in2mentalhealth

This is the fifth interview in the Global Mental Health Inside Stories series. In this series I want to collect and spread information/ideas from people active in mental health from all over the world and specially from low resource settings or fragile countries.
I hope this series contributes to more insight in the challenges and wishes from people active in these settings and adds to a more bottom up movement in global mental health.
Ignicious Murambidzi from Zimbabwe answered the 10 interview questions as follows:

Work location and some background information:
My name is Ignicious Murambidzi and I’m a Clinical Psychologist and Intern Public Mental Health Research Fellow. I have a MSc in Clinical Psychology (University of Zimbabwe) and currently I’m studying Mphil Public Mental Health (University of Cape Town). I’m the National Coordinator/Acting Director of the Zimbabwe National Association for Mental Health (ZIMNAMH) in Harare, Zimbabwe.

Brief country profile:
Zimbabwe is in Southern Africa with an estimated area of 390 757 square km, bordering South Africa, Botswana, Zambia and Mozambique. The national census reported a total population of nearly 13 million with an overall sex ratio of 93 males per every 100 females (Zimbabwe National Statistics Agency, 2012).
Zimbabwe is categorized a low income country according to the World Bank 2004 classification. The 2010/2011 Multidimensional Poverty Index (MPI) survey estimates that 39.1% of the Zimbabwean population lived in multidimensional poverty while an additional 25.1% were vulnerable to multiple deprivations (UNDP, 2013).
There is no specific mental health budget in Zimbabwe. Mental health services are funded from general health budget. However mental health services are provided free of charge in government institutions.
Mental health treatment was decentralized and is now a part of primary health care system. However there are few community mental health facilities such as day care centers, half way homes and rehabilitation centers to strengthen the primary mental health care concept. As a result the tertiary mental health institutions are still overpopulated and characterized with the revolving door syndrome.
The following therapeutic drugs are generally supplied at the primary health care level: carbamazepine, phenobarbital, phenytoin sodium, amitriptyline, chlorpromazine, diazepam, fluphenazine, haloperidol, biperiden,
However medical supplies in government institutions are erratic.
The WHO reported in 2005 the following mental health resources: Per 10 000 population: Total psychiatric beds 1.2; Psychiatric beds in mental hospitals 0.9; Psychiatric beds in general hospitals 0.2; Psychiatric beds in other settings 0.1. Per 100 000 population: Number of psychiatrists 0.1; Number of neurosurgeons 0.07; Number of psychiatric nurses 4.6; Number of neurologists 0.009; Number of psychologists 0.9; Number of social workers 0.2.

Overview of work activities:
ZIMNAMH is a registered welfare organization (W.O39/81) whose primary goal is to promote the recognition of the rights of people with mental disabilities in a society where mental health is valued and managed with parity. It started operating in 1981.
Our aims and objectives are: To represent the interests of people who suffer from mental health problems and facilitate their participation in issues which directly affect them; To work towards better care, treatment, rehabilitation and recovery of people who suffer from mental health problems; To promote mental health for all throughout Zimbabwe.
ZIMNAMH has community working groups in all the provinces and collaborates with mental rehabilitation centers and psychiatric institutions. We propose, review and influence laws and policies related to mental health and disability, and advocate for a better care, treatment and rehabilitation of people who suffer from mental health problems. We education the public and raise awareness through print and electronic media campaign to increase understanding on mental health issues. We have a residential rehabilitation service at Tirivanhu Centre, offering life skills training to people recovering from mental illness. We offer disability appliances support in order to promote the inclusion and participation of PWDs (people with disabilities) in mainstream activities. We offer counseling, training and psycho-social support services on mental health among vulnerable groups like children, women, ex-prisoners and displaced persons. And we are expanding and sharing our knowledge base on mental health promotion and service provision.
ZIMNAMH subscribes to both international and national networks to advance its mandate. The organization is a member of the World Federation for Mental Health and the National Association for the Care of the Handicapped (NASCOH). It has working agreements with three line ministries; Ministry of Labour and Social Services, Ministry of Health and Child Welfare, and the Ministry of Education, Sport, Arts and Culture.

Members of the ZIMNAMH Board touring the rehabilitation centre farm[/caption]ZIMNAMH is a membership driven organization. The Board of Trustees is elected at the Annual General Meeting for a term of 3 years. The Board is assisted by the Finance and Management Committee, Human Resources Committee and Programme Development and Advocacy Committee in monitoring, reviewing and evaluating the organization’s programmes and activities. The organization has a constitution and a policy procedures manual that regulates internal relationships and provides policy guidance. The Secretariat headed by the Director is accountable to the day-to-day smooth running of the programs supported by a staff compliment of twelve members with specific program functions and job descriptions. In addition, the organization has close working relations with mental health practitioners who sometimes provide their services on voluntary basis.

The main challenges personally in work/study/life:
Limited resources and opportunities for career advancement such as master classes, conferences, exchange programs, and research support.

