MENTAL HEALTH IN AN UNEQUAL WORLD: INSIGHTS TO RESTORE BALANCE

By Lawani Ambrose Onivefu

Preamble:

The theme for the October 10, 2021 World Mental Health Day as declared by the World Federation for Mental Health (WFMH) is, “Mental Health in an unequal world”. WFMH anticipates that individuals will take steps to enhance their mental health and that of their relatives and associates, while governments should implement policies that will ramp up delivery of evidence based mental health care services that will reduce the stigma associated with mental illness.

Some definitions:

Health is defined by the World Health Organization (WHO) in its Constitution as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”. WHO further defines mental health as a “State of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community”. From the above definition one can extrapolate that the key criteria for good mental health include:

  1. Ability to realize ones potential
  2. Ability to cope with the normal stresses of life
  3. Ability to work productively and fruitfully
  4. Ability to make contributions to the community

Prevalence of mental illness:

Mental illnesses as defined by the American Psychiatric Association are “health conditions involving changes in emotion, thinking or behavior (or a combination of these).WHO estimates that about 450 million people worldwide have a mental disorder. In addition 25% of the population will suffer from mental illness at some times in their lives.

Rationale for selecting the theme:

According to the Secretary General of WFMH Prof. Gabriel Ivbijaro, the theme was chosen in recognition of the fact that the world has become increasingly polarized along the lines of the very wealthy versus the very poor nations, with the very wealthy becoming wealthier. The theme also highlights the inequality in access to care with about 75% to 95% of people in low and middle income countries unable to access mental health. The WMHF also emphasizes the adverse impact of the COVID-19 pandemic on mental health through the impact of the pandemic on interpersonal relationships, job losses and death. Owei Lakemfa in the article “Drama, disputes, hope and hopelessness in a fractured world”, published recently in the Vanguard, highlights the grave concerns of the United Nations Secretary General, Antonio Guterres during the 76th UN General Assembly when he “lamented that COVID-19 vaccines and treatments are being hoarded by the rich, thereby frustrating efforts to curb a pandemic that has already cost 4.5million lives”. The COVID-19 pandemic is associated with the phenomenon of vaccine hesitancy and pseudo forceful vaccination schemes by some tiers of government in Nigeria. The latter scenario has negative impact on the mental health of individuals.

Conceptual Issues:

According to WHO, Nigeria’s mental health policy was formulated in 1991 and includes the following components: advocacy, promotion, prevention, treatment and rehabilitation. The mental health policy of Nigeria is based on the principles of social justice and equity.

The inequality in the world with respect to mental health care issues can be viewed from the perspective of the quality and access to care delivered. WFMH ,reports that research evidence reveals a deficiency in the quality of care provided for people with a mental health problem, as it takes about 15yrs before evidence based medical, social and psychological treatment for mental illness are delivered to the patients in low income countries. With respect to access to mental health care, over 70% of the Nigerian Population live it the rural areas, which lack functional health facilities and mental health professionals. The preceding scenario is complicated by unequal access to Health Insurance Schemes necessitating out of pocket payment as the modus operandi for accessing services where they exist. Alawode and Adewole in their article on the Assessment of the design and implementation challenges of the National Health Insurance Scheme in Nigeria published by BMC Public Health in 2021, report that only 5% of Nigerians have health insurance and 70% still finance their healthcare through Out-Of-Pocket (OOP) expenditure.

The first criteria highlighted above for good mental health is the ability to realize ones potential. A framework that is relevant in this regard is the Abraham Maslow’s hierarchy of needs which is a theory of motivation that postulates that human needs are in five categories, which include physiological needs, safety needs, love and belonging needs, esteem needs and self actualization. Maslow stated that these needs dictate human behavior. Maslow opined that failure to meet lower needs in the hierarchy could precipitate mental and behavioural disorders as a result of difficulty in attaining higher needs. The prevailing state of insecurity in the Nigeria that creates large numbers of internally displaced persons has a negative impact on the capacity of such victims to fulfill basic physiological needs. The realization of an individual’s potential is a matter that cuts across the period of the cradle to the grave, thus issues that have an impact on the wellbeing of the individual across the life span can have an adverse impact on mental health. Access to health and education by the child and adolescent in Nigeria by anecdotal accounts is unequal especially with the large number of out of school children, rampant spate of kidnapping of students from their school premises and the huge number of children and adolescents in internally displaced persons camps in some parts of Nigeria. Another aspect of inequality is access to tertiary education in terms of public versus private institutions vis-a-viz the fulfillment of their mandate and the realization of the potential of their students. How many public tertiary education institutes have facilities for online learning? How many parents in Nigeria can afford the cost of private tertiary education for their wards, where strike action by the lecturers is an anathema? These posers reveal some inequality that will no doubt have negative impact on the ability of some youths in Nigeria to realize their potential.

