by Victoria de Menil, David Ndetei, Milka Waruguru, Martin Knapp, David McDaid
In much of sub-Saharan Africa, community mental healthcare and specialist mental healthcare are not synonymous. Apart from traditional and faith healing, primary care providers are thought to be the sole purveyors of mental healthcare outside of hospital settings, while specialists operate through hospital-based outpatient clinics. While true of the public sector, this dichotomy is missing something. The hidden face of community mental healthcare in Africa is private specialist providers in outpatient settings.
Kenya serves as an interesting case study, since its private health sector is particularly well developed. We conducted a small-scale study, administering semi-structured interviews to 11 private mental health specialists (8 psychiatrists, 3 psychiatric nurses) from the capital and a more rural area to better understand what services they provide, what type of patients were accessing those services, and at what cost.
Less wait, more time
The private outpatient providers had an average active case load of 128 mental health patients, and the number of mental health patients seen per clinic day was 5. Private clinics usually operated half-time (24 hours a week). Typical wait-time was 20 minutes, as compared to the public sector, where patients queue up for hours to see a specialist. First visits lasted an hour and follow-up half an hour, on a monthly basis – again significantly longer than a typical visit to a specialist in the public sector.
More access for women
Those who walk through the door of a private outpatient mental health clinic in Kenya differ markedly from patients found in a hospital. According to their clinicians, half of patients came for common mental disorders, and over half were women, whereas in the public hospital setting two-thirds were men and the majority were diagnosed with a schizophrenia-spectrum disorder.
In a context where the term “mental” is associated with psychotic behaviour, a private clinic in the community may offer a less stigmatizing option of care for individuals experiencing depression or anxiety. Privately owned clinics are also more “private” to clients in that care can be sought with greater confidentiality. Since depression and anxiety affect women more commonly than men, the possibility of attending a private mental health clinic increases women’s access to healthcare.
It costs about two days of work
The cost of private care was high from psychiatrists, but much more affordable from psychiatric nurses. One visit to a psychiatric nurse in private practice cost Int$ 13.0, which represents approximately 2.5 days of basic farming work. By contrast, a visit to the psychiatrist cost the equivalent of one month’s pay by the same farmer. However, most of the private providers said they adjusted fees based on how long the person stayed and their ability to pay — judged in part by their occupation.
Cross-subsidising public health?
We found a large cross-over between private and public sectors: three quarters of the private specialists split their time with the public sector. Most said the care they offered in private practice was different – mainly thanks to a greater choice of drugs, especially atypical antipsychotics. In a context of under-paying public health providers, private employment may be seen as cross-subsidizing public health care.
de Menil V, Ndetei D, Waruguru M, Knapp M, McDaid D (2014) A hidden face of community mental healthcare in Kenya: specialist care from private providers, World Psychiatry, February p100.
About the authors
Victoria de Menil is a PhD student in the Department of Social Policy at the London School of Economics and Political Science.
David Ndetei is Director of the Africa Mental Health Foundation.
Milka Waruguru is a Research Officer at the NGO BasicNeeds in Kenya.
Martin Knapp is Director of the Personal Social Services Research Unit at the London School of Economics and Political Science.
David McDaid is a Senior Research Fellow in the Personal Social Services Research Unit at the London School of Economics and Political Science.