MENTAL HEALTH FOR ALL: GREATER INVESTMENT, GREATER ACCESS
10th OCTOBER 2020
In commemoration of the World Mental Health Day, the Kenya National Commission on Human Rights (KNCHR) and the Civil Society Organizations working on mental health in Kenya welcome the opportunity to call for more serious action in addressing mental health concerns, in line with this year’s theme of “greater investment and greater access to mental health services”. This year’s World Mental Health Day is being commemorated amidst an unforeseen pandemic: the COVID19 pandemic. Sadly, the global denial and failure to invest in mental health over many years has resulted in a shameful situation in which access to treatment has limited individuals’ rights to wellness and health which has been unearthed and further exacerbated by the COVID-19 crisis. The socio-economic impact of this pandemic has no doubt contributed to worsening mental health outcomes for populations world-wide. Job losses, closures of crucial institutions such as education and religious facilities, lockdowns and separation from loved ones, and fear and uncertainty of what the future holds are just some of the root causes of mental illness among individuals during this period. There is no better moment to call for greater investment and access to mental health services.
Context of Kenya
The reality of the state of mental health care in Kenya is a sad one. This year’s theme is indeed timely and resonates with the concerns the Kenya National Commission on Human Rights has held over the years regarding the mental health sector in Kenya. In its 2011 report entitled ‘Silenced Minds: A Human Rights Audit of the Status of Mental Health in the country”, the Commission raised concern over the chronic underfunding of the mental health sector in Kenya, leading to a high treatment gap. The recent report of the Taskforce on Mental Health entitled, “Mental Health and Wellbeing: Towards happiness and National prosperity”, published nine years later similarly revealed that the sector is still grossly underfunded. It revealed that Kenya is among the 28% of World Health Organization States that do not have a separate budget for mental health. Further, that government expenditure on mental health is 0.01% of the total expenditure on health. This is despite the fact that mental illness accounts for 13% of the entire disease burden in Kenya.
Due to under-investment in the mental health sector, there is a shortage of human and physical resources to cater for treatment of mental illness. There are 0.19 mental health workers per 100,000 population in Kenya. The ratio of psychiatrists to the overall Kenyan population is 0.18 per 100,000 population (as opposed the recommended ratio of 1:10,000) while that of nurses deployed by the Ministry of Health is 51.5 per 100,000 population. Furthermore, community based care for persons suffering from mental illness is lacking. Physical access to mental health care facilities is a challenge to most Kenyans. The report of the Taskforce on Mental Health revealed that 75% of Kenyans are unable to easily access mental health services. This is evidenced in the fact that only 29 of the 284 Level 4 Hospitals in Kenya provide mental health services, and only 26 of the 47 counties in Kenya have psychiatric units. The only national referral hospital for mental health is the Mathari National Teaching and Referral Hospital located in Nairobi. Even when patients do manage to access mental health services, the services they receive are offered in an inpatient setting under deplorable conditions that violate their right to freedom from inhuman and degrading treatment, and other rights.
As a result of chronic underfunding of the mental health sector, poverty, lack of knowledge the visible lack of community services and support, incarceration and deprivation of the liberty of persons with mental health conditions and persons with psychosocial/intellectual disabilities has often been the rule rather than the exception. This widespread incarceration is primarily done based on actual or perceived impairment, the alleged danger of persons with disabilities to themselves or others, and the apparent need for care or treatment. This is in contravention of article 14 of the Convention on the Rights of Persons with Disabilities which Kenya is a State party to, and which prohibits the deprivation of liberty of persons with disabilities based on actual or perceived impairment. Sadly, the deprivation of liberty of persons with mental health conditions and persons with psychosocial/intellectual disabilities is supported by an outdated and harmful legal and policy framework, including the Mental Health Act and the Criminal Procedure Code. Such frameworks need to be amended to conform to the Constitution and the Convention on the Rights of Persons with Disabilities. The situation is further compounded by widespread stigma and discrimination surrounding mental health conditions.
Worryingly, even the limited funding has been focused predominantly on bio-medical model that has contributed to the exclusion, neglect, coercion, and abuse of people with intellectual, cognitive, and psychosocial disabilities, and those who deviate from prevailing cultural and social norms. Investment in excessive biomedical interventions, including psychotropic medications and non-consensual treatment must be replaced with community based mental health services that are compliant with the Convention on the Rights of Persons with Disabilities.
