Jenkins et al. International Journal of Mental Health Systems 2011, 5:6
http://www.ijmhs.com/content/5/1/6
RESEARCH
Open Access
Developing and implementing mental health
policy in Zanzibar, a low income country off the
coast of East Africa
Rachel Jenkins1*†, Mahmoud Mussa2†, Suleiman A Haji1, Mohammed S Haji2†, Ahmed Salim2†, Said Suleiman2†,
Alya S Riyami3†, Abdul Wakil3†, Joseph Mbatia2†
Abstract
Background: The Zanzibar Ministry of Health and Social Welfare, concerned about mental health in the country,
requested technical assistance from WHO in 1997.
Aims: This article describes the facilitation over many years by a WHO Collaborating Centre, of sustainable mental
health developments in Zanzibar, one of the poorest countries in the world, using systematic approaches to policy
design and implementation.
Methods: Based on intensive prior situation appraisal and consultation, a multi-faceted set of interventions
combining situation appraisal to inform planning; sustained policy dialogue at Union and state levels; development
of policy and legislation, development of strategic action plans, establishment of intersectoral national mental
health implementation committee, establishment of national mental health coordination system, integration of
mental health into primary care, strengthening of primary-secondary care liaison, rationalisation and strengthening
of secondary care system, ensuring adequate supply of medicines, use of good practice guidelines and health
information systems, development of services for people with intellectual disability, establishment of formal
mechanism for close liaison between the mental health services and other governmental, non-governmental and
traditional sectors, mental health promotion, suicide prevention, and research and development.
Results: The policy and legislation introduced in 1999 have resulted in enhanced mental health activities over the
ensuing decade, within a setting of extreme low resource. However, advances ebb and flow and continued efforts
are required to maintain progress and continue mental health developments. Lessons learnt have informed the
development of mental health policies in neighbouring countries.
Conclusions: A multi-faceted and comprehensive programme can be effective in achieving considerable
strengthening of mental health programmes and services even in extremely low resource settings, but requires
sustained input and advocacy if gains are to be maintained and enhanced.
Background
While other regions of the world are making economic
progress with accompanying improvements in health
indices, poverty and low life expectancy remain major problems in sub-Saharan Africa (SSA) with a doubling of the
number of people living in poverty in Africa in the last 20
* Correspondence: rachel.jenkins@kcl.ac.uk
† Contributed equally
1
Department of Health Services and Population Research, King’s College
London, Institute of Psychiatry, David Goldberg Centre, De Crespigny Park,
London, UK
Full list of author information is available at the end of the article
years [1]. Zanzibar, comprising two main islands, Unguja
(normally known as Zanzibar island) and Pemba, with a
constellation of surrounding small islets, has a population
of 1.2 million. It is one of the poorest countries in SSA
with malnutrition, political conflict, and growing problems
of HIV and substance abuse. Zanzibar’s original settlers
were Bantu speaking Africans from the mainland. Persians
arrived from the tenth century onwards, and in later centuries Arabs arrived, especially from Oman, to trade in
ivory, slaves and spices.
© 2011 Jenkins et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
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Zanzibar provided a base for the Omani Arabs to control 1,000 miles of the mainland coast from present day
Mozambique to Somalia. Indeed, in 1832, Sultan Seyyid
Said moved his Sultanate from Muscat to Zanzibar
which remained part of Oman until Zanzibar became
independent in 1963 and, since 1964, it became part of
the Union of Tanzania Mainland and Zanzibar. Widespread intermarriage between Shirazi Persians and Africans gave rise to a coastal community with distinctive
features and a language derived in part from Arabic,
which became known as Swahili (derived from the Arab
word Sawahil meaning coast). The Zanzibar descendants
of this group were mainly involved in agriculture and
fishing. Those Shirazi who did not intermarry retained
their identity as a separate group. Indian traders arrived
for the spice and ivory trade, and settled as shop keepers, traders, artisans and professionals. The British
became involved in missionary and trading activities in
east Africa and attempted to suppress the slave trade
centered in Zanzibar. With these influences, Zanzibar
has become predominantly Islamic (97%) - the remaining 3% is made up of Christians, Hindus and Sikhs.
Due to its historical roots, Zanzibar retains its own
President, Revolutionary Government, House of Representatives, and some ministries, including the Ministry
of Health and Social Welfare (MOHSW).
Mental health is not often perceived by governments
as a priority issue in resource poor settings, but in 1997
the deputy health minister for Zanzibar requested expert
assistance from the WHO “Nations for Mental Health”
[2,3], for the preparation and implementation of mental
health policy and legislation for Zanzibar. Technical
support was given by the first author RJ, Director of the
WHO Collaborating Centre at the Institute of Psychiatry, London (WHOCC) at the request of WHO HQ, in
collaboration with WHO AFRO, and was followed by
continued support by RJ/WHOCC over the ensuing decade, in close liaison with the Zanzibar and Tanzania
mainland respective Ministries of Health and Social
Welfare and WHO country offices. This paper describes
an integrated approach to mental health policy development and implementation in Zanzibar 1999-2009, combining detailed situation appraisal, integrated mental
health policy and plans; mechanisms for sustainable
implementation, using locally available resources and
integrated into local systems; and monitoring to fine
tune implementation (see additional file 1).
production of toolkits, development of guidelines, and
establishment of intersectoral partnerships. Local collaborators and key stakeholders were involved at every
stage, with whom information from the appraisal was
regularly discussed, enabling regular triangulation of
findings, and contributed to fine tuning of the strategic
action plans.
