Introduction
Zambia has been an independent republic since 1964, and like many relatively new post-colonial states, it has experienced challenges in developing postgraduate training in healthcare. As a former colony of the United Kingdom, Zambia has points in common with Ireland, who achieved independence just four decades earlier, and there have been historical connections between doctors in Zambia and Ireland.
There is a critical shortage of healthcare professionals in Zambia. Zambia has fifteen psychiatrists (four trained overseas) for a population of 20 million and as such is under-resourced to provide mental health services to meet the needs of the population. There is little literature on the mental health of the population of Zambia. Much of the published research in the mental health sphere has been in mental health comorbidities of other conditions such as tuberculosis, HIV and diabetes where the research has been funded to address the issues facing the management of these infectious diseases, rather than research with a primary focus on mental illness seen as a priority in its own right. (Asombang et al., Reference Asombang, Helova, Chipungu, Sharma, Wandeler, Kane, Turan, Smith and Vinikoor2022; Chishinga et al., Reference Chishinga, Kinyanda, Weiss, Patel, Ayles and Seedat2011; Hapunda, Reference Hapunda2022; van den Heuvel et al., Reference van den Heuvel, Chishinga, Kinyanda, Weiss, Patel, Ayles, Harvey, Cloete and Seedat2013)
Global Mental Health has been defined by Collins as:
“an evolving field of research and practice that aims to alleviate mental suffering through the prevention, care and treatment of mental and substance use disorders, and to promote and sustain the mental health of individuals and communities around the world. It prioritizes equity, and is informed by many disciplines, including neuroscience, genomics, social sciences (especially psychology, medical anthropology and sociology), epidemiology, health services research, and implementation science. Advocacy plays a central role in the dissemination and translation of evidence into actionable policies and plans for communities, health systems and policy-makers to implement.” (Collins, Reference Collins2020)
Internationally, global mental health allows for the development of various initiatives to foster joint learning and to be considered along with global priorities such as sustainability. (Patel et al., Reference Patel, Saxena, Lund, Thornicroft, Baingana, Bolton, Chisholm, Collins, Cooper, Eaton, Herrman, Herzallah, Huang, Jordans, Kleinman, Medina-Mora, Morgan, Niaz, Omigbodun, Prince, Rahman, Saraceno, Sarkar, De Silva, Singh, Stein, Sunkel and UnÜtzer2018) It is widely acknowledged that there is a need for a joined-up approach to brain health globally. (Winkler et al., Reference Winkler, Gupta, Patel, Bhebhe, Fleury, Aukrust, Dua, Welte, Chakraborty and Park2024) Other Global Mental Health projects have had significant success in developing programmes which transcend individual nations and continents, such as the Scotland-Malawi Mental Health Education Project. (Baig et al., Reference Baig, Beaglehole, Stewart, Boeing, Blackwood, Leuvennink and Kauye2008). Similarly the Toronto Addis Ababa Academic Collaboration between Ethiopia and Canada, and the Centre for Global Mental Health at King’s College London supports a range of initiatives in partnership with a number of African countries, including an African-led network of mental health researchers. (Chibanda et al., Reference Chibanda, Abas, Musesengwa, Merritt, Sorsdahl, Mangezi, Bandawe, Cowan, Araya, Gomo, Gibson, Weiss, Hanlon and Lund2020; Wondimagegn et al., Reference Wondimagegn, Pain, Baheretibeb, Hodges, Wakma, Rose, Sherif, Piliotis, Tsegaye and Whitehead2018)
The primary aim of the collaboration (the Zambia-Ireland Psychiatry Academic Collaboration: ZIPAC) is to utilise the principles of Global Mental Health (Johnson et al., Reference Johnson, Malimabe, Yoon, Osborn, Falgas-Bague and Swahn2025) to build an academic partnership between training bodies, universities and psychiatrists in Zambia and Ireland fostering mutual learning, Zambian-led research, and the sharing of educational resources and knowledge.
