This morning I met with Stefan Jansen. Stefan is a lecturer in Psychology working at School of Medicine and Health Sciences at the University of Rwanda. Stefan talked me through the structure of mental health services in Rwanda. Ndera Neuropsychiatric hospital is a 288 bed facility that is the largely psychiatric hospital in Rwanda. There is also a smaller satellite site in Butare which has 70 beds. Butare is a university city in the south of the country. Psychosocial services are based in the big hospital but tend to serve outpatients mainly. The Psychosocial Services are coordinated by the Ministry of Health. There are a number of district hospitals, which are mainly staffed by mental health nurses or clinical psychologists. The district hospital system has helped to facilitate the decentralization of mental health services in the country.
There are a total of 44 district hospitals across the country. The next tier down in the health service comprises of 10 Centres de Sante for each and every district hospital. However, there is no mental health component to the services that they offer. However, since this year the 44,000 community volunteers who are affiliated to the Centres de Sante have been receiving training in identifying particular forms of mental health problems. This training is coordinated by the Ministry of Health but is offered by the University of Rwanda. The Head of Department (Claire) and Donatelli (Dean of Faculty) coordinate this training. The community volunteers, although not formally paid, form cooperatives which can facilitate opportunities for shared wealth generation e.g. investing in goats. These volunteers tend to represent the first contact with service user to health services. Their engagement tends to be quite limited.
Stefan and I then picked up Darius Gishoma (a local Clinical Psychologist) and we paid a visit to Centre Psychotherapeutique Icyizere, which is run by the Ministry of Health in conjunction with the Freres De La Charite. The head of the centre (Boneface) had kindly arranged to meet with us. The center was first opened in 2004 to treat victims of trauma when it became apparent that using Ndera Psychiatric Hospital to treat trauma victims alongside more complex mental health difficulties such as schizophrenia was not appropriate. The building was neat, orderly and clean. The staff were polite and professional.
Boneface explained that the centre delivered good results in combatting trauma. However, as time progressed the remit of the centre evolved to include substance abuse related mental health problems. The most common types of substances abused in Rwanda include alcohol, cannabis, and opiates. In addition, local herbs with hallucogenic effects may also be used.
The Centre Psychotherapeutique Icyizere offers 3 main types of intervention offered at. These include:
1. Medicine-based interventions
2. Psychotherapy. This can be 1-1 or based-group work. Following the completion of the psychotherapy, some service users will be offered on-going monthly appointments with a social worker.
3. Eye Movement Desensitization and Reprocessing (EMDR)
As a group, Boneface, Darius, Stefan and myself discussed the extent to which individuals in Rwanda engage with mental health services. This included a focus on alternative forms of support that people might access. Darius reported that research conducted by Dr. Eugene Rutembesa (a psychologist who previously worked at the National Centre for Trauma, Rwanda) has indicated that 70% of people living in Rwanda visit a traditional healer first to seek advice about mental health related difficulties.
Despite the best efforts to address the levels of trauma in the population, rates of Post-Traumatic Stress Disorder continue to be as high as 25% rates. This gives rise to suggestions that there has been a trans-generational aspect to the events surrounding the genocide.
The discussions with Boneface and Darius revealed that there are four concepts that determine the direction of existence for Rwandans. These are Kubaho (exist, live) and Kubana (living with and among), Gutunga (possess) and Gutunganirwa (live happy, tranquil in peace, prosperity). In terms of early intervention to help combat mental health difficulties, the Workforce Development Agency has been conducting an outreach programme for vulnerable children. This programme aims to create a therapeutic environment for children in 6 schools and 9 vocational training centres. As part of the programme, mentors are identified who receive basic mental health training on the identification of mental health difficulties.
Boneface showed us around the facilities (including some residential beds for short admissions) and talked about the plans for the future. It was a really interesting visit, and I am grateful for the opportunity to spend time talking with the staff there.
Darius and I went for lunch together. This provided time to talk about interesting research that he has conducted into the retraumatization and distress that a number of people experience in April every year during the commemoration events for the Rwandan genocide. Darius’s research sought to investigate the efficacy of an intervention to minimize retraumatization. Important work.
Later in the afternoon, Stefan and myself visited Hôtel des Mille Collines; a large hotel in Kigali. It was this hotel that featured in the feature-film called ‘Hotel Rwanda’ that explored events related to the genocide.