This morning I met briefly with Nancy Misago and Dr Jean Damasene. Nancy and Jean are both based at the Rwanda Biomedical Centre (RBC) in Kigali and contribute to the mental health section of the Ministry of Health. Nancy explained about some of the challenges associated with implementing mental health services at community level. A reasonably good range of psychotropic medications are available through the public health insurance that people are required to sign up to (the basic package costs 3000 Rwandan Francs per year – approximately £3). However, the medications can only be dispensed from the district hospital, and the cost of this travel to the district hospitals for service users is often prohibitive.
I then met with Stefan and travelled to the main psychiatric hospital in Rwanda, Ndera Hospital. The hospital is approximately 30 minutes away from Kigali city center. We had arranged to meet with Jean Michel Iyamuremye (Michel), the Director of Nursing at the hospital. Michel along with Darius, Gishoma and Jean Damascene were part of the first cohort of students to complete the training of Psychiatric Nurses that commenced in 1995. As with the clinic that I visited on Friday, the hospital building and infrastructure is supported by the Belgium organization Freres de Charite. The organization has branches in US UK, Africa and Asia. The day-to-day costs of running the hospital (staff-costs, medications etc) is provided by the Ministry of Health.
The hospital was first opened in 1972. Prior to this date, people experiencing mental health difficulties tended to be incarcerated in prison or consigned to a life of poverty and living on the streets. The hospital has beds for 250 inpatients. As with Butabika Hospital, the hospital is operating well-above capacity. Michel spoke about the devastating impact that the events of 1994 had on the hospital. Many of the inpatients were killed, and many of the staff were forced to flea to the Democratic Republic of Congo.
The hospital offers a range of services including occupational therapy, psychological services, services specifically focusing on comorbidity between HIV and mental health, and social work that is offered to addressed social issues and difficult family dynamics. The social workers provide an opportunity to link with the broader community and can help the person to transition out of the hospital.
The main diagnoses that present at the hospital are as follows:
3. Affective Disorders – including depression
4. Post-traumatic Stress Disorder (PTSD)
5. Mental health problems with comorbid substance abuse
6. Mental health difficulties comorbid to HIV (this includes emotional adaptation following diagnosis as well as neurological complications associated with mental health problems).
7. There are also a number of inpatient beds for children at the hospital for difficulties such as epilepsy and/or behavioural disorder.
Michel explained that, with epilepsy being the single biggest issue, a neuropsychiatric service was established 7 years ago. The hospital possesses a range of EEG machines, which have been provided by the Hernandez-Miguel University in Spain.
It seems that the biggest problem faced by the staff at the moment relates to there not being enough beds to meet the demand of patients. In addition, there is a shortage of medical doctors in Rwanda. The doctors that are there may opt to work for private hospitals or NGOs because this can provide increased salaries. The buildings that house the hospital are aging and require some investment.
There have however been positive recent developments. The hospital has introduced electronic records that help facilitate fast and accurate sharing of information. Ndera is recognized as a teaching hospital, that provides students and qualified staff with opportunities for supervision and continued professional development.
The hospital mainly offers inpatient services, however some service users attend the hospital for some outpatient psychology appointments. On discharge from psychology, these individuals are then passed to district hospital for on-going prescribing of medication if this is required. In addition, there is also a rehabilitation unit named: ‘Maison Sainte Jules’ for individuals who are clinically stable, but do not have a place to go. It is very much viewed as a house for every day activity. There are currently 13 service users who are resident there, and the hospital is not keen to see these numbers increase – the emphasis is instead on trying to integrate people back with their families and/or communities.
Michel took us on a tour of the hospital. The units included designated wards for men, women and children. Some wards that had 70 beds have at times had over 100 people staying there. We visited some of the Occupational Therapy facilities. There was a dedicated building for the Neurology Department, which had facilities for assessing seizure activity, as well as some inpatient beds for individuals who were being stabilized on medication.
After leaving Ndera Hospital, Stefan and I returned to the RBC building in Kigali and met with Dr Yvonne Kayiteshonga (Head of Division of Mental Health, Ministry of Health). Yvonne has a key role in advising on policy direction for mental health in Rwanda. It was great that she was able to make time to meet with us.
After a quick lunch, it was off to meet Dr Charles Mudenge. Charles is one of only six psychiatrists working in Rwanda. He completed his psychiatry training at the University of Nairobi, Kenya. He works at the Psychosocial Outpatient Clinic which is art of the Centre Hospitalier Universitaire Kigali. This center first opened in 1994 in the aftermath of the genocide and is funded exclusively by the Ministry of Health. The original remit of the center (i.e. treating trauma) was broadened to encompass the treatment of neurological difficulties. The clinic is now part of the Department of Mental Health at the University of Rwanda.
Charles informed me that an Association of Psychiatrists had recently formed in Rwanda. There are currently no psychiatrists working at the district hospital level. Instead, psychiatric nurses working at the district hospital tend to make the prescription of psychotropic medication. In terms of improving capacity for psychiatric interventions at community level, Charles highlighted that there are plans to commence some basic trainings for GPs.
Consistent with what other people have said to date, Charles stated that the most common difficulty presenting at assessment at the center is epilepsy. He added that somatoform difficulties are a highly prevalent issue. We discussed how the rapid economic growth in Rwanda means that the levels of stress are on the rise. Mood disorders were also highlighted as a common form of mental health difficulty. He also treats people with psychosis who are being maintained on antipsychotic medications in the community.
Charles was very candid in highlighting that implementing psychosocial interventions can be a challenge. He recognises the importance of addressing the social determinants of mental health difficulties. He stated that there are lots of myths in the general population regarding mental health difficulties and its causes. Charles also discussed the range of medications that are available to treat mental health difficulties in Rwanda. There seemed to be a good range of antipsychotic, mood stabilizing, antidepressant, and anticonvulsant medications. The antipsychotics tended to be older, first generation medications, although some atypical medications are available, but these tend to be prioritized for private health insurance schemes.
Charles was kind enough to take me to my next meeting, which was in the Psychology Department at City Tower (Kigali’s tallest building with 17 floors). Stefan, Darius, Marie-Claire Gasanganwa (a psychiatric nurse and Head of the Department, Mental Health Nursing at the University of Rwanda) and Rebecca (a nurse who is in Rwanda as part of the HRH programme. It was a very helpful meeting that brought together a lot of the ideas that had emerged through the discussions that I had been involved in to date. Moving forward this working group will be helpful for developing ideas for promoting mental health and well-being in Rwanda.