Voices from the Ground: Ethnographic Perspectives on Strengthening the Ugandan National Mental Health System: An Ethnographic Needs Assessment

doi:10.21203/rs.3.rs-4114227/v1

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Research Article

Voices from the Ground: Ethnographic Perspectives on Strengthening the Ugandan National Mental Health System: An Ethnographic Needs Assessment

https://doi.org/10.21203/rs.3.rs-4114227/v1

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Background

Mental health capacity building is a critical need and a growing priority in Ugandan health and education systems. Despite increased governmental attention to community mental health and mental healthcare needs, no published assessments garner qualitative perspectives directly from stakeholders in the Ugandan mental health system. Addressing this gap, the goal of the current needs assessment study was to systematically explore stakeholders’ perceptions of strengths, challenges, and recommendations for enhancing capacity in the national mental health system in Uganda.

Methods

Using qualitative ethnographic methods, data was collected from key informants through interviews and focus groups. A total of 44 stakeholders, who were engaged in the mental health system, were included in our final sample.

Results

Thematic analyses of data yielded several themes in each category, including system strengths related to existing policy and action plan, free medications, private sector, partnerships and collaborations; system challenges including socioeconomic constraints, stigma, and limited family engagement; and recommendations for improvement including enhanced education and training, integrating systemic approaches, and policy advocacy.

Conclusion

The results of this study have clinical, research, and policy implications that may inform mental health capacity, not only in Uganda, but in other global settings, advancing capacity to respond to pressing community mental health needs.

Mental health capacity building

Uganda

Stakeholder

Qualitative perspectives

strength

challenges

Recommendations

Ethnographic methods

Thematic analysis

Policy implications

Uganda is relatively progressive among Sub-Saharan Africa countries as it relates to its establishment of a national mental health policy, along with robust research and practice sectors [1]. The 2019 National Mental Health Action Plan increased attention to mental health legislation, practice, research, and other priorities required to address significant mental health needs across Uganda. For example, positive changes were witnessed after the action plan in terms of increased awareness of the contributions of non-medical psychosocial professionals, and related opportunities to integrate more psychologists, counselors, and social workers more formally in the mental health system. Despite these positive priorities, the mental health system in Uganda continues to grapple with significant challenges, particularly concerning resources, both in terms of finances and human capital, needed to deliver high-quality mental health care to the expanding population. For example, a mere 1% of Uganda's annual healthcare budget is allocated to mental health [2], and this allocation is insufficient to address the escalating demands for mental health care within the growing Ugandan population. The global refugee crisis has added significantly to mental health needs on a national scale [3]. Although commendable, this effort places an additional burden on Uganda's mental health system, exacerbating the challenges it already faces in providing comprehensive care.

While progress in mental health research, practice, and policymaking in Uganda is expanding [2], there is a gap in research highlighting the insider perspectives and experiences of key stakeholders involved in mental healthcare. The goal of this study was to understand diverse stakeholders’ (e.g., mental health providers, graduate trainees, service users, policy officials) perceptions of strengths and challenges within the Ugandan mental health system, and recommendations to enhance its capacity, particularly when it comes to supporting common family-level and community mental health needs.

Literature Review

Global Mental Health

The World Health Organization (2022) estimates that approximately one billion people are living with mental health disorders, with 75% of the global disease of burden existing in lower- middle-income countries [4]. Global mental health is focused on improving access to quality mental health services in diverse settings globally [5, 6]. Global mental health includes research, training, and practice rooted in social justice principles surrounding equity, access, community, culture, and context [7]. The Center for Global Mental Health Research was developed by The National Institute of Mental Health (NIMH), recognizing that improving the availability, quality, and accessibility of culturally appropriate mental health resources in lower-middle income countries (LMIC’s) is imperative to improving mental health outcomes across global settings [8, 9]

Mental health challenges persist sub-Saharan Africa due to inadequate access to quality mental health care in most countries. Studies show that the global average of mental health professionals per service user is 9.0 per 100,000 service users, however, in the SSA region, there are only 1.4 mental health professionals per 100,000 service users [10] Moreover, estimates show that the population of Africa is expected to double over the next three decades, implying that the rates of mental health needs and disparities are also likely to increase [11]. Particularly, mental health of African youth is likely to be jeopardized by the highly competitive labor market, and as many fail to achieve their economic ambitions, some are likely to turn to substances (e.g., alcohol, marijuana, etc.) to cope with their frustrations.

Mental Health in Uganda

Similar to other Sub-Saharan African countries, mental health and substance use disorders represent major public health concerns in Uganda [12]. Depression, anxiety disorders, and chronic stress are common; Uganda ranks among the top six African countries for rates of depressive disorders [13]. After two decades of civil conflict, high occurrences of post-traumatic stress disorder (PTSD) with prevalence rates as high as 54% are documented in northern Ugandan communities [14]. Research also documents high rates of intimate partner violence [15] and disruptions in parent-child relationships [16]. Like elsewhere, social, and economic losses (e.g., isolation, unemployment) from the COVID-19 pandemic have exacerbated mental and relational health concerns. Rates of depression, anxiety, posttraumatic stress, and substance use disorders are projected to rise in Uganda, and cases of gender-based violence, child abuse, and neglect have shown increase during the COVID-19 lockdown [17]. Many regional psychiatric treatment centers were converted into isolation units to help manage the pandemic, further straining the national mental healthcare system [17]. Uganda is also one of the top-receiving African nations for refugees and asylum seekers. More than 1.6 million refugee individuals and 400,000 refugee and asylum-seeking households were recorded in Uganda at the end of 2023 [18]. This influx amplifies the need for quality and accessible mental healthcare in Uganda.

