6 mei 2019
Voor geïnteresseerden plaatsen we een uitgebreide tekst over openbare GGZ in Burundi.
Hope for public mental health and psychosocial support in Burundi
Notes on a training on mhGAP-HIG in 2019
May 2019
Amy Besamusca-Ekelschot
Summary
Making mental health care in post-conflict Burundi accessible for all Burundians needs building decentralized mental health facilities by educating local professionals in sustainable structures, implemented in general health care and society. After discussing former NGO publications on reforming mental health in Burundi, the question was arisen whether or not community building had to be an integrated part of mental health care development. An mhGAP-HIG training strategy was developed that included training of medical professionals and community workers. The findings during trainings in 2019 in the provinces Cankuzo, Ruyigi and Cibitoke were used for reflection on choises made and to describe needs on strengthening public mental health in Burundi in the future.
Reinstalling social fabric is a sociopolitical responsibility in the country, but psychosocial emotional support has to be part of public mental health and can assist in breaking the vicious circle of poverty by enabling people to work if economic conditions improve. It is essential that the development of public mental health in Burundi is seen from the perspective of local professionals, using national and cultural rules and habits. Long-term financial help is much needed for mental health trainings in the sector as a whole, while government guarantees salaries of staff. Short-term financial help for sector related projects will be useful if such projects fit in the national strategy. The country as a whole needs economic empowerment, in order to resolve poverty as a source of difficult socio-economic situations like hunger and unemployment, which cause psychosocial problems for many Burundians.
I.
This story starts after a terrible war that caused an estimated four hundred thousand killed Burundians from before the independence in 1962 till 2002. Some eight hundred thousand were forced to flee to neighboring countries and hundreds of thousands were internally displaced (1). The war was based on ethnic conflicts between Hutu and Tutsi. Or should we say that it was based on a disrespectful colonized history that disturbed traditional equilibrium?
Like in many other African post-colonial and post-conflict areas, a ride over the moldered roads of Burundi took you past many signs of rebuilding projects in the beginning of the twenty-first century. Poster after poster showed you which foreign organization helped with what kind of project in the devastated country. Either bricks, concrete, shelves or professional knowledge were proudly clarified on billboards, showing that the unfortunate partition between Burundi and the rest of the world was being redressed. Rebuilding the country and rebuilding Burundian society was buzzing. And after the Arusha Agreement of 2001 was ratified in 2005, even the Burundian Hutu and Tutsi themselves started to believe in a peaceful society, like they more or less used to have before colonization. They even restarted to speak in ancient cryptic proverbs, about friendship, morality and unity. People were happy with their new president now and for the first time after many years of war, murder and cruelty, they could believe in a future for themselves. Humanitarian aid, support in agriculture and in the production of goods was a blessing they embosomed. The atmosphere in Burundi became clear, much safer than in neighboring DRC and more open than in Rwanda. People that never had enjoyed the opportunity to look forward started to think and even talk about a future. Some sectors expanded. In Africa it was a miracle. For the Western world it was a success story. Health centers erected and employees were trained. Mother and child projects got attention. Water pumps multiplied. Resilience was promoted everywhere in the country by NGOs and by new churches. Of course there still were many inconveniences, like lack of electricity, lack of food and housing, diseases, infant mortality, orphaned children, low level of education and lack of laws, but both Burundian private and public sectors made use of foreign help and were dreaming of economic growth. Hope, ‘izere’, was the new word and funny enough many Burundians returned to ancient beliefs, traditional healers and spiritual life just because they felt free to do so in a country that finally was theirs again.
Since 2005 Burundi was not mentioned in the international press as often as other African countries, but there still had been some violence in the country. It was no longer based on ethnics, so the Burundians said; it was based on politics. Democracy is a Western pleasure, they added, and although Burundian politics officially was based on a multi-party system, some features of a single-party dominance became manifest. And the influence on politics of a military system with powers from both important Burundian ethnicities, composed of quota based on the Arusha Agreement, attributed to turbulence, as were armed militias. Burundi had become a superficial democracy.
In these days there were some foreign NGOs in Burundi that directly focused on mental health. They raised awareness of Western ideas about well-being and social welfare. No health without mental health, so for the sake of Burundians information was spread and trainings were developed for the mental health sector in French by NGOs. In some rural areas, in refugee camps and in the capital Bujumbura you could see their posters too. Psychosocial support was taught, but most of the time not offered. In the only psychiatric hospital in the country however, where patients with epilepsy were consulted more often than with psychosis, more patients had to be dealt with than in the previous years. This Centre Neuro-Psychiatrique de Kamenge (CNPK) in the capital Bujumbura, supported by Belgian fathers since 1981 and now collaborating with the Ministry of Public Health and the Fight against HIV (MSPLS) who paid the salaries, accommodated many refugees during the war and the remaining buildings now served again as therapy rooms or clinical units. A Belgian NGO supported the CNPK by several trainings per year in French on psychiatric and neurologic illnesses, and I worked with them as a volunteer expatriate psychiatrist. We trained physicians, psychologists and nurses to help improve their work for about 190 hospitalized patients (including rehabilitation units) and many outpatient services every day. We also did many case studies to learn from and to help improve the quality of the lives of patients and their families. Patients were presented with mental illnesses, epilepsy and addictions. The whole range of mental illnesses was presented, from schizophrenia up to psychosomatic symptoms. Although many Burundians only speak Kirundi and for those that speak French it is mostly not their native language, I could only teach in French. During consultations I needed the company of an experienced nurse for translation, while respecting local customs and traditions.
We tried to work according to the ‘Notions de base’ (2), that was published (but not yet officially signed by the minister of Public Health) for mental health education in primary health care in 2007, but we were not very happy with it because the staff of the CNPK had a far higher standard. We also tried to follow the pharmacological protocol that had been composed in Belgium (3) and that didn’t follow the ‘Notions de base’. Sometimes pharmacy stocks didn’t provide the psychotropic drugs that we needed. The WHO list of essential psychotropic drugs was not available anyway. Nevertheless we tried to help as many patients as possible while preventing a medicalized model and all kinds of psychological techniques were practiced for people with mental and psychosocial problems. It was very interesting to witness how psychologists in the CNPK could comfort and – by far more important – strengthen vulnerable people by a combination of traditional behavior and professional counseling. This we called socio-therapeutic counseling. We developed multidisciplinary teamwork based on a biopsychosocial approach and the role of psychologists became more important than it had been. We didn’t work on resilience-building in society, as some NGOs promoted, but we worked on public mental health. In this period the government started a school for psychiatric nursing with a three-years training in mental health in the National Institute of Public Health (INSP). For psychologists no official trainings and hardly jobs were available to develop clinical skills after studying. Burundi had a countless number of unemployed psychologists. The happy few provided counseling for the 10% of wealthier people. Burundian general physicians employed in primary and secondary health care hardly had been informed about psychiatric and neurologic illnesses during their studies and the country had only one psychiatrist that was trained in francophone Senegal and now worked in a private practice.
