Post colonial psychiatric care in Ghana

The development of psychiatric care in Ghana since the colonial era in the 19th century, up to the present, is described. Distorted planning and limited accessibility to psychiatric services in many parts of the country, coupled with shortage of trained staff of all grades (including psychiatrists and nurses) plus inadequate funding, have adversely affected the establishment of a fully comprehensive psychiatric service. Suggestions for improving services into the 21st century are briefly discussed.

Historical background

In the early colonial era in the 19th century patients suffering from mental illness in the Gold Coast (now Ghana) were usually kept in prisons (Ministry of Health, 1988). Prior to this period psychiatric patients were left on their own to fend for themselves, or sent off to traditional healers. In 1888 the colonial government passed a legislative instrument (The Lunatic Asylum Ordinance), signed by Governor Sir Edward Griffiths, to establish a ‘lunatic asylum’ in a vacated High Court building in Accra. It was not until 1904 that a purposeful psychiatric hospital was built, called The Accra Psychiatric Hospital. The hospital was officially commissioned in 1906, initially to accommodate 200 patients. By the late 1940s, with psychiatric treatment primarily in the form of custodial care, there was soon to be overcrowding. The Accra Psychiatric Hospital has undergone major expansion in the past 50 years and currently houses about 700 inmates; about one-third of them are long-term because they have no place to go.

Between 1929 and 1951 many changes occurred in the Accra Psychiatric Hospital under the successive leadership of Dr Maclagan (1929-1946), Dr Wozniak (1947-1950) and Dr Foster (1951-1976). There were extensive changes to the hospital buildings, and staff training and recruitment were expanded. The application of innovative treatments such as the use of chlorpromazine and electroconvulsive therapy from the 1950s was encouraged. Other reforms introduced were the removal of chains from patients, refraining from punishing patients and discouraging isolation. The Accra Psychiatric Hospital, during this period, was the only established psychiatric facility in West Africa. A second psychiatric hospital was built in 1950, followed by a third 20 years later. The three hospitals have about 1200 beds altogether. Indeed, many patients from neighbouring West African countries came to receive psychiatric treatment in the Gold Coast in the late 19th century.

Despite recent advances in psychiatric services many citizens still believe in the traditional forms of psychiatric treatment. Up to 70% of patients or their relatives would opt for herbal or traditional treatment (Maame A. F. Ewusi-Mensah, 1996, personal communication). It is not uncommon for a patient to be unceremoniously removed from hospital by a relative in order to consult a traditional or spiritual healer because of a widely held belief that psychiatric illness is caused by supernatural evil forces that can best be banished by traditional medicine. This is the reality in which psychiatric practice has existed for more than a century in Ghana. In some situations it is almost impossible to determine if a patient's recovery can be attributed to medication or through the intervention of the traditional healer, or both.

Training of staff

The training of psychiatric nurses in the Gold Coast started in earnest from 1952, and the establishment of 3-year courses for registered mental nurse (RMN) and community psychiatric nurses (CPNs), since 1972.

Government policy in the long-term is to establish psychiatric facilities in all the regional hospitals, but the reality is that funding is presently not forthcoming and there are few trained personnel. Many Ghanaians who had qualified abroad are not returning home after the completion of their courses because there is little prospect for job satisfaction and adequate remuneration, while some staff presently at post might be contemplating leaving for these reasons.

Since 1994 the Danish International Development Assistance (DANIDA) (Danish non-governmental organisation) has provided funding and expertise to expand the training programme for CPNs and medical assistants in the Northern and Upper regions, in collaboration with staff of the University of Ghana Department of Psychiatry. This programme has significantly improved primary psychiatric care in the North (DANIDA, 1994).

Accessibility to psychiatric care

With a population of 18 million, and three psychiatric hospitals with 1200 beds, the ratio of one bed per 15 000 persons is grossly inadequate. Accessibility to psychiatric service is difficult and uneven because all three hospitals are located in the South of the country. It is no wonder then that some patients or their relatives would seek help from traditional sources, not only because of their cultural or religious beliefs in the cause of psychiatric illness, but because of easy or inexpensive access to traditional healers who live in their community.

Existing psychiatric facilities

Patients who prefer traditional treatment can visit shrines and herbalist centres or prayer camps in many communities; some centres have long-term residential care. However, there are primary psychiatric services in health centres and health posts, usually run by a CPN with support from a district or regional hospital.

Patients with serious psychiatric illness are normally transferred to the psychiatric hospitals, two in Accra and one in Cape Coast. The hospitals also provide teaching and research facilities to the medical schools. There are no special services for old age psychiatry, forensic psychiatry and child psychiatry; while a couple of private establishments provide rehabilitation and training for learning disability. Admission to the hospital is free to all patients; medication and tests are subsidised but free to those declared as paupers. Two university psychiatric departments in Accra and Kumasi also offer out-patient clinical services, in addition to teaching and research work. The departments' staff establishment numbers are low and have no adequate premises.

Present workforce

There is the perennial problem of inadequate staffing. Psychiatrists, nurses, clinical psychologists, occupational therapists, social workers and CPNs are hard to come by. In two of the hospitals there are fewer or no paramedical staff and until very recently one hospital had no psychiatrist in post for many years. There are presently only 12 psychiatrists practising in the country. One has recently retired, four are employed by the medical school, three work in private practice and the rest with the Ministry of Health. Thus, in all, there is one psychiatrist per 1.5 million people. This unrealistic work-load has serious implications for patient care and job satisfaction.

Suggestions for improved services

Since the 19th century great strides have been made in the development of psychiatric services in Ghana from its humble origins in 1886. However, a lot more needs to be done if the standard of psychiatric care is to be raised to the level commensurate with recent advances. This would require massive investments in infrastructure and not least in trained personnel.

The Government's policy of expanding psychiatric services to district and regional hospitals ought to be commended. This includes extension of services for primary psychiatric care in remote areas owing to the present skewed distribution of facilities, where patients have to travel hundreds of miles for treatment. Establishing an accelerated training programme for all levels of personnel, including psychiatrists, locally (not compromising on internationally accredited standards of teaching and care) should provide a regular stream of staff to man the hospitals and health centres. Adequate remuneration of staff should help to solve the long-term problem of ‘brain drain’ and, indeed, encourage personnel trained overseas to return home.

More than 100 years ago the fundamental human right to have access to care and especially legal rights for those suffering from mental illness, were probably not recognised in the Gold Coast, as in many other countries. Since then the rights of those suffering from mental illness have been propagated by the World Health Organization and should not only be enshrined in legislation, but also be seen to be practised by all professionals involved in the care of those suffering from mental illness.

Public education to overcome widely held traditional myths about mental illness, which are still fairly prevalent in the society, would help to encourage more patients and relatives to seek early professional treatment than was the case over 100 years ago.