Background on Ugandan Mental Health System

Until the late 1990s and beginning of the 2000s, mental health services in Uganda received minimal attention and limited national funding. The Ugandan government established frameworks for policies and strategies to direct the delivery of mental health care around the beginning of the twenty-first century [19]. These included the National Mental Health Policy and the Mental Health Act of 1964, updated in 2006 to reflect contemporary norms [20]. The updated Act sought to preserve and advance the civil rights of people with mental disabilities, to provide all-inclusive mental health care, and to advance mental health care. Despite these policies, Uganda's mental health services continue to be underfunded and under-resourced, with one percent of the annual national healthcare budget allocated to mental healthcare [2]. Butabika National Referral Hospital remains Uganda's primary center for mental health treatment [21]. The hospital offers inpatient and outpatient care, community outreach programs, counseling, and rehabilitation services [22]. The institution is facing difficulties such as a lack of financing and a scarcity of mental health personnel [23].

Ugandan Mental Health Workers

Inadequate government funding limits employment of qualified mental health providers in the national mental health system [24]. Psychiatry is the only discipline officially employed by government. However, only 32 psychiatrists and 60 psychiatric clinical officers who support psychiatric services across the country [25]. There are more than three times the number of clinical psychologists, counseling psychologists, social workers, and counselors in-country, most of whom are employed in the non-governmental (NGO) and private sectors. Traditional healers also play a key role in Uganda's mental health landscape [26] Studies show that up to 60% of Ugandans seek mental health therapy from traditional healers [27]. Many Ugandans also seek spiritual assistance from religious leaders to cope with personal health and relationship issues [28]. Despite their popularity, traditional healers and religious leaders have limited training in evidence-based mental healthcare [29, 30]. Increased investment in training mental health professionals, expanding mental healthcare to marginalized areas, acknowledging religious and traditional healers, and funding mental health research are all necessary [31] for building capacity.

The Current Study

The purpose of this study was to conduct an ethnographic needs assessment of the national mental health system in Uganda. This study addresses a gap in the dearth of qualitative perspectives published in the global mental health literature. We also explored common perceptions of community mental health needs and stakeholders’ observations of help-seeking in families. Within the scope of this paper, we detail findings surrounding stakeholders’ perceptions of strengths, challenges, and recommendations for improving system-level capacity to respond to common community mental health problems.

Researcher Positionalities

This research took place in the context of an academic partnership between researchers at a major university in the United States and researchers from the largest higher education institution in Uganda. The partnership was born out of authors’ shared interests around: 1) global mental health research in African contexts, and 2) efforts to strengthen mental health system capacities by prioritizing culturally and contextually relevant interventions and supports for children, youth, and families in Uganda. This partnership and the many alike are important to global mental health efforts as we conduct this research to ultimately improve access to quality mental health care for populations in lower-income settings, such as those in Sub-Saharan Africa [32]. Further, enabling collaborations between researchers from high income-settings and lower-income settings ensures that relevant and rigorous cross-cultural research is conducted. Together, the diversity of the research team and our shared interests in the subject of mental health in Africa added value, direction, and richness during this study.

Study Design

The current study was informed by an ethnographic qualitative design, given the central importance of culture in ethnographies. This design aligned with authors' goals to garner deeper understandings of mental health and system-level functioning in local Ugandan settings. The Developmental Research Sequence [33] guided aspects of the ethnographic study design, including data collection with a specific focus on: 1) system strengths, 2) system challenges, 3) recommendations for improvements, and 4) youth and family experiences related to mental health in Uganda.

Recruitment and Sampling

Snowball sampling procedures were used to recruit a total of 44 stakeholders who participated as key informants (n = 15) or focus group participants (n = 29). To recruit key informants, we began with an initial list of professionals who were identified as institutional leaders at Butabika National Referral Hospital, Makerere Schools of Medicine and Psychology, and the Ministry of Health. Key informants identified as clinical psychologists (n = 8), psychiatrists or psychiatric clinical officers (n = 5), a traditional healer (n = 1), or a public health officer (n = 1). Eleven key informants were interviewed in central Uganda, while four key informants were interviewed in northern Uganda.

Focus groups helped generate dialogue between stakeholders working in shared settings at the time of the study. Three groups were held in central Uganda, and one was held in northern Uganda. In the central region, focus groups included psychology graduate trainees (n = 7), practitioners at a local counseling center (n = 5), service users (n = 9). In northern Uganda, one focus group was held with service users in Gulu (n = 8). Across the 44 total participants, an equal number of stakeholders identified as women (n = 22) and men (n = 22).

Data Collection Procedures

Prior to data collection, this study was approved by the institutional review board at a higher education institution in the U.S. and one local higher education institution in Uganda. Participants provided written consent to audio record interviews for later transcription. Individual key informant interviews were one-hour in length, focus groups were 90–120 minutes, and both were semi-structured. The first grand tour question [33] asked participants how they got involved in the mental health system and a typical day in their role. For example, we asked, “As a [e.g., psychiatrist, psychologist, graduate student, institutional leader, service user], how do you typically engage with the national mental health system?” What is an ordinary day like in your role?” This was followed by mini tour questions about their specific perceptions of strengths, challenges, and recommendations that could enhance services, training, and support for common mental health challenges addressed in their work.