After one of the landslides that occur in this country, when people were floated out of their beds and drowned, we collected money for an employee of the CNPK that lost her house and family. Burundians, basically living in a group culture showing solidarity without many features of Western individualism, looked like one big family now, and all the time I wondered how people who murdered each other’s families could be so kind. They lived together and they helped each other. They seemed to restore ancient times with traditional friendly manners. They shared one history, one language and one culture and restored society with this. And they shared one tragedy, the ethnic tragedy. Nobody blamed the colonizers from the past. Nobody blamed failing UN. They only blamed themselves and they were sure ethnic war was never ever to happen again.
II.
Then it became 2015. Violence and fear had already been increasing in 2014, but it wasn’t a real war. The president decided for whatever reason to be eligible for a third term in 2015, saying he didn’t violate the law based on the Arusha Agreement. The Western world didn’t agree with him. Small groups of Burundians, like students, didn’t either and they demonstrated. The president was elected again. What followed was a revolte and an attempted military takeover while the president was out of the country for a meeting. Finally the power party controlled the situation, but not without violence. For students it was a very dangerous time. There may have been four hundred or thousand deaths in this year (information is not clear) and more than two hundred thousand refugees to neighboring countries again. Although the situation stabilized, fear had returned. The president never left the country again, while many NGOs left after contingency studies. Based on the Cotonou Agreement seeing on peace and security and many other principles for cooperation in development, that was connected to the Arusha Agreement, in 2016 the European Union (EU) suspended direct financial support to the Burundian administration, including budget support, but promised to maintain financial support to the population and humanitarian assistance. But the population suffered from this, and nobody else. Did EU not realize that they were prejudicing the well-being and the livelihood of Burundian citizens? Nobody could explain why this punishment didn’t occur to other African countries where the impact of cruelties had been more significant, except the Burundians: they were aware that Burundi never signed other documents in favor of European countries like other former colonies did to become independent. What started now was a cold war between Burundi and EU, but neither this EU-decision nor diplomatic interventions could stop Burundian pride. Burundi was forced to start an internationally led internal dialogue with opposition leaders fled abroad, and Burundian government refused its participation over and over again. Several African countries blamed the International Criminal Court (ICC) in The Hague for only prosecuting Africans and discussed their withdrawals, but the only country that really abandoned the future jurisdiction of the ICC in October 2017 was Burundi. Burundian government already had prepared new rules for NGOs, including the employment of ethnic quota and obliged contributions to the national bank, and these rules were activated in October 2018. Many NGOs thought it was disrespectful to select employees by ethnicity. Burundians reacted on this and said ‘In the Western world they do the same thing for women. And by the way, why do NGOs only employ Tutsi?’ Again many NGOs left. Since 2015 the Burundian economy declined dramatically. The dream was over.
III.
Thus some years went by. As a small, hilly, landlocked and resource-poor country in the Great Lakes Area, crowded with now 12 million inhabitants and many refugees from neighboring countries, Burundi still suffers from many infirmities. The agriculture driven country produces only enough food for its population for 55 days per year (4). Many Burundians are not very proactive. Yesterday or tomorrow, it is the same word in Kirundi. They live day by day, saying they never reached the level of having enough food: every day you have to look for food and only if there is time left, you can do something else. Food has to be imported for about 600 million dollar a year but Burundi can only export coffee and tea for about 100 million dollar. Two third of the population is chronically underfed, the highest percentage in the world. For one out of four Burundians there is no food safety, making it an official crisis. The average age of Burundians is 17 years and 65% of the population is younger than 24 years. More than 25% of Burundians has no access to clean water. About 52% of people have no access to health care at all. Information on infant mortality rate differs from 60 to 104 per 1000. On average people live of less than a dollar a day. Two out of three people live below the poverty line, for decades already. Burundi is the third poorest country in the world. Migration is 0 per 1000. Inflation in 2018 was 17% and was expected to rise to 20% in 2020. One in three Burundians is in need of urgent humanitarian assistance. The UN Humanitarian Response Plan is only 25.9% funded making it one of the least funded plans globally, as was literally said by UN Assistant Secretary-General for Humanitarian Affairs Ursula Mueller in September 2018. Billboards announcing international projects in Burundi have lasted, but there are no projects behind them anymore. Some of those signs have partly been used to build small houses with. No wonder that we speak about a forgotten country. Who knows Burundi? And who knew the by WHO estimated 19 to 23 per 100.000 persons (6 or 7 per day) that committed suicide per year?
IV.
After the Burundian crisis of 2015, the Belgian NGO decided not to send expatriate psychiatrists to Burundi anymore. I decided to continue work in Burundi without the NGO, if it was safe enough, because we had realized so much progress already and we had to go on with this. I became a voluntary employee of the CNPK. Next to consulting patients, the CNPK wanted to make mental health care accessible for more Burundians. In rural areas, where 90% of Burundian population is living, despite former help by NGOs no mental health structures existed anymore. We wanted to create structures that were deeply rooted in the Burundian system. New plants only have small roots, so first we needed to assist structures to keep them upright. The idea was to open decentralized mental health centers in the communities and to collaborate with community workers to organize psychosocial support. We needed the agreement of authorities; first of all public mental health activities had to be accepted as parts of the national strategy for mental health care. In our discussions we focused on building structures for Burundians and with Burundians. We looked for publications on lessons learned to benefit from research done.
We found recommendations for building MHPSS systems in Beyond the crisis: building back better mental health care in 10 emergency-affected areas using a longer-term perspective by JoAnne Epping-Jordan et al. (5), based on successful outcomes from the perspective of NGOs. Of the ten reviewed countries in this publication, there were only two African countries, being Burundi and Somalia. We made a list of recommendations, described as not realized in Burundi or in Somalia:
– Mental health reform has to be supported through planning for long-term sustainability from the outset;
– The broad mental health needs of the emergency-affected population has to be addressed;
– The government’s central role has to be respected;
– Coordination across agencies is crucial;
– Mental health reform involves review and revision of national policies and plans;
– The mental health system has to be considered and strengthened as a whole.
