By Jean Baptiste Ndabananiye
We promised, in our last article, that we would produce an article responding to “What unseen gaps are preventing Africa from breaking free from persistent mental health barriers to economic resilience?”
Seeking to fulfill that promise, through a careful analysis of these hidden challenges, this piece aims to shed light on the factors that are continuing to restrain progress and discuss potential pathways toward sustainable economic strength. This piece consists of these parts:
- Gaps in mental health, despite a vow spanning more than two decades
- Role of colonization, as a key reason behind those gaps
- Recommended action, to holistically address the crisis not only in Africa
- What are African systems which can fulfill a great role in mental health disorder treatment?
- Conclusion
Gaps in mental health, despite a vow spanning more than two decades
BMJ Global Health is an open access, online journal dedicated to publishing high-quality peer-reviewed content relevant to those involved in global health, including policy makers, funders, researchers, clinicians and frontline healthcare workers.
BMJ Global Health published a paper titled “Reimagining Global Mental Health in Africa” on 4 September 2023. It argues that Western mental health approaches, despite being promoted as universally effective, are inadequate for addressing mental health challenges in Africa. Life In Humanity also concurs with this perspective, recognizing that context-sensitive mechanisms remain crucial for effectively tackling mental health issues on the continent. A renowned physician, Dr. Jeffrey Rediger— in these articles: Spiritual health, thoroughly explained for you to deeply understand it. “Western medicine has it all wrong” and Once a skeptic of spiritual healing, a prominent physician is now its fervent promoter— underscores the point that Western ways of health are extremely mistaken.
The paper was written by six authors. They include Dawit Wondimagegn, Nardos Seifu and Azeb Asaminew Alemu from the College of Health Sciences in Addis Ababa University in Ethiopia. The remaining ones involve Clare Pain, Carrie Cartmill and Cynthia Ruth Whitehead. The last three work for the Department of Psychiatry at the Temerty Faculty of Medicine at the University of Toronto in Canada, the Wilson Centre at the University Health Network and Temerty Faculty of Medicine/ University of Toronto as well as the Wilson Center, the Department of Family and Community Medicine at the Temerty Faculty of Medicine/University of Toronto and Women’s College Hospital, Toronto, Ontario, Canada respectively.
The paper first addresses WHO’s World Health Reports and 10 recommendations, an initiative spanning over two decades. WHO launched the World Health Report most specifically addressing low-income and middle-income countries (LAMICs) in 2001. It emphasized upon the importance of mental health (MH), identifying the severe public health impacts of mental ill health. This paper reads “Year 2001 was a critical juncture in the development of global mental health (MH). That year, the WHO launched The World Health Report under the theme ‘mental health: new understanding, new hope.
This report highlighted the critical role MH has in promoting the well-being of individuals, societies and nations at large. The 2001 World Health Report was identified as ‘one of the earliest and clearest global MH frameworks. it made 10 recommendations to drive the development of MH services globally, but most importantly in LAMICs.”
The recommendations involved (1) provision of MH care in primary care settings, (2) increasing availability of psychotropic medications, (3) provision of care in the community, (4) the need to educate the public about MH, (5) involvement of families, communities and consumers in care provision, (6) establishing national policies, programs and legislations, (7) development of human resources for MH, (8) the need for intersectoral collaboration, (9) monitoring of community MH, and (10) the need to support more MH research.
In 2022, the WHO released another world MH report and reaffirmed the 10 recommendations, while concluding that ‘business as usual for MH will simply not do’ without higher infusions of money.
BMJ Global Health’s paper nevertheless suggests the reason for so little change over the last 20 years is due to the importation and imposition of Western MH models and frameworks of training, service development and research on the “assumption they are relevant and acceptable to Africans in LAMICs. This ignores the fact that most mental and physical primary care occurs within local non-Western traditions of healthcare that are dismissed and assumed irrelevant by Western frameworks.”
“These trusted local institutions of healthcare that operate in homes and spiritual spaces are in tune with the lives and culture of local people. We propose that Western foundations of MH knowledge are not universal nor are their assumptions of society globally applicable.
Real change in the MH of LAMICs requires reimagining. Local idioms of distress and healing, and explanatory models of suffering within particular populations, are needed to guide the development of training curricula, research and services. An integration of Western frameworks into these more successful approaches are more likely to contribute to the betterment of MH for peoples in LAMICs.”