Data Analysis

Following data collection, the research team developed and reviewed field notes, memos, and initial summaries of key perspectives from the data collection phase. This early processing as a full team enabled reflexivity and analytic dialogues prior to in-depth analysis of the transcripts. Interview and focus group recordings were transcribed by local Ugandan graduate students, supporting a key goal to develop transcripts as close to local idioms and expressions as possible. Taken together, initial summaries were included with interview and focus group transcripts to enable triangulation during analyses. Data were analyzed using thematic analysis [34] strategies to develop categories, themes, and sub-themes representing findings from the needs assessment. Three research team members equally divided and analyzed one third of transcripts using thematic analyses procedures in full-text deductive analyses of participants’ descriptions of strengths, challenges, and recommendations reported herein.

Enhancing Trustworthiness

The research team employed various strategies to enhance the quality and rigor of data collection and data analysis procedures, as well as the representation of results. Lincoln and Guba’s (1985) trustworthiness criteria of credibility, dependability, confirmability, and transferability were used to guide and strengthen the rigor of the current study as these criteria are well established in the qualitative research literature [35]. Credibility, which reflects the degree to which findings accurately reflect the lived realities and experiences shared by participants, was enhanced by prolonged engagement, persistent observation, and data triangulation strategies.

Our research team is comprised of African mental health clinical researchers, several of which are natives of Uganda. As a credibility strategy, prolonged engagement helped us to build awareness of the study context and rapport with stakeholders. The research team spent nearly one year planning the study prior to data collection. Reflexive dialogues were held via Zoom starting in early phases to process personal values, biases, and assumptions that influenced study goals and subsequent data collection and analysis. Persistent observation, or the repeated observation of relevant study contexts, was also discussed as a strength among local team members as their knowledge and engagement in various mental healthcare settings in Uganda strengthened participant recruitment and sampling efforts, as well as contextually and culturally relevant interpretations of the results. Data triangulation, or the use of multiple types of data (i.e., interview and focus group transcripts, audio recordings, field notes, memos) were used to enhance analyses, emerging interpretations, and overall study rigor.

To enhance dependability or confidence in the study findings across time, researchers consistently documented key approaches, decisions, and techniques employed for data collection and analyses. We developed a comprehensive log for data management and analysis, which enabled an external audit to be conducted by a team member who was not involved in data collection and analysis procedures. This audit trail and documentation of study procedures enables reproduction of the study and enhances the dependability of the study results. Providing thick descriptions of data is a strategy that enhances transferability of research studies. This strategy is reflected in the results section, which includes rich, in-depth participant quotes to represent results as close to participants’ perspectives and observations as possible. We include both brief and detailed quotes to demonstrate key findings.

The results section below delineates key reflections and provides rich descriptions through participant quotes that directly reflect stakeholders’ perceptions of strengths, challenges, and recommendations for increasing service, training, and supervision capacity in national mental healthcare efforts in Uganda. In-depth participant quotes are provided to enhance the results section with rich descriptions of participants’ direct observations and perspectives. Table 1 provides an overview of key themes and sub-themes relevant to study results.

Table 1

Overview of Domains, Themes, and Sub-themes in Study Results
Domain	Theme
System Strengths	Existing Policy and Action Plan
	Free Medications
	Robust Private Sector
	Partnerships and Collaborations
System Challenges	Socioeconomic Constraints
	Community and Professional Stigma
	Limited Family Engagement
System Recommendations	Enhance Education and Training
	Integrate Systemic Approaches
	Policy Advocacy

[INSERT Table 1]

Strengths of the Mental Health System

Participants described a range of strengths, assets, and resources that promote current mental health service delivery, training, and supervision of services to address common family and community mental health needs in the Ugandan mental health system. Reported strengths surround the existing mental health policy, free psychotropic medications, the availability of a robust private sector, partnerships and collaborations, and the existing use of evidence-based interventions to address community mental health needs.

Existing Policy and Action Plan

Most participants acknowledged that there is a mental health policy that exists in Uganda to support human resources and professionals working in national mental healthcare. There is not only a government vision for mental healthcare but also current momentum as policies are being implemented. The government acknowledges mental health as a public health issue at various community levels. As one key informant shared, “...since 1990s it [mental health] has been taken on as a minimum in [the] healthcare package that had to be integrated at the primary health level, so now we are getting into 30 years of that...” (K8). Another stakeholder discussed the goal for policy, stating “we are actually... revising the clinical guidelines and we are trying to see that we include non-medical treatment as part of treatment in mental health.”

Free Medications

Key informants widely agreed that the availability of free psychotropic medications is one of the greatest strengths and resources available in the mental health system. Most key informants discussed this as an asset in the national mental health system because individuals are not required to pay for medication they are prescribed by a psychiatrist. A sentiment shared by many, one stakeholder shared “We have also improved our medicines list…generally the medicines are there, the people who are to give them out are also there, you need to see a psychiatrist, you don’t pay (K2).” Most medications are delivered from India, linking to the strength in partnership between the Ugandan national mental health and Indian health and pharmaceutical systems. Key informants shared that medication supplies sometimes run out, presenting a challenge for medication access and management. However, free medications were framed as a strength given their lack of cost, which would have otherwise been prohibitive.

Private Sector

Participants discussed ways that clinical and counseling psychology have grown in recent decades and resulted in trained professionals with the knowledge and capacity to engage in psychosocial efforts. Although this strength is limited by lack of funding to employ many of these trained individuals in the national mental health system, both central and northern Uganda were described as contexts with robust private sectors supported by professionals trained in psychosocial mental health approaches. As one key informant discussed their perceptions of human resources availability and training of community mental health workers, “We have the human resources, not so specialized but at least they can offer the basics like managing the common mental health disorders at the community level” (K8). This available network means there are professionals ready to receive additional training and support to integrate family and community mental health models in both private sector (e.g., NGOs) and government-funded settings (e.g., Butabika hospital, district-level hospitals) provided the opportunity for employment in national mental healthcare efforts. A majority of clinical psychologists, counseling psychologists, counselors, and other psychosocial workers are employed in private sector settings, and this private sector workforce plays a crucial role in offering supportive services, increasing awareness, and reducing mental health stigma.

