Historical considerations

The historical development of MH services, education and research in Africa has followed two main pathways: imported and imposed. Most MH services in Africa were set up by colonial institutions; they were entirely imposed22 and after the geographic decolonisation process was completed, these institutions continued with structure and function unchanged. In Ethiopia, where there was no direct colonial history, MH services developed from indirect colonial pressures and internalised assumptions that imported Western structures were superior.23–25 In North Africa, psychiatry was developed not only as medical science but as one of the ‘weapons in the arsenal of racism and a way of negotiating citizenship’.26 In West Africa as well, psychiatry developed through the asylum system with specific conceptualisations of the African mind.27 While North and West African developments stem from the perspective of dealing with ‘primitive madness’, in East African colonies it developed as a way of dealing with problems of ‘crime and disorder’.28

As most LAMICs have scrambled to keep up with the rest of the world, it is perhaps inevitable that they have sought the adoption of Western institutions such as education, that were effective in facilitating the formation of modern high-income country (HIC) societies. Many countries in Africa have turned to importing Western education either through sending their youth for training abroad (the majority do not return),29 or inviting Western educational institutions and teachers to teach in newly formed African institutions (most onsite trips are less than a week). However, all teaching of MH in Africa that we are aware of, uses Western MH theories of pathology and treatment, therapy manuals, teaching videos, etc. These processes facilitated the spread of Western models of MH training and services to the region. This on its own might not be a problem if the foundations of MH knowledge were truly universal and their assumptions of society globally applicable. However, when the epistemic status of MH knowledge is not well defined, and its practice dynamic, the translation of such a knowledge base across cultures remains problematic.30

Conceptual considerations

One of the most significant flaws in the import or imposition of a Western MH model is a failure to examine assumptions underpinning the model’s development. MH service models were developed with a particular understanding that an individual, initially a middle class European adult, equipped with a unique sense of agency and the money and tools that will enable mastery over one’s life.31 32 However, the African conception of a person is diametrically different,33 where the central organising principle of personhood is ‘connectedness’ and agency that socially equips the individual with tools that enable competence in relationships.34 Each model leads to different ideas about what constitutes particular forms of ‘suffering,’ how they are perceived and understood, how idioms of distress are expressed, and how particular explanatory models are shaped and organised along the domains of personal, social, environmental and spiritual relationships.35 On the other hand, the historical development of MH services, education and research in Africa does not begin with ‘universal’ assumptions of personhood or conceptualisations of illness and treatments, but with an African mind invented and constructed by the coloniser.36 37 This calls for an MH model that incorporates these differing considerations into MH service development.

Structural considerations

Mental illness has always been with us. Societies across the world have designed institutions to take care of those who suffer. For the most part, effective traditional African social institutions are based in the community. They have been made invisible by the emphasis on asylums in the past, and the more recent development of ‘modern’ MH services,38 as well as by the Western assumption that traditional healing is outdated and irrelevant. In most parts of Africa, people prefer to use traditional healing institutions that are already present and located in homes and spiritual spaces.39 These healing structures are powerful because they invoke knowledge and experience that is in harmony with people and their way of life. The merit and wisdom of recognising that the knowledge and experience contained in these institutions is important for healing is a matter open for exploration. However, their relevance, accessibility and local acceptability is undeniable.40 If we accept that healing institutions are an irreplaceable asset for society, we must also accept that none of the imported/imposed models can claim to be a reasonable substitute. Far from being irrelevant, quaint or of historic interest only, traditional healing institutions carry the highest burden of care for the mentally ill in African communities. The low outpatient visit average of 94 visits per 100 000 population stated above for MH care in Africa becomes stark in the face of this, as the majority of ‘outpatient’ service is delivered completely outside ‘modern’ MH ‘systems.’

