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 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 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 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 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, 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.