And we made a list of recommendations, described as realized in both Burundi and Somalia:
– National professionals play a key role;
– Health workers have to be reorganized and trained;
– Demonstration projects offer proof of concept;
– Advocacy helps maintain momentum for change.
We also found interesting statements in Psychosocial assistance and decentralised mental health care in post conflict Burundi 2000 – 2008 by Peter Ventevogel et al. (6), based on not very successful outcomes in one NGO project in Burundi, saying that:
– For the integration of mental health there is a necessity to integrate at all levels of health care, but health services are not always best suited to assist people who have common mental disorders such as depression and anxiety disorders, whose etiology is strongly related to social problems;
– One should distinguish community-oriented social psychiatry from community-building social work.
Ventevogel concluded that:
– MHPSS was insufficiently anchored in government policies and actions.
– Financial sustainability of MHPSS remained problematic.
– Integration of mental health into primary care was not yet realized.
The topics in this publication were described in detail in Borderlands of Mental Health. Explorations in Medical Anthropology, Psychiatric Epidemiology and Health Systems Research in Afghanistan and Burundi by P. Ventevogel (7). Ventevogel promoted installing basic mental health care in a general health-system strengthening approach alongside healing social wounds of war, by embedding within an approach of community-system strengthening.
We wondered if these relevant publications for the Burundian situation fitted together, because they reviewed the same NGO project but didn’t agree about outcomes. It was clear that perspectives of NGOs were different from the perspective of the CNPK, but the publications raised new questions on building decentalized public mental health to find answers for, being:
– Did we have to develop public mental health including or without psychosocial assistance?
– If in public mental health the broad mental health needs of the Burundian population had to be addressed, did we have to make special structures for people with so-called common mental disorders, ‘whose etiology is strongly related to social problems’?
– Did we have to advocate for community-building social work but distinguish it from public mental health and should this community-building social work be meant as a resilience strategy?
We had neither power nor means to work on healing all social wounds in Burundi after the war and the new crisis of 2015, nor was there an organization working on this goal now that could easily fit in a decentralization process for MHPSS. If 12 million people suffer from a shared history in a country where people could help and understand each other in the past but recent decade, then we hoped their attitude should be willing enough to accept and to help to develop new MHPSS facilities in their communities. We were not able to replace former donors and helpers in Burundian social problems, but we were aware that social problems in Burundi needed to be resolved. One part of this, the emotional part, could be implemented in mental health. But another part of this asked for material impulses alongside mental health. Since EU still didn’t work on this, how could we?
For decentralizing public mental health, the only psychiatric hospital in the country had to play a role, which quite amazingly was not promoted in the past by foreign organizations that worked on decentralized MHPSS, based on strengthening mental health as a whole and coordinating across agencies. Building sustainable public mental health without at least one central referral hospital was not consistent with the recommendations given afterwards, nor did it fit in the well-known Pyramid of the IASC Guidelines for Mental Health and Psychosocial Support in Emergency Settings (8). We concluded that we had to emphasize the word ‘public’ in public mental health, meaning that MHPSS had to be built not only for special groups (but for them as well), but for all Burundians, being vulnerable as a whole. To reach this, we had to start with decentralizing, not by starting humanitarian or social or even mental health projects for smaller groups. Another conclusion was that the publications did not offer an independent assessment on the work done by the CNPK, to learn from. But we tried to use the three questions that we distilled from the publications, that could help to expand our vision.
In 2013 already the MSPLS integrated mental health as a section in the national programme for chronic and non-transmissible illnesses (PNILMCNT). In the meantime two Burundians had returned to the country after being trained as psychiatrists in Senegal and they became part-time members of the medical staff of the CNPK. They consulted and they also trained other staff and disciplines. A plan was made for training more Burundian psychiatrists in Senegal in the future. A Burundian neurologist also trained employees several times a year now and facilities for online trainings by Swiss psychiatrists were made as well. There was not a single so-called momentum for change, but the CNPK advocated on every single opportunity to realize accessible, so public, mental health in Burundi and in 2016 the CNPK participated in the development of a new national strategy and an action plan for mental health (9a and 9b) with the PNILMCNT, keeping the three questions in mind. Decentralization became part of it now and some phrases of the strategy will be quoted:
* L’Organisation Mondiale de la Santé (OMS) définit la santé mentale comme étant « un état de bien-être dans lequel une personne peut se réaliser, accomplir un travail productif et contribuer à la vie de sa communauté ».
* Dans les pays ravagés par les guerres et des conflits sociaux dont le Burundi, la prévalence des troubles de santé mentale varie de 12 à 40%.
* Les crises socio-politiques répétitives que traverse régulièrement le Burundi depuis des années, les catastrophes naturelles, la pauvreté, les consommations des substances psychoactives etc., déstabilisent l’état de santé mentale des populations. Les problèmes psychiques ont augmenté alors que le pays n’était pas préparé pour y faire face.
* Les données parcellaires en consultation psychiatrique recueillies au CNPK, le seul centre de référence national, ont progressivement augmenté passant de 4228 en 2011 à 11437 en 2015.
* Le pays fait face à d’énormes défis dans ses efforts visant à promouvoir la santé de la population. Il persiste une certaine dichotomie entre la santé somatique et la santé mentale alors que la personne humaine est une unité psychosomatique indivisible qui se traduit par le bien-être physique, mental et social.
* Dans la société burundaise, les malades mentaux deviennent une problématique du fait que la société ne parvient pas à gérer leurs comportements agressifs, délirants, leur instabilité psychomotrice et l’inadaptation. De plus, selon les croyances populaires, certaines personnes disent qu’une maladie mentale aurait une source dans le méso cosmos, (ibihume, ibisigo, abaganza). Les autres font allusion aux conflits, jalousies, sorcelleries (amahembe, ibihago, uburozi), fétiches, transgressions et sanctions par les ancêtres et hérédité. Les maladies mentales sont aussi considérées comme des maladies surnaturelles, l’action des forces occultes, les esprits ancestraux (intezi, abavyeyi, …), des attaques des démons (amashetani, amadayimoni, imiyaga mibi, impwemu mbi, ibihume, amajini, imizuka…). Ces fausses croyances et l’ignorance de la maladie mentale entrainent la stigmatisation, la discrimination et entravent l’orientation et le recours précoce aux services de prise en charge. Certaines familles abandonnent carrément leurs malades mentaux à leur merci, d’où la chronicité de la maladie ralentissant ainsi la stabilité de ces derniers.
