in2mentalhealth

Tanzania is one of the poorest countries in the world with an astonishing shortage in mental health care. And Tanzania hosted the big eLearning-Africa 2011 summit, with all modern cyber techniques exposed and discussed. Do this two facts merge? What can mental health in Tanzania gain with these new technologies in education?

Introduction:
This article is a result of my 7 day trip to Tanzania in May 2011. I attended the eLearning-Africa summit in Dar Es Salaam and visited several organizations in Tanzania in the field of mental health and education:

• Muhimbili University of Health and Allied Sciences (MUHAS) Department of Psychiatry and Mental Health
• BasicNeeds Tanzania (international mental health NGO)
• Regional Psycho-Social Support Initiative regional center East (REPSSI)
• Tanzanian Users and Survivors of Psychiatry Organization (TUSPO)

At the summit I had a change to meet and see work of (among others):

• Tanzanian Training Center for International Health (TTCIH)
• African Medical and Research Foundation (AMREF)

I did not have the opportunity to visit other parts of Tanzania and/or to talk with all stakeholders or people involved, but did receive very valuable information by mail from:

• Tanzanian Counselors Association (TACOA)
• Kings College London, Institute of Psychiatry, Health Services Research Department, UK

In this article I try to answer 4 questions:

1. How is the current mental health care in Tanzania?
2. How is the current mental health capacity building in Tanzania?
3. What is the current state of art in eLearning in Africa?
4. Merging 1+2+3: what is applicable and useful for the Tanzanian mental health care?

1. The current mental health care situation in Tanzania:
Tanzania is a vast country with a population of around 40 million people, plus 274.000 refugees from neighboring countries. Up to 80% are living in rural area’s and 33,6% are living under the poverty line. It counts 7 tertiary hospitals, 18 regional hospitals, 86 district hospitals, 541 health centers, 4.904 dispensaries, and thousands of volunteer community health workers (CHWs), with each about 50 houses to take care of.
The total number of psychiatric beds in the country is 900 and in most regions there are only 20 beds for a population of 1,5 million people. There is one Tanzanian government mental health hospital: the Psychiatric Referral Hospital Mirembe in Dodoma, with 600 beds, allied to Isanga the Forensic Institution. The Lutindi Mental Hospital of the The Evangelical Lutheran Church of Tanzania (ELCT), in Lutindi, is the only mission mental health clinic with 100 beds and additional occupational therapy. Basic mental health care and beds are also available in Dar Es Salaam (Muhimbili University Hospital) and in Mbeya.
In Dar Es Salaam and in the Southern district Mtwara the NGO BasicNeeds is offering comprehensive mental health care (treatment, case management and rehabilitation) in partnership with local organizations and the state care. In the Pugu area (just 22 km North of Dar Es Salaam) TUSPO is providing care on a small scale, about 300 mental health patients, with plans to scale up. I did not stumble upon other mental health NGOs or projects in Tanzania. But I assume that there are, scattered over the country, other small mission or charity initiatives for people with mental disorders.
In 2009 Tanzania counted 18 psychiatrists of whom 13 were working in the public sector and only 4 outside Dar Es Salaam. There were two clinical psychologists, 8 social workers who work in the mental health, approximately 460 mental health nurses (but not all of them work in the mental health). Most mental health care is provided by the community health workers (CHWs), general nurses and assistant medical officers (AMOs) in the primary health care centers. The bulk of this information is derived from a report about the mental health policy in Tanzania, October 2010 by Mr. Joseph Mbatia of the Tanzanian Ministry of Health and Social Welfare (MOHSW) and Mrs. Rachel Jenkins of the Institute of Psychiatry, Department of Health Services Research, Institute of Psychiatry London. In this report sounds a quite optimistic tone: There are, according to this report, a couple improvements in the last 10 years, due to a 1999-2009 collaborative project between the World Health Organization Collaborating Center (WHO CCIOP) and the MOHSW. The national health budget is improved from 3 to 9%. The mental health care is integrated into primary care in most regions in mainland Tanzania. There is more awareness and knowledge about mental health illnesses and a stronger referral and inter-sectional coordination. The number of patients with neuro-psychiatric disorders attending in the primary care six folded between 2001 and 2007 to 118.730. But, according to this report, still the supply of psychotropic drugs do not serve the demand sometimes, and ‘much remains to be done’.
The people I had the opportunity to speak with in the Tanzanian mental health field sounded more pessimistic and even still very worried. Compared to 10 years ago there is improvement and a direction to go; you could say ‘from nothing to something’. But still mental health seems no priority in all levels of policies, and stigma and marginalization of people with mental health disorders is still rampant. If you count for instance 25% of the population having some form of mental disorder or brain condition during their lifetime (WHO calculations) then in a country like Tanzania 1.000.000 people will be in need of care somewhere in their lifetime. Estimates for people developing Schizophrenia are 0,4-0,8%: 16.000-32.000 in current Tanzania.