Situation appraisal included analysis of available data
and documents on general health and mental health
issues in Zanzibar, rapid situational assessment, using an
approach drawing on previous work in infectious diseases [4-12], and which has subsequently underpinned
the development of similar work in mental health elsewhere, and included site visits, discussions with key stakeholders and key informant interviews covering
contextual issues (social, geographic, political, historical,
cultural), needs, service structures, resources, processes
and outcomes; as well as further examination of documents, and routine data. Key informant interviews, focus
groups and direct observation of clinical practice were
used to explore attitudes towards mental illness; contextual, and health system barriers to change and care
delivery, especially those factors which hindered intersectoral approaches and the engagement of users and
civil society organisations in the planning and delivery
of care. Once analysed, the information from this rapid
appraisal informed the third stage of sustained policy
dialogue, resulting in the development of a multifaceted
set of interventions, tailored to the country context, and
formulated into policy, legislation and strategic action
planning (see additional file 2). The strategy included
the establishment of a national intersectoral mental
health implementation committee, establishment of a
national mental health coordination system (see Figure
1 in additional file 3), integration of mental health into
primary care, strengthening of primary-secondary care
liaison, rationalisation and strengthening of secondary
care system, ensuring adequate supply of medicines, use
of good practice guidelines and health information systems, development of services for people with intellectual disability, establishment of formal mechanism for
close liaison between the mental health services and
other governmental, non-governmental and traditional
sectors, mental health promotion, suicide prevention,
and research and development. The fourth stage, which
has so far lasted ten years, has comprised sustained
implementation, regular review of progress and constraints, fine tuning action plans, and continued dialogue
with stakeholders.
Methods
A multi-faceted and comprehensive programme was
instituted which combined situation appraisal to inform
planning, sustained policy dialogue at national level,
strengthening a mental health service coordination system, supervision and training, development workshops,
Results
Situation appraisal
Many if not most people with mental disorders consult
traditional health practitioners (THPs), who are common
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across Zanzibar [13-15], have a professional association,
“u Jumuiya ya Watoaji Huduma za Matibabu ya Asilia
Zanzibar” and are registered with the MOHSW. Discussions with traditional healers on both Unguja and Pemba
indicated that they were familiar with psychosis, different
forms of epilepsy and alcohol abuse; that they had clear
views of what they could manage and what was best dealt
with by the hospital, and that they would often refer clients to the general or mental hospital for hospital tests
and treatment.
The mental hospital had no means of communication,
and no transport for transferring patients from the port
(for referrals from Pemba) or to the general hospital (for
severe physical illness). Security at the hospital was a
problem, with theft from the site and sexual harassment
of women. The supply of essential psychotropic medication was inadequate, resulting in patients remaining
untreated and hence unable to return home. There was
also difficulty in obtaining antibiotics and other physical
treatment for psychiatric patients, especially those with
TB whom the general hospital refused to treat or to
send the proper supply of medicines. Co-ordination
between primary and secondary care was haphazard,
and there were no good practice guidelines for mental
disorders. The KC annual report to the MOHSW gave
no account of the high mortality in the inpatient unit,
and indeed hospital staff were unaware of the total as
there was no collation and review of the data. There
were no case registers of clients with complex needs
who required sustained follow up. All patient admissions
were theoretically on a section; the Act (Cap 72 section
5) did not allow for voluntary admissions.
The human resource situation in the specialist service
was inadequate, with too few nurses, no permanent fully
qualified occupational therapist, social worker or psychologist. The only psychiatrist in Zanzibar was semiretired, but assisted the KC outpatient clinic one day a
week. All inpatients were assessed and treated by nurses.
There were no psychiatrists or trained social workers
available to give independent opinions on involuntary
admission, and no review tribunals for patients to appeal
against involuntary admission. Stakeholders identified a
pressing need for access to marital therapy and adequate
treatment because under Islamic religious law, a person
may readily obtain a divorce if the spouse has a mental
illness, resulting in major social and economic vulnerability, especially of female clients.
Primary care
In 1997, Zanzibar already had a functioning primary
health care system staffed by nurses and health educators, with regular continuing professional development
(CPD), but the primary care system was focused almost
exclusively on physical health, and its information collection form contained 34 categories for physical disorders and only one overall category for mental disorders,
which exemplified and encouraged neglect of mental
disorders in planning. Links between primary and secondary care were not systematic, and primary care had
no medicines for mental disorders or epilepsy. However,
all male nurses graduating from the College of Health
Sciences had done one year’s psychiatric training as part
of their 4 year basic training, and so most PHCUs contained staff with some mental health expertise.
Secondary care
The secondary care system for physical health consisted
of a national hospital Mnazi Moja on Unguja and three
district hospitals in the towns of Chake Chake, Wete,
and Mkoani on Pemba). The secondary care system for
mental health consisted of an inpatient hospital,
Kidongo Chekundu, (KC) for Unguja but no inpatient
unit for Pemba; and outpatient departments (OPD) on
both Unguja and Pemba. The structural environment
for mental health inpatient care was highly disadvantaged relative to physical inpatient care, with holes in
the roof letting in rain, blocked drains, unhygienic toilets, and no water supply. Half the beds had no mattresses, sheets, blankets, or pillows. There were no
mosquito nets, and bed bugs and cockroaches were prevalent. The in-patients had no regular activity programme and Occupational Therapy (OT) was only
available for around 11 out of the 120 inpatients. There
were no available psychological and social treatments.