Underfunding of the mental health sector in Africa has always been raised as a key barrier to promoting this sphere on the continent. Notwithstanding, the paper underlines that even if a lot of money were poured into this field in Africa, it could achieve little, if the local context weren’t respected. “Despite more visibility, clear recommendations and multiple attempts, little progress has been made in the last 20 years to improve the mental health of those in low-income and middle-income countries (LAMICs), according to the WHO. Even if large infusions of money were possible, will not result in significant improvement in the mental health of LAMIC populations, particularly in Africa.
The historic and current imposition of Western mental health models and frameworks of training, research and service development fail to be relevant or useful to those in need. We imagine that if the local non-Western traditions of healthcare that are known, trusted and in tune with the lives and culture of the people they serve, are used to integrate relevant principles of mental health training, research and service delivery, real benefit will accrue.”
Role of colonization, as a key reason behind those gaps
The paper released by BMJ Global Health states “The historical development of MH services, education and research in Africa has followed two main pathways: imported and imposed. Most MH services in Africa were set up by colonial institutions; they were entirely imposed and after the geographic decolonisation process was completed, these institutions continued with structure and function unchanged. In Ethiopia, where there was no direct colonial history, MH services developed from indirect colonial pressures and internalised assumptions that imported Western structures were superior.”
This paper adds that several countries in Africa have turned to importing Western education in two ways: through sending their youth for training abroad— “the majority do not return”—, or inviting Western educational institutions and educators to teach in newly formed African institutions. “All teaching of MH in Africa that we are aware of uses Western MH theories of pathology and treatment, therapy manuals, teaching videos, etc.
These processes facilitated the spread of Western models of MH training and services to the region. This on its own might not be a problem if the foundations of MH knowledge were truly universal and their assumptions of society globally applicable. However, when the epistemic status of MH knowledge is not well defined, and its practice dynamic, the translation of such a knowledge base across cultures remains problematic.”
Recommended action, to holistically address the crisis not only in Africa
The paper advocates that local traditional structures should be recognized as invaluable resources in the fight against mental health disorders in Africa. “Mental illness has always been with us. Societies across the world have designed institutions to take care of those who suffer. For the most part, effective traditional African social institutions are based in the community.
They have been made invisible by the emphasis on asylums in the past, and the more recent development of ‘modern’ MH services, as well as by the Western assumption that traditional healing is outdated and irrelevant. In most parts of Africa, people prefer to use traditional healing institutions that are already present and located in homes and spiritual spaces.”
Asylums in the past refer to mental health institutions or psychiatric hospitals that existed historically, particularly before modern mental healthcare reforms. These asylums were designed to house and treat people with mental illnesses, but they were often associated with poor conditions, mistreatment, and lack of effective treatment. Many past asylums were known for inhumane practices, such as forced confinement, electroshock therapy, and lobotomies.
Electroshock therapy uses electrical currents to treat severe mental illness. Lobotomy is a surgical procedure that involves cutting connections in the brain’s prefrontal lobe to treat mental disorders. These practices were inhuman for several ways.
Both procedures often resulted in significant and debilitating side effects, including cognitive impairment, personality changes, and loss of autonomy. These treatments were frequently applied indiscriminately, often as a solution for various mental health issues without thorough evaluation or consideration of less invasive alternatives. The procedures involved dehumanization, treating patients as if they were merely subjects rather than individuals with feelings and rights, reflecting a broader societal stigma toward mental illness. Many patients experienced long-term negative consequences—a decline in quality of life following these treatments, leading to a loss of agency and support in their communities
The paper indicates that it is now time for African structures to be investigated, to see how they can be promoted. “These healing structures are powerful because they invoke knowledge and experience that is in harmony with people and their way of life. The merit and wisdom of recognising that the knowledge and experience contained in these institutions is important for healing is a matter open for exploration.
However, their relevance, accessibility and local acceptability is undeniable. If we accept that healing institutions are an irreplaceable asset for society, we must also accept that none of the imported/imposed models can claim to be a reasonable substitute. Far from being irrelevant, quaint or of historic interest only, traditional healing institutions carry the highest burden of care for the mentally ill in African communities.”
Moreover, according to the paper, social healing institutions possess knowledge systems and approaches that can be effectively recognized and utilized as a foundation for developing modern mental health services. The paper adds that instead of being merely integrated as a cultural supplement to the Western biomedical model, these systems can serve as a core component of mental health advancements. “In principle and practice the majority of primary care services, be it physical or mental, in most parts of Africa, are provided by these local healing institutions.
Any integration that fails to acknowledge and engage these systems beyond a rhetorical nod is bound to be unacceptable to the majority of users even when accessibility claims are made. Recognising the importance of traditional healthcare systems, there have been some tentative efforts to integrate traditional and modern MH services, but this usually entails the two systems running separately and in parallel (eg, a traditional clinic and modern MH clinic with bidirectional referral capacity).”