Partnerships and Collaborations

Key informants identified clinical intervention and research collaborations as important sources of community mental health support in Uganda. Several key informants shared about the positive impact of clinical research studies on local mental health efforts across Uganda. Research collaborations were noted as key to advancing knowledge and improving existing clinical strategies, particularly when developed in partnership with local researchers, clinicians, and community members. Participants credited collaborations for existing progress in evidence-based intervention science and delivery. Cognitive Behavioral Therapy (CBT) and Group Interpersonal Therapy (IPT-G) for depression were noted as the most common interventions observed and endorsed by stakeholders. As one informant stated when asked about contextual fit, “…a lot of IPT-G...which is specializing in treating depression. And CBT. Where I’ve seen it work is within the humanitarian setting” (K6). A few stakeholders acknowledged that although limited, growing attention to family-level interventions reflects progress in mental health efforts and discussed their awareness of family interventions for reducing corporal punishment, youth conduct problems, and other child and family-level issues. As one recounted, “[NGOs] are testing play therapy and it is implemented within schools… they go and assess those who might be having issues, those who might be not performing very well maybe they have problems homes and so they take on these play therapy which helps them think about whatever they are going through....” (K8).

Challenges in the Mental Health System

Key informants shared perspectives on a range of challenges and barriers to family and community mental health, most of which were explained by themes of economic constraints, stigma, and burden on the psychiatric care system/limitations around family-based intervention. Economic constraints and stigma were discussed across participants as multi-level concerns impeding existing mental healthcare efforts. The existing burden on the psychiatric system also limits availability and capacity to integrate family-based mental health practices.

Socioeconomic Constraints

Participants identified socioeconomic constraints as an enduring hindrance to mental healthcare, including strains in institutional funding and family economics. Family financial and economic difficulties were largely attributed to Uganda's status as an LMIC, as articulated by one participant, “this being a low-middle-income country, I think priority goes to survival” (K5). This sentiment reflects what numerous stakeholders acknowledged; for many Ugandans, supporting numerous family members’ needs with limited financial resources substantially constrains the ability to financially support mental healthcare for one or more family members.

Community and Professional Stigma

Stigma was discussed as a multi-level barrier. Negative attitudes toward mental health not only emerge in families and communities, but also permeate professional settings. Cultural stigma in families, communities, and professions operate to hinder mental healthcare.

Participants described their observations of stigma at both family and community levels citing factors such as limited knowledge, fear, and reluctance to engage in discussions about mental health and the needs of family members. As one participant openly expressed, “many people fear the diagnosis of a mental illness. They will accept to go to a health facility for anything but not for a mental illness (K7).” Family and community stigma stem from limited mental health knowledge and education, and negative stereotypes around help-seeking. As one participant illustrated, “attitudes towards mental health services and the changes our youth are experiencing, it is not a good one, it's not good. Because in Uganda, when or if the youth is found abusing substances, in most cases they treat it as their own fault. We treat it as a lifestyle choice that you made, and you [youth] should be able to face the consequences (K12).” They described typical consequences to illustrate stigma, “That is the attitude out there, in fact, today, if you are found abusing drugs, you are most likely to end up in police custody and you are likely to end in the hospital. A suicide attempt is also likely to end you in police custody, so that is how much the gap we have in terms of mental health services in Uganda” (K12).

In one focus group, participants reached a consensus that most Ugandan men tended to hold adverse attitudes towards mental health and displayed a reluctance to be associated with such matters, often leading to blame and responsibility placed on women for children’s struggles. One participant remarked, “Mainly men do not want to associate themselves with any issue related to mental illness and they tend to run away from the family; that’s why we have very many broken families” (MC2). This results in some families isolating their children with mental health concerns.

Professional stigma also hinders community mental health. As one key informant shared from their experience, “when I was going to train for my diploma in mental health, my close friend asked me what are you going to be doing, how many madmen do you see on the streets that you will be able to help. They are just 2 or 3 and that’s all you will be doing in life (K12).” Negative stereotypes permeate from even outside of the mental health profession. As one participant shared, “there are instances where the president came out publicly and said we don’t need psychologists, and I think it is about the people who advise him. So, we need the right people to advise him. So we need people in parliament to lobby for mental health” (K13).

Limited Family Engagement

Many participants recognized the value of family-based and relational mental health models as resources to progress community mental health needs outside of existing psychiatric models. These are therapy models that include family members or significant others in some way in treatment, either as direct support, or as a part of the problem resolution. With this acknowledgment, key informants described how limited training in systemic family therapy and family engagement skills impedes current efforts and contributes to the significant burden on the psychiatric care system. For example, if an adolescent was experiencing difficulties, not including caregivers or parents directly into treatment would add challenges when the individual returned home.

System Recommendations

Participants’ recommendations for strengthening the mental health system in Uganda included strategies to build on existing capacities, enhance education and training, implement systemic and integrated approaches, and advocate for policy and funding changes.