The hospital diet was inadequate in quantity and quality
(consisting of only rice and beans), relying on supplementation by relatives. Many patients had obvious malnutrition and vitamin deficiencies, including scurvy.
Hospital cooking facilities were unhygienic and dangerous, and there was frequently no money available for
cooking fuel.
Human resource development
Since 1985, the College of Health Sciences has produced
“nurse psychiatrists” and nurse midwives (each with 3
years general training and 1 year specialist training), and
this course has recently been reduced to three years
duration in total, with all students studying both mental
health and midwifery. In addition, 4 batches of community health nurses were produced 1994-1998 with only 1
year training. The graduates of the College of Health
Sciences are used to staff primary and secondary care
posts across both Unguja and Pemba, and are expected
to prescribe in both primary and secondary care, to
cope with the lack of fully qualified doctors (none in
primary care and few in secondary care). The MOHSW
obtained the overseas training of one psychiatrist in the
1970s, who returned to Zanzibar, leading the service
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through the 1980s and early 1990s, but took early retirement and so by 1998, it had none (except 1 voluntary
day a week from the retired psychiatrist), nor any in
training. Zanzibar also had no sustainable plan to
develop or recruit occupational therapists, psychologists
and social workers. The training of one social worker
was arranged who immediately went to work elsewhere,
and one nurse had received a one year occupational
therapy course on the mainland. Stakeholders reported
that staff consider it as a punishment to be sent to work
in the mental hospital, and that the MOHSW sometimes uses it as a place to employ ineffective workers,
making it difficult to recruit quality nursing staff and
effective managers.
had recently been started, and by 1998 was fundraising
and collaborating with the MOHSW and other NGOs.
Child services and intellectual disability
The Ministry of Education has a division of special education and started a special education programme in
1998, with Unguja and Pemba each having a special
education unit containing 2 specialist teachers, aiming
to rehabilitate children with intellectual disability back
to normal schools. The special education units teach for
4 hours a day, organise field trips and do special Olympic games. Many of the children have specific neurological problems such as cerebral palsy and epilepsy, but the
supply of medicines for epilepsy is inadequate. Many
also have specific psychological problems, some of
which are referred to KCH outpatient clinic but there is
no specific dedicated provision in the current psychiatric
services for either normal or intellectually handicapped
children, and there is no speech therapist in Zanzibar.
Police and prisons
There is liaison with the prisons which aim to transfer
most prisoners with psychosis to KC. Police are often
called upon to transfer psychotic patients in the community to hospital and to provide cell accommodation
while awaiting funds from the MOHSW to pay for the
ferry from Pemba to Unguja. There were some allegations of mistreatment, and no clarity on whose responsibility it is to provide food for people with mental illness
in a police cell, so that often the responsible nurse had
to find the food out of his own pocket.
The general health education programme
By 1997, the general health education programme was
already establishing good links to schools, the media
and health workers. There was an addiction programme
which already had links to the school health programme, youth to the Ministry of Education, women
and children youth and tourism, and labour Ministries.
A mental health NGO, Saida Wagonjwa wa Akil Zanzibar (Help Mentally Ill People in Zanzibar, SWAZA)
Morbidity and Mortality
An epidemiological household survey of schizophrenia
and epilepsy was conducted in the 1980s [15]. There
was no official mortality data collection in Zanzibar and
senior Ministry of Health officials indicated that rates of
suicide were extremely low. However, suicide is a taboo
in Zanzibar, suicide is believed to prevent entry to heaven, and it remains a crime (Cap 7, Section 5 of 1948),
resulting in general under reporting of suicide, lack of
proper care and attention to deliberate self harm, lack
of education about suicide risk management, and
reduced access to help for patients and families. Stakeholder consultations revealed a number of young people
(especially pregnant unmarried teenagers) who had
killed themselves jumping from high buildings, and people with psychosis who had recently killed themselves
by jumping off the ferry while on their way to be
admitted to KC, underlining the need for community
awareness, mental health promotion in schools, suicide
risk assessment and management in primary care and
specialist staff, and also underlines the need for an inpatient unit on Pemba. Local TV also reported extensive
details of suicides, and their methods, a practice likely
to aggravate suicide rates [16].
The overall mortality figures at the mental hospital
were extremely high, sometimes related to epidemics of
cholera [17], and reviews of cholera on Zanzibar [18]
had not investigated the high cholera mortality at the
mental hospital, another example of exclusion from the
health mainstream, with major consequences for client
outcomes.