The secondary aims are to:
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Support post-graduate training in psychiatry in Zambia leading to increased capacity in the mental health service and improved mental health care for people living in Zambia.
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Improve awareness and competence in international psychiatry in the Irish mental health service.
Current model of mental healthcare provision in Zambia
Mental health care delivered by specialists is available only in the capital, Lusaka. Outside of the capital, care is provided on an outpatient basis by clinical officers. In Lusaka, both inpatient and outpatient care is provided at the single psychiatric hospital, called Chainama Hills Hospital, which has 210 beds. The hospital has six large units: a male unit, a female unit, a forensic psychiatry unit, an addiction unit, a physical healthcare unit and a private unit. These units are staffed by 15 psychiatrists (four trained outside Zambia), doctors undertaking postgraduate training in psychiatry, approximately 130 mental health nurses (90 of whom have training in mental healthcare) and clinical officers. The average duration of inpatient stay is four to seven days. There is severe pressure on beds, so admission is reserved for acute stabilisation with rehabilitation occurring in the community. Families are often quite heavily involved in caring for patients, with visiting permitted all day. About 60% are very supportive; others are less engaged. Patients are usually reviewed in the outpatient clinic two weeks after discharge and can be recalled to the hospital if required. It was reported that the discharge home can be challenging, with stigma and social factors having an impact on reintegration into the community.
Mental healthcare is also provided at the University Teaching Hospital in Lusaka, a tertiary general hospital with 1,655 beds. However, there are no inpatient psychiatric beds. The hospital has a busy psychiatry outpatient clinic, and the psychiatry team also sees patients referred from the medical and surgical wards.
Outside of the capital, mental healthcare is delivered by clinical officers at generic health clinics in local areas, and these represent the largest part of the mental health workforce. The Clinical Officers have specific training: those who work in Mental Health are Clinical Officers in Psychiatry. They undergo three-year a Diploma in Clinical Licentiate with an internship (last 7 months of their 3-year programme) at a Mental Health Institute.
A paper in 2004 reported that people experiencing mental illness were likely to seek assistance from traditional healers before approaching medical services. (Mayeya et al., Reference Mayeya, Chazulwa, Mayeya, Mbewe, Magolo, Kasisi and Bowa2004) This was approximately one-third in those admitted for treatment of psychosis. (Mbewe et al., Reference Mbewe, Haworth, Welham, Mubanga, Chazulwa, Zulu, Mayeya and McGrath2006) Of those admitted to hospital with a psychotic disorder there are high rates of comorbidity with both substance misuse (56% in males) and HIV/AIDs (9%). (Mbewe et al., Reference Mbewe, Haworth, Welham, Mubanga, Chazulwa, Zulu, Mayeya and McGrath2006)
In Zambia, it can be challenging to access the full range of psychotropic medications, with two to three commonly available in each category of antidepressants, antipsychotics, etc. Substance misuse was described as a significant challenge with alcohol, cannabis, cocaine, and heroin the most commonly used substances. Suicide was described as a major problem, with organophosphate poisoning a common cause of death. (Paul et al., Reference Paul, Panchal and Zimba2017)
The Mental Health Act, 2019 was passed by the National Assembly of Zambia which repealed the earlier Mental Disorders Act, 1949. (Zambia, Reference Zambia2019) It outlines the standards of care for people requiring treatment in Zambia and outlines the structures and functions of the National Mental Health Council, which include to “promote and protect the rights” of people with mental illnesses and to “facilitate the development of integrated, effective and efficient methods or systems of providing mental health services at all levels.” (Zambia, Reference Zambia2019) It is progressive in its aims, especially in aspiring to parity of esteem with physical health care, but has been criticised for its wording around legal capacity. (MHUNZA, 2019; Sheikh et al., Reference Sheikh, Jato, Msoni, Paul and Maila2021) Zambia’s Mental Health Act of 2019 provides for involuntary admission, but few people are admitted as involuntary patients. Some psychiatrists also offer private care on an outpatient basis in the capital, Lusaka.