Enhance Education and Training

Participants identified continuing mental health education and training, and notably family therapy and community mental health trainings, as strategies to increase existing capacity. Family-level engagement, assessments, and psychoeducation were discussed as enhancements to service delivery as many service users may benefit from systemic therapy and intervention rather than, or in addition to medication support. One participant expressed, “There is a gap, how I wish we meet the families, have a discussion maybe these issues will go away (MC2).” Group counseling training was also notably discussed. Participants in one focus group shared: “continuous education in group counseling is something we need to learn before starting to practice (MC2).” Another discussed telehealth training; “I know we have it but students have not yet appreciated tele-counseling, people have these beliefs that I must meet physically...so tele-counseling should also be advanced… sometimes they get used [to it]. For example, if someone has stigma and when we do tele-counseling, they realize that this is something good and they can come to the center after” (MC2)

Further, participants shared that additional education on mental health conditions, relational effects, systemic approaches, and coping strategies would enhance the ability to respond to common, prevalent, and unaddressed needs related to depression, anxiety, substance use, trauma, caregiving stress, and relational violence. Participants also underscored community sensitization as a strategic effort that has demonstrated progress in enhancing community knowledge and reducing stigma around common mental health concerns. One participant shared knowledge of the approach, “...we reach out to the communities at their location, that is their local villages, and we sensitize them. [We] work through their leaderships, their stakeholders at the community level...we work with them to identify places where we go and meet the people that have a need and we first give them information about mental health, and they actually get to realize that these things they have actually been suffering in the community are mental health conditions. So, then they come in for screening, we screen them (K12).” Altogether, when delivered in professional, clinical, and community settings, education and training on family and community models was discussed as key source of mental health capacity building when delivered in professional and community settings.

Systemic and Integrated Approaches

Key informants shared the need for an integrated referral system. Suggestions focused on integrating providers that are available and trained in systemic-family therapy, community mental health models, social work, and other psychosocial intervention approaches. Many called for greater collaboration among providers with various training to enhance holistic responses to common community mental health needs. Traditional healers were frequently discussed by key informants due to the high likelihood of herbalists, traditionalists, and spiritual leaders being the first source of support community members seek to resolve personal and interpersonal issues. Key informants acknowledged that stigma would need to be addressed in order to successfully integrate and promote collaboration with traditional healers, many of whom are not included as referral sources of formal collaborators in the mental health system. Key informants also recommended that efforts shift toward greater focus on disability, religion, poverty, gender, and other social intersections that influence family and community mental health experiences.

Policy and Advocacy

Participants agreed that policy advocacy was necessary enhance the Ugandan mental health system. Funding was most frequently discussed. As illustrated by a stakeholder, “More funding, more resources to put mental health in the spotlight. I can give an example with HIV/ AIDS the government put a lot of effort, so, if they can put the same effort towards mental health, we would be in a better place (K11).” Participants emphasized a pressing need to augment the budget allocated to mental health services. One participant articulated this sentiment, stating: “mental health services get about 1% of the portion that is given to the health sector. That is really so little and it gives us a picture that mental health services have not been prioritized in Uganda. And yet, recently the statistics that were all over the media are that over 14 million Ugandans have been mentally ill...” (K9).

While recognizing that national funding constraints limit the current distribution of resources in the mental health system, key informants equally recognized that lobbying for increased funding would help strengthen the foundation for an integrated referral system. Key informants shared that advocacy must also focus on creating employment pathways for professionals trained in family and community mental health to work within nationally funded healthcare centers. In the words of another, funding would also increase the potential for training and continuing education opportunities on systemic-relational approaches.

The goal of this study was to assess key stakeholders’ perceptions of the mental health system in Uganda; particularly their observations of strengths, challenges, and recommendations for improving capacity in the national system. This is important given the high rates of mental health difficulties in Uganda, and exacerbation of these difficulties by the COVID-19 pandemic and the high number of refugees present in Uganda. Stakeholders not only described their mental health system experiences engaging in service delivery, training, clinical supervision, research, and policy efforts to enhance mental healthcare, but they also offered critical perspectives on strategies to enhance capacity around existing efforts to address some of the most common mental health problems experienced by individuals, families, and communities in local Ugandan settings. They emphasized leveraging existing assets for sustainability, highlighting strengths like the mental health policy and referral system, despite resource constraints. However, barriers such as funding and stigma hindered efforts, underscoring the need to address socioeconomic and structural limitations to improve mental healthcare delivery in Uganda.

In terms of strengths, participants described a number of initiatives and realities that made mental health treatment access a reality for many Ugandans. High on the list of strengths is that the Ugandan government is aware of mental health prevalence and is committed to lowering mental health challenges in the country. Even though some pointed out that mental health care represents only a small percentage of the overall budget, and is small in comparison to the healthcare budget, there is, in policy, a commitment to alleviating mental health challenges. This is well reflected in the low costs of treatment for those who seek it, and free psychotropic medications provided. In addition, the mental health system is supported by a private sector (e.g., NGOs, private hospitals and health centers) that is also committed to the best treatments for mental health, along with a willingness to partner and collaborate among researchers, clinicians, and the government. These joint efforts are essential in working to solve difficult problems. These strengths have contributed to increased awareness across Uganda of mental health concerns, possible treatments, and has worked to reduce stigma even though much work remains. In this sense, even though there is a shortage of mental health providers in Uganda (as in other African contexts), Uganda has important initiatives underway when it comes to mental health care and treatment. Even though there are these initiatives, Uganda still lags in the eyes of the World Health Organization which ranks Uganda 119/190 for health systems. While Uganda has the intent as is illustrated in Uganda being one of 5 countries that had all the health documentation for an evaluation of the International Alliance of Patients Organization. Uganda also assented to the Abuja declaration, where alongside other African states, agreed to raise health funding to 15% of the total budget in 2001. However, mental health is a small part of this budget, and overall growth has been slower than expected [36]. In this regard, it is important that the next steps in mental health care involve the leveraging of existing assets and resources. Focusing on the existing strengths in a system enables more sustainability, a critical outcome in capacity building. Stakeholders described a host of available assets and resources that currently contribute to national mental health efforts, while describing a range of opportunities to optimize the use of such assets. Participants largely endorsed the existing mental health policy and mental health system as a strength, despite existing resource and staffing constraints.