And along basic care or treatment (psychotropic drugs), the patients need rehabilitation or other guidance to an independent and fruitful life, in order to prevent a further vicious cycling down from poverty-more stress-more physical problems-more symptoms-stigma-marginalization-more poverty etc. Currently most patients are even so poor that giving free medication without food can create a breeding ground for side-effects and discontinuation of the drug intake. And the supply of medication in remote districts is what one told me ‘erratic’. The supply system is complicated and often patients have to interrupt their drug treatment, with the risk of relapse.
In Tanzania there is not yet a strong national advocacy or lobby organization for mental health. Mental health is on a international level also struggling for more recognition and attention. Other patient groups like the blind, people with disabilities, diabetes, malaria, HIV/Aids and other health areas like reproductive health and family planning are much further in international campaigns and cooperation. This means that in Tanzania lobbying and advocating for a better mental health is still in it’s infancy and one can not rely on external or strong international umbrella organizations to take the lead.
If I dared to compare the Tanzanian mental health situation with the one in my country, the Netherlands, with 16 million people, 2164 registered psychiatrists and ‘uncountable psychologists’, it was quite saddening hearing all these stories.

2. The current mental health capacity building in Tanzania.
Tanzania has a few universities with medical faculties, but only at the MUHAS one can study for becoming a psychiatrist (now 11 students) or clinical psychologist (now 16 students). There are also people studying for psychiatrist in neighboring countries and elsewhere, but there’s a risk that they won’t come back. There are institutes where one can study for occupational therapy, like Kilimanjaro Christian Medical College, or for social worker, like the Institute of Social Work, Dar Es Salaam and for psychiatric nurse. The Mental Health Association of Tanzania MEHATA) is the national organization of psychiatrists and psychiatric nurses and is involved in a lot of training and education in the mental health field.
In Tanzania a big part of the medical services and management is conducted by Clinical Officers (COs, secondary school followed by 3 years of training in management of common medical, reproductive health and simple surgical problems), and the AMOs (a cadre between the COs and the holders of a first degree in medicine). The TTCIH in Ifakara provides the AMO/CO courses and additional refreshing courses on specific health topics (see example in next section).
There are also additional trainings in place for leadership and educational skills, since most mental health professionals are responsible for the supervision and coordination of the frontline health workers in their region, as well as for advocating and budget management. Several NGOs and donors partnered in these trainings and in 2009 94% of the 18 regions and 121 Tanzanian districts had trained mental health coordinators, according to the mental health policy report. By 2009 a total number of 3.895 primary care health workers had received at least 5 days of training in identification and management of 13 severe and common neuro-psychiatric disorders with a planned follow up supervision 4 times a year. There are 4 guidelines in use, which complement each other: the facilitators’ guide, the English primary care guide for trainers, a Kiswahili guide (with the 13 mental health conditions), and a mental health sensitization guide for local council leaders, health management teams and traditional healers.
On a kind of side road, but a very interesting one, is the Certificate Course in Community-Based Work with Children and Youth of the REPSSI. This distance learning program does not work with computers or internet yet, but with 6 handouts on paper. The students follow 6 modules in a 18 months period in their own region while continuing work. In each module they attend 4 facilitated discussion meeting with 10-15 local students from different organizations and one mentor. They write 2 assignments for each module, which are marked by academic institutions. The course is accredited by the University of KwaZulu Natal. In 2010 1000 students were enrolled in 10 East and Southern African countries, including Tanzania, and there are plans to expand.

A general weakness of the Tanzanian mental health care capacity building is the lack of health workers with mental health expertise, at all levels. This jeopardizes the quality of the supervisions and trainings. You can imagine that in this model where high educated mental health specialists (university degree) train middle cadre (AMOs, nurses and COs), and they in their turn train low educated workers in the field, in a country with 18 psychiatrists and 2 clinical psychologists…………
Another weakness is the lack of incentives for people to work in mental health and/or rural areas. There is still an general idea that ‘crazy people’ can’t be treated, so why choose psychiatry; better send the crazies to traditional healers. There are also not many well paid jobs in the sector. There are not much international NGO involvement or job opportunities either, like in the HIV/Aids and Malaria sector. There are even examples where mental health specialists are now working in other health sectors or even in totally other professions like banking.
Last weakness is still the lack of structural funding for the supervision and refresher courses. Although there is a country wide mental health education and training policy, budgets for mental health care and training are a responsibility on district level. This means that in all districts awareness and lobbying must be done in order to get mental health on the agenda’s. And since other health area’s are also venting for more money and resources, this is a continues battle. Even money for fuel to get to a supervision session can be a hurdle.

