Mental health and primary care in Nigeria.
Authors: Olabisi Odejide, Jide Morakinyo
Journal: World Psychiatry (2003)

Nigeria is a typical case of a developing nation. As rightly pointed out by David Goldberg, the country is generally short of physicians and, with a population of over 120 million, has less than 100 psychiatrists. The majority of general practitioners are without postgraduate training and located in private practice, in most cases working on their own. This group of physicians, along with others in government owned institutions (general and teaching hospitals), offer primary care services. Unfortunately, these services are mainly located in urban areas, and most of the rural areas, where the majority of the populace (approximately 70%) reside, are deprived of health services. As part of the government's efforts in meeting some of this challenge, between 5 and 15 local health facilities have been established in each local government area (district) of the country. Specially trained individuals with or without medical background and with different educational levels run these facilities.

However, contrasting what David Goldberg points out for a few developing countries, in some other developing countries like Nigeria, the emphasis of the primary care has been geared mostly towards maternal and child care and, occasionally, treatment of minor physical ailments and infectious diseases. Recent findings (1,2) revealed that primary health care workers have very poor knowledge of mental disorders and virtually no mental health services are provided at the primary health care facilities studied. The mental health services offered at the private general practice and government owned hospitals seem to be the only hope for the minority of the populace. However, the level of capability and effectiveness in delivering these services is an area yet to be investigated. Judging by the level of mental health training received by primary health care workers (mainly from undergraduate schools), tied with deeply seated negative attitudes and superstitious beliefs on mental disorders, mental health services offered to the populace at the primary care level is likely to be minimal.

David Goldberg will agree that the roles of the traditional and religious healers in most developing countries, especially in Africa, cannot be ignored. Though orthodox psychiatric practice has expanded considerably in many developing countries, it is well documented that many psychiatric patients still seek primary help from the traditional healers and the syncretic churches. Traditional and religious homes probably look after the majority of mentally ill Nigerians. Traditional and religious healers are easily accessible to the people, and Africans, regardless of their level of education, adhere in varying degrees to the belief in the supernatural causation of mental illnesses (3). However, in most instances, people seek orthodox treatment when the efforts of these healers seem to have failed.

Comparing the scenario here to what David Goldberg describes, the gap between the developed and some (if not many) developing countries is pretty large. The needs and the challenges in this part of the world are diverse and much greater than what is depicted. First is the need to get the government convinced and committed to the importance of delivering adequate mental health care at the primary care level; then, the need to educate the populace on the nature of mental illnesses, to ensure the availability of effective treatment and the provision of adequate facilities and resources; then, the challenge of adequate mental health training of physicians and other health workers working at primary care level. Also, adequate and appropriate remuneration and conditions of service are needed, in order to halt brain drain. Furthermore, there is the need to design a suitable model of mental health care and linkage that will be cost effective, cutting through the primary and secondary care levels to the tertiary/specialist centres.

This discourse is quite timely, bringing to the fore the progress and areas of opportunities of mental health in primary care, especially in the developing nations, and highlighting the need for a concerted effort to meet the challenges fostered by underdevelopment in many nations of the world.