Current model of postgraduate training in psychiatry in Zambia
There are two postgraduate training programmes, one run by the University of Zambia (UNZA) and the other by the Ministry of Health via the Zambia College of Medicine and Surgery (ZACOMS), which is based in Chainama Hills Hospital. The ZACOMS programme is called the Specialist Training Programme (STP). Currently, there are no membership examinations for postgraduate trainees, although in recent years there has been the development of licenceship examinations as part of undergraduate medical training. The University of Zambia is the main medical school for undergraduates, although a number of private medical schools have opened in recent years, adding to the teaching duties of the small number of psychiatrists.
The UNZA programme has been running since 2010. It is a four-year training programme with a broad curriculum leading to a Master’s degree in psychiatry (MMedPsych). The programme is under the aegis of the Ministry of Education (not Health). The number of doctors participating is small, typically ranging from 1 to 3 per year (well below full capacity of 15 trainees), with three psychiatrists providing teaching and supervision. The MMedPsych focuses on clinical training and research, and trainees have one day of protected academic time each week. In the past, some of the trainees had access to a three-month period of travel overseas for training in child psychiatry and forensic psychiatry, which is currently unavailable in Zambia.
The STP is newer and is described as competency-based and clinical; it lasts four years. Those who graduate from the STP are awarded a Specialist Fellowship with ZACOMS, the post-nominal FZCMS (Fellowship of the Zambia College of Medicine and Surgery). The two postgraduate training programmes have totally different curricula. Just two doctors in total graduated from the two programmes last year.
There are no subspecialists in the country. There is a severe deficit in human resources to teach and train postgraduate doctors, with the small existing number of psychiatrists being stretched in providing a service to a large population in addition to undergraduate medical education. The fact-finding visit identified that child psychiatry and addiction psychiatry were key gaps, as well as access to training in psychotherapy skills and supervision.
Barriers to development
The barriers identified included the paucity of senior psychiatrist time for the delivery of postgraduate teaching and clinical supervision of trainees. The trainees reported that training is self-directed in the main and there is a need for additional supports in attaining their learning goals. Another barrier identified by trainees was the lack of availability of hospital internet provision. There is a need to have a consistent standard of training across the two programmes, and some joined-up working, in order to avoid duplication of teaching and training. In addition, clinical and service delivery pressures often compete with the time and resources needed for training, making it difficult for both trainers and trainees to prioritise educational activities. These competing demands can lead to variability in training quality and reduced opportunities for meaningful supervision and mentorship. Many of the barriers could be addressed by forming a partnership between the relevant Zambian training bodies and an Irish training body.
ZIPAC
ZIPAC had its origins in a Zambia project, initiated by one of the authors (JS), in the Special Interest Group in Global Mental Health (SIGGMH) in the College of Psychiatrists of Ireland. Established in 2021, the SIGGMH aims to raise awareness of global mental health and to explore the clinical, educational and research applications and collaborative opportunities in the field. It embraces the principles of mutual partnership and benefit with due respect to the autonomy of global partners. Having worked in Zambia, one of the authors (JS) was aware of existing global health inequities and the critical shortage of doctors and other health and social care professionals in Zambia. In order to explore training needs, in 2021, he initiated contact with senior psychiatrists (RP, FB) in Zambia and established a working group in Ireland consisting of both consultants and trainees. Prior to this, another of the authors (FMcN) had delivered a two-day one-off teaching event in child and adolescent psychiatry in Zambia in November 2017, in response to the recognised paucity of training opportunities in this subspecialty. These initiatives were consistent with the UN Sustainable Development Goals and the Irish government’s development policy, A Better World, which promotes the “furthest behind first.” (Ireland, 2019; UN, 2015) The next step was a fact-finding and relationship-building visit to Zambia in 2023 where four Irish psychiatrists (AD, FF, FMcN, JS) travelled from Dublin to Lusaka. This allowed for some preliminary meetings with senior psychiatrists and the establishment of a preliminary basis for a partnership. The visiting group brought clinical expertise spanning general adult psychiatry, child and adolescent psychiatry, liaison psychiatry, perinatal psychiatry, and psychiatry of substance use disorders. In addition, members of the group were affiliated with academic institutions, including the College of Psychiatrists of Ireland and University College Dublin, providing valuable insight into academic accreditation processes and structures.