* Dans la continuité de l’intégration des soins, le MSPLS a initié le projet pilote d’intégration des soins de santé mentale dans les soins de santé primaires au niveau des Provinces sanitaires de Kirundo et Muramvya, avec l’appui de la CTB, et dans le DS de Kibuye avec l’appui de HN-TPO depuis 2013. Malgré ces efforts, l’intégration n’a pas été effective dans les provinces ci-haut citées, suite à l’insuffisance d’appropriation compromettant ainsi le circuit normal et le continium des soins du malade.
* Bien que le CNPK reste le seul centre de référence national en santé mentale, ses prestations restent lacunaires par manque de mécanismes de collaboration avec la communauté pour la réinsertion psychosociale des malades stabilisés.
* But : Contribuer au bien-être mental des populations dans un système intégré garantissant la santé pour tous avec solidarité, équité et éthique en offrant des soins promotionnels, préventifs, curatifs et réadaptatifs de qualité, accessibles géographiquement et financièrement, avec la participation effective et responsable de tous les acteurs.
* Objectif général : Réduire la charge de morbi-mortalité liée à la maladie mentale, par des soins adaptés au contexte burundais et accessibles à la communauté.
* Objectifs spécifiques : of which to mention :
Intégrer les soins de santé mentale dans au moins 20% des structures de soins (indicated as a task of the CNPK and a taskforce of the MSPLS); Renforcer les capacités des ressources humaines en qualité et en quantité ; Amener les décideurs et la communauté à s’impliquer dans la lutte contre les problèmes de santé mentale ; Renforcer la coordination et collaboration intersectorielle.
* Les services offerts en santé mentale sont lacunaires : pas d’identification des besoins et de lignes directrices pour les interventions en santé mentale.
* (Il y a) insuffisance de renforcement des capacities des prestataires et des Assisstants de Santé Communautaire (ASC) en santé mentale.
* (Il y a la nécessité à ) sensibiliser les communautés à la prévention et à la prise en charge des problèmes de santé mentale et psychosociaux.
Mental health care regards a wide range of problems, irrespective of the etiology. The national strategy showed a great need of care. Well-being was seen as based on a biopsychosocial triangle. Social interventions had to accompany medical aspects of mental health care, a strategy being even more important since traditional beliefs didn’t make a difference between the kinds of problems people suffered from. The social cohesion and Burundian context was important. For psychosocial reintegration of stabilized people, collaboration with community structures was indicated. The national strategy was based on creating integrated decentralized structures. Decentralization had to focus on human resources and training, integration in general health care and collaboration with social leaders. Strengthening in case-finding and in referral systems was needed in the communities. Training for physicians and nurses as well as for ASC was important and sensibilisation on MHPSS had to be community-based. The pilot project in the past didn’t succeed because it was not funded sustainably in general structures. Regarding the question about special structures for people with common mental disorders, the IASC Guidelines for MHPSS in emergency settings offered a superficial answer by promoting a referral system for complex pathology, but not an answer to social problems related etiology: the question about distinguishing psychosocial assistance was answered by the statements on integrated public MHPSS, but the question about community-building social work to heal the social wounds of war and resilience-building was too delicate to discuss in the Burundian socio-political context.
The CNPK got the permissions needed to work on it. Unfortunately but predictably there was no extra governmental budget for the plan, but the CNPK found international help to start small branches in the provinces Gitega and Ngozi. For further decentralizing public mental health care the CNPK first started collaboration with secondary health structures in the provinces and train their employees, because if you train people that don’t work in an official structure, the knowledge will flow away. The CNPK started mobile clinics in several provincial hospitals in other provinces and in prisons as well, it was a great job. The intension was to transfer the tasks of the mobile clinics to local caretakers after training and some of these mobile clinics could already continue as semi-permanent clinics in provincial hospitals with provincial staff that was salaried by the MSPLS and coached by the CNPK. One of these, in Rutana, was opened in 2018 by the minister of Public Health, who in his speech stressed on the prevention of addictions. As a consequence the CNPK staff, also salaried by the MSPLS, had to travel around for consultations as well as trainings and coaching of caretakers in the provincial hospitals. There were three problems now: Psychologists were not employed in these hospitals, regular budget for training was lacking and relevant staff of the CNPK traveling around was not available to consult at the same time in the CNPK.
Fortunately a Dutch donor helped to start a training project in secondary health care: we first started a training of trainers (ToT) in mhGAP-HIG basic course (further I will only mention it mhGAP-HIG) in French in Bujumbura Mairie (10). This module is created for mental health trainings in emergency settings by WHO and UNHCR, but fits very well in the poor post-conflict setting of Burundi as a whole and sees on basic mental, neurologic and addiction problems: it sees on the development of awareness and the treatment of and assisting of people with mental illnesses (including neurologic illnesses) and psychosocial needs. All related training materials were available. A total of 14 Burundian trainers in mhGAP-HIG were trained in 2018 and 2019. These trainers are psychiatrists, general physicians, psychologists and specialized nurses, all of them being experienced and well trained and employed by the CNPK or by the few semi-permanent clinics in the country, or by the MSPLS.
In the beginning of 2018 the new trainers were supervised by expatriate master trainers in Bujumbura Mairie and they trained 50 caretakers of the CNPK and provincial hospitals in two classes. Pretest results of these medical classes in Bujumbura Mairie were 73% and posttest results were 81%. Later this year some of them were supervised by an expatriate master trainer to train 89 participants in Rutana, Makamba and Muyinga with the financial help of a German NGO, working on a humanitarian project for vulnerable groups near the Tanzanian border, but these participants were a medical group consisting of 29 physicians and nurses in one classroom from both provincial hospitals and health centers (so secondary and primary health care structures) and also 60 ASC in two classrooms assembled from each province. Based on the IASC Guidelines, the national strategy, advice after the first mhGAP-HIG training and experiences in mobile clinics in Rutana, Makamba and Muyinga, the decision was made to train ASC too. This was the first integrated mhGAP-HIG training in the decentralization training project as a whole. The ASC are hardly remunerated volunteers, officially working in the communities to assist ill people and their working structure is connected to social habits in traditional society. They are selected by provincial authorities by their school results in the fourth class, must be able to read and write Kirundi, and by social behavior. They are respected citizens, like those who were chosen by the kings in ancient history and served communities, but they have no other official qualifications that will impress Westerners. Many of them don’t speak French. In the communities you find no employed psychologists. For the medical class the training was fully in French. For the ASC it was translated chapter by chapter in Kirundi by the trainers: every lesson, every demonstration video and all other materials were explained in Kirundi. The content of the mhGAP-HIG was easy to understand for all selected participants. But over the course of time we discussed that a written translation of several chapters of mhGAP-HIG in Kirundi could be helpful for the ASC to work in their communities. The discussion focused on local traditions that were not taken into account in mhGAP-HIG and also the use of a kind of foul language in Kirundi to indicate mental problems, which was also mentioned as undesirable in the national strategy. Kirundi words for Western classifications for mental illnesses didn’t yet exist and the participants and trainers wanted to invent and to introduce better and respectful words for the mentally ill and for people with psychosocial problems. Many meetings were spent on translating Western classifications into Kirundi to indicate the differences between traditional and modern classifications. In these meetings much attention was paid to the etiology of mental illnesses and lack of psychosocial well-being. Eventually psychologists of the CNPK translated the most important parts of mhGAP-HIG into a draft of written text that could facilitate the ASC in their future work in counseling and raising awareness of MHPSS in their communities. The CNPK also produced a draft flyer with drawings to help them explain psychiatric treatments in traditional surroundings to (many) illiterate people. Pretest results of this medical class in Rutana, Makamba and Muyinga were 23% and posttest results were 72.2%. Pretest results of these ASC classes were 65.2% and posttest results were 79.7%. The low pretest results from the medical class could be explained by the fact that participants from the health centers never had trainings in MHPSS before, while the ASC had been trained before by employees of the CNPK in mobile clinics.
