After providing mental healthcare for inmates in a prison in Harare, Zimbabwe, for over five years, Doctors Without Borders / Médecins Sans Frontières (MSF) recently handed over its project to government authorities. Manighandan Sivaramakrishnan, a public health professional from India, was associated with the project in its concluding months and coordinated the handover. In this interview, he explains the origins and outcomes of the project.
Could you give us an idea of the mental health needs in Zimbabwe?
The mental health situation in Zimbabwe is dire. There is a real shortage of psychiatric institutions, psychotropic drugs and mental health specialists. According to one estimate, there are only 14 psychologists in the country (home to approximately 15 million people). There is a general lack of awareness about mental illness, and patients are routinely stigmatised. As existing facilities are inadequate, psychiatric patients are often committed to prisons.
In response to the situation, MSF teams ran activities at two locations in the capital Harare – a psychiatric unit of a prison and later a psychiatric hospital – to provide and improve mental health services.
How did prisons become an area of focus for MSF in Zimbabwe?
MSF responded to a massive cholera outbreak in the country in 2008. During the intervention, our teams assisted a few prisons where inmates fell sick with cholera. We noticed that there was a lack of basic resources for inmates, including food, water and clothes.
With overcrowding, a lack of dignity and very low access to healthcare, especially mental healthcare, there was a recipe for mental illness to thrive in prisons and no system to address it. It was obvious we had to do something about it.
From 2012-2017, MSF provided treatment, care and support to inmates with mental illness at the Chikurubi Maximum Security Prison psychiatric unit. In addition, our teams provided training to healthcare staff in eight other prisons. We took steps to ensure that patients continued to receive mental health support after their release from prison by establishing links with community-based clinics in Harare.
We also recognised that when people become inmates, their access to routine health services gets disrupted. This can have disastrous consequences for inmates who have chronic conditions such as HIV and TB. That is why we also provided HIV and TB diagnosis and treatment in the prisons.
What was the biggest practical challenge in providing healthcare in prisons?
People living with HIV and TB require strict adherence to treatment regimens. However, this is difficult to ensure in a prison setting; even if drugs are available, patients may not take it at the correct time or may not feel comfortable to be seen taking medication. Given the dearth of trained mental health staff, we had to find a different way to counsel patients to ensure they adhere to their treatment.
We rolled out peer-to-peer counselling, wherein inmates provide guidance and counselling to other inmates so as to sensitise them, reduce stigma and improve drug adherence. Some of our peer counsellors were patients themselves.
The initiative yielded good results. We trained multiple batches of inmates to become counsellors, and prepared a full-fledged training manual so this initiative can be rolled out in other prisons as well.
What according to you was MSF’s biggest achievement?
People living in remote areas of Harare are now aware of mental health and its importance. They know that services are available in the periphery. MSF supported 13 satellite centres, known as polyclinics, to address mental health issues in patients from the villages.
Even though MSF is no longer working on mental health in Zimbabwe, and while challenges still remain, people will continue receiving quality mental health care because of the structures MSF helped put in place. This model is scalable, and has the potential to make a huge difference to how mental health is addressed throughout the country.
MSF continues to support Zimbabwe’s Ministry of Health and Child Care (MoHCC) to provide treatment, care and support to people living with HIV, non-communicable diseases including diabetes, hypertension and asthma, and cervical cancer screening services.