The paper authors point out “However, this area of exploration remains at best on the margins, leading to neglect of much-needed efforts to incorporate modern MH service models into existing societal and institutional structures.
As traditional institutions are already taking on the majority of the burden of care for the mentally ill, they present modern health services with an opportunity to identify ‘situated knowledges’ that may be used for developing meaningful policy directions and mitigate the potential of epistemic genocide.”
Epistemic genocide means the systematic destruction, erasure, or marginalization of a group’s knowledge systems, ways of knowing, and intellectual traditions. It occurs when dominant cultures or ideologies suppress, devalue, or replace indigenous, traditional, or alternative forms of knowledge, often in favor of Western or colonial perspectives. Here in the context of mental health, epistemic genocide refers to disregarding traditional healing practices and imposing Western biomedical models, thereby erasing culturally rooted ways of understanding and treating mental health issues.
SDG Move supports valuing local knowledge, while also underscoring that epistemic genocide is to be abolished. “Addressing knowledge imbalances: promoting the decolonization of knowledge to support research that benefits all nations equally, prioritizing local knowledge generation and utilization.” SDG Move is a research and engagement center based at Northumbria University in the United Kingdom.
What are African systems which can fulfill a great role in mental health disorder treatment?
The University of Pretoria is one of the top public universities in South Africa, being ranked 354th in the world the QS World University Rankings 2025. This university’s website features an editorial headlined “UP EXPERT OPINION: Ubuntu as a solution to mental illness challenges” written by Professor Nontembeko Bila and published on February 23, 2024.
This Associate Professor— in the Department of Social Work & Criminology, with some publications relating to mental health—Bila says “In the grand narrative of human history, the battle against mental disorders has seen notable progress. Yet, as we think back to the Middle Ages, with its pervasive ignorance and often barbaric treatment of those afflicted with mental disorders, it becomes clear that our contemporary world is still grappling with a crisis of mental health.
Today, amid the complexities and demands of modern existence, individuals worldwide face a myriad of challenges – from childhood traumas to poverty, social isolation, discrimination and stigma – all exacerbated by global pandemics, disasters and wars. These challenges manifest in various psychological conditions that profoundly impact how individuals think, feel, and behave.”
Professor Bila argues that Ubuntu constitutes a mechanism which possesses the potential to deal with mental health problems, since according to her, modern solutions alone don’t suffice. “Despite advances in understanding and treatment, many of these conditions persist undiagnosed, acting as significant barriers to emotional, psychological and social well-being. Although we have moved beyond the Middle Ages’ view of mental disorders as a divine punishment, the stigma and inequities in mental healthcare persist across the globe.
The World Health Organisation’s Comprehensive Mental Health Action Plan 2013 – 2030 outlines global efforts, yet the statistics remain staggering. Around 450 million people struggle with mental disorders, with one in eight individuals living with a mental disorder. Suicide attempts are 20 times more frequent than fatalities. Despite the immense burden, mental health receives a disproportionately small allocation of healthcare budgets, with limited access to specialists, particularly in middle-income countries. The ongoing global crisis around mental health issues presents an important opportunity to advocate for ubuntu as a solution.”
Ubuntu, deeply rooted in African culture and philosophy, she says, holds profound wisdom that can offer an alternative approach. “As I champion ubuntu as a solution from Africa to the global mental health crisis, I’m reminded of a quote from American memoirist and poet Maya Angelou, who once said ‘When you learn, teach; when you get, give.’
Africa has long embraced ubuntu, a profound philosophical and ethical concept deeply ingrained in South African culture. Originating from African languages, ubuntu broadly translates to ‘humanity towards others’ or ‘I am because we are’. It is high time we share this invaluable ethos with the world, offering it as an alternative solution to the challenges of mental illness.”
Mental health is not just an individual matter—it thrives within the strength of community, according to Professor Bila. “With its roots firmly planted in African tradition, the ubuntu philosophy presents a holistic perspective on mental health. It underscores the interconnectedness of individuals, emphasising that personal well-being is intricately linked to the welfare of the community.
By nurturing strong social bonds and fostering communal support, ubuntu creates an environment that is conducive to positive mental health outcomes. Unlike approaches that prioritise individualism, ubuntu places emphasis on relationships and communal harmony, thereby cultivating a supportive social fabric that contributes significantly to emotional well-being.”