Even though numerous strengths were reported, there remain significant barriers and challenges to mental health care in Uganda. Participants’ reflections of challenges revealed the significant role of socioeconomic and structural limitations (i.e., funding, human resource limitations) on mental health care efforts in Uganda. Stakeholders unanimously acknowledge the constrained resources that have impeded the delivery of adequate services to Ugandans grappling with mental health difficulties. This necessitates urgent attention from parliament, which holds the key to resource allocation. There has been progress in this regard in recent years. For example, on the 27th of September 2022, the Parliament of Uganda adopted a motion to urge the government to urgently increase the budget allocation to mental health and improvement of mental health services [37]. It is ideal if the Ministry of Health's budget is augmented, with a direct impact on boosting the mental health budget. This is especially crucial when it comes to continued increases of awareness of mental health concerns, reduction of stigma, and increasing accessibility to treatment. Stigma appears to still play a substantial role in hindering mental health care efforts in spite of progress, and this stigma as we show in this study, occurs at both the community and the professional levels.

A similar study that involved service users from Kampala and Kamuli in Eastern Uganda showed many of the same deficits in the mental health system. While Mugisha et al found that service users were not knowledgeable on policy [38], service users in our study were knowledgeable of policy, and they knew about the Uganda Mental Health Act, its revisions, and the fact that it was heavily based on a medical model. However, consistent with other papers, service users felt that their voices were marginalized in the grand scheme of Ugandan healthcare.

On the whole, our findings are very similar to the findings of [38] who also engaged service users. However, some of the differences in our findings could be due to the fact that the data were collected 3–4 years later. Given that both the government and their NGO partners and peer support groups have had more time to develop the work. The other possibility is whereas the previous research had been carried out in Kampala and Kamuli, our study was carried out in Kampala and Gulu. Gulu in northern Uganda had been a hotbed for guerrilla warfare in the past and due to high prevalence rates of PTSD, many psychosocially focused NGOs targeted the Gulu population. So it is thinkable that there is a more well-established awareness of mental health and a more robust peer support network.

Feedback from mental health service recipients interviewed in this study underscores a crucial aspect often overlooked in LMIC settings. Many individuals facing mental health challenges emphasize that their issues do not always demand medicinal solutions. However, a prevalent obstacle remains—the difficulty in accessing mental health service providers who offer non-pharmacological interventions. This appears to be because of the lack of human resources with the time available to meet with individuals/families over a period of time. This was especially true when it came to considering treatments with strong evidence for their effectiveness in other contexts, treatments that engage members of the family, or other evidence-based approaches. There is still work to be done to move mental health treatments beyond medication prescribing and management to talk therapy approaches proven to work including evidence-based individual therapies, group therapies, and family-based treatments.

When reflecting on changes that could enhance the quality of services, training and education were frequently requested. Participants were interested in training in systemic and relational approaches. In addition, participants were interested in greater advocacy at the policy level that would involve a more aggressive approach to mental health. This would include more funding for mental health treatments as well as more training for mental health workers, essentially creating more workforce opportunities in mental health care.

In this study, participants discussed a dearth of evidence-based family interventions contrary to a systematic review conducted by Asiimwe et al. that found that the existence of family and parenting evidence-based interventions in over 6 African countries including Uganda, were a unique strength [39]. The reason for this discrepancy might be that the implementation of these evidence-based family interventions are mostly in targeted communities that have been reached by researchers and NGOs coming from outside Uganda, and they are not systematically rolled out to the public domain nationally through mechanisms facilitated by the ministry of health. While these types of systemic interventions are frequently mentioned in the literature and have promise of effectiveness, they were not experienced by our participants.

A noteworthy observation is the inclination of mental health service providers towards Western methods, sidelining the role of traditional healers or local culture and customs in treatment. One thing that stood out is that service recipients often resort to mental health hospitals as a last option, having exhausted traditional avenues. However, this is often after they have wrestled with the problem for a long time and tried different “home remedies.” Once they have received treatment at the hospital, a significant number continue seeking services from traditional healers. Bridging this gap is paramount, especially when it comes to aligning the approaches of mental health professionals and traditional healers. Sensitizing policymakers and service providers on the inextricable role of traditional healers in people's lives could erode the existing divide. Education and mutual understanding may lead to an improved referral system, fostering collaboration between these two pillars of mental health support. Our findings align with research on sociocultural considerations of mental health in Uganda and support the idea that many Ugandans deeply value their culture and spiritual beliefs, thus a comprehensive mental health strategy would adequately attune to culture and context [39]. Using decontextualized care would undermine community mental health efforts and progress.

Clinical Implications

The implications drawn from the study emphasize the need for an integrated approach beyond medications, integrating non-psychiatric mental health professionals, engaging spiritual leaders and traditional healers, forming partnerships with NGOs, and enhancing training and supervision. This section delves into the clinical implications derived from the study, highlighting their significance in transforming the mental health landscape in Uganda.

The study advocates for changes toward more comprehensive approaches to mental healthcare in Uganda. Mental health is a multifaceted concern, and the integration of non-psychiatric mental health professionals is crucial. It incorporates clinical psychologists, counseling psychologists, social workers, and family counselors into the mental health system. By doing so, the system can offer a comprehensive range of interventions, addressing psychological, social, and familial aspects of mental health beyond traditional medication-focused approaches.

