A plea for the 22 UN standard rules and a request to redefine psychiatry.
Authors: René VAN DER Male
Journal: World Psychiatry (2006)

Developing countries, such as those in sub-Saharan Africa, face many challenges in trying to establish and offer psychiatric rehabilitation services. Many of these countries cannot commit to health the minimum of US$ 12 per capita recommended by the World Health Organization (WHO) and also face severe human resource constraints, making the running of a Western style psychiatric rehabilitation service such as that described by Rossler virtually impossible (1,2). Most of the countries on the continent have largely adopted and are in various stages of implementing the primary health care strategy, which emphasizes integration of health services, including mental health, and community involvement, building on the supportive family networks and taking advantage of the rehabilitative resources available in communities (1-3).

Building on the strength of the extended family social support system found in most of the continent, indigenous models of psychiatric rehabilitation have been developed. One such model is the rehabilitation  in Tanzania, first established in 1969, modeled on the pioneering work by Lambo in the Aro Village in Nigeria (4,5). These Tanzanian rehabilitation  offer psychiatric services similar to those available in hospitals in an environment intended to duplicate the social and economic milieu of a rural community. The staff who run these  include agricultural and livestock officers, nurses, nursing assistants, artisans who perform occupational therapy and traditional healers. A psychiatrist and a medical social worker who undertake weekly visits to these  work with the local therapeutic team and the patients and their relatives on formulating and implementing a rehabilitation plan for each patient (5). A major drawback of these psychiatric rehabilitation villages is their inability to co-exist with urban centres.

Civil society organizations have also undertaken to provide psychiatric rehabilitation on the continent. One example is Basic Needs, which operates in Uganda, Tanzania, Ghana and Kenya (6). Basic Needs addresses the mental health needs of people in community settings using the sustainable livelihood approach. In this model, mentally ill patients and their caregivers are actively supported to participate in consultation workshops and self-help groups. This organization, working in partnership with various stakeholders including government, also helps to identify and ease bottlenecks to accessing mental health services in the communities. Once the mentally ill patients are feeling more stable, they are encouraged and facilitated through programs such as microfinancing to return to work. The Basic Needs model is not only in agreement with the primary health care strategy, which is the guiding principle in health care delivery in most of the countries in Africa, but also provides a flexible model that can be implemented in both rural and urban settings.

In summary, although both the WHO-supported primary health care model and some indigenous models of psychiatric rehabilitation have been implemented on the continent with various levels of success, there is a paucity of studies on the cost-effectiveness and sustainability of these approaches to psychiatric rehabilitation in the region. The challenge to today's mental health workers in Africa is how to scientifically assess the cost-effectiveness of each of these models and how to enhance them with lessons learnt elsewhere.