According to WHO, the mental health budget in Nigeria is financed by about 3.3-4%, with over 90% going to the few neuropsychiatric hospitals in Nigeria. The Nigerian health sector is in a near comatose state, characterized by undue emphasis on curative care against preventive care, decrepit infrastructure, paucity of health care professionals, recurrent episodes of industrial disharmony and strike actions and such system cannot support the realization of an individual’s potential from the cradle to the grave. A young Nigerian that survives all these hurdles and cannot be gainfully employed upon graduation owing to inequality in the criteria for recruitment arising from socio-cultural or ethno religious sentiments may not be able to navigate other milestones in life and might not realize potential.

The second criterion of good mental health is the ability of an individual to cope with the normal stresses of life. Some researchers have defined stress as “a state of mental or emotional strain resulting from difficult or demanding circumstances. Examples of life events that are stressful include, the death of a loved one, divorce, change of residence, getting married, job loss, developing a chronic or terminal illness. Another issue of concern that hinders the ability of some elderly retirees to cope with the normal stress of ageing is the failure, refusal or delay in payment of their monthly pension benefits. How about the experience of relatives of staff that died before they reached retirement age or who died as pensioners without writing a will, leaving behind accrued benefits under the Contributory Pension Scheme which can only be accessed if a will was written? It is important that individuals recognize the potentially negative impact of some life events, so they can adopt strategies to cope with them rather than living in denial or rationalizing them away.

The third criterion of good mental health is the ability to work productively and fruitfully. A requirement for productivity in the work place is the ability to work as an effective member of a team. Some essential team working skills include capacity to listen well, collaborate with other, think critically, solve problems and manage time effectively. Leadership skills and capacity to communicate effectively are also desirable for any individual who desires to be productive. A relevant question that now pops up is to what extent does the system of education in Nigeria imbue individuals with such skills that will engender fulfillment of the third criteria?

The fourth criterion of good mental health is the ability to make contributions to the community. Examples of ways in which individuals make contributions to society include; volunteerism, embarking on fund raising for projects that benefit the community (establishment of community libraries, organizing free health outreaches e.t.c).The desire to make contributions to the community is a phenomenon that cuts across all age groups and socio economic strata of the community. The spectre of migration by professionals, especially health professionals in search of greener pastures deprives them of the opportunity to give back to the society.

The Way Forward:

  1. Greater emphasis should be placed on preventive measures against development of mental illness through massive public health education in the media and other platforms like schools and religious organizations.
  2. The ongoing effort to stem the tide of insecurity nationwide is commendable and should be stepped up.
  3. Platforms should be created for internally displaced persons to access affordable mental health care services.
  4. Citizens should be taught how to manage normal life stresses of life through; relaxation training, deep breathing exercises, adequate nutrition, routine exercises and taking out time to rest and discussion of life challenges with significant others.
  5. Early intervention services for young persons who develop mental illness should be made accessible and seamless linkage with services should also be provided for such individuals as they become adults.
  6. Majority of the institutions that provide professional mental health care services in Nigeria are located in the urban areas and young persons with mental illness residing in rural areas have to overcome some logistic challenge before they present in such institutions for treatment. Utilization of telemedicine will provide digital therapy to individuals who require some form of intervention in remote areas.
  7. More Non Governmental Organizations (NGO’s) and Professional Mental Health Associations should crusade for improved care of mentally ill persons in Nigeria.
  8. Giving effect to the spirit and letter of Primary Health Care that incorporates mental health as its ninth component will improve access to mental health care for all and reduce the stigma associated with the illness. Lagos State and few other States in Nigeria are blazing the trail by making mental health care services available at the Primary Health Care level. Other States should take a cue from them.
  9. Government needs to exercise the political will to ensure that the Mental Health bill is enacted. WHO reports that Mental Health Legislation serves as a key component of good governance, especially concerning issues related to protection of the human rights of the mentally ill, involuntary admission, professional training for mental health workers and the framework for service delivery.
  10. Efforts should be made to increase the annual budgetary allocation to the health sector
  11. The coverage of Health Insurance Schemes in the public and private sectors as well as across all tiers of government should be enhanced.
  12. The Contributory Pension Scheme should be made more effective and efficient in the private and public sectors and across all tiers of government.
  13. There should be improved budgetary allocation to the health sector.
  14. Efforts at local production of vaccines should be stepped up.
  15. The high powered committee on reforms of the Nigerian health sector, recently appointed by President Muhammadu Buhari and Chaired by the Vice President, Prof Yemi Osinbajo should give top priority to mental health.
  16. The Federal Ministry of Health should conceptualize culturally appropriate and evidence based strategies for identification of issues that constitute a challenge to the mental health of Nigerians.
  17. Nigeria should implement the WHO Comprehensive Mental Health Action Plan 2013-2030, which recommends adoption of Universal Health Coverage and Evidence Based Practice; respect for the human rights of the mentally ill, empowerment of persons with mental disorders and utilization of a life course and multisectoral approach as a means of improving the delivery of mental health care services.
  18. The teacher training curricula in Nigeria should be redesigned to enable Teachers to identify early signs of mental illness in students, to facilitate early intervention.

Conclusion:

Finally, all hands must be on deck to restore balance by extirpating factors within the polity that breed inequality which have been identified as purveyors of mental illness.

 

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