Governmental attitudes
The situational analysis identified a number of governmental attitudes and beliefs likely to impede the implementation of the project aims, including a narrow
understanding of mental health policy as solely hospital
provision of mental health services; lack of recognition
of the scale of population morbidity, and of the important potential for decentralized interventions outside the
hospital; a view that the grossly inadequate conditions
within the mental hospital were somehow the fault of
the clients themselves (e.g. the inadequate food supply
was caused by psychiatric patients eating more than
other people); and that mental health was not sufficiently important to warrant solutions to the problems
of shortage of essential drugs, no reliable communication or transport, and limited number of qualified personnel. In contrast, the community population and
mental health staff recognised the multi-factorial
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causation and consequences of mental illness, and the
potential for community interventions [13].
and presence in the MOHSW, accountable to the minister; coordination of the mental health programme in
both Unguja and Pemba, and detailed implementation
of primary care and secondary care of mental disorders,
and public mental health promotion and education
(see additional file 3). The national mental health coordinator was appointed immediately, and the zonal coordinators followed shortly after. A separate national
coordinator was appointed for substance abuse, but with
the intention of eventually merging the mental health
and substance abuse programmes. The primary care and
community coordinators were appointed in 2001-2 but
some left the country for additional training, and replacements have been difficult without enhanced salaries
for the additional responsibilities, especially in Pemba.
The MOHSW obtained two UN volunteer psychiatrists
who were posted to KC and Pemba for several years,
coordinating specialist services, but UN rules prevent
the long term continuation of these psychiatric postings
to Zanzibar.
Considerable advocacy has been needed to ensure that
the national mental health coordinator is included in
relevant generic health sector meetings, and while this is
now largely routine, the coordinator is still occasionally
excluded from some key committees. The national mental health implementation committee was established,
but has never been allocated MOHSW funds, and has
only occasionally obtained external financial support. Its
role has therefore now been merged with that of the
mental health legislation board which has received
sporadic MOHSW funding. It has been difficult for
Pemba colleagues to attend, or for meetings to be held
in Pemba through lack of a travel budget. Collaboration
with the Tanzania mainland programme for mental
health and substance abuse programme was initiated,
funded by the mainland MOHSW, and there have now
been a number of joint strategy development and training activities. Although funds for mental health were
agreed within the ADB lending programme for Zanzibar, subsequent staff and policy changes within the ADB
headquarters resulted in the funds never being allocated
to mental health until this year when the ADB plans to
build an inpatient unit for Pemba.
Measures to strengthen Primary Mental Health Care
included recommendation of inclusion of Mental Health
into the Continuing Education Programs, development
of good practice guidelines, an adequate supply of essential medicines, the inclusion of common mental disorders into the Primary Care Stroke Form, regular support
and supervision from specialist teams to Primary Health
Care, the development of liaison with traditional healers,
access to transport for outreach work and health education to the community including schools, workplaces
and linking to the media. There have been a number of
Governance and financing of the mental health
programme
Mental illness was not well represented in the MOHSW
with no full-time representative, no clear lines of
accountability, and no national mental health co-ordinator. Such current attention as there was within the
MOHSW was focused on the mental hospital, especially
its shortage of food, cooking fuel and blocked drains,
but not on the wider mental health programme. Thus
mental health expenditure, which was subsumed into
the budget for Mnazi Moja hospital, was entirely
focused on the inpatient unit, and was completely inadequate even to support that. Financing was needed for
three parallel streams of activity: community action to
promote mental health, primary care of mental disorders, and decentralized specialist services. In 1999, as
part of a wider health sector reform project for Zanzibar
planned by the African Development Bank (ADB), RJ
was commissioned to produce a funding proposal for
mental health services in Zanzibar. This was developed in collaboration with MM and other Zanzibar
stakeholders.
Subsequent Policy, Legislation, Coordination and Service
Delivery
The issues identified in the 1998 situation appraisal were
considered and addressed in the draft policy which was
extensively reviewed by stakeholders, revised and then
passed by the House of Representatives [19]. The policy
set out the need for mental health and substance abuse
legislation which were produced and passed [20,21],
which were all endorsed by the President of the Zanzibar Revolutionary Government. The substance abuse
legislation has since been revised [22].
Organisational changes proposed in the mental health
policy included measures to enhance the capability of
the Ministry to Implement the Mental Health and Substance Abuse Programme, measures to strengthen primary care and secondary care, and their linkages,
linkages with other sectors, and measures to enhance
availability of human resource. (Additional file 1 sets
out the five major domains for policy implementation
and additional file 2 sets out the detailed outputs and
activities covered in the mental health policy).
The capability of the Ministry of Health to implement
the Mental Health and Substance Abuse Programme
was strengthened by the establishment of a mental
health coordinating system, a national intersectoral
committee to steer implementation, and mutual collaboration with the Mainland. The mental health coordinating system was designed to provide overall leadership
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continuing education courses for primary care staff, on
average about 50 staff trained each year, initially funded
by the MOH continuing education budget donated by
Save the Children Fund, latterly by the WHO country
office, and the WHOCC. The challenge remains to identify a sustainable budget for regular PHC continuing
education, either within the national mental health programme or identified within DHMT budgets. Around
250 primary care staff have now received a one week
CPD course, based on the WHO primary care guidelines, which have been adapted for Zanzibar, using consultation workshops and dialogue with the MOH, and
are distributed during training, together with print outs
and CDs of teaching slides, role plays, and the teacher’s
guide.
