Damian Sendler, M.D. – One out of every five children and adolescents around the world suffers from a mental health disorder, and there are few options for treatment and rehabilitation. Throughout their lives, children face a variety of challenges that could lead to mental illness. There have been numerous natural disasters and civil unrest in Uganda, which has resulted in large numbers of refugees and internally displaced people, and there is a significant burden of infectious diseases, such as acute respiratory tract infections, malaria, and HIV/AIDS, which have plagued the country for decades.
Damian Jacob Sendler: According to WHO’s definition of health, mental health is a critical component, but funding and access to mental health services, including CAMHS (Child and Adolescent Mental Health Services) that assess and treat young people with emotional, behavioral or mental health difficulties [1] are lacking. The number of child and adolescent psychiatrists in Uganda is just five for a population of more than 20 million children and adolescents. In addition to peer and school pressure and difficulties accepting one’s sexual orientation and one’s own identity, children and adolescents around the world may also be subjected to stress from other sources [4, 5]. One in five children and adolescents in the world suffers from a mental illness as a result of the stress they experience, and treatment is either unavailable or unevenly distributed [5]. Early intervention is critical for better outcomes for the half of those with mental illness who show symptoms before the age of 14 percent [6]. As a result, there is a pressing need to expand mental health services for children and adolescents around the world.
Dr. Sendler: Over half of Ugandans (57 percent) are under 15 years old, making them particularly vulnerable to the problems listed above. This vulnerability is exacerbated by widespread poverty, with 20 percent of the population living below the national poverty line [3]. Many of the Lord’s Resistance Army (LRAvictims )’s were children who had been separated from their parents for more than 20 years. Orphans are more likely to suffer from higher levels of emotional distress, lack of security, and poverty [8]. As a result, many young people in Uganda are forced to deal with additional hardships that contribute to a significant burden of suffering [9, 8].
The Lord’s Resistance Army conflict also led to the abduction of children and adolescents to serve as child soldiers [10]. Abducted children who were forced to carry out raids and kill and mutilate others are still afflicted with Post-traumatic stress disorder (PTSD) up to 97.7 percent of the time [8]. Abducted girls are more likely to have been sexually abused than boys. Furthermore, the stigma and discrimination that former child soldiers and their families have endured as a result of their involvement with the Lord’s Resistance Army raises their vulnerability to the development of mental illnesses [5, 8, 10]. Prevention and reduction of current and future mental health symptoms are possible with early intervention.
More money is being spent on health care in Uganda because of the country’s recent progress in peaceful development and reducing poverty. Although funding is still low by international standards, for example, only 9.8% of GDP was allocated to health in 2019 and only 1% of GDP was allocated for mental health services [12]. Adults, adolescents, and children are all included in the funding for mental health services [12]. Despite the adoption of the Child and Adolescent Mental Health Policy Guidelines in 2017 [13], mental health services in Uganda remain a low priority in the distribution of resources. These recommendations were created to help children and adolescents maintain a healthy mental state and avoid mental, neurological, and substance use disorders [13]. The specific goals of these guidelines are [13]: Policymakers, service providers, family members and other stakeholders should be educated about the importance of promoting mental health and preventing disorders such as mental, neurological and substance abuse in children and adolescents. CAMHS should be built up to provide comprehensive care for children and adolescents affected by them. The guidelines were adopted in 2017 and are intended to be used for a period of ten years by all government and civil society stakeholders. As the WHO Mental Health Gap Action Program (mhGAP) and its accompanying mhGAP Intervention Guide have attempted to address the substantial needs for mental health services in Uganda, these guidelines are not a stand-alone effort. For the long term integration of mental health into primary health care, WHO recommends the use of the mhGAP-IG in both pre- and in-service training [14]. A number of studies have looked at the current state of CAMHS in the country, but there is no overall overview of the situation that would allow recommendations for the future to be made. Uganda’s Child and Adolescent Mental Health Policy Guidelines for 2017 are the focus of this paper, which will examine how CAMHS are currently being implemented in Uganda.