Groups most left behind
The youth and adolescents are one age group that is adversely affected by mental ill health. Youth unemployment, pressure to perform in school, social media exposure, and human rights violations are among the key determinants of mental ill health among this group. Poor investment and lack of access to mental health services contributes to a decreased ability among youth and adolescents to make rational choices and an increase in their probability of engaging in risky sexual behaviour and substance abuse further exacerbating their mental health and life outcomes. Measures geared towards improving youth and adolescent mental health must therefore be aimed at prevention (by addressing the social and structural determinants of mental ill health), intervention, and rehabilitation
Not to be forgotten are the mental health needs of prisoners. Prison authorities need to develop policies and strategies which address the needs of this vulnerable group in prisons. More decisive action needs to be taken concerning those in psychiatric institutions under the ‘President’s pleasure sentence’. Their incarceration continues to violate fundamental tenets of criminal justice, constitutional rights and the rights of persons with disabilities. The Kenyan Courts have long pronounced themselves on the discriminatory nature of section 167 of the Criminal Procedure Code to people with mental illness.
Mental ill health in older persons are not a ‘normal’ aspect of aging. During this time of COVID19, there has been an increase in mental ill health amongst the aging, largely due to isolation and neglect. As a result, they are the most at risk from the virus. They too should NOT BE LEFT BEHIND!
Focus on prevention and support for mental health
Noting the adverse impact of mental ill health on individuals, we recognize the importance of prevention mechanisms that alleviate symptoms of mental ill health and contribute to well-being of individuals. Community-based mental health services are indeed crucial. However, prevention mechanisms should equally be emphasised upon. In addition, more investment needs to be made into research on mental health in Kenya. Notably, people need to be made aware of how they can cope with mental illness and the organizations dealing with mental health care in Kenya.
Gains from investing in mental health
The burden of mental illness and the gains that could be derived from prioritising it have indeed been overlooked. The World Health Organization has determined that the onset of a mental disorder increases the risk of disability and premature mortality from other diseases such as cardiovascular disease, HIV/AIDS and other chronic conditions, due to neglect of the person’s physical health, elevated rates of substance abuse, and diminished physical activity, and risks of suicide. Economically, mental disorders lower individual performance and output which ultimately affects a country’s economic growth and development. A 2011 study by the World Economic Forum estimated that the cumulative global impact of mental disorders in terms of lost economic output will amount to US$ 16 trillion over the next 20 years, equivalent to more than 1% of global gross domestic product (GDP) over this period. Investing in mental health would therefore result in greater economic gain for a country.
Recommendations
In view of the critical state of investment and access to mental health care in Kenya, the Kenya National Commission on Human Rights together with the Civil Society Organizations working on mental health in Kenya; WE RECOMMEND:
1. THAT National Government increases allocation to the health budget to 15% in line with the Abuja Declaration.
2. THAT the national and county governments establish a separate budget for mental health, and work to progressively increase the mental health budget in view of the mental health burden in the country.
3. THAT county governments increase funding for mental health services to ensure accessible and quality community-based care, improved peer support in the community among persons with disabilities, and strengthened psychosocial support in Level 1 hospitals where community health services are offered.
4. Parliament fast tracks the amendment to the Mental Health Act by removing provisions on involuntary hospitalization/admission and introducing explicit provisions fully recognizing the legal capacity of persons with mental illness and persons with psychosocial and intellectual disabilities.
5. THAT county governments should deliberately invest in wellness and recreational facilities and programs as a preventive measure.
6. THAT the National and County Governments should invest to reduce the over reliance on medical led interventions to mental health services. Instead they should commit to address the social determinants of mental ill health especially of vulnerable groups and permanently commit to fund community-based services for mental health.
7. THAT the Ministry of Health ensures that mental health services are available under the Universal Health Coverage essential package. In addition, that the Ministry actively involves and consults with persons with lived experiences, persons with psychosocial and intellectual disabilities in policy discussions around Universal Health Coverage
8. THAT the Ministry of Health adopts a swift but measured and effective approach in considering, analyzing and implementing the recommendations espoused in the Taskforce report while concurrently incorporating proposals by civil society stakeholders on the specific areas and methods of addressing the mental health countrywide.
9. THAT the National and County governments fund community support services to support independent living.
10. THAT Parliament repeals the provisions on presidential pleasure sentencing under the Criminal Procedure Code. Instead, specific clauses providing for accommodations to persons with psychosocial or intellectual or cognitive disabilities who are disproportionately affected by provisions of “unfitness” to stand criminal trial should be included. This will enable participation in trial proceedings and forestall indefinite detention in mental health facilities or prison
11. The meaningful involvement of organisations of persons with lived experiences in line with the CRPD call that nothing for us without us. A human rights approach to mental health conditions demands that person with lived experiences and their organisations must be at the fore in decision making, designing programmes and policy making that involves their rights. Everyone has the right to the highest attainable standard of health. There can be no health without mental health. We encourage everyone to team-up towards reducing stigma for better and happy livelihoods.
We celebrate; -
You who have come out You who are broken but still press on.
You who have voiced your fears.
You who have come out stronger.
You who continue to keep protecting your space.
You who is your brother’s Keepers.
You who are winning the battle.