V.
In 2019 the Dutch donor could finance the next trainings. These will be described more detailed for discussion. What was done to realize this project and what happened in these three weeks in Cankuzo, Ruyigi and Cibitoke? The objective was to assist in the development and implementation of community-based MHPSS in sustainable primary and secondary health care structures and in the sustainable community based structure of ASC by capacity building trainings of one week per province. Two project assistants, salaried directly by the CNPK so indirectly paid by the MSPLS, followed the action plan we drew up for them. One week of training takes one month of work for two project assistants. Together with the GD of the CNPK they visited the health authorities and other local authorities in each province to discuss the objectives of the project. The authorities selected the medical participants and the local authorities selected the ASC. All were invited officially. The project assistants selected the training locations based on criteria on prices, quality, food, hygiene, safety and surroundings. One logistic assistant, salaried by the CNPK, was selected by the GD to assist during the training weeks in the provinces. The General Director (GD) of the CNPK selected the trainers per week after discussing this with the master trainer. One expatriate mhGAP-HIG master trainer first fulfilled a two days refresher course for the trainers before supervising the trainings. After the refresher course, the trainers prepared their work and selected the materials to use. Four trainers per province, whose salaries were paid by the project, divided modules to work alternately in two classes. We had decided to put together each team of trainers of man and women, of at least one physician or psychiatrist, one psychologist and one psychiatric nurse trained by the INSP and both ethnicities should be represented in the team. Participants were 148 people in the provinces Cankuzo, Ruyigi and Cibitoke, being 61 women and 87 men, equitably represented among 58 medical employees and 90 ASC. This last province was quite a challenge because no mobile clinic had been started there yet. During this period of trainings in each province again medical employees from hospitals and health centers formed one class and the ASC formed another class. Each class had 20 to maximum 30 participants, being both males and females, most Christians and some Moslims, from both ethnicities but most Hutu. The participants received compensation for traveling to and from the training location and six nights of lodging, and were supplied with water and meals during the day, paid by the training project. At the end of the trainings both classes worked together to show each other’s competences and to discuss about referral and follow-up services in their province. This was witnessed by representatives of the MSPLS and the GD of the CNPK. The Kirundi draft text and flyer were used in these trainings for the ASC as a try-out and they were adapted if appropriate, based on remarks and group discussions. Finally both documents will be presented to the MSPLS for approval.
The capacity building in the provinces regarded the recognition of mentally (including neurologically) ill people and people in other kinds of psychosocial need and the integration of MHPSS techniques in communities and in primary and secondary health care structures. At the end of the trainings the participants should be able to offer diagnostic evaluations and treatments on the most important groups of classified mentally ill as well as sustainable psychosocial assistance for all citizens in the selected provinces. They also had to develop a relevant referral and back referral system between medical and psychosocial services. They had to be able to assist in the prevention of mental illnesses and psychosocial problems and in the rehabilitation in society of stabilized patients.
The mhGAP-HIG trainings took five days each. For the trainings in general we left on Sunday to return to the CNPK on Saturday, because the selected provinces were several hours drive away on still moldered roads. Every week on the first training day all participants were shy and they didn’t really know what to expect. After the introduction and the pretest the trainers explained the training materials and demonstrated some role plays. From that moment on the participants became more active and in the next days step by step they got familiar with the idea of mentally ill presenting a broad scale of problems and not all being chronically ill as such and they showed growing capacities to intervene, to counsel and to treat. Like in Rutana, Makamba and Muyinga we saw differences between the classes, the medical class more interested in medical techniques and the ASC more active in counseling strategies, like socio-therapeutic counseling. For this reason it was beneficial to work with separated classes according to their future tasks, that collaborate at the end of the training week. During a week of training all participants proved to enjoy role plays and some were really good performers in a kind of narrative theatre. They enjoyed the demonstration videos that were translated by the trainers even in the French classes because the sound was not good and the subtitles disappeared too quickly. In the classes one or two or even three participants sometimes suffered or at least reacted in an emotional way of what was told or clarified. One of the trainers then took that person out of the classroom and counseled in private and after an hour or so the participant appeared again in the class with full attention. But let’s not forget that some of our trainers themselves suffered from losses and complicated situations or war induced and other psychosocial problems in the past, one of the trainers being the lady that lost her house and family in the landslide, another being a widow who recently had lost her husband on a young age. Some others lost children on several occasions. They all performed without hesitation and in role plays they demonstrated life-events like their own without making it personal. The trainers behaved very professional and their past didn’t undermine their training work. This is how Burundians in general are: vigorous, as they had to be to survive a war and natural diasters and to cope with deaths in their families. Every day the participants prayed together, sometimes before we started the training and always before meals, although their religions differed.
On the fourth day in Cankuzo a community member known by several ASC as a victim of domestic violence killed herself by hanging and this sad affair was shared in the class. Participants cried for a few minutes and comforted one another. Everybody was sad that their community member and her family were not helped in the way they could have helped them now. On the last day one of the ASC’s father died from cancer. But after the formalities that he had to help his family with, the ASC attended the training day and money was collected in the class for the funeral, according to tradition.
In Ruyigi we had three sick ASC. One of them we sent to hospital. He was diagnosed with malaria and started treatment, but he came back and attended the full training with full attention. From the other two ill one recovered with medication and the other with counseling. Both proved to be active participants afterwards. As a Burundian habit we paid attention to Womensday and this was very much appreciated. On the last day we tried to make a video of the role plays in Kirundi that were presented, to serve as demonstration material in the communities. We didn’t have very good equipment and directing knowledge for this,so the results were not good enough.