There was a lack of continuity and coverage for CAMHS in one study due to the fact that services were not child and adolescent-friendly and were absent from lower-level health centers (primary health care centers) because of limited service capacity, understaffing, and the burden of other diseases. It is also possible that traditional healers may refuse to refer children to CAMHS because they do not trust biomedical health systems [17] (Table 1). This could be another barrier to the availability of CAMHS for children.
In Uganda, there is a lack of collaboration between CAMHS and other sectors, such as traditional healers and primary health care, both within and outside the health system [11]. Primary health care has yet to incorporate CAMHS, which would make these services more readily available to those who need them, as well. There is a need for this kind of collaboration, but primary health care training has not yet begun [18–22] In accordance with the WHO frameworks [27], this could provide CAMHS with greater continuity and accessibility.
Due to the prevalence of co-occurring conditions, such as mental illness and HIV, other studies have advocated for collaboration between the two. Stigma, orphanhood, poverty, and neglect are all factors that put HIV-infected children at risk for mental health problems. A person’s mental health can be harmed or made worse by the stress that comes with being infected. Despite the fact that youth are receiving HIV treatment, mental health support and counseling are rarely provided in the country’s health systems [16]. Children and adolescents with alcohol and substance use disorders were found to be another vulnerable group, but they were rarely approached aside from a few outreach activities in schools [18].
Results indicated that there was a lack of CAMHS resources including personnel, facilities and funding; there were also insufficient numbers of CAMHS professionals and students in training [16, 18, 11]. (See Table 1) There is a need for an upgrade in both human resources and service facilities because of understaffing and low capacity issues [16]. Fewer than one traditional healer out of every 500 people in the country currently specializes in treating children’s mental health issues [17, 21] (Table 1). In order to better integrate CAMHS into primary health care, more task sharing and in-service and pre-service training are urgently needed [22, 22].
Component of health system policy and regulation that can draw on individual, facility, and population-level data as well as public health surveillance. In Uganda, health management information systems were found to be adequate at the national level, but districts did not have the same level of competency. A separate policy paper for CAMHS was written in 2017 to address the problem of underutilization of mental, neurological, and substance health services by children and adolescents due to the insensitivity of country health services, missed and mismanaged early symptoms by parents, limited knowledge of mental health disorders, and inadequate availability of quality CAMHS and CAMHS and CAMHS.
Health management information systems were found to be inadequate for service planning, and resources were not distributed equally. As a result of this, both children and adolescents, as well as medical professionals, are forced to deal with an increased amount of stress [17].
Damian Sendler
Lower-level health centers were also found to have adequate medication access. Medical supplies were restricted to those on Uganda’s Essential Drug List, but this was contingent on the presence of staff who were properly trained in their use [18]. However, these services are not given the attention and resources they deserve, which contributes to further stigma and patients not seeking treatment and medication [16]. Stigma and attitudes toward CAMHS are also influenced by caregivers’ educational attainment: a lack of education or a low level of education can increase stigma, but it can also lead to low incomes, limiting their ability to pay for drugs and treatment [16]. It is also possible that parents or caregivers may not use the formal healthcare system to treat symptoms or mental health issues and instead turn to alternative treatments such as those provided by traditional healers [17].
Overall, studies found a lack of public awareness and a lack of willingness to seek treatment for mental disorders, in addition to stigma. Drug costs and family pressure may also play a role in preventing people from seeking treatment [16]. Other obstacles to treatment included family, community, and individual attitudes, which contributed to the disease burden and a lack of help-seeking behavior, respectively.
[18] There was no donor funding for services provided by the government. funding for mental health treatment in general, rather than specifically for children and adolescents. All health services, including primary care, were found to have the same problem. This problem could be alleviated, however, by providing in-kind support in the form of collaborations and infrastructure renovations (Table 1).