3. The current state of art of eLearning in Africa.
More then 1700 people attended the eLearning-Africa summit in Dar Es Salaam, 25-27 May 2011. There where more then 300 speakers from 57 countries and more then 50 exhibitors with a stand. A well organized, bit overwhelming, but pleasant and interesting event.
Within the definition of eLearning fall distance learning programs via the internet or mobile phone, but also programs via CD’s or on a computer brought from one place to another. The presentations and exhibitions on the summit ranged further from digital video recording in education, interactive whiteboards, free and open source software (FOSS), Open Education Resources (OERs), low-bandwidth web-conferencing, Bandwidth Optimalization Monitoring (BOM), new education pedagogy, ICT in remote and poor regions/schools, cloud computing and other one-server/multi-users solutions for electricity/funding shortages, eLearning management programs, examples of best practices and a special attention for ‘youth, skills and employability’, the central theme of the summit.

I/in2mentalhealth, conducted a brief presentation in one of the parallel sessions about the (lack of) mental health care and capacity in Africa and a plea for more attention for this field (a kind of summary of my article about this issue 21st April 2011). I did not see the mental health or psychiatry topic in any other presentation or exhibition, but lets not give up hope.

I was impressed by AMREF and partners. They developed ‘Kenya’s Nurses eLearning Upgrading Program’. This program has enrolled 7.000 students, dispersed in 108 centers across Kenya and is evaluated as quite successful, using eLearning and sometimes printed media in poor resource settings.
Another solid sounding example came from the International Atomic Energy Agency (IAEA) Austria: the Virtual University for Cancer Control and Regional Training Network. They conducted, in partnership with the WHO, a 5 year pilot in 7 African countries, building on the educational structures which already existed.
Also successful, but unfortunately no mental health included yet, is the Global Health eLearning Center (GHeL) of the John Hopkins Center for Communications Programs, with more then 45 courses online, more then 67.000 learners from all over the world and 90.000 certificates already granted.
Inspiring is also the African-European Medical and Research Network (AEMRN) with interactive programs for health workers in 11 sub-Sahara countries using low-bandwidth web-conferencing. With this technology multiple internet users can view images/material at the same time, while engaging in two way voice communication (VoIP) even with an internet connection as slow as 13Kb/sec.
But what attracted me most was the ICATT program of the Tanzanian TTCIH, the Novartis Foundation for Sustainable Development (NFSD) and the WHO. ICATT stands for IMCI Computerized Adaptation and Training Tool and IMCI stands for Integrated Management of Childhood Illness. This ICATT tool is a software program which can be delivered online or on CD, individual or in classrooms using a beamer. It has an attractive design with several modules all with a Read, See, Practice and Test component. There is no IT specialist needed for changes in the program or updates. The basic ‘empty’ platform can be filled with educational content by everyone who has basic computer skills. The program is initially designed for IMCI, but other health areas can use it as well and build there own education content within the basic software. The software is free of charge and available on CDs including several guidelines. And that’s where the TTCIH and Novartis captured my interest. I saw immediately ‘MHCATT’ programs full with training materials about psychiatric care, counseling skills, psychotropic drugs, rehabilitation etc….. Another example of such a ‘free content authoring tool’ is the Learning Content Development System (LCDS) of Learnthings, South Africa.

Striking at the summit was that on the one hand the high tech developments go fast and look sometimes even surrealistic. It was not easy for me to catch up immediately with all the new terms and applications. And on the other hand the daily reality of Africa’s poverty, poor electricity/internet coverage, lack of financial resources and the ‘digital divide’. This forces people in the field to take sometimes a few steps back or lower their high cyber expectations. In order to have success with an eLearning program in Africa and in order to prevent more digital divide, one must give people in (rural) Africa time to catch up. Improvising, improvising and improvising and now and then a lot of patience, seem essential. Other essential ingredients which often came to the surface where ‘multi media use’, ‘open source’, ‘open and free access’, ‘sharing’, ‘multi level cooperation and partnerships’, ‘don’t invent the wheel again’, ‘good pedagogic plan’, ‘do everything in consultation with the national ministries or boards’, ’build on what already exists’.