In 2024, a reciprocal visit to Ireland of two Zambian psychiatrists (FB, RP) took place. The psychiatrists were welcomed to the College of Psychiatrists of Ireland and were met by the College President. They met with Irish psychiatrists and doctors undergoing post-graduate training in psychiatry. They conducted site visits across general adult, substance use psychiatry, and child and adolescent psychiatry settings. In Leinster House (Irish Houses of Parliament), they met with the Minister of State with responsibility for the National Drug Strategy. Other meetings involved representatives of Irish Aid and the HSE Global Health Programme.
Following the visit, a primary goal was agreed, which was to increase overall capacity in the mental health services in Zambia, by supporting the postgraduate training programmes for psychiatrists. To do so will involve working with both the Ministry of Education/ University of Zambia/ MMedPsych programme and the Ministry of Health/ ZACOMS/ STP programme. Due to advances in telemedicine, most of the work will be done remotely, online.
It was agreed that the means to achieve our common goals would be to focus on the quality of teaching, training, and research. Priorities were agreed which included the establishment of a research training and supervision programme, shared online case conferences and journal clubs, and a review of the curriculum of the STP programme. To date, a series of eight half-day research seminars, and one-to-one individual research mentorship have been delivered and are currently being evaluated. More ambitiously, discussion about the development of a child and adolescent mental health service and the development of a substance misuse service for Zambia took place. A business case was submitted to the Department of Health and has been successful in securing funds to support the development of a Substance Use Disorder service in Zambia.
Mutual benefits of the ZIPAC programme
The collaboration will significantly enhance cultural awareness among psychiatrists and trainees in Ireland, deepening their knowledge and understanding of international psychiatry. This endeavour is genuinely shared, with Irish trainees actively contributing to and attending on-line research seminars, as well as engaging in one-on-one mentoring on individual research projects, supervised by a senior colleague based in Ireland or Zambia. The evaluation of these workshops will also form a component of an Irish NCHD’s Master’s in teaching and education. This bidirectional approach will foster authentic mutual learning. The ZIPAC initiative, has already received significant support within the Global Mental Health Special Interest Group in the College of Psychiatrists of Ireland and has been approved by the Board of the College of Psychiatrists of Ireland. This projects aims to develop joint teaching where Zambian and Irish trainees can learn together. While there are differences in the social context, in cultural manifestations of distress and in the availability of treatments, there are sufficient areas of commonality. Indeed, the differences may provide some of the richest learning. As the Irish population becomes more diverse it is increasingly important that trainees in Ireland have a better understanding of mental health presentations and services in other parts of the world.
Conclusion
Based on parity of esteem, ZIPAC has the potential to be of benefit to the psychiatrists and trainees in both Ireland and Zambia. Ongoing engagement between Irish and Zambian colleagues is helping to ensure that the intended collaboration is responsive to local training needs, culturally sensitive, and feasible within the broader constraints of service demands, infrastructure, and available resources. The collaboration also aims to bring together two distinct educational schemes under one roof, promoting integration while respecting local contexts and systems. The agreed programme will assist in the development of a sustainable mental health service and the strengthening of the health system in Zambia. The collaboration will increase cultural awareness among psychiatrists and trainees in Ireland and deepen their knowledge and understanding of International psychiatry. This programme is mutually beneficial and has the potential to greatly improve relationships between the two nations.
Funding statement
This work was supported by a Seed Grant from Esther Ireland.
Competing interests
AMD and FMcN are on the editorial board of the Irish Journal of Psychological Medicine; they were not involved in the review process of this paper.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that ethical approval for publication of this perspective piece was not required by their local Ethics Committee.
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