In Cibitoke, a province known to have more risk of violence and criminality (code red), where the power party is said to recruit youth and where recently a school had disappeared in a landslide, around the corner of the training location a drunken man dropped dead. All participants were upset. During this week one trainer and one participant didn’t eat during the day because of Lent, but it didn’t undermine their concentration. They drank water during the day and ate in the evening. One day, when the logistic assistant wanted to pay the compensation for lodging in the morning, the participants asked to postpone this to the evening as usual, because with money in the pocket concentrating could be too difficult for them. The role play at the end of this week was a very well compilated theatre play and we were sad that we didn’t have the opportunity to make a video.
Every week finished with a celebration (we offered a fanta) and the delivery of WHO-certificates by the GD of the CNPK and a representative of the MSPLS. Participants sang and sometimes they danced as well. And what did we hear the participants say at the end of trainings?:
ASC: ‘If I only had known that epilepsy is not infectious, I could already have helped more villagers.’
Nurse: ‘I didn’t know that alcohol was that dangerous. I thought one has to drink and beer is made of cleaner water than we have available.’
ASC: ‘It is good to invent new Kirundi words for these problems, because the old words are rude and indecent.’
Physician : ‘We all have problems like this.’
ASC: ‘There are so many relation problems and there is much domestic violence and as we have seen people kill themselves for that reason.’
ASC: ‘Words are important in healing from trauma.’
Nurse: ‘We all suffered so much. Some people are stronger and some are weaker, but they are all human and we must help the weakest. We have more power now to do so.’
ASC: ‘Several villagers lost all their relatives. Others moved here without a family. They are loners. Now I have learned and I will go and visit them to help them.’
ASC: ‘Most people spend their little money on traditional healers. We will inform them that there are other ways to be helped. We will talk to them. Now we can do an evaluation and decide if they need to see a doctor.’
Physician: ‘I have learned a bit about mental illnesses, but I have learned so much about communication. I feel much more confident in my professional work since I have learned how to behave towards my patients.’
ASC: ‘Our eyes are opened now for all the problems. We learned so much that we didn’t know.’
And the newest trainer, a psychiatrist, said: ‘First I thought what is mhGAP? Why do we only teach a part of psychiatry? But now I understand and it is so useful what we did in such a short period.’
We worked from 7.30 am till 5 or 6 pm every day and after this, every day, we assessed the whole day and prepared the next. Most trainers suffered from hoarseness at the end of a week. We looked at the results of the posttest and we laughed. Pretest and posttest results from the medical class in Cankuzo went from 68% to 83,5%. Results from the ASC in Cankuzo went from 35% to 81%. In Ruyigi the medical class went from 61,6% to 84,4% and the ASC from 39,1% to 83,1%. In Cibitoke the medical class went from 71% to 76,5% and the ASC from 29% to 72%. We laughed, because of course the pretests from the medics in the provinces were not as good as in Bujumbura Mairie in 2018, but the posttests showed an average of almost 81,5%, being slightly higher than the results in Bujumbura Mairie. It is not a match, we all know, but the trainers were aware they had done a good job. For the ASC the results were even more amazing : from the average of 34,4% to an average of 78,7%. It fitted the impressions we had had during the trainings, when all participants performed better and better in communication and showed more and more self-confidence which they also registrered afterwards in the tests. How had we done that ? We had accepted the way that participants use to learn, which is different from the structured Western way. Many Burundians learn detailed, like they live: detail by detail and day by day. They hear and see everything, they know what is in front, aside and behind them. They remember every detail. They only don’t present this during a course in the same way as Westerners have learned. But every new morning they presented the resume of the lessons of the day before in a structured way and they hardly missed anything.
VI.
Reflection
Looking back at the given recommendations we made up our minds during the evaluation with the trainers and the GD of the CNPK after the trainings in Cankuzo, Ruyigi and Cibitoke. Although we are aware that our thoughts are nothing more than an informal exchange of views and cannot be seen as scientific findings and that results may not be generalized, we think we can react on the current Burundian situation of building and strengthening sustainable mental health services:
Long-term planning is needed for the development of public mental health and is coordinated by the PNILMCNT of the MSPLS. The activities resulted in a national strategy and action plans that are based on WHO advices. There is a political will to review and revise action plans every few years. Government wants accessible MHPSS in all provinces, fitting in sustainable general health and community based structures, which need to be strengthened as a whole. The CNPK wants to improve its branches in Gitega and Ngozi, to become referral centers too. In this way long-term planning foresees that all IASC levels are functional in future northwestern, eastern and southern regions for public mental health. Distinctive facilities for the treatment of distinctive illnesses or specialized psychotherapeutic centers are not foreseen now as a part of public facilities.
Short-term assistance by humanitarian or emergency projects or even mental health projects can not in itself develop a sustainable national system of public MHPSS, but if coordinated collaboration of such projects with the national public mental health structures can be realized, their impulses can be strenghtening or demonstrating. The recent and current collaboration of the CNPK with foreign humanitarian agencies and NGOs fits in the long-term plan and is coming to successful activities in the sector. Temporary private or NGO initiatives that go hand in hand with stand-alone MHPSS facilities should not be included in public mental health. Emphasizing that strengthening help is needed in the existing structures, we hope that donors will continue to help in the coming years, and that new donors will present themselves for this.
The broad mental health needs of the population will be addressed in public mental health. In mhGAP-HIG both psychosocial problems and classified mental health diagnoses are presented. About 90% of the population can be seen as crisis-affected, with or without psychiatric classification, but all with psychosocial needs with which we mean in particular emotional needs. Mental health services cannot work without paying attention to those needs. During the trainings we listened to the broad variety of emotional needs that almost all participants have to deal with while working with Burundians in general health care and in communities. In some Western countries splitting up services for mentally ill and for people with ‘only’ psychosocial needs dramatically diminished the quality of services in the end and brought many people back to worse conditions. No mental health without sufficient psychosocial conditions, not elsewhere and not in Burundi. Besides this, if awareness of mental well-being has to be promoted as a base of life in a population that doesn’t make a distinction between medical mental problems and psychosocial problems, dividing medical health care from psychosocial assistance is counter-productive. Herewith our answer to one of the three questions is given.