4. Merging 1,2,and 3: What is applicable and useful for the Tanzanian mental health care.
Most if not all points of conclusions and discussions from my previous article: ‘Can eLearning boost the Mental health capacity building in low income countries?’ are applicable in here. A summary:

• What is available in eLearning for mental health capacity building is still quite disappointing, fragmented and immature
• More advocating and lobbying is necessary in order to get mental health on more agenda’s (policy makers, educational institutes)
• International and multi-sector collaboration as a starting point
• Central planning and alignment of accreditation can avoid more fragmentation
• Consider the local and personal circumstances of the users, consider mobile phone learning
• Use mix media and personalized support
• Include communication skills and training on the spot
• More incentives for students/workers in the mental health sector are needed
• Don’t forget the community health workers; they are the spine of mental health care

But this trip to Tanzania shed new light on a few things.
In a report of the Tanzania Communications Regulatory Authority in June 2010 only 11% of the Tanzanians had access to internet (55% through organizations, 40% in households, 5% in cybercafes) and 45% access to a telephone network. Only 12% of the Tanzanian population has electricity, mostly in urban areas. So, computers are still rare in most households and although Tanzania is participating in ‘computer for all’ like programs, it will take time before Tanzania is cyber ready.
But waiting until everything and everybody is full online is not necessary and will probably create more delay in the long term. I think that when one starts now, with small pilots, it’s easier to catch up and implement broad national programs later. And small successes, like a nice operating system, can be demonstrated to all stakeholders, from government leaders to primary care workers, in order to make them enthusiastic and on board.
But the current ICT situation in Tanzania demands a lot of restrictions and adaptations in any eLearning program, like:

• Multi media in the beginning (material via internet if possible, otherwise on CDs if possible, otherwise use print versions in underserved regions)
• Low bandwidth and slow internet solutions
• Alternative energy supplies
• Additional ICT trainings for the majority of computer illiterates
• On the spot technical support and maintenance
• Attention for the fear and resistance that may be present in the new users

In the Tanzanian mental health field eLearning sounds still much like science fiction. But in the several talks I had with people from organizations, an urge for more efficient, up to date, step by step and continues education was often heard. Although ‘science fiction’, most of them could fantasize with me how eLearning could boost the national mental health capacity building.

In my previous article I divided eLearning in 4 mental health capacity areas (1. Academic courses and degrees, 2. Additional training of mental health staff, policy makers and human resource managers, 3. Ongoing supervision and on the job training, 4. The informal learning and Open Source Ware). What is already developed international in these areas you can find in that article.
Since mental health in Tanzania is in a transition from ‘virtually zero mental health care’ to ‘mental health care integrated in the primary health care’, the most important area seems the ‘ongoing supervision and on the job training’. But How and Where to start and Who’s going to start, is the biggest hesitation here. With 18 psychiatrists and 2 clinical psychologist in a country of 40 million people…….
And the content and curriculum of the current training materials need also revision and extension. But where to start here? First more adequate education material and then implementation eLearning; or start eLearning together with updated and/or new material?
And because there are very limited existing mental health programs in eLearning from somewhere else to use or copy, one must ‘lean’ by other health sectors. There are best practice examples nearby like the ICATT and AMREF, among others, and there is a lot of free software available. So one don’t, and must not, start from scratch. And there are clever digi enthusiasts everywhere, also in Tanzania. And maybe there is an international NGO who wants to participate and fund. Or maybe at the October 2011 Global Mental Health Summit in Cape Town an international initiative on eLearning in mental health can be forged. I keep on being optimistic.

So, I think in the near future, eLearning can add a lot in the Tanzanian mental health field. In the high education sector by (affordable) international academic courses, OER and free accessible wiki’s, journals, best practice communities etc. In the middle and lower education sector by multi media modules in combination with ongoing face2face training and supervision sessions.
To end with a summary of the main benefits of eLearning above the traditional paper/chalk/teacher methods in mental health capacity building in Tanzania:

• Time and cost savings (on the long term) for the organization: less paperwork, teacher time and costs of accommodations and transport
• Time and cost savings for student: less travelling, less staying elsewhere and no interruption of work
• Up to date and easy to adapt/modernize material
• Far more information can be easily distributed and shared; a whole library can be included or info from internet can be send to remote area’s via CDs or hard discs
• Attractive for students; taking part in the new era of ICT
• Step by step learning in own pace and time, and on the spot applying what is learned
• Easy insertion of multi media and tasks like theory, video, assignments, tests, games
• Easier scaling up of projects (even crossing boarders) and reaching the remote areas

Some disadvantages:

• Dependency on electronic devices and electricity
• In the start up it will cost extra’s; it’s an investment in the long term
• People can limit their study to theory and reading without practice and teacher guidance or supervision; this is not enough for working in the mental health
• Without some technical support the program is vulnerable for interruptions and failure

So, yes, it’s a big challenge, but it can add a lot.

Roos Korste, psychologist and trainer, founder of in2mentalhealth

Acknowledgements: I would like to thank all who took the time and effort to provide me with the necessary information: Peter Stephen Massesa (REPSSI-East), Samuel Likindikoki and colleagues (MUHAS), Eliezer Robert Mdakilya, colleagues and users (TUSPO), Samuel Philip Mganga (BasicNeeds), Daniel Charles (TACOA), Rachel Jenkins (Kings College London) and attendees and speakers at the eLearning-Africa summit.