice is recognized by the government. Knowledge is passed down from generation to generation, and leaders are found within the groups of practitioners. One surprising point made by the authors is that while many people believe traditional practitioners to be utilized because they are both accessible and cheap, costs are not necessarily low. The authors found that traditional medicine treatments could easily go up to 33.3% of the monthly minimum wage. Since traditional practitioners are not regulated, their fees can vary wildly and that may present a temptation to take advantage of an already susceptible population of people. The authors found that one of the main reasons traditional healers are so wildly utilized is the fact that their use is firmly embedded in the established belief systems of the population. Some healers are more spiritual than others, with the most extreme of them attributing their abilities to supernatural causes, or what the authors call mimbilis. The presence of spiritual beliefs in the treatment of the mentally ill is evident in the way they are described locally. The authors outline a locally held belief system in which symptoms of mental illness are interpreted as supernatural possessions, and are treated in very different manners depending on the specific traditional healer the individual is taken to for treatment. It is not clear what is used to medicinally treat the individuals in care, but restraints are often used in an attempt to calm highly agitated individuals.
Returning to the situation analysis, he authors were concerned with five main survey topics: the demand in mental health care from primary care, the attention for mental healthcare from primary care providers, the attitude towards the mentally ill, access to psychotropic medicine and the attitude towards further training in mental health care. While the authors found participation to be low (31%) due to what was cited as a lack of familiarity with mental health care, they were able to complete an analysis of the mental health climate in general. They found that there is no specific policy or legislative framework related to mental health, no organization of mental health services, no local psychiatrists or mental health nurses. Having said all of that, it looks like a lot of this is set to change in the coming years.
The Ministry of Health in Equatorial Guinea is moving steadily towards the implementation of mental health services in the country. There is a lot of work to be done to bring their plans to fruition, but the government seems committed to making this happen. According to the authors, the government appointed a Mental Health Responsible and drafted a Mental Health Policy that was approved in 2010. The policy includes everything from the creation of legislative support for the provision of mental health services, training and access to pharmacology to combating the stigma associated with mental health services, prevention of substance abuse and coordination of services.
In all, it looks like Equatorial Guinea is beginning its long journey of integrating mental health services into its primary health care system. The commitment of the government in moving this effort forward is evidenced in the resources it has expended in an effort to make this possible. It will be interesting how it tackles the issues of human capital scarcity and accessibility to long-term treatment. Psychology in Africa looks forward to following the country along its journey and sharing any and all progress made with the public.
Morón-Nozaleda, M., de Tojeiro, J., Cobos-Muñoz, D., & Fernández-Liria, A. (2011). Integrating mental health into primary care in Africa: the case of Equatorial Guinea. Intervention (15718883), 9(3), 304-314.