Prior to the COVID-19 pandemic, mental health in Africa was a major concern with the
continent underperforming on several key mental health metrics, including the numbers
of hospital beds for patients with mental illness and coverage of outpatient facilities
being lower than the global average.
Crick Lund, Professor at the Alan J Flisher Centre for Public Mental Health (University
of Cape Town, South Africa) notes that due to the numerous challenges that African
countries are dealing with, including poverty, infant and maternal mortality, and
infectious diseases, the importance of mental health had been overlooked. He adds
that the state of mental health in Africa has also been compounded by factors including
low awareness of mental health conditions, stigma, and the perception of mental health
illnesses as untreatable. These issues not only affect the mental wellness of Africans,
but also the practice of mental healthcare. Africa also has a mental healthcare expertise
problem; most countries with the fewest mental health professionals per 100 000 population
are in Africa.
Olatunde Ayinde, a Nigerian psychiatrist, tells The Lancet Digital Health that few
doctors are choosing to specialise in psychiatry because of stigma associated with
“Not only are clients stigmatised, even we who are psychiatrists are also stigmatised.
There is that differential preference of medical graduates for specialties other than
psychiatry,” Ayinde says.
On Oct 10, Africa joined the rest of the world in celebrating World Mental Health
Day. As well as bringing attention to the state of mental wellness across the continent,
this year it also drew attention to the impact of the COVID-19 pandemic. Aside from
exacerbating mental illnesses among patients with a history of mental health conditions,
the socioeconomic impacts of COVID-19 can also precipitate mental illnesses in individuals
without any previous history. Unlike economies that were able to provide social safety
nets for citizens during and beyond lockdown, Africans in most countries had to deal
with the effects of the pandemic with little or no social support, putting them at
risk of conditions including anxiety and depression.
In May, 2020, the Africa Centres for Disease Control and Prevention issued guidance
for mental health and psychosocial support during the COVID-19 pandemic. Similar to
WHO guidance, it provides practical steps to reduce stress, anxiety, stigma, and psychological
disorders associated with COVID-19 and improve overall mental health and wellbeing.
But despite such guidance, the COVID-19 response measures introduced by many African
countries largely excluded mental health provisions, even though need for them soon
Mental health specialist Victor Ugo leads the team at Mentally Aware Nigeria Initiative
(MANI). He argues that the lockdown measures triggered mental illnesses, and exacerbated
already existing mental health conditions.
“One of the key things we know that doesn't help with mental health problems is isolation.
We now have people who are more lonely, jobless, and now have more reasons to be hopeless.
They struggle to keep food on the table. So we're seeing increasing levels of stressors.
Those also apply with those that have mental health conditions.”
The surge in mental health stressors, Ugo says, culminated in an increased demand
for mental health services which could not be met as many hospitals were only attending
to COVID-19 cases and very severe emergency cases; other patients, including patients
with mental illnesses, were asked to go back home.
With hospitals now reopening and patients returning to clinics, a backlog has been
created. Moreover, with COVID-19 measures requiring social distancing, appointment
times are now being spaced out, and in the few hospitals with psychiatrists, patients
may not get an in-person mental health therapy session appointment until 2021.
Several countries in Africa, including Nigeria, Ghana, South Africa, and Kenya, already
have a telecommunications density exceeding 100%, and according to the Global System
for Mobile Communications (GSMA), mobile telephone connections in sub-Saharan Africa
are expected to increase from 816 million in 2019 to 1·05 billion in 2025. The Mobile
Economy 2020 report further predicted that smartphone connections in sub-Saharan Africa
will nearly double by 2025. Realising that more Africans will continue to have mobile
devices with which they can be potentially reached with information, African disease
control agencies and partners began to roll out technology-based services to aid efforts,
particularly addressing COVID-19 misinformation and providing information on local
Technology-based services are also aiding efforts to clear the mental health backlog.
Prior to the COVID-19 pandemic, patients seeking mental health consultations were
required to visit the hospital and be booked for an appointment if necessary. But
COVID-19 has forced a reawakening. Even though in-person consultations are still happening,
attention has shifted to expanding access using telehealth methods as it is now easier
and quicker to book a virtual session than pursue the conventional approach. Across
Africa, mental health tech startups including Wazi in Kenya, PsyndUp in Nigeria, MindIT
in Ghana, and the MEGA project in South Africa and Zambia are joining local and national
associations of psychiatrists who are providing free virtual online mental health
consultations, to provide easier and quicker access to mental health services.