In addition, social healing institutions have knowledge systems and methods that can be productively identified and used as a basis for developing modern MH services, as opposed to their incorporation as a cultural adjunct to the Western biomedical model. In principle and practice the majority of primary care services, be it physical or mental, in most parts of Africa, are provided by these local healing institutions.41 Any integration that fails to acknowledge and engage these systems beyond a rhetorical nod is bound to be unacceptable to the majority of users even when accessibility claims are made. Recognising the importance of traditional healthcare systems, there have been some tentative efforts to integrate traditional and modern MH services, but this usually entails the two systems running separately and in parallel (eg, a traditional clinic and modern MH clinic with bidirectional referral capacity). However, this area of exploration remains at best on the margins, leading to neglect of much-needed efforts to incorporate modern MH service models into existing societal and institutional structures.42–45 As traditional institutions are already taking on the majority of the burden of care for the mentally ill, they present modern health services with an opportunity to identify ‘situated knowledges’ that may be used for developing meaningful policy directions and mitigate the potential of epistemic genocide.

Socioeconomic considerations

It goes without saying that the African continent, both historically and in its present, has suffered the impacts of chronic poverty, war, conflict, natural disasters and population explosion. The impact of this enduring reality on the psychological and social development of particular societies within Africa is far from understood. Where this has been explored, analysis rarely gets further than a pathological characterisation of the reactions of people as ‘traumatised’. However, we have yet to see an attempt at a comprehensive understanding of the impacts of inhabiting such a context on the overall development of the individual and societal psyche. Has it, for instance, influenced the centrality of community to the development of individuals? The attempt to reduce all reactions to suffering as trauma, and all services to the clinic, has not led to meaningful changes in the lives of people who are affected by difficult collective experiences. The fact is that most African societies continue to not only survive and cope, but in many ways thrives and flourishes, aspiring and working to building a better future. This inspires a call to explore ways people continue to resist, endure and succeed. Understanding the impact of how context shapes how to see, engage and be in the world should form the basis of models of services that aim to alleviate the burden of mental illness. As illness involves the subjective experience of individuals, being in a particular world will affect how the person reacts to that world.

Reimagining curriculum

While there are various ways of understanding the curriculum, we are framing the curriculum following Lunenburg,46 as an explicit approach to incorporating social and philosophical perspectives. This makes it a tangible target for reimagining. The underpinnings of MH curricula throughout Africa have Western origins and this remains for now an unavoidable necessity. Many African medical schools have adopted competency-based models,47–49 and the overall outcome of these curricula is the production of human resources with a predefined competence to enable the delivery of MH care. However, competent graduates frequently leave these training programmes with limited capacity to deal with what awaits them in practice. A basic assumption of professional practice is that the competencies of practitioners and the needs of society will align. In Africa, this alignment is hard to come by: what professionals have to offer is not what society needs or wants. Graduates are left in a state of isolation both from society and themselves. Additional competencies helpful in these circumstances are critical reflection and reflexivity. Critical reflection challenges assumptions and practices, while critical reflectivity and cultural humility involves recognising one’s own social position so as to understand the experiences of others.50 A reimagined curriculum that includes these concepts may prepare professionals to provide locally relevant, compassionate, humanistic and equitable care51 and contribute to individual, social and systemic change.50 52 53 A reimagined curriculum should aspire to envisage all the potential spaces for intersection and alignment and build content accordingly.

Reimagining research

In recent years, both the quantity and quality of MH research from the African continent has increased markedly. The number of international organisations that fund MH research has also gradually increased. However, we have yet to see MH research from Africa that has impacted how services are developed. Whether driven by funding agency priorities, Western academic pressures, research that serves HIC policy-makers or other interests, or the uncritical engagement of LAMIC researchers in established research priorities, the lack of service delivery research is unacceptable. Despite this, there are calls for more research in the field.17 54 Research that does not recognise local socioeconomic, political and cultural contexts is contestable, and research without moral and societal accountability can do more harm than good. Reimagined MH research should take relevance, context and accountability as its core drivers.

Reimagining services

As previously noted, most MH care is provided by societal healing systems which have been rendered invisible by the parallel development of more prominent ‘modern’ MH services that respond to a negligible proportion of the burden of care. This sad reality contributes to a lack of alignment between society and professionals as they operate in different spaces. A reimagined MH service model needs to acknowledge this lack of alignment and seek to build bridges between the two. There are knowledge systems and practices in both systems that can be used for the provision of better services to society.