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Improving psychiatric care in Uganda

In May 2008, Delia Bishara, principal pharmacist at South London and Maudsley NHS Foundation Trust, was invited to accompany a consultant psychiatrist to Uganda and help him run a series of workshops for staff in a psychiatric hospital. She describes her experience

by Delia Bishara

In May 2008, Delia Bishara, principal pharmacist at South London and Maudsley NHS Foundation Trust, was invited to accompany a consultant psychiatrist to Uganda and help him run a series of workshops for staff in a psychiatric hospital. She describes her experience

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My first reaction to Uganda was amazement at its beautiful and striking landscape of verdant and copious vegetation. This was not at all what I had expected from an African country situated on the equator.

The general friendliness and warm greetings from the people also came as a welcome surprise to a Londoner. The attention we were given when walking through the streets of the capital, Kampala, also took some getting used to.

The main cultural difference that was difficult to adapt to was the relaxed attitude to time-keeping. Everything seemed to start two hours late and it was, therefore, difficult to adhere to a plan.

There was also an obvious hierarchy among staff at the hospital we visited and the pecking order is a lot more prominent than in hospitals in the UK.

Butabika Hospital is a large psychiatric hospital in a beautiful setting with spacious grounds on the outskirts of Kampala.

However, patients’ experiences are different from those of patients in the UK — during my visits, I witnessed the compulsory shaving of the heads of all patients admitted to Butabika in order to prevent the spread of lice, the generic green uniforms they had to wear, even when they were allowed out on day trips, and the use of batons by the guards at the gates.

Unlike many African countries, physical restraint of patients is not common practice but seclusion (or “supervised confinement”) is still a means of managing those in acute states of mental illness. This is a practice I had often seen when I worked in Australia in 2006 but which is only occasionally used in the UK.

Ugandan demographics

Population30.9 million (2007)
Age structure
  • 0–14 years (50.2 per cent)
  • 15–64 years (47.6 per cent)
  • >65 years (2.2 per cent)
Major languages
  • English (official)
  • Swahili (official)
  • Luganda
  • Bantu
Major religionsChristianity, Islam
Life expectancy
  • 51 years (men)
  • 52 years (women)
Main exportsCoffee, fish, tea, tobacco, cotton, corn, beans and sesame
HIV prevalence rate4.1 per cent (2003)
Population per doctor13,037 (2004)
Population per nurse1,775 (2004)
Total annual health expenditure per headUS$18 (2003)
  

Uganda has a serious need for considerable input from healthprofessionals from developed countries. Many areas are rural and accessto healthcare is poor. Developing services in these areas is crucial.

There is also lack of funding and limited opportunities for staff todevelop their knowledge and skills

Workshops

During our stay, we ran a series of workshops for psychiatric clinical officers (PCOs). PCOs are psychiatric nurses who are trained to act as psychiatrists in the community. They are most useful in difficult-to-reach rural areas. They visit patients at home and provide psychiatric care, including diagnosis, prescribing and administration of medicine.

Although we had thoroughly planned the workshops in advance, we found that we had to make considerable changes following our arrival and assessment of what would be most useful. We made initial enquiries as to which drugs were available and what issues PCOs faced, after which last-minute alterations to the workshops were made so that drugs that were not available were not covered in as much detail as planned.

In contrast, the clinical practice of rapid tranquillisation, which we had not planned to discuss in detail, quickly became the main focus of workshops.

In fact, the general management of acutely disturbed patients provoked many discussions, most probably because of the large difference in practices occurring throughout the country.

The workshops often started late and overran. It seemed acceptable to speak during presentations and to distribute drinks and food, even though this could be distracting to the speakers, but we soon got used to this cultural difference.

The Ugandan teaching style is formal and authoritative, lacking participant involvement and interaction. The attention and enthusiasm to learn, however, was great and audience participation improved dramatically throughout the week.

We ran sessions on bipolar disorder, schizophrenia, organic disorders (including delirium) and their pharmacological management. We also included interactive workshops on audit, continuing professional development and team management. These workshops were well received and the ideas that were put forward during the discussions were valuable for the development of the individuals and their services.

In addition, we provided the PCOs with useful literature, information leaflets and evidence-based guidelines that they would have had difficulty accessing due to slow internet connection.

Many issues emerged during the workshops. It appears that the Ugandan National Medical Stores purchases medicines from different countries throughout the world, such as India and Kenya, selecting the supply source based on price. This results in inconsistent supplies and variable quality of drugs obtained.

Prescribing practices also vary widely between districts as a consequence of the uneven distribution of drugs. For example, some districts use haloperidol and promethazine in rapid tranquillisation whereas others use high doses of chlorpromazine intramuscularly. (Intramuscular chlorpromazine has not been used for years in the UK because of its erratic absorption and serious risks of adverse cardiac events.)

There is also a huge issue of medicines being diverted and the lack of accountability for them. This is a major problem that has been occurring for years in Uganda but workers have been powerless to resolve it. It seems that all medicines are equally likely to be diverted, irrespective of their abuse potential.