The public mental health structure to develop, we base on the national strategy. The publications brought us extra questions. The suggested distinction between facilities for severe and modest mental disorders seems useless for the same reasons as mentioned above and might be falsely based on the idea that modest mental illnesses always are related to social conditions. But we noticed that etiology was not clearly described. And what did the authors mean by ‘social’ problems? Is this poverty, hunger and inflation-related lack of livelihood? Then the country needs financing for it. Or is it related to resilience and social fabric? In our evaluations we regretted that ‘social’ or ‘psychosocial’ problems seem to become a not well defined broad concept. Our daily experiences in the CNPK and in mobile clinics, showing that socio-therapeutic counseling could be supportive and problem-resolving for many referred people (including biology based illnesses) and their families, were confirmed by the stories of the training participants. Socio-therapeutic counseling and other techniques are very useful tools for all disciplines now. Sure, we should be wary of medicalising and promoting psychiatric classifications as explanatory models for social suffering, but this is no reason to dispose community-based public mental health from psychosocial assistance. On the contrary, an integrated multidisciplinary structure will be best and will offer a worldwide appreciated professional approach, also in Burundi. Distinct facilities in the given culture and area might even provoke more stigma. Alltogether we judge the statement that raised the second question as an unwanted and risky policy.
The content of public MHPSS needs to be developed. The functioning and stability of societies recovering from emergencies can benefit from a strong mental health structure, as Epping described, and we don’t follow Ventevogel’s idea of advocacy for a distinguished community-building social work for resilience or other reasons. Burundi is proudly rejecting external claims on national resilience strategies and we stick to our own profession, while noticing that social fabric is recovering even when poverty is getting worse.
Looking for information on WHO websites we were amazed not to find recent information about Burundian mental health structures. But we did find another article by Ventevogel et al. there, again about the same project, with the same title Psychosocial assistance and decentralized mental health care in Burundi 2001 – 2008 (11). Psychosocial problems found in the described project were mentioned and only 3.8% of them were registrered as human rights violations or legal problems, so here we also didn’t find a reason for a separate structure ‘to heal the social wounds of war’. We would like to advocate for healing the material wounds of war and of other bad events in the past. This is our answer to the third question. Generally spoken we would have liked that definitions were explained better in the publications in order to let the country benefit from it.
In our view socio-therapeutic counseling as an integrated professional intervention fits in Burundian society and in public mental health and it implies aspects of the narrative exposure therapy that has become in vogue. We are convinced of the negative impact of war on society and the reduced capacities to cope with problems when social fabric breaks down, but we also noticed how Burundians restarted to use traditional culture with kindness and pride to survive, share and support each other. During and after the happy ten years of hope we didn’t witness a long-lasting erosion of traditional mechanisms for social support and conflict resolution, and we were happy to add knowledge to improve the activities of the ASC as a part of the whole public mental health system and of society. Socio-therapeutic counseling, that we describe as a combination of traditional behavior and professional counseling, is a tool that empowered them to do the good things. Awareness-raising psycho-education must also be part of MHPSS. It will all fit in traditional mechanisms for social support and interpersonal conflict resolution in communities, as the ASC have explained to us. None of the ASC suggested that mental illness classifications in itself offer an explanation for social suffering. They all were aware that poverty, war and natural disasters can cause individual mental, emotional and social welfare related problems, as can infections, malnutrition and other general health problems. After following the training they were convinced that both medical and psychosocial techniques can be needed to improve quality of life in such cases.
Making narrative theatre on MHPSS might be a very useful technic to add in Burundian society, like Kirundi spoken demonstration videos. In the trainings we didn’t teach complicated psychotherapeutic techniques, which were questioned in the standardized mhGAP-HIG tests, but we worked on culture sensitive resolving technics for family disputes, sexual violence, depression, bereavement, suicidal behavior and health related complaints, being frequently presented problems. Practice in the CNPK learned us that psycho trauma is not often presented in the way it is classified in Western countries, but many psycho trauma related psychoses and other classified illnesses are seen. Most Burundians suffer from socio-economic problems but not all of them suffer from psychosomatic or other signs as a consequence. In mhGAP-HIG trainings the participants taught us what kind of problems they encountered. Ventevogel described that 50% of emotional problems are caused by family problems, suicide related thoughts, socio-economic problems or general health related problems (11). The ASC that we trained in three provinces mentioned unemployment, family problems and trauma related problems as the most important causes of suicide. Although we couldn’t scientifically review the information of the ASC and the definition of trauma is unclear in this context, we cannot ignore these remarks that were similar in three different provinces and it strikes us that they could fit in the details given by Ventevogel, although problems of people with serious classified mental disorders and epilepsy were not included in his list. These problems need special attention in the trainings.
In this paragraph only policy headlines of content of MHPSS are described and for detailed overviews technical literature can be used. But a policy headline that is often missing and that has to be mentioned is the supply of essential psychotropic drugs that has to be improved, like roads have to be built and water and food have to be made available. Building a good chain for the supply of psychotropic medication is a challenge.
National professionals play a key role, because they have to continue the good work in the end and they know their compatriots, the culture, tradition, habits and language. And they need to develop themselves as well during the process of development of the sector on the level of management and as mental health professionals. If national professionals don’t promote mental well-being and offer services, who does? Who else could have translated mhGAP materials and explained MHPSS in the local situation? Who else is able to ensure culturally appropriate, acceptable interventions? For public MHPSS the number of medical employees has to grow. Psychologists have to be employed and trained as soon as possible to intensify psychological assistance on all IASC levels.
Training is needed for health workers and ASC to become equiped to manage mental problems. Bringing knowledge asks for a policy. For decentralization mhGAP-HIG supplies an appropriate method with basic information on evaluation, treatment, assistance, support and communication that suits the current Burundian needs of public mental health. The active learning process of mhGAP-HIG is appreciated by Burundian participants. To improve capacities for all levels of public mental health by providing future ongoing trainings, we started by creating a first Burundian team of trainers in mhGAP-HIG. Medical classes and ASC classes in all provinces have to be trained by them. Trainers should be able to work in details. The most relevant chapters of the training were translated in Kirundi by psychologists of the CNPK for the ASC and a flyer was added for awareness raising of the large number of their illiterate community members.
What we missed in mhGAP-HIG were explanations about etiology and comorbidity of mental problems. To raise awareness in traditional society, not only protocols but also causes of illnesses have to be explained. Adaptation of mhGAP-HIG can also be advised on culture-sensitive aspects. As already mentioned, training materials should be available in Kirundi, like demonstration videos.
Pretest results of classes that had been trained by the CNPK staff before in mobile clinics were much higher than of those that had not been trained before, which is a positive finding in itself. Posttest results are very encouraging. For the medical classes it will be useful to add more medical details in the future, but training of medical classes and ASC classes in a province have to take place in the same week and end together with the conception of a referral and counter referral structure.
