Arguments

Individuals from different cultures have distinct conceptions of the person that underpin self-understanding and self-representation. These concepts influence many aspects of mental health within the biopsychosocial model, which is universally recognised and considered valid. The biological component, including genetic variations, is universal, influenced by race and environment. On the other hand, the social and/or sociopsychological component is subject to significant variations that should be taken into account in any intervention or strategy for implementing mental health initiatives in Africa.

Kpanake examined cultural concepts observed in many African cultural contexts. He found that African cultures encourage a relationship-oriented personality, shaped by three types of factor: spiritual factors, including God, ancestors and spirits influencing the person; social factors, including family, clan and community; and autonomy, which is responsible for the person’s inner experience. ^{Reference Kpanake3} The Western foundations of mental health knowledge are not universal, and their assumptions about psychosocial factors are not necessarily applicable worldwide. ^{Reference Saade, Parent-Lamarche, Khalaf, Makke and Legg4} Hence, questions arise regarding the concepts of mental health and the ideal form of personality, the concept of mental illness, and what the needs and expectations of patients are. ^{Reference Wondimagegn, Pain, Seifu, Cartmill, Alemu and Whitehead5}

Challenges

A work of reflection and collaboration by academic institutions, non-governmental organisations (NGOs) and the WHO reported various health system challenges in Africa (Table 1). ^{Reference Trudell, Burnet, Ziegler and Luginaah6} These included poor coordination between national and local authorities, inadequate drug supply, weak information systems, heavy workloads on health professionals, human resource shortages, inflexible bureaucracy, lack of follow-through among agencies in implementing programmes, constraints related to demand for care, including limited community awareness, high levels of stigma and discrimination against people with mental illness, and the various metaphysical explanatory models of illness. ^{Reference Saade, Parent-Lamarche, Khalaf, Makke and Legg4}

Another group of experts meeting in 2007 and 2008 identified other gaps, focusing on the lack of understanding of the contribution of mental disorders to morbidity and mortality, the lack of inclusion of mental health in the core health indicators, the lack of evidence from economic research, the absence of a strategic approach to human resource planning, the lack of partnerships with the social development sector, and the need for mental health professionals to have public health skills to effectively lead national advocacy. ^{Reference Hassan and Sharif7}

A review of studies on barriers to care conducted in six African countries (Ethiopia, Mali, Egypt, South Africa, Nigeria and Tunisia) found three most frequently encountered obstacles: a preference for traditional/alternative and complementary treatments (33.33%), stigmatisation of mental illness (25%) and a lack of knowledge about and/or misunderstanding of mental disorders (25%). ^{Reference Hassan and Sharif7} Other constraints highlighted in the scientific literature included extreme weather events, ^{Reference McEwen, El Khatib, Hadfield, Pluess, Chehade and Bosqui8} political instability and food insecurity. ^{Reference McEwen, El Khatib, Hadfield, Pluess, Chehade and Bosqui8}

Outlook

Real change in mental health in African countries requires innovation; therefore, explanatory models of suffering within particular populations (elderly people, children, working women, immigrants, etc.) are needed to guide the development of training programmes, research and healthcare services. ^{Reference de Oliveira, Dal Sasso Mendes, de Almeida, de Almeida, Souza Gonçalves and Strobbe9} In 2022, the WHO’s World Mental Health Report: Transforming Mental Health for All concluded that the mental health status quo will not change without significant funding. Indeed, little change has occurred over the past 20 years. ^{Reference Liu, Jack, Piette, Mangezi, Machando and Rwafa10} Changes in Africa will have to respect the continent’s resources, both human and financial. It will be necessary to define a minimum care package, such as low-threshold psychiatry (minimal mental healthcare). It will be important to specify the list of priority care activities and to define the optimal in-patient and out-patient circuits, aligning with international recommendations.

In each country, mental health managers need to establish care priorities according to the human and financial possibilities of each nation. Hence, specific mental disorders should be prioritised, such as suicidal behaviour, mood disorders, psychotic disorders and addictions. Basic primary care must be provided for in-patients (for example, sufficient psychiatric beds) and accessibility to out-patient care within the community should be ensured.

Similarly, the distribution of human resources throughout African countries should be a major objective of any mental health promotion strategy. Among the potential solutions to address the unequal distribution of mental health professionals, telepsychiatry offers a means of overcoming barriers that prevent certain demographic groups from accessing mental health services, including at least some form of psychotherapeutic treatment. ^{Reference Hassan and Sharif7} Indeed, psychotherapy delivered via videoconference has been shown to be as effective as face-to-face therapy, although it may be less suitable in certain contexts. ^{Reference Nobre, Oliveira, Monteiro, Sequeira and Ferré-Grau11} In a study conducted by McEwen et al among children and adolescents in humanitarian settings, phone-delivered psychological therapy, implemented using simplified technology, demonstrated promising evidence of feasibility and acceptability. It also showed potential to enhance access to mental health services for hard-to-reach populations. ^{Reference Sodi, Quarshie, Oppong Asante, Radzilani-Makatu, Makgahlela and Nkoana12}