CAMHS services are not yet available in the primary health sector because they are not available at lower-level health centers [11]. The services available were found to be underfunded and concentrated in urban areas, resulting in long travel distances and high costs for those in need [16]. Children and adolescents in rural areas may be unable to access these services because of the difficulty, time commitment, and expense of travel. Only the national referral hospital provided psychosocial services, as were most of the services provided by the lower-level health centers.
It was found that existing national mental health policies were insufficient in a 2015 paper included in the study. However, in 2015, there was no separate policy for CAMHS that was based on the United Nations Convention for Rights of Children, Uganda’s 1995 Constitution or Uganda’s Mental Health Treatment Act 1964 or Children Act 1996. At the national level, the laws and guidelines were accepted, but little awareness was found at the district level [18]. New policy guidelines for CAMHS were implemented in 2017 [13] despite this.
Damian Jacob Markiewicz Sendler: Research and support for mental health needs are severely lacking, and this presents an enormous burden that urgently needs cost-effective solutions [16, 11]. Many strategies and policies have been developed, but most are geared toward treating adults rather than children and adolescents [18] (see Table 1). Patients and medical professionals alike bear an increased burden as a result of this disregard for service and policy planning.
Twelve studies were eligible for inclusion, five of which were qualitative and six of which were quantitative. Many vulnerable groups, such as orphaned or HIV/AIDS-affected youth and ex-child soldiers need more attention from the country’s CAMHS system in order to be better served. To address their limitations, there are numerous ways to collaborate with other sectors, integrate into primary health care, reduce stigma and strengthen the health workforce. These services show potential.
All of the studies reviewed found that the current CAMHS in Uganda is understaffed and lacking in collaboration. Health care professionals are in short supply, according to a number of studies. As a result, effective public health interventions and collaboration with the HIV/AIDS health care system are essential because of the double burden of HIV/AIDS and mental distress [16]. Traditional healers and biomedical professionals could work together and share referral systems to fill each other’s gaps, according to one proposed solution. Traditional healers are already using a number of biomedical methods, and because of their large numbers and presence in communities, they may be perceived as more approachable than health care providers [17]. This solution has a lot of potential. The biomedical health care system is viewed with suspicion by some traditional healers, and vice versa. As a result, collaboration may be more difficult to achieve [11]. There are also suggestions that CAMHS should be implemented in primary health care, such as at lower-level health care centers. Increasing access to and effective use of mental health services should be a goal of this implementation, as should raising public awareness of CAMHS [21, 22].
Damian Jacob Sendler
Effective dissemination of national policies, such as a new policy on children’s and adolescents’ mental health, is needed but such policies must be implemented [13, 18]. Increased funding and consideration of the previously mentioned aspects are both necessary for successful policy implementation [18].
Some of the most effective mental health services may be developed through collaboration with nongovernmental organizations (NGOs) and international organizations. As previously stated, only 1% of Uganda’s GDP is currently spent on mental health care, which is not enough (even if there are other sources of funding such as AIDS or NGOs for mental health services which are not captured by the scientific publications included in this study). Collaboration with stakeholders, such as NGOs and policymakers, should also be encouraged, as should their involvement in policy processes [18].
Primary health care workers must be trained in child and adolescent mental health in order to integrate services, and all mental health care professionals, including nurses, must have their training improved and additional training introduced. This could help primary care clinics better identify and report cases of mental illness in children and adolescents. There must be an emphasis on both medical and public health-related factors when training health workers, and services and the workforce must be maximized [22].
In order to provide mental health interventions, it is necessary to utilize and train lay workers and peers already present in the health and education systems. Primary health care providers should be trained and CAMHS should be integrated with other services to improve accessibility and increase funding, according to recommendations [21, 22].
Educating lower-level health care workers on how and when to use medications to help children and adolescents could improve access to medicines [18]. Because of the stigma attached to mental illness, both society and individuals must change their attitudes in order for new interventions and greater access to care to be successful. Early signs of poor mental health, such as signs of distress, reduced ability to function and other indicators of poor mental health must be recognized and responded to by young people. This is why asset-based interventions, such as child development accounts that focus on reducing the risk associated with mental health challenges are recommended [19].