Considerable attempts have been made to obtain an
adequate supply of essential medicines for primary care,
with a number of meetings with the district health management teams (DHMTs) and the MOHSW. In 2004,
the DHMTs identified 20 PHCs for a pilot trial of distribution of psychotropics (funded by DANIDA) including
amitryptyline and anti-epileptics, with the PHC staff
encouraged to assess, diagnose, treat and refer where
appropriate. Staff in the 20 pilot PHCUs have been
prioritised for the CPD course, and are visited monthly
by a visiting team of psychiatric nurses from KC (subject
to availability of funds for fuel). The visiting specialist
team review people with severe mental illness who have
been discharged from KC, see new referrals, and discuss
complex cases with the primary care team. Since this
system was initiated, inpatient numbers at KC have
fallen steadily from 120 to less than 50 inpatients at any
one time, and the average length of stay is now only a
week or two rather than many months.
For the last six months of 2010, the medication supply
has been good but remains fragile, paid for by intermittent funds from the Ministry of Health and Social Welfare and DANIDA. There is a long term agreement
between the MOHSW in Zanzibar and Medical Store in
Dar es Salaam, Tanzania mainland that the Zanzibar
MOHSW has to procure medication from them. However, stocks of psychotropics are frequently not available
in the Medical Stores, even when the MOHSW has the
funds with which to buy them.
The policy recommendation to replace the single category with around 12 categories of mental disorders in
the information collection system has not yet been
implemented, making current routine data from primary
care still useless for mental health planning purposes.
The current version of the Primary Health Care Stroke
form includes 3 categories, namely “ Mental health diseases”, Epilepsy and substance abuse. However, the
stroke form for specialist care does now include 12 categories of mental disorder.
The recommendation for regular liaison between primary and specialist care to discuss criteria for referral,
discharge letters, shared care procedures, need for medicines, information transfer, and any other co-ordination
issues, training, development of good practice guidelines
and consideration of appropriate resources is now starting to happen through the regular visits of psychiatric
nurses from KC to the 20 pilot sites. Neighbouring
PHCUs adjacent to the pilot sites also make use of the
regular specialist visits, by referring clients for those visits, and plans are now being made to extend coverage of
the liaison programme to the rest of Unguja and Pemba,
although availability of fuel for transport will remain a
major constraint.
Measures to strengthen and decentralise the specialist
service included recommendation of structural repair of
KC, provision of an 8 bedded inpatient unit on Pemba,
together with an adequate supply of food and essential
medicines; regular fumigation; intensive rehabilitation;
continuing education and good practice guidelines; and
a sustainable human resource strategy. Since the policy
was adopted, there has been significant decentralisation,
increased access to local care (initially at district outpatient clinics, but now directly at PHCU level in 20 pilot
sites (12 on Unguja and 8 on Pemba), supported by
training, good practice guidelines and some improvement of physical infrastructure. There has been specialist outreach support to the 20 pilot PHCUs (12 Unguja
and 8 Pemba). Eight inpatient beds were allocated for
acute admissions in Chake Chake hospital, Pemba, thus
avoiding transfers to Unguja. Funding was allocated
within the ADB lending programme for a purpose built
unit in 2000 but has been subject to multiple delays and
will be built this year at Wete, as a 20 bedded wing of
the general hospital.
KC was renovated in 1999, and again deteriorated
rapidly due to termites and flooding, but the female
ward has now been successfully renovated again in 2008
with government and donor funds; and the ward toilets
have been reengineered for easier maintenance. The
water supply was improved with a bore hole in 2001
with donor funds, communication in the hospital wards
was improved by installation of a landline funded by
MOHSW, mosquito nets were obtained from a donor
but are now regularly supplied by MOHSW, and the
hospital is now regularly fumigated. The hospital van
was repaired in 2003, which facilitated the transfer of
patients to the main hospital and also general national
activities by the mental health programme, but it broke
down again in 2004 and was replaced by another former
ambulance from Mnazi Moja in 2008.
The number of the patients participating in the Occupational Therapy Unit (OT) activities was increased and
there was an increase in the ward-based activities. Only
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10 patients per day attended OT in 1997, but has
increased from time to time to around 30, depending on
how many volunteers/students available to support the
KC occupational therapist. Following the training of 3
nurses in the three year Occupational Therapy course at
Moshi, on the Tanzania Mainland, occupational therapy
services are now also available at Mnazi Moja hospital
and UWZ, with whom there is good collaboration.
A regular programme of continuing education at KC
was initiated to develop psychosocial skills in the ward
staff but because there is still often only one qualified
nurse and two orderlies on duty for around 50-60 patients,
so the nurses have limited time to engage in direct therapy. Good practice guidelines for taking a history, care
planning, and psychosocial treatments were introduced by
the WHOCC through the Continuing Education programme for the hospital staff at KC which was started in
2000, coordinated for a few years by a UNV psychiatrist
but lapsed after his departure, and has recently been reinvigorated. Textbooks were supplied to the KC library and
to the College of Health Sciences by the WHOCC.
The quality of OT delivered has improved in its
detailed assessment, planning and variety. Radio, TV,
football and other games are also now available, as well
as farming on the hospital land. The supply of medication at KCH, funded by DANIDA, for many years was
sporadic and insufficient, because the Medical Store
Department on the mainland fails to deliver on time,
leading to prolonged inpatient stays, However, in the
last 12 months, the medicine supply has been much better, and this combined with the outreach programme
which delivers medication to the primary care clinics for
clients living at home, has resulted in greatly reduced
occupancy of KC (60 instead of 120 patients). The hospital food supply continues to fluctuate, vulnerable to
rising food costs and the restricted funds received from
Mnazi Moja. Physical care of inpatients was improved
by the posting of a medical officer to KCW, resulting in
reduced annual mortality of inpatients.
