Model Mental Health Care in Rwanda

Hategekimana Bashar first began suffering from hallucinations and paranoid delusions when he was 26 years old. Dismayed, his family watched his behavior change until he was unable to care for himself, let alone his farm or cherished livestock. They tried to help—they even consulted a variety of traditional healers—but nothing seemed to work. At a certain point, desperate, they had no option but to tie him up at home to keep him from what they felt would be even greater harm.

Relief eventually came in the form of Sifa Dorcas. A year ago, community health workers told Dorcas—the mental health social and community support coordinator at Inshuti Mu Buzima, as PIH is known in Rwanda—about Bashar’s predicament. Dorcas visited Bashar’s family and raised the possibility that Bashar was suffering from a serious mental illness, and that treatment would be able to help him function in the community again. Dorcas accompanied Bashar and his family to Kinyababa Health Center, where Bashar was diagnosed with schizophrenia.

At the time, Dorcas was working with government health center nurses who IMB has trained and supported in delivering mental health care to people living in rural areas. This health center-based model of mental health care is new for the country, started in 2012.

About 1 in 100 people globally suffers from schizophrenia, a biological illness. Per PIH’s model, Bashar and his family received education about his illness, as well as caregiver support, social assistance, and medication support by a public primary care nurse supervised by a psychiatric nurse (both Rwandan Ministry of Health staff) who travels to the health center from Butaro District Hospital, a hospital built by the government in collaboration with PIH.

The improvement was as immediate as it was marked. Within a month, Bashar’s hallucinations stopped and he was able to farm and participate in community activities again.

Such are the transformations that PIH’s mental health team strives for, and sees, daily. While much of the world still, somehow, debates the idea that quality mental health care can be effectively provided to people in poor countries, PIH’s mental health leaders are working with governments to push ahead in treating neuropsychiatric disorders such as depression, schizophrenia, bipolar disorder, and epilepsy.

With the “radical” idea that people have a moral obligation to eliminate suffering when they can, PIH Mental Health Director Dr. Giuseppe Raviola and colleagues are advising dedicated mental health teams at PIH’s 10 partner country sites to develop safe, culturally sound, evidence-based, and dignified programs that focus on integrating mental health care into the organization’s public health systems-strengthening efforts.

That’s no small challenge. “Mental disorders impose an enormous burden on society,” states the overview to “Out of the Shadows: Making Mental Health a Development Priority,” a two-day conference hosted in April by the World Bank, headlined by researchers from institutions such as Harvard University, the World Health Organization, and the United Nations, and featuring PIH’s work in Rwanda, Haiti, and Peru. Roughly three-quarters of people who experience a mental disorder come from poor countries—precisely the kinds of places with the fewest resources available for mental health care. Indeed, in low-income countries, upwards of 90 percent of people receive no care for a treatable illness such as Bashar’s.

It was the high burden of mental disorders coupled with the dearth of psychiatrists and other specialized mental health professionals that caused PIH to begin applying its expertise to mental health care. 

Bashar and Dorcas confer near his family home. A year ago, Dorcas helped Bashar, a farmer who was suffering from hallucinations and paranoid delusions, get his illness diagnosed and treated.

In Rwanda, PIH’s efforts began in 2009 with the establishment of IMB’s first mental health team to support the Ministry of Health’s goal to integrate mental health care at district hospitals. Over the past seven years, the program has grown from a small community education program to a robust team supporting quality mental health care at district hospitals and health centers, with support provided by community health workers.

Each player in this comprehensive system has a key role in helping people such as Bashar to feel better, and in supporting their families. Primary care nurses provide support, medications, and education. Government-employed supervisors travel to the sites to mentor frontline nurses. Community health workers support family caregivers and help people access care.

The IMB mental health team, comprised of Dr. Christian Rusangwa, Hildegarde Mukasakindi, Beatha Nyirandagijimana, Dorcas, and others, has worked closely over the past five years with PIH’s cross-site mental health team and Dr. Stephanie Smith to track the clinical and economic progress of 150 patients in Burera district. Findings suggest marked improvements, with both symptoms reduced and functioning improved by over 50 percent in the vast majority of patients. The program works, and it now serves more than 1,200 people via 15 decentralized health centers in Burera district. It is increasingly held up as a model for possible scale-up across the country.

The program may also fuel the world’s increasing appreciation of the burden of mental disorders. In September 2015, the U.N. included “promote mental health and well-being” in the Sustainable Development Goals, 17 goals that world leaders agreed to try to meet before 2030. And in April 2016, dozens of foreign ministers gathered in Washington, D.C., to hear experts from the World Bank, WHO, and the field argue the case for increased spending on mental health, citing new evidence that the return on investment for mental health care is up four-fold.

Bashar and his family’s experience show firsthand how small investments in mental health care pay off. Bashar no longer suffers from debilitating hallucinations and paranoia, and his illness is treated. He does the washing and collects water from the well. He walks to the clinic independently to receive care. He cooks for his busy sisters and mother.

“I am very happy,” says his mother. “Now I agree that everything is possible and will usually praise God.”