Coaching of trained health workers will be provided by the mhGAP-HIG trainers, coordinated by the CNPK. In mobile clinics and in semi-permanent clinics the experiences will be followed and discussed. The ASC will need refresher courses that can be organized during the coaching period of health workers in the provinces.
For CNPK staff specialized online trainings are foreseen while regular capacity building will continue as usual. There is a need for more general physicians to be trained abroad as psychiatrists and the CNPK started collaboration for this with a donor. More CNPK nurses have to benefit from mental health training at the INSP.
Long-term policy for trainings will have to be developed and multidisciplinary specializations have to be discussed over the course of time.
Opportunities for changing public mental health can be helpful, when emergencies draw (press) attention and resources to crisis affected populations and efforts are made to convert short-term interest in mental problems into strategic reform, but in Burundi an independent advocacy project alongside the existing facility – that might look small through Western eyes but was functioning and respected since 1981 – didn’t work. In the past the local structure wasn’t addressed to by the NGO project to collaborate in longer-term perspectives. Respecting local central role was mentioned, but empowering local role might have been more beneficial. Fortunately the national decision makers made a change and focus on both pre-existing and new-onset mental problems.
Because of poverty Burundi is still crisis affected, but unfortunately the international society doesn’t offer opportunities for change now. With foreign financial resources new possibilities will be more realistic now than previously and the building of strategy based public MHPSS in all provinces will be reached more quickly. Media attention in crisis situations was mentioned as a positive force to implement a good structure for mental health care, but the country is not fuelled by international media interest.
The financial situation in Burundi is worse than five years ago and despite new governmental projects to improve agriculture, jobs and industry the corresponding external budget to realize it all was withdrawn. Who do you have to lean on in a population with an average age of 17 years? In general lack of funds and infrastructure also will inhibit larger-scale improvement. If you want to build bridges between government, professionals and a variety of structures to improve public mental health, you also have to build better roads and bring budget for financial sustainability and economy to the resource-poor country. Without roads, food and computers, just to mention a few social needs, it is quite a challenge. Comprehensive, decentralized and effective community-based mental health care, like other sectors, needs infrastructure and logistic improvements. Preparation of trainings could be done in less time and trainers could safe two days out of seven in better conditions.
Next to this advice on funding for society-building materials and economic recovery, budget is indispensable for public MHPSS. Service delivery costs are financed by government, but more health workers are needed, to start with more psychologists in communities and in multidisciplinary health structures, whose salaries are not sustainably budgeted. Continuation of mhGAP-HIG trainings needs to be financed. Costly coordination tasks and costs for start-up of mobile clinics and coaching in semi-permanent clinics lean on the CNPK, where extra employees are indispensable to continue the work. Often we can read that countries after a crisis lack budget for their plans, either appraised or not, but then we would like to know how funding is recommended, since the help of EU in Burundi was suspended already in 2016. There are opportunities not to be missed, we are sure of this. Like Epping wrote about strenghtening mental health: ‘Taking action would benefit not only people’s mental health, but likely also the functioning and stability of societies recovering from emergencies.’
To summarize, for making progress in building sustainable public mental health in Burundi the needs are:
* More Burundian psychiatrists as soon as possible. Educations for the first group will be paid by a country outside EU.
* More Burundian trainers on mhGAP-HIG, so more training of trainers. We hope to find donors for this.
* Demonstration videos and other mhGAP-HIG materials in Kirundi. We would be happy to find donors to realize this.
* More Burundian psychologists that have to be trained and employed in existing health structures and in communities for multidisciplinary teamwork. We hope to find start-up financing for this, but in the end their salaries have to be paid by the government.
* The number of employees of all disciplines in mental health has to grow step by step. This will also be a task for the government in the end.
* A continuum of refresher courses and coaching on all IASC levels in all provinces. We hope to find new donors for this.
* Psychosocial support integrated in mental health structures and in communities and vice versa. This is a policy that is foreseen in the national plan and paid by government.
* Money. All remarks on human resources and trainings have to be seen alongside economic help for other sectors in Burundi. Sustainability is the magic word in building new things and it needs budget.
VII.
Discussion
In the past phrases like ‘do no harm’ or ‘what to do if there is no psychiatrist’ were used for building mental health services in post-conflict settings, but for us ‘do no harm’ was not enough and too costly. In the CNPK we hoped that publications about Burundi could provide us with more strategic tools for making public mental health accessible for all Burundians, although they were described from an NGO perspective. But relevant recommendations based on a former Burundian project on building MHPSS were partly conflicting and the role of the CNPK was not assessed at all. The national strategy however, that was created by the governmental PNILMCNT with the assistance of the CNPK, gave direction to decentralizing services and the collaboration of health structures and social structures. We started training in both structures on classified and unclassified mental problems while paying attention to culture, socio-political and socio-economic circumstances. The behaviour and the rapid learning of participants in trainings was empowering for the trainers and provoked the development of training materials in Kirundi next to the international mhGAP-HIG in French. This policy of appropriate and culture based trainings need to continue to build public mental health in Burundi, a country that despite complicated socio-political situations can be described as a society full of kindness, solidarity and mutual assistance.
We wondered why the former NGO project didn’t succeed. It was meant to spread like an oil spot, but facilities didn’t last. The publications don’t offer enough insight to let us conclude about this, but most important reasons seems to us that created structures were not embedded in the existing structure for mental health, not part of the national strategy and not sustainably financed. In Western countries mental health facilities were started in the distant past by religious charity that could pay their services for many decades before governments reacted on advocacy and started to take over responsibility. Burundians don’t have decades to wait and need a pressure-cooker policy for building public mental health. This incapacity to wait for decades is not based on social anthropological or sociological aspects of which economic facts might play an important role, but on simple financial aspects. In Burundi people are poorer than Westerners can imagine. Poverty is still growing, food is lacking, life expectation is short and there are too many young people to build an economy, while EU suspended help (2016), humanitarian help from UN is not funded (2018) and the Dutch minister of Foreign Trade and Development Cooperation promotes mental health in the Great Lakes Area without paying for it anyway in Burundi (Dutch Television: Buitenhof, 17.02.2019). So Izere is still the name of some very small ramshackled and almost empty shops, but we wonder what entertains the optimism in their owner’s hopes.
We had several reasons to describe our training project. The first was that assessing our own activities independently is impossible and we hope that critical reactions will come to learn from. The second reason was that mental health in this forgotