By Maji Hailemariam, MSW, PhD @MajiHailemariam
Addis Abeba, June 02/2020 – Bekele, who suffers from a mental illness, hails from a small rural town in the Gurage zone. He lives with his sister, her husband and their three children. “When the illness starts, he does not communicate with people. He gets aggressive and fights sometimes,” his sister explains. “He doesn’t like me. He’s kept behind closed doors without a toilet.”
For families like Bekele’s, getting access to adequate care his condition requires had always been a mammoth, costly endeavor. But things have been compounded considerably since the outbreak of covid19 in Ethiopia.
The famous World Health Organization (WHO) slogan “No health without mental health” has perhaps never made better sense than now. As the world faces unprecedented challenges due to the coronavirus pandemic, within the first few weeks, the failures to integrate mental health into the pandemic response became glaringly evident.
Low-and middle-income countries like Ethiopia, are home to some of the world’s weakest and fragile healthcare systems. The pandemic put health care systems in these settings under a serious strain. Since the announcement of a global pandemic, the health system responses of countries are being tested. In low-and middle-income countries, the scale of the response needed, the speed at which the virus is spreading, and the limited resources available make it particularly difficult to contain the virus. The burden of the pandemic befell on completely unprepared systems. Access to mental health care in low-resource settings has been significantly disrupted by the covid-19 outbreak.
Mental health service users in low-resource settings could be among the hardest hit. The pandemic incontrovertibly amplified underlying structural inequalities in access to healthcare including access to inpatient and outpatient treatment services. Some individuals with mental health challenges may also have other pre-existing health conditions that may require prompt and ongoing access to healthcare. For example, individuals with serious mental illnesses (SMI) may experience serious adversities due to the pandemic. Their risk of morbidity and mortality could be significantly elevated compared to the general population. If they contract the virus, their risk of developing serious complications would be higher due to the widely prevalent underlying health conditions which are common in this group. Thus, individuals with SMI and their families/caregivers could be disproportionately affected by the sequel of the pandemic.
Access: the intricate concept
Even before the pandemic, access to mental health care is significantly complicated by pervasive mental health stigma, weak infrastructure, inadequate services and widespread poverty. Families taking care of someone with severe and persistent mental illness experience a ubiquitous burden of caring. Specialized mental health care in Ethiopia is highly centralized, which often involves travel for families needing the service.
Bekele for instance, has been chained up for eight years. Bekele’s sister and her husband care for him, but the severity of his illness makes it exceptionally difficult for them to transport him to Addis Abeba for an inpatient hospitalization. It could then take up to a month before they see signs of recovery.
“He eats, pees and sleeps in the same room, on the dusty floor” his sister added. “We give him food though the window. We put the food in a plastic bag and throw it in for him. We put water in a plastic bottle and throw it in. The door to his room remains closed unless my husband wants to clean the room. Then my husband enters with someone and cleans.”
The prospect of receiving proper healthcare for families like Bekele remains remote, exacerbating the strain of caring for him. “It has been eight years since he was treated at Amanuel. We can’t take him again because we don’t have someone to look after him while he is at the hospital.”
Initiatives rolled out by Ethiopia to contain the spread of the coronavirus has rendered access to care a virtual luxury for some of the society’s most vulnerable. Health institutions designated for treatment of people with mental illnesses, no longer provide such services. There was a lot of pomp and praise at the October 2019 inauguration of the Eka Kotebe General Hospital, which was said to have 150 beds for mental health patients. Fast forward to today, that hospital has been converted to a coronavirus frontline treatment center, with patients suffering from mental illnesses offered medication refills, early discharge or transfer to another facility.
Amanuel hospital, the pioneer mental health facility in the country, is currently at 50% capacity, to observe physical distancing guidelines. Some of the patients who were transferred to Amanuel for inpatient care resisted and went home because of the stigma attached to the facility. Moreover, psychotropic medications are mostly in short supply. Providers in Addis Abeba underscored the need for long-acting antipsychotics. For a patient who has been enjoying recovery while on one medication, switching medications would mean experiencing new sets of side-effects and figuring out a new balance. Thus, providers fear that they may see an increase in relapses and subsequent hospitalizations in the next couple of months. A caregiver of a person with serious mental illness in Addis Abeba said, “mental health is an afterthought.”
Eka Kotebe was a general hospital also providing inpatient and outpatient psychiatric care. The hospital was built with the objective of reducing mental health stigma through integrated care. It had 150 psychiatric beds and offered outpatient service for over 250 patients in a given day. The hospital was chosen for COVID19 treatment center because it served less than 400,000 patients per year and because of its location, away from the city. Nevertheless, providers and families of service users say the mental health wing has always been at full capacity.
Inauguration from October 2019.
Prime Minister Abiy Ahmed’s visit to Eka Kotebe General Hospital after its conversion into a covid19 frontline facility.