The policy proposed the establishment of a sustainable
human resource and development strategy, but there has
been no systematic resource for this. There are now 463
psychiatric nurses in Unguja and Pemba are 463, produced at a rate of 10-20 per year. A number of mental
health nurses have received advanced post-basic training
on the mainland, in the US and UK. Three nurses
received the three year OT training at Moshi and two
members of the mental health coordination team
attended the advanced psychiatric nursing course at
Dodoma. One nurse obtained a masters in the UK on
substance abuse. One doctor is now being trained as a
psychiatrist in Cuba. Meanwhile the semi-retired psychiatrist sees about 500 cases a year, or 10 a week, with
severe mental illness.
The policy proposed strong coordination between the
mental health programme and the substance abuse programme in order to tackle the co-morbidity between
drug abuse and mental illness and this has happened,
with close liaison with the NGO Zayadesa (Zanzibar
youth against drugs, education and substance abuse ),
and establishment of outreach and counselling services
and a VCT clinic for drug users.
Measures to further strengthen community linkages
included recommendations for dialogue with traditional
health practitioners, and health education for the community. The MOHSW has met with THPs and the 20
pilot PHCs have been asked to initiate dialogue with
THPs to encourage early referral of severe cases and
discourage harmful practices. Some traditional healers
have asked PHCUs for assistance with the further management of clients with malaria, psychosis and epilepsy.
A vigorous health education programme for the community has been conducted over the last ten years,
including talks in schools, workplaces, TV and radio,
with district and national celebrations of World Mental
Health Day, and mental health events linked to the Zanzibar Film Festival. Primary care workers have conducted local village visits, giving talks to schools and the
general community, thus achieving good population coverage. Good cooperation has been established between
the Health Education Unit, the Ministry of Education,
the Department of Drug Control Programme and the
Mental Health Programme. Direct collaboration has
been established with the Youth and Child Welfare
department in the ministry of women and children’s
affairs, and the director of the YCWD is now a member
of the Mental Health Board.
Policy recommendations for learning disability services
have resulted in liaison between the MOHSW, the Ministry of Education (MOE) and the learning disability
NGO. The MOHSW and MOE have carried out joint
trainings on the management of people with learning
disabilities, training for teachers, and have developed a
client needs assessment form. Activities remain limited
by budgetary constraints, and need to be incorporated
into routine budgets. It has not yet been possible to
establish a dedicated clinic for the assessment and management of children with intellectual disability including
a child psychologist and speech therapist, in collaboration with the dept of paediatrics at MM. However the
MOE has now opened resource centres in almost all
districts, to give support to teachers at all levels, from
pre-school to secondary levels, about the care of children with intellectual disability. The mental health programme has taught the teachers in 5 resource teaching
centres on Unguja and 4 on Pemba, each with 45 teaching staff, on normal child development, conduct disorders, emotional disorders and substance abuse. Training
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manuals have been produced and disseminated for teachers about mental health problems in children, which
were funded by UNDP through the MOE. UNICEF
(2008) sponsored a survey of intellectual disability in 4
districts, which assessed 1994 children and brought
them into school under the Inclusive Education Programme. This inclusive education programme had been
established in 1996 and gradually implemented thereafter as part of the Zanzibar Education master plan. The
‘Zanzibar Poverty Reduction Plan: Basic Education and
Skills Development’. Government of Zanzibar 2002
reported that although efforts have been made to promote equalization of opportunities in the field of education, disabled children are still a disadvantaged group in
Zanzibar and still have limited access to education. Few
schools cater for their specific needs and are mainly
located in urban areas with only few qualified teachers
to assist disabled children [23]. In addition, a subsequent
case-finding survey of Zanzibar Town has identified a
further 1,000 children with intellectual disability.
Policy recommendations on intersectoral liaison proposed national and local liaison between the prisons,
police and MOHSW, and training for prison staff and
police on mental health issues. The national mental
health coordination team have established regular meetings with the Prison Commissioner, and have a Prison
service department representative on the National Mental Health Board. The specialist staff at KC hospital are
in communication with the Prisons department, and
have established reliable methods of referral for prisoners who need regular follow up in the outpatient clinics
or who need inpatient admission. Regular education and
support for prison officers and prison nurses in recognition of mental disorders and criteria for referral to hospital has been achieved by dint of inviting the prison
nurses to continuing education sessions for primary and
specialist nurses, but the former prison commissioner
would not allow the mental health staff to enter the
prison. The mental health good practice guidelines have
also been distributed to prison nurses. There is extensive liaison with police on the drug prevention programme, and some police nurses have attended primary
care CPD courses, and been supplied with the good
practice guidelines. For both prison staff and police,
there is a major need for specific educational programmes about mental health issues.