Although the pandemic has driven more attention to telemedicine, not only for mental
health but also for other aspects of healthcare, Ayinde argues that this paradigm
shift predated COVID-19.
“Before the pandemic, many places were already putting in place virtual consultations
for and beyond mental health,” he says, describing telemedicine for mental healthcare
as an emerging platform for general healthcare delivery that is allowing him to deliver
counselling services to patients in any part of the world in real time.
“Even though the human touch is missing, patients are still able to get the service
which is still better than nothing.” He adds that the approach enables African countries
to increase access to mental healthcare while maximising the scant mental health resources.
“In a situation where mental health resources are scarce and people are widely dispersed
across the regions, online is a useful platform.”
Ugo, on the other hand, argues that online counselling is as effective as in-person
“We have to start thinking about how to ensure that services become available to people,
we have to think about telehealth services. They are well advanced. It's not a case
of one replacing the other; I will say it's about combining different approaches.”
Since the pandemic forced organisations like Ugo's to suspend in-person activities,
they have moved more of their operations online, and this approach is emerging as
a great opportunity for the organisation to expand to more locations at reduced cost.
“If we want to reach as many people as possible in Nigeria, we are not going to have
offices in every state. Most of our volunteers are healthcare professionals who have
their own jobs and we don't want to take people away from their jobs. They don't have
to leave their comfort zones and their office space to counsel people physically.
But it comes down to people's preferences,” Ugo says.
Ayinde notes that online mental health consultations have gone from an ambitious idea
to “the new normal” while Ugo adds that MANI had to acquire more capacity—technology
and personnel—for it to be able to handle the additional number of users of its online
Hauwa Ojeifo, founder of mental health-focused platform She Writes Woman, said traffic
to its associated helpline has increased by over 60% since the pandemic began to hit
African countries and 80% of inquiries were on how to cope with uncertainty, fear,
Since the outset of the pandemic, telehealth service providers have rapidly scaled
offerings and are seeing 50 to 175 times the patients via telehealth than they did
before the pandemic. Africans are opening up to telemedicine for mental health and
are joining the rest of the world in using social messaging tools such as WhatsApp
to provide telemedicine services.
Habiba Amin, a Mental Health Practitioner working in emergency COVID-19 response in
Nairobi, Kenya, revealed that online platforms are also being deployed to help citizens
through daily strains, such as isolation, unemployment, and a disrupted social life,
that were brought about by the pandemic.
In Ghana, misinformation regarding COVID-19 was a stressor for anxiety, fear, and
confusion among citizens, which was why Atsu Latey and his team at MindIT Ghana created
the Telegram chatbot to address this issue.
MANI is pushing the limits of virtual interaction to ensure Nigerians in need of its
services continue to stay socially connected and engaged, even though they cannot
physically meet in groups.
“We set up programmes on our social media pages that encourage people to participate—something
like a community. You join a bookclub for example, movie night, something to keep
people occupied and to provide an outlet for the struggles and difficulties they are
facing,” Ugo said.
In their review of Kenya's mental health response to COVID-19, Florence Jaguga and
Edith Kwobah, psychiatrists at Kenya's Moi Teaching and Referral Hospital, recommended
that the country's 24h COVID-19 call centre should be expanded to incorporate delivery
of brief psychological interventions to the general public.
However, although African psychiatrists welcome the concept of leveraging web-based
tools for counselling and therapy sessions to maximise the few mental health professionals
on the continent and to expand access to professional care, concerns now exist regarding
the standardisation of online mental health practices.
In South Africa, the mHealth policy that was introduced in 2015 provided no guidance
on the use of telemedicine for the delivery of mental healthcare. The implication
of this, according to Andrew Wooyoung Kim, human biologist and medical anthropologist
at Northwestern University (IL, USA), is that there is no standard of service delivery
for telemedicine platforms in mental health care, and a lack of clarity regarding
liability—largely leaving the regulation of the services to their providers.
Despite the numerous bottlenecks facing telemedicine for mental health in Africa,
Ugo feels the pandemic has drawn attention to a threat to mental wellbeing that can
only be properly controlled by ensuring access to services, and online platforms are
emerging to fill the wide gap—both in the short term and long term.
“Most importantly for us, we want to make sure people have someone to talk to. With
COVID-19 exacerbating mental health, we need to start integrating mental health into
the conversation right from the start [because] in crisis situations, people are more
likely to develop mental health problems.”
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