Creating a collaborative model that integrates various mental health professionals is vital for a comprehensive and effective mental healthcare system. Establishing frameworks and training programs that foster teamwork between psychiatrists, psychologists, social workers, and other professionals can lead to a more cohesive and holistic approach. The diversity of skills and perspectives within the integrated team ensures a nuanced understanding of mental health issues and facilitates tailored interventions for individuals.

The study recognizes the cultural context of mental healthcare in Uganda and advocates for the engagement of spiritual and traditional healers. To bridge the gap between modern mental health practices and traditional healing methods, cultural competency training for mental health professionals is essential. By establishing communication channels and collaborative platforms between spiritual leaders, traditional healers and mental health professionals, they can enhance the accessibility and acceptability of mental healthcare services among the population.

Furthermore, acknowledging the role of non-governmental organizations (NGOs) in providing psychosocial services, the study suggests formal partnerships between governmental and non-governmental entities. These partnerships can lead to collaborative projects and initiatives, pooling resources, sharing expertise, and implementing best practices. By harnessing the strengths of both sectors, the mental health system in Uganda can be fortified, expanding its reach and impact on the community.

Moreover, the study underscores the importance of continuous professional development through additional training programs. Focused on the assessment and intervention of common community mental health problems such as depression, anxiety, and PTSD, these training modules can enhance the skills of mental health professionals. This investment in training ensures a workforce that is well-equipped to address prevalent mental health issues in the Ugandan community effectively.

The results in this study suggest strengthening supervision processes and integrating community mental health skills to reinforce the mental health system. Regular supervision sessions emphasizing community-oriented approaches and family and community mental health skills training can empower mental health professionals. This, in turn, contributes to better community mental health outcomes by fostering resilience and well-being.

The study's clinical implications on the Ugandan national mental health system offer a roadmap for transformative change. By embracing a holistic approach, integrating diverse professionals, engaging spiritual leaders and traditional healers, forming partnerships, and investing in training and supervision, Uganda could build a mental healthcare system that is responsive, culturally sensitive, and effective. When implemented thoughtfully, these recommendations can improve mental health outcomes and contribute to the overall well-being of the Ugandan population.

Research Implications

One crucial research implication is the call for increased opportunities for research partnerships. By fostering collaborations between researchers, governmental bodies, and non-governmental organizations, prevalence studies can be conducted to understand better the diverse landscape of mental health challenges across different regions. This collaborative approach ensures a more comprehensive and nuanced understanding of mental health issues, facilitating the development of targeted interventions tailored to the unique needs of each region.

The study advocates for a shift in research focus from Western-centric models to an exploration of mental health experiences within the sociocultural context of Uganda. This implies engaging cultural advisors in research endeavors to provide insights into the cultural nuances that influence mental health perceptions, experiences, and help-seeking behaviors. By adopting a culturally sensitive approach, research can contribute to a more inclusive and representative understanding of mental health in Uganda.

Another significant implication is the call to increase mental health research in remote areas. Research should include underrepresented and underserved regions, ensuring findings reflect geographical diversity. This geographic diversification promotes a more equitable distribution of mental health research, uncovering challenges and opportunities unique to rural and remote communities and addressing disparities in mental healthcare access.

To enhance the inclusivity of mental health research, the study emphasizes the importance of engaging underrepresented service users. Research should actively involve individuals from diverse backgrounds, considering age, gender, socioeconomic status, and cultural heritage. This inclusive approach ensures that research findings reflect the varied experiences within the population, fostering a deeper understanding of mental health challenges across different demographic groups.

Recognizing the influence of traditional healing practices in Uganda, the study advocates for the inclusion of spiritual, religious, and traditional healers in mental health research. Research endeavors should seek collaboration with spiritual leaders and traditional healers to understand their perspectives, practices, and role in the mental health landscape. This collaboration can bridge the gap between traditional and modern mental health practices, fostering a more holistic and culturally sensitive approach to mental health research and intervention.

The research implications outlined in this section offer a roadmap for a more inclusive, culturally sensitive, and geographically expansive approach to mental health research in Uganda. By fostering research partnerships, embracing sociocultural perspectives, reaching beyond urban centers, engaging underrepresented service users, and involving traditional healers, future research endeavors can contribute significantly to a more comprehensive and contextually relevant understanding of mental health challenges and opportunities in Uganda. This approach enriches the research landscape and lays the foundation for more effective and culturally responsive mental health interventions.

Policy implications

A paramount policy implication of the study is the urgent need for increased funding and financial resources dedicated to mental health. Policy advocates should actively engage with government bodies, international organizations, and stakeholders to underscore the importance of allocating substantial financial resources to mental health initiatives. Adequate funding is essential for the implementation of comprehensive mental health programs, the establishment of community services, and the development of sustainable interventions. Policymakers must recognize the value of investing in mental health to improve public health and well-being.

The current study emphasizes the importance of decentralized resources to strengthen mental health services. Policies should promote equitable distribution of resources at the district level, including personnel, infrastructure, and funding. This decentralization fosters accessibility to mental health services in remote areas, addressing regional disparities and promoting community-based interventions. Policies advocating for resource allocation at the lower district levels are crucial for building a resilient and responsive mental health infrastructure.

Effective mental health policies require collaboration between researchers and policymakers. Advocacy efforts should focus on establishing partnerships that facilitate the translation of research findings into actionable policies. Policymakers should be engaged in research, providing insights into policy needs and challenges. Collaboration with advocacy organizations enhances the visibility and impact of research, contributing to developing evidence-based policies. Policies that integrate research findings into mental health frameworks are essential for creating compelling, responsive, and culturally sensitive mental health services.