Professor Bila adds that unlike Western individualistic approaches, ubuntu prioritizes relationships and communal harmony. “It recognises that individual well-being is inseparable from community welfare, and emphasises the importance of strong social bonds and communal support in fostering positive mental health outcomes. In a world where personal achievements often overshadow collective well-being, ubuntu reminds us of the significance of harmonious relationships, mutual support and a shared sense of belonging.
Communities that are rooted in ubuntu principles foster a supportive social environment that promotes emotional well-being. They provide robust social support networks that give individuals a profound sense of belonging, and act as buffers against stress and isolation. Ubuntu-driven communities counteract the loneliness epidemic by encouraging regular social interactions and shared experiences that actively promote psychological well-being.”
Furthermore, as explained by Professor Bila, ubuntu strengthens a sense of collective efficacy, where community members believe in collaborative goal achievement. “Shared cultural values create an environment that mitigates the impact of cultural stressors on mental health. In ubuntu-driven communities, individuals have opportunities to actively contribute, fostering a sense of purpose and accomplishment that positively impacts self-esteem and mental well-being.
Importantly, ubuntu can play a pivotal role in reducing the stigma associated with mental health issues within communities. Its core principles of interconnectedness, shared humanity and collective responsibility lay the foundation for understanding, empathy and acceptance.”
She highlights that ubuntu promotes open dialogue, normalizing discussions about mental health and encouraging individuals to share their experiences openly. In her mind, it is time this approach were promoted worldwide.
“By emphasising shared humanity, ubuntu challenges the “us versus them” mentality often associated with mental health stigma, and fosters a culture of empathy and compassion. In ubuntu-driven communities, mental health is not seen solely as an individual concern, but as a shared responsibility for the welfare of all members. By actively creating mentally healthy environments and challenging stigma, ubuntu empowers communities to support one another in times of need.
As Africa leads the way in championing ubuntu principles, it has the opportunity to offer invaluable lessons to the global community. By embracing ubuntu and its emphasis on interconnectedness, communal support and collective responsibility, we can pave the way for a more compassionate, understanding and mentally healthy world for all.”
Conclusion
The paper which has appeared in BMJ Global Health, it advocates for reimagining. As it explains, the state of MH care in Africa is far from meeting the needs of African people. “The complexities of delivering MH care requires careful thought to be useful to the people who need services in a continent with enduring historical, socioeconomic and structural challenges yet with rich sociocultural resources. Our hope is that by reimagining MH development in Africa we help illuminate a way forward for the development of meaningful models of global MH care.”
The authors also advise to reimagine curriculum. “The underpinnings of MH curricula throughout Africa have Western origins and this remains for now an unavoidable necessity. Many African medical schools have adopted competency-based models, and the overall outcome of these curricula is the production of human resources with a predefined competence to enable the delivery of MH care.
However, competent graduates frequently leave these training programmes with limited capacity to deal with what awaits them in practice. A basic assumption of professional practice is that the competencies of practitioners and the needs of society will align. In Africa, this alignment is hard to come by: what professionals have to offer is not what society needs or wants.”
The authors argue that additional competencies helpful in these circumstances are critical reflection and reflexivity. “Critical reflection challenges assumptions and practices, while critical reflectivity and cultural humility involves recognising one’s own social position so as to understand the experiences of others.
A reimagined curriculum that includes these concepts may prepare professionals to provide locally relevant, compassionate, humanistic and equitable care and contribute to individual, social and systemic change. A reimagined curriculum should aspire to envisage all the potential spaces for intersection and alignment and build content accordingly.”
These authors also recommend to reimagine research and services. They agree that in recent years, both the quantity and quality of MH research from the African continent has increased markedly. They additional concur that the number of international organizations financing MH research has also gradually risen. “However, we have yet to see MH research from Africa that has impacted how services are developed.”
“Whether driven by funding agency priorities, Western academic pressures, research that serves HIC policy-makers or other interests, or the uncritical engagement of LAMIC researchers in established research priorities, the lack of service delivery research is unacceptable. Despite this, there are calls for more research in the field. Research that does not recognise local socioeconomic, political and cultural contexts is contestable, and research without moral and societal accountability can do more harm than good. Reimagined MH research should take relevance, context and accountability as its core drivers.
As previously noted, most MH care is provided by societal healing systems which have been rendered invisible by the parallel development of more prominent ‘modern’ MH services that respond to a negligible proportion of the burden of care. This sad reality contributes to a lack of alignment between society and professionals as they operate in different spaces. A reimagined MH service model needs to acknowledge this lack of alignment and seek to build bridges between the two. There are knowledge systems and practices in both systems that can be used for the provision of better services to society.”