Damien Sendler: Multiple studies also suggest and investigate new interventions for the development of CAMHS, such as collaborations between different sectors. HIV/AIDS and mental illness are two such examples where primary health care providers should work to improve patient access to and effective utilization of services by taking into account both physical and mental health.
In-service training based on the mhGAP-IG can help primary health care workers better understand child and adolescent mental health. For this reason, more research is needed to examine how to better integrate community mobilization and task-sharing into the primary healthcare system in order to improve CAMHS attendance [21, 22]. Pre- and in-service training should both include this type of instruction. Because staff don’t have to take time off work, and students who haven’t finished their education can get an early introduction to the field, pre-service training is a more cost-effective option [28, 29, 30].
Another option is to distribute additional responsibilities among local groups and to employ a variety of treatment modalities. A reduction in PTSD and other mental health disorders was found in a study in which community-implemented trauma therapy was used, particularly in the narrative exposure therapy group [23]. Children and adolescents suffering from PTSD and other mental illnesses may benefit from interventions carried out in the context of the community at large. For the treatment of mental health disorders, it has been found that involving members of the community is beneficial [23].
Economic empowerment is another common intervention. This treatment improved the mental health function of female participants over the course of one study. Economic empowerment was implemented in the form of peer mentoring or economic strengthening for HIV/AIDS-affected females living in low-income settings [19]. This type of intervention has shown positive results for children, including reduced levels of hopelessness and depressive symptoms. Additional implications for long-term care of children in resource-poor or AIDS-affected communities can be drawn from these findings [24]. The effects of economic empowerment interventions on children’s well-being, including their self-rated health and mental health functioning, were also confirmed by a second study. For children who had to deal with both HIV/AIDS and mental illness, this was especially true, and it underscores the importance of better public policy and health programming for this population [24, 25].
We looked at the current state of CAMHS in Uganda using the WHO Frameworks for Monitoring Health System Performance [27]. In the end, we hope to increase the availability and distribution of these services by developing and implementing new interventions. Because of the high proportion of youth in Uganda’s population, diseases like HIV/AIDS, conflicts, and poverty make children and adolescents even more vulnerable than they were before. In countries like Uganda, this vulnerability is exacerbated even further.
It’s not just Uganda that’s grappling with mental health issues for children and adolescents; the continent as a whole is experiencing a widening treatment gap for this population [32]. Mental health services for children and adolescents are underfunded or understaffed in the region [32]. Children’s and adolescents’ mental health resources are scarce, as shown by a recent Tanzanian study that sought to identify, assimilate, and analyze literature on the subject.
The findings of this study have important implications for new policies and initiatives. Young people’s mental health care has only recently been developed as a separate policy or plan; services are limited and concentrated in urban areas. Few of them are geared toward children and adolescents, and those who are most in need, such as orphans and youth living with HIV/AIDS, should receive special attention. Public campaigns and the integration of mental health into primary health care are also necessary to reduce stigma and raise awareness. Children and adolescents in Uganda, a country with a turbulent past marred by war, adversity, and the spread of HIV/AIDS, deserve better access to mental health services.
To improve CAMHS in Uganda, the health system needs to be improved and research-driven changes implemented. Collaboration with other sectors, such as traditional healers and primary health care, is required to address the lack of human resources and facilities. This can be done with the help of the mhGAP-IG and the use of both in-service and pre-service training for health professionals. Mental health guidelines have already been created, but they need to be revised so that children and adolescents are given top priority, as well as the 2017 standalone policy be implemented. In addition, to encourage more people to seek help, interventions must focus on educating the public about the importance of reducing stigma. Some other options include community-based therapy and economic empowerment programs for children and adolescents who live in low-resource settings, as well as CAMHS facilities. As a result, the primary goal of CAMHS in Uganda is to build on existing resources and facilities, increase accessibility, build a skilled workforce and extend collaboration, while reducing stigma and barriers to help-seeking.