As such, there are now fewer care facilities available. Lockdown restrictions on transportation have made just reaching them a complicated affair. In the cities, strict physical distancing guidelines were enforced, and the number of passengers permitted aboard public transportation vehicles dropped by half as drivers adhered to the new regulations. To recoup losses of income incurred by the drop in passengers, transportation tariffs spiked to double what they were initially. As mental health is yet to be integrated into the existing medical care model, most mental health providers are located in urban centers. Meaning those hailing from rural parts in the country, could be on the road for as much as two days, just to get to an appointment to specialized care.
Belay is in his late twenties. He spent the last decade of his life shackled to a pole in the middle of the family’s hut, also in a town in the Gurage zone. Securing admission to a hospital was a challenge for families like Belay’s that predates the pandemic. His father sought to get him proper treatment in Addis Abeba and described being repeatedly extorted by transportation service workers who took advantage of his woes.
“We paid 90 birr, to rent a horse carriage that would take us to the bus station. The carriage guy arrived and stated that we should pay 180 birr because of my son having a mental illness. I had no choice but to give him what he asked, as there is no other way out of our village. We arrived at the bus terminal and were told that we’d have to pay 2000 birr. The rate is 60 birr per person, but since other passengers refused to board a vehicle with my son on it, we had to pay the amount. We need government assistance because I’m unable to handle the transportation and treatment. I can’t afford this anymore, I’m too old for this.”
The existing mental health providers must adapt to the rapidly evolving health care context. In Addis Abeba, families of service users reported that since the pandemic started to impact life in Ethiopia, some private mental health providers have stopped offering inpatient services to observe new physical distancing guidelines.
Similar to other low-resource settings, in Ethiopia, individual service users finance their care with an out-of-pocket payment system. In rural parts of the country, the government introduced fee waivers and cost reductions for the “poorest of the poor”. In recent years, the government introduced community-based health insurance system but its implementation has not been comprehensive nationwide. Even with these subsidies, available evidence suggests that families still struggle to cover their treatment expenses.
“I wish my district administration could issue me the certificate for cost reductions. That would have helped me get injections for half the price,” a caregiver shared. “However, even for certificates, they will ask me for a bribe. Yes, treatment is free upon presentation of a certificate, but even that certificate requires money. Forget 25 or 50 birr, for the poor saving 1 birr is tough.”
With the restrictions and the lockdowns in place, people who do not have a steady income are hit hard. With businesses closing and job layoffs aplenty, Ethiopians have been feeling the financial crunch of the pandemic for months now. Treatment is already costly, and nothing has been done to accommodate the financial difficulties many patients are likely to face. A family member who recently took her loved one to a private practice in Addis Abeba shared her experience:
“There is a big capitalist privatization of medicine or access to health. All except one of the institutions were all about making money. At one facility, you are expected to pay 1,500 birr per day, including food. Down-payment is a must and they take only cash and no other form of payment on the day of discharge.”
Access to digital information and communication technologies is key for continuing engagement with mental health providers. In other countries, innovative approaches such as telepsychiatry helped to keep people with mental health needs in care during the pandemic. Access to these innovative evidence-based treatment options, however, remains virtually nonexistent in Ethiopia. With ~18% people having access to the internet, a third of the population has access to telephone and only 30% electricity coverage, the country has one of the lowest internet penetration rates in the continent.
Lack of reliable internet access and poor telephone network service make the prospect of telepsychiatry highly unlikely in this setting. The state-owned internet provider, Ethio Telecom is known for its notoriously poor internet network and abrupt unexplained blackouts. Moreover, a vast majority of the population (~80%) inhabit rural Ethiopia. Rural residence often serves as a proxy of low-education, poor access to technology and lower socioeconomic status. These barriers to care make it tremendously difficult for people with mental health needs, especially for those with severe and persistent forms of mental illness who require ongoing treatment. Remote telephone consultations with mental health specialists located in Addis Abeba or other big cities also may not be an option because of lack of structure, patient data safety, and other related concerns.
A growing body of evidence suggests that IPV can be intensified during home isolation. Some groups may face unique and unprecedented challenges during stay-at-home orders. Evidence exists that individuals with pre-existing mental health needs are at greater risk of IPV compared to the general population. Ethiopia does not have mental health first responders. There are a few shelters to protect survivors from subsequent violence, but the need is so great.
In summary, low-income country contexts offer a delicate and complicated environment to address the pandemic while ensuring ongoing access to mental health care. Integration of mental health care into primary care settings can significantly ease the reliance on specialist care, and expand access to treatment. The need for introducing a national mental health hotline, access to counseling services and trauma-informed response at all levels is apparent. In the midst of all this, the need for measured and comprehensive response is critical. Consistent communication in the face of uncertainty could help reduce the impact of the barriers. Maintaining strong partnerships between communities and providers, flexible service delivery, and the use of creative avenues to ensure continuity of care is crucial. Our resolve and commitment to health equity will be put to test over the next several months based on how we treat those who are vulnerable and unwell. AS
Editor’s Note: Dr Maji Hailemariam is Mental Health Epidemiologist and Assistant Professor at Michigan State University College of Human Medicine. She can be reached at firstname.lastname@example.org.