As a result of these issues, we set up a meeting with the commissioner for health and the head of public health in Uganda. The commissioner appeared alarmed at the safety risks involved with the poor quality of some medicines when these were explained to him.

He agreed that samples of ineffective drugs should be saved and sent for analysis. If they are found to be of poor quality, they should no longer be procured.

In addition, he insisted that prescribing guidelines should be developed in order to standardise prescribing practices throughout the country. We also discussed how future workshops could be funded.

Traditional healers

An issue faced daily by PCOs is the practice of traditional healers in Uganda. Patients often seek the help of traditional healers instead of going to see a doctor. These healers use various herbs to attempt to manage mental illness, epilepsy, hypertension and many other conditions.

They often advise patients to stop taking their prescribed medicines and to take their herbal cocktails instead. This leads to poor compliance with prescribed treatments and an increase in relapse rates of mental illness.

The PCOs are fighting a difficult battle. They are increasingly trying to form relationships with the healers so that they can educate them and gain their trust. They believe that this will increase the healers’ understanding and awareness of the importance of medical treatments and encourage them to refer their patients to qualified doctors and to ensure patients continue to take their prescribed medicines.

Epilepsy

Epilepsy is the most common nervous system condition in Uganda, with a higher prevalence than that reported in the Western world. The number of people with epilepsy per 1,000 of the general population has been estimated as between two and five in most areas.

This is due to greater birth trauma (resulting from the lack of trained midwives and poor conditions during labour) and complications of cerebral infections, especially malaria and meningoencephalitis.

In 2004, 5 per cent of all admissions to Butabika Hospital were due to epilepsy. Although epilepsy is a neurological disorder, in Uganda most cases are treated in psychiatric services. This may be due to a belief that any disease involving the head is for psychiatrists, but also possibly because there is only one neurologist in the entire country.

Unfortunately, epilepsy still holds considerable stigma in most African countries, as does mental illness. People believe that it occurs as a result of being possessed by the devil or having committed wrong in a previous life.

They think that it is a highly infectious disease and children are often immediately abandoned and disowned by their parents following a seizure. We went to visit an orphanage where many children with epilepsy, some from high profile and wealthy families, had suffered such a fate.

This was heartbreaking to witness. The urgent need for education and increased awareness of the nature and causes of epilepsy was immediately apparent. The battle against stigma is a difficult one but of utmost priority.

Going home

The end of my visit came but it was clear that our work would be a long-term project and partnership. Our mission is far from complete. We planned to continue to advise staff at the hospital on the maintenance of effective record keeping thus enabling them to identify drugs of poor quality and account for medicines supplies so as to reduce the risk of them being diverted.

I also agreed to advise PCOs by e-mail on audit designs in order to identify problems within their service. In addition, with the approval from the commissioner for health, we will help to develop prescribing guidelines for psychiatric disorders that will be ratified throughout Uganda to standardise prescribing practices.

Finally, a complete series of workshops is planned, designed to cover all aspects of epilepsy thereby increasing knowledge and raising awareness of the causes and management of the illness. It is hoped that these will be run next year. PCOs can then continue to spread this information and, therefore, attempt to tackle the stigma associated with the condition.

I learnt many things as a result of undertaking this project, not only about Ugandan people, cultures, beliefs and health problems, but also about myself. Overall, my experience in Uganda has been positive and has helped me to develop both personally and professionally, particularly skills in effective planning, communication and negotiation.

Providing advice and support to health professionals in Uganda should enable them to develop and raise the standards of their psychiatric health services despite the limited resources available. Before I left for Uganda, I attended various meetings with physicians and pharmacists who had made similar trips.

The most valuable advice, however, came from a colleague. Her last words to me before my departure were: “You cannot change the world in two weeks. The most important thing is to leave them with something to think about.”

These words stayed with me throughout the entire visit but it was only towards the end of my stay that their meaning became clear.


ACKNOWLEDGMENTS Thanks to

  • Nick Bass, senior consultant, East London and the City Mental Health Trust (ELCMHT) for allowing me to accompany him on this visit and for his encouragement
  • Louise Blanks, senior occupational therapist (ELCMHT) who spent eight months at Butabika Hospital
  • Cerdic Hall, co-ordinator, Global Health Partnerships, and Butabika link committee and professional development nurse (ELCMHT) for co-ordinating the link
  • Hannah Maule-ffinch, professional photographer who accompanied us throughout the visit
  • Tom Onen, consultant psychiatrist, Butabika Hospital and link co-ordinator for Uganda
  • David Taylor, chief pharmacist, and pharmacy staff at South London and Maudsley NHS Foundation Trust for their invaluable support
  • the Tropical Health and Education Trust for its financial support

Citation: The Pharmaceutical Journal URI: 10043818

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Supplementary images

  • Medication round at Butabika Hospital (Hannah Maule-ffinch)

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