The new policy explicitly encouraged liaison with relevant NGOs. The mental health NGO, SWAZA, has
grown from strength to strength during the last ten
years, with regular meetings, fundraising and activities,
and is in active dialogue with the MOHSW. The Global
Fund supported SWAZA to conduct home visits for
mentally ill people, families and neighbours, to advise
about mental health, substance abuse and HIV, and the
risks of sexual abuse; about prevention of HIV and
about how to care for people with mental illness and
children with learning disabilities. SWAZA has also conducted a Football Bonanza for teenagers, with a football
competition whereby the finalist teams compete in front
of the House of Representatives to a large audience who
are all given talks about substance abuse, and about
how to be a good footballer without taking drugs or
exposure to HIV risk. The message is promulgated that
good football players are free from drugs and alcohol.
SWAZA has also been given funds by UNODC to go to
the 9 teacher training centres in Unguja and Pemba to
teach the trainee teachers about mental health and substance abuse and how to recognise, and refer and advise.
A number of additional NGOs have now worked with
the Mental Health Programme, including Zanzibar
Information Against Drugs and Alcohol Abuse(ZIADA);
ZASARNET (Zanzibar Substance Abuse Re-education
Network-unfortunately now no longer operational);
Youth Society in Zanzibar (TAQWA), especially on primary prevention of psychoactive abuse in youth, where
they have worked together on the development of a
training manual and training programme for peer trainers, and the design of brochures and banners for public
information, and the delivery of health education about
substance abuse through the media, community visits
and schools; Zanzibar’s Association of the Child ‘s
Advocate (ZACA); and Zanzibar Association of Disability (UWZ). Training was delivered recently to the community based rehabilitation field officers, covering
mental disorders, causes, early identification of children
with intellectual disabilities, epilepsy, autism, referral to
specialist services, and long term support to child and
family. The KC specialist services and Community
Based Rehabilitation field assistants carried out joint
home visits to patients with complex needs living at
home. Good communication has been achieved with the
mental health association of Tanzania (MEHATA) and
there has been mutual exchange and technical support,
with collaboration on primary care guidelines and primary care training programmes. Zanzibar association of
the parents of children with developmental disabilities
(ZAPDD) is working with mental health programme
and inclusive education-visiting schools to assess learning capacity of children and advise the parents and teachers on how to support their children in learning.
The mental health programme collaborates with the
annual Zanzibar International Film Festival, working
together since 1998 on community participatory
approaches to mental health. Mental health talks have
formed part of the annual Village Panorama. SWAZA
has provided regular advocacy to the MOHSW, given
extensive support to KCW by obtaining money from
local donors for a bore hole to establish a water supply,
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hospital repairs, and a consultant led outpatient clinic is
run by the retired psychiatrist who is chair of SWAZA.
The mental health programme has a good relationship
with Red Cross International of Zanzibar, collaborating
on World Mental Health Day.
There has been extensive collaboration with the
WHOCC in London which has given systematic technical support, occasional funds, regular dialogue, appraisal
and review with the MOHSW, coordinators, staff of primary and specialist care, traditional healers, administrators and members of SWAZA; and also with the WHO
liaison office in Zanzibar, which has supported the mental health programme through its biennual budget, and
with the WHO country office on the mainland. VSO
supplied two volunteers for KCH, and the United
Nations Volunteer service (from UNDP) supplied a psychiatrist each for Unguja and Pemba for a few years
(2001-4). Cuba has now deployed a psychiatrist to KC
for two years, and is funding the training of a psychiatrist in Cuba. The presence of a psychiatrist in KC and
on Pemba makes a significant difference to the quality
of patient assessments and management, to patient survival, and to the training courses run at the College of
Health Sciences.
The policy proposed the establishment of a computerised mental health information system covering needs,
service inputs and processes, and health and social outcomes. In particular, the primary and secondary care
information systems need to incorporate a more substantial mental health component so that they can serve as a
basis for adequate planning and monitoring. Secondary
care information has been improved but primary care
information remains inadequate with all categories of
mental disorder still recorded in a single category, despite
earlier agreement to include a more detailed breakdown.
A national mental health report has been produced
annually since 2003, and its content expanded. Suicide
data is now collected by the police, but there is still a
need to include the cause of death, diagnoses and information from health records. The law criminalizing suicide attempts still needs review. The policy proposed that
deaths from physical illness in the inpatient units should
be carefully monitored and audited, and this has
improved to some extent but more could be done. The
policy proposed systematic public education on mental
health and mental disorders, and cooperation has been
established between the Health Education Unit, the Ministry of Education, the Department of Drug Control Programme and the Mental Health Programme. Health
education has been delivered via visits to villages to carry
out talks to schools and the general community, radio
programmes and TV programmes. The village visits were
conducted by primary care workers, thus achieving good
coverage of the islands.
The policy proposed the development of a suicide prevention strategy. An audit of all suicides is needed to
gain a better understanding of causes and means of suicide. The mental health programme has held discussions
with the Department of Information and Media to
encourage more responsible reporting of suicide, but
this remains problematic. Education of primary and secondary care teams about assessment and management
of suicidal risk and support to high-risk groups has been
included in the CE programmes, and is now being
included in the college curriculum for basic training.
More needs to be done to support high risk groups, and
to change the legislation on attempted suicide to make
it easier to access help.