A significant policy implication highlighted by the study is the necessity to promote collaboration in referral systems. Policies should be developed to encourage and regulate collaborative efforts between spiritual leaders, traditional healers, hospitals, and other professionals trained in mental health interventions. Advocacy efforts should focus on breaking down barriers between traditional and modern mental health practices, fostering an integrated approach. Policies promoting a harmonious referral system are essential for creating guidelines, protocols, and standards that ensure effective and culturally sensitive mental health care.

The policy implications derived from the study on the Ugandan national mental health system underscore the imperative for advocacy, collaboration, and inclusivity. Advocating for increased funding, decentralized resource allocation, collaboration with policymakers, and promoting a harmonious referral system are crucial steps toward building robust mental health policies. These policies, rooted in research and developed in collaboration with key stakeholders, will contribute to a more resilient, accessible, and culturally sensitive mental health system in Uganda. As policymakers embrace these recommendations, they have the potential to effect transformative change, enhancing the mental health and well-being of the Ugandan population.

Limitations

A few limitations should be noted and considered in future studies to build on existing knowledge about the mental health system and capacity building efforts in Uganda. Prevalence studies continue to be important in order to map the diverse mental health issues affecting Ugandans, as well as the resources available to address common community mental health concerns. Prevalence studies can inform stakeholders on the areas that demand focused attention. Additionally, since the current study was limited to Kampala and Gulu, gathering perspectives from mental health service providers in other regions of Uganda is imperative to comprehensively understand the nation's progress in delivering mental health services.

The current ethnographic assessment of the Ugandan national mental health system offers a rich tapestry of insights into the strengths, challenges, and opportunities inherent in the current landscape. The study serves as a compass for navigating the complexities of mental health care in Uganda, providing a foundation for transformative changes. System strengths, including the resilience and dedication of mental health professionals, lay the groundwork for building upon existing positive aspects. However, the study also illuminates challenges that necessitate targeted interventions and policy adjustments. The call for increased funding and financial resources emerges as a crucial aspect of the study's implications. Recognizing the importance of adequate financial support for mental health initiatives, the study advocates for reevaluating resource allocation, particularly emphasizing decentralized distribution to the lower district levels. This shift is essential to bridge regional disparities, ensuring that mental health services are accessible and responsive across diverse communities. Moreover, the study underscores the significance of collaborative efforts in mental health research and policy development.

The call to partner with policymakers, advocacy organizations, and traditional healers represents a recognition of the multi-faceted nature of mental health care. Collaboration amplifies the impact of research findings and fosters a more inclusive and culturally sensitive approach to mental health services. The results of this study emphasize collaboration between hospitals and clinics, NGOs and other mental health workers as a pivotal recommendation, recognizing the importance of cultural context in mental healthcare.

The ethnographic assessment catalyzes change in Uganda's mental health system. Its comprehensive analysis illuminates the path forward, urging stakeholders to advocate for increased funding, decentralize resource allocation, foster collaborative research, and promote a harmonious referral system. Implementing these recommendations has the potential to address the current challenges and unlock opportunities for a more resilient, accessible, and culturally sensitive mental health system that caters to the diverse needs of the Ugandan population. The study, therefore, stands as a roadmap for shaping policies and practices that prioritize mental health and well-being in Uganda.

Ethics approval and consent to participate

This research received ethical approval from the Ethics Committee of Michigan State University on April 1^st, 2022, and a local Ethical Commitee of Makerere University College of Health sciences in May 2022. Informed consent was obtained for data collection and publication of data. All the data collected from the study participants was conducted in accordance with the ethical standards of the institutional research committee Consent for publication

Availability of data and materials

Available upon request from authors

Consent for Publication

Not applicable

Competing interests

The authors had no competing interest

Funding

The study received funding from the Alliance for African Partership, Michigan State University

Authors' contributions

LD spearheaded the project from inception to completion, overseeing study design, data collection, analysis, and manuscript writing in collaboration with the team. IL and RA actively participated in data collection, analysis, and contributed to writing specific sections of the manuscript. PG conducted a comprehensive review of the entire document, offering valuable feedback to enhance its quality. AB and RK provided invaluable professional and technical support throughout the project, contributing to data collection, writing various sections of the manuscript, and meticulously proofreading and reviewing the final draft.

Availability of data and Material

Upon request from the authors

Acknowledgements

We would like to thank our dear participants who consented to take part in this study.

Author Details

^1,24,5Michigan State University, East Lansing, USA, ³University of Minnesota, Twin Cities, USA, ⁶ Makerere University, Kampala, Uganda.

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No competing interests reported.

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Voices from the Ground: Ethnographic Perspectives on Strengthening the Ugandan National Mental Health System: An Ethnographic Needs Assessment

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Abstract

Background

Methods

Results

Conclusion

Background

Methods

Study Design

Recruitment and Sampling

Data Collection Procedures

Data Analysis

Enhancing Trustworthiness

Results

[INSERT Table 1]

Strengths of the Mental Health System

Existing Policy and Action Plan

Free Medications

Private Sector

Partnerships and Collaborations

Challenges in the Mental Health System

Socioeconomic Constraints

Community and Professional Stigma

Limited Family Engagement

System Recommendations

Enhance Education and Training

Systemic and Integrated Approaches

Policy and Advocacy

Discussion

Clinical Implications

Research Implications

Policy implications

Limitations

Conclusions

Declarations

References

Additional Declarations

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