The main challenges for the organization(s)/colleagues/clients:
-The organization, colleagues and clients lack training opportunities in key areas such as human rights, effective advocacy and lobbying, project management, governance, resource mobilization among other areas to ensure effective programming.
-The organization lost a number of qualified staff due to lack of financial resources.
-The organization is currently understaffed (i.e five at the national office and four the rehabilitation center) and at risk of losing more staff as the funding program is ending this coming October 2013. Rehabilitation center and half way homes across the country are failing to attract and retain qualified staff such as nurses and occupational therapists.
-The organization has two vehicles and four computers. Our rehabilitation centers and half way homes do not have computers, recreational and sporting facilities, occupational therapy facilities and resources for rehabilitation and community education and reintegration programs.
-Clients recovery and treatment progress is often retarded by frequent shortage of mental health medication in this country. The situation is further compounded by lack of community mental health facilities which creates pressure on our few and poorly resourced halfway homes and rehabilitation centers.

The main challenges for the country regarding mental health care:
Mental health in Zimbabwe continues to be marginalized, poorly resourced and largely institutionally based. Below are some of the gaps in mental health care in Zimbabwe.
1. Partial implementation of the Mental Health Act and Mental Health Policy. The Mental Health Act is Reviewed in 1996 and the Mental Health Policy is formulated in 2004. These documents have never been fully implemented due to the following reasons:
a. Both documents were not publicized and widely disseminated. Generally the public, service providers and mental health users are not aware of the provisions of the two documents so that they can make use of them to improve the services, rights and welfare of people with mental health problems.
b. Lack of financial resources to implement both documents. This is however despite the fact many progressive provisions of the Mental Health Act and Policy (for example Part IX on Mental Hospital Boards and Special Boards and Part X on Mental Health Review Tribunal) require very minimum budget to safeguard and advance the human rights of people with mental illnesses.
c. Difficulties in implementing some sections of the Act. The Zimbabwe Mental Health Act is very cumbersome, procedural and lack community and human rights based approaches to the management of mental illnesses, i.e it is pro institutionalization of mentally ill persons.

2. The country has poor mental health information systems for the collection, processing, dissemination and use of mental health information to monitor the magnitude and burden of mental disorders as well as valuate policy implementation. In addition there has been limited support towards mental health research in the country. The absent reliable and empirical mental health data have impacted negatively on mental health planning, lobbying and advocacy.

3. Mental health services have been severely affected by the shortage of human resources. An official report by the Zimbabwe Ministry of Health and Child Welfare, the 2012 National Health Strategy, indicated a 50% vacancy rate for psychiatric nurses while about 90% of the in-post psychiatric nurses were disproportionally situated at one of the country’s referral hospital for mental illness, Ingutsheni Central Hospital, in Bulawayo. The country has one school of nursing offering post basic mental health training. Currently there are no initiatives to strengthen mental health workforce through refresher and or short training courses on mental health for general nurses.

4. There are very few community based halfway homes and rehabilitation centers to support recovery and reintegration of people with mental illnesses. Currently there is very minimum or no support from the government towards the sustenance of these centers resulting in their failure to meet their day to day needs

5. Myths and misconceptions about mental illnesses perpetuate negative attitudes, stigma and discrimination which expose people with mental illness to human rights abuses while hindering them from accessing mental health care and support.

What should be changed in mental health care on a local or national level:
1. Government’s commitment and political will towards mental health care, so that mental health will have priority in government. Zimbabwe will soon have new government and parliament and I believe this is the prime time to push mental health agenda. This can be achieved through scouting and courting elected members in both the lower and upper house of parliament to be mental health advocates and ambassadors. This can be concurrently be run with mental health motion being steered through the following: parliamentary portfolio committee on health, the junior parliament and public mental health debates and workshops. The ZIMNAMH however has limited resources to spearhead this lobbying and advocacy process.

2. Public knowledge, perceptions and attitudes toward mental health to change. More importantly there is urgent need for human rights education among mental health consumers to both safeguard consumers against human rights abuses as well as strengthen grassroots mental health user movements. Law enforcement agents and service providers need to be sensitized on mental health rights. This can be achieved through education and dissemination of the Mental Health Act and Mental Health Policy among other related national and international instruments. Zimbabwe has just ratified the CRPD (Convention on the Rights of Persons with Disabilities) and this is also an opportune time to advance metal health rights.
A protracted media program to unpack and publicize both the Mental Health Act and Mental Health Policy will be vital in raising government political will and commitment, educating law enforcement agents and other service providers as well as changing public attitudes and strengthening mental health consumer movements.

3. There is also need to strengthen mental health research and mental health information systems in the country. This can be achieved through resuscitation of the WHO mental health information systems as well as build the capacity of the ZIMNAMH to establish and run a mental health databank and resource unit which can be used by students researchers, journalist, policy makers mental health consumers and public in general.

What is the right direction for the global mental health movements:
-Capacity building for mental health users and support organizations in Zimbabwe to effectively advocate for improvement of mental health care.
-Support mental health research and information systems in Zimbabwe.
-Facilitate linkages, partnership and exchange programs between mental health users and support organizations in Zimbabwe with those from high income countries.

What can ICT, mhealth and e-learning contribute to mental health care:
-Mental health information sharing, i.e enable the replication of innovative and or best practices on mental health across the world.
-Easy access to mental health information for planning, programming, lobbying and advocacy.
-Facilitate flexible and cost effective personal development and training opportunities.
-Connects mental health users, families and organizations in the global quest for mental health parity.

Other links and contact information:
Website of the ZIMNAMH, Zimbabwe National Association For Mental Health
E-mail address: zimnamh@mweb.co.zw
ZIMNAMH on Facebook
Telephone: + 263 4 308523 / 308719

With many thanks to Ignicious Murambidzi!
Roos Korste, psychologist, international trainer and blogger