Discussion
The request of the MOHSW to WHO for technical
assistance in 1997 provided an entry point for the
WHOCC to provide long term technical support to
Zanzibar to move from a mental health programme
entirely focussed on the national mental hospital to a
more decentralised holistic vision for the mental health
of Zanzibar. The early agreement of the MOHSW to
establish the mental health coordination team (see additional file 3) has been key to systematic governance and
implementation of the programme. The establishment
and growth of SWAZA has also been crucial in providing local support for the implementation of the programme, including mobilisation of local donor funds,
and continued advocacy to the MOHSW.
Implementation of the policy has been very challenging; it has needed iterative and sustained discussions
with the MOHSW to develop the holistic vision for the
evolution of services, to perceive that change was feasible, and that multiple interventions were possible and
realistic. Resource constraints have been severe across
the whole of the health and social sectors, but especially
for mental health which is not a priority for any major
international donor [24]. As well as lack of financial
resource, lack of human resource is critical. As in other
countries, Zanzibar struggles to expand its health personnel. It trains nurses locally, and this has provided the
backbone of the health service. Its decision in the 1980s
to give all student nurses a 4th year of either psychiatry
or midwifery was inspired and has led to the production
of able staff who are able to deliver mental health services. It will need to be seen whether the recent reduction to 3 years will reduce the psychiatric competence
of the staff produced.
The government of Zanzibar has to send students to
other countries to train as doctors, and to specialise,
including as psychiatrists. Such overseas training risks
brain drain [25], and the length of time taken to produce a psychiatrist makes it a heavy investment (around
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6 years of medical training followed by 4 years of psychiatry) for a small country to make, only to risk loss to
a wealthier country at the end of the training. Nonetheless Zanzibar is now training another psychiatrist to fill
the gap left by the first who retired in the mid 90s. The
MOHSW also needs to urgently initiate training of a
second psychiatrist for Pemba. There is no doubt that a
psychiatric presence can greatly influence the quality of
assessments and interventions by the nurses, and is
always desirable. While UNV supplied a psychiatrist
each to Unguja and Pemba in the early 2000s this provision could only ever be short term, as UNV rules prevent its extension, so it is essential for Zanzibar to
become self sufficient in terms of psychiatric leadership.
Sustainability of human resource is a national problem
not only for the health service. Many reasons contribute
to health staff leaving Zanzibar, but the main one is low
pay, even relative to Tanzania mainland. A junior Nurse
with a diploma in the Mainland earns a basic salary of
about 600,000/-T Shillings compared to only 150,000/-T
Shillings in Zanzibar. In addition, there are no incentives
to encourage staff in Zanzibar to choose the mental
health field rather than other speciality areas or primary
care, and work overload in mental health care is
considerable.
Much still remains to be done. Funding for CPD and for
supervision to PHCUs remain the priorities, and for this
access to transport by the senior specialist staff is essential.
Despite enormous efforts it has not been possible to
improve the food supply from MM to KC for the patients
whose diet remains rice and beans; however the long term
impact of such dietary restriction is now greatly mitigated
by the fact that inpatient stay is now usually a few weeks
rather than many months or years. Nonetheless it remains
imperative that KC should have its own budget, separated
from that of MM, otherwise it will always find its annual
allocation drained by MM, with an obvious lack of equity
between the psychiatric and the medical and surgical inpatients. Nonetheless our long term follow up suggests that
despite extremely difficult resource constraints it has
proved possible to make significant progress, with decentralised services, integration into primary care, and community education. Further progress would be greatly
enhanced by better inclusion of mental health into mainstream health sector funding and developments such as
HMIS. It has proved difficult to get mental health properly
integrated into HMIS in other East African countries as
well, encountering strong resistance from health sector
reform teams which tend to be dominated by communicable disease specialists [25].
It is likely that once such integration is achieved, considerable progress will follow, as the relative priority of
mental disorders will be clear in the annual routine
health service dataset [26]. This year, mental health is
clearly specified in the Zanzibar national health sector
strategy and this may lead to better funding flows.
Conclusions
A multi-faceted and comprehensive programme can be
effective in achieving considerable strengthening of
mental health programmes and services even in extremely low resource settings, but requires sustained
input and advocacy if gains are to be maintained and
enhanced.
Additional material
Additional file 1: The Implementation Process.
Additional file 2: Outputs and activity components of the Zanzibar
mental health programme.
Additional file 3: Organogran for Implementation of the National
Mental Health Plan.
Acknowledgements
Grateful to WHO for funding the original technical support in 1998, and to
the Ministry of Health for its long standing concern for the mental health of
Zanzibari people. We are also grateful for continued budgetary support from
the WHO liaison office and Danida.
Author details
Department of Health Services and Population Research, King’s College
London, Institute of Psychiatry, David Goldberg Centre, De Crespigny Park,
London, UK. 2Department of Community Mental Health Services, Ministry of
Health and Social Welfare, Zanzibar, Tanzania. 3Saidia Wagonjwe Wa Akili
Zanzibar (SWAZA), Zanzibar, Tanzania.
1
Authors’ contributions
RJ led the first draft and, MM, SH, MH, AS, SS, AR, AW, JM contributed to
subsequent drafts. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 9 August 2010 Accepted: 14 February 2011
Published: 14 February 2011
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Cite this article as: Jenkins et al.: Developing and implementing mental
health policy in Zanzibar, a low income country off the coast of East
Africa. International Journal of Mental Health Systems 2011 5:6.
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