Cordial greetings from TUSPO – (Tanzania Users and Survivors of Psychiatry Organization) Tanzania. As members of the Global Forum for Community Mental Health we thank the forum for realizing TUSPO’S contribution towards providing community mental health services in Tanzania. In the context that the Global Forum website is an implementation of the second main objective of the Geneva Conference i.e. “to share selected experiences of regional and country activities on community mental health services and to derive some lessons” we would like, as TUSPO, to narrate here our experience in Tanzania as a low – income country. It is our hope that the African context of community Mental Health will be explored from our point of view. As an exploration from a low-income country the reader may well find the paper to be critical of the system, as it identifies the barriers that community mental health services are confronting, rather than manifesting the positive side of its implementation. This, as one can note, is not a deliberate move but a spontaneous consequence of the socio – political economic situation in many lesser developed countries. To provide a good understanding of this situation I will describe the situational analysis of these socio – political economical aspects one by one and try to relate that situation to the possibility of whether or not a community mental health approach can be smoothly workable.    

 Tanzania is one of the poorest countries south of the Sahara desert, with per-capital income of 164 USD of which only 4 USD is spent on health. The remaining 160USD is spent on food, shelter and clothes. Worse still, the 4 dollars spent on health goes to physical diseases like malaria, tuberculosis and HIV/AIDS leaving nothing to be spent on mental health in general and mental illness needs in particular.  Yet village poverty compels an influx migration of youths to urban centers to seek employment, this leads to urban overcrowding, poor housing (SLUMS) and sanitation which leads in turn to a more stressful life and therefore an increased chance of mental illnesses. Due to unemployment there is also high levels of crime + prostitution. Cultural integration and rapid advances in information technology, exposeses youths to negative cultures, much to their disadvantage. With so little financial resources allocated then CBR remains a nightmare.  

   Institutional wise, mental health resources are almost not available. Only one Mirembe Central Psychiatry Hospital, with inpatient admission capacity of 600 beds, is expected to serve the vast country of 945sq km and the estimated population of 1,000,000 patients suffering from psychiatric illnesses. The number of mental health workers is also profoundly limited to cope with the existing large numbers of mental patients. The country has about 11 psychiatrists in public service, 1 clinical psychologist, 9 AMO in psychiatry, 8 social workers and roughly 250 psychiatric nurses doing mental health duties. All these professionals are clustered in towns and leave the entire village population, which is 80% of the total population of about 40,000,000, without mental health workers and therefore mental health services. (Mbatia and Kilonzo 1999 pg – iii) The same trend follows. We need community level workers and medical social workers plus occupational, psychological and biological therapists in every locality as a team to implement community mental health. With such a number of professions, Tanzania remains miles away from CBR.    

Tanzania like many other world nations is severely affected by the HIV/AIDS epidemic, which has increased afflictions of mental health problems that lead to a rising mortality rate among young adults who form the larger part of  the labor force of the country. The incidence of tuberculosis has increased dramatically in the last two decades driven by the spread of HIV/AIDS infection. This increase is a blow to the government budget which is already stricken by other factors such as low literacy level contributing to poverty. These factors further elevate the poverty levels and contribute to the rise in psycho-social problems.   

    In Tanzania most people view psychiatric illness not as disease but as a curse, a product of both witch craft and evil spirits of which the patient himself is counted as the main contributor. This self generating attitude of mental illness leads to psychiatric stigma, and laxity by the community to take care about the illness, causing patients to go without drugs for a long time which leads in turn to chronicity. People neither tolerate nor try to understand people with mental illness as they already blame them for having self generated the disease. Where drug treatment could be effective/ available  (hardly as it is now) there is a tendency for patients to refuse to take them, and due to a lack of  these drugs being available in the government hospitals patients fail to purchase them due to high prices in the private infirmaries. This leads to relapse of the disease and creates further complications. Due to supernatural beliefs most of the patients are attended by traditional healers where stressful methods of treatment are adopted, such as skin burning etc. These methods accelerate the degree of the illness of the patients. Statistical data on the status of mental illness are difficult to collect as many cases end up with traditional healers. Planning for services and allocation of resources rely merely on hospital data which is unrealistic.     

  Others problems are related to illicit drug abuse and trafficking. These problems have been alarmingly on the increase in Tanzania. The negative socio – economic effects of drug abuse are now enormous and complex. Alcohol is the most commonly used drug while tobacco and cannabis leave aside heroin, and mandrakes are affecting youth population and just like HIV/AIDS lead to mental illness and high mortality rate among this crucial productive force.  Drug abuse in various forms ranging from alcohol to heroin is quite common in the TUSPO’s target group and is seen as a ground for psychiatric disease. Ironically, while the government is waging war against drug abuse it has made tobacco and alcohol industries among its very important source of its budget. A number of citizens are beneficiaries of illicit drug business, making Tanzania one of the greatest routes in Africa. With such conflicting interests, implementation of community mental health becomes even harder.    

  There is also another reason why community mental health policy is not possible to implement in Tanzania. This other reason is Gender. A circumstance that is likely to victimize women in particular is the misconception that sexual intercourse with a disabled person lessens the risk of contracting AIDS. The survey conducted by the disability movement of Tanzania within African Decade Framework discloses for instance a form of sexual abuse where men outside the disability sector abandon disabled women whom they have made pregnant. Most of the village population still cling to traditional values of circumcision and patriarchal attitude where women are objects of production and child rearing, succumbing to decisions taken by men and have no voice. Self determination inside and outside psychiatry by a woman patient and access to community mental health services remains at the discretion of male alone.

 Lack of formal laws and praxis on mental health is quite another hindrance. An official policy documented for mental health in general and mental illness in particular has not been adopted forty five years after the country attained its independence, although there are some indications that one will be adopted propinquity. The few laws directed towards the rights of disabilities in general are not in touch with the times and they are also quite inadequate. People with mental illness are not represented in the National Assembly or any other decision making organisation. How can one, for example, provide local access to services to a patient whose parents believe totally that their relative is bewitched and therefore opposes community mental health services provided to the patient?  Does the law of the land provide for his right to obtain treatment? How do the law enforcers make sure that such a person obtains that fundamental right? How does the law view cohesion and stigma? What is TUSPO’S legal base of arguing against such deeds? Etc. Without concrete laws, community mental health lacks an important wedge on which to hold on. As a conclusion community mental health and its implementation is directly related to the poverty level of the country concerned. The Global Forum to our opinion should set criteria on the level of poverty (poverty status) at which a nation should set itself in motion towards CBR. Are there stages in which a country should pass before it adopts CBR? Is CBR the end or means towards primary Health care? And if it is the means, is it possible to implement if even base hospitals, drugs and professionals are not available? Maybe these are issues the Global Forum should address soon.