LSE’s Victoria de Menil argues that hospitals are not a viable alternative for community mental health care in Kenya and other low and middle-income countries.

“They are not criminals,” so asserted Samuel Anampiru, divisional police chief, to BBC reporters following the escape on Sunday 12 May of forty mentally ill men from Mathari Hospital, Kenya’s national referral hospital for psychiatry. However, conditions at the hospital were described as “prison-like” in a recent report by the Kenya National Commission on Human Rights.

A recent report revealed the poor living conditions of mentally ill patients at Mathari Hospital in Kenya

A recent report revealed the poor living conditions of mentally ill patients at Mathari Hospital in Kenya

The National Commission found staff to patient ratios at Mathari of 1:80. Basic hygiene was compromised: “ventilation in the buildings is poor…sewerage blockages are common.” Furthermore, an atmosphere of insecurity was said to reign with reports of robberies from a neighbouring slum, and both patient-on-patient and patient-on-staff violence. The problems found in Mathari were equally present in other public psychiatric facilities. Occupancy rates ranged from a low of 105% to a high of 200%.

These challenging conditions affect both patients and staff morale, and cannot be blamed on the professionals working within the institutions. The National Commission rightly points the finger at “systemic neglect”.

Within Kenya’s poorly-resourced public health system, mental health is among the lowest priorities. The national mental health budget amounts to less than 1% of the total public health budget, which is insufficient to carry out the current national mental health policy.

Kenya’s public psychiatric hospitals are overcrowded partly because of the absence of community mental healthcare. Hospitals are no community substitute. National mental health policy posits that there must be a psychiatric nurse to provide outpatient care in every district hospital. However, with the current nursing shortages, half of psychiatric nurses work as generalists, and the Director for Mental Health, Dr. Kiima estimates it would take 100 years for there to be enough psychiatric nurses to fulfil this policy.

A number of NGOs, namely the Africa Mental Health Foundation, the Institute for Legislative Affairs and BasicNeeds, have been working closely with the Kenyan government to research and implement community mental health policy in selected districts, providing an example of what is possible with the right resources in place. Strategies for preventing hospitalisation include bringing psychiatric nurses into outpatient health centres, training community workers to provide supportive counselling, and facilitating the creation of self-help groups of service users and carers.

The health system challenges highlighted by the incident at Mathari are not specific to Kenya. In most low- and middle-income countries globally, over three-quarters of mental health expenditure goes to hospital care, and mental health accounts for an average of 0.5% of total health expenditure. Outside of Kenya, efforts to expand community mental healthcare are at the heart of the agenda of the Movement for Global Mental Health, which brings together researchers and practitioners focused on scaling up evidence-based and rights-based mental healthcare in low- and middle-income countries.

For the majority of Kenyans, who are not lucky enough to afford mental healthcare in one of the three private facilities in Nairobi with designated psychiatric wings (Chiromo Lane Medical Centre, Nairobi West Hospital, and Avenue Nursing Home), Mathari Hospital is their best option in a time of acute psychiatric crisis. It is incumbent on Kenya’s Treasury and international aid agencies, such as the UK Department for International Development, to adequately resource mental health, so as to ensure that Mathari becomes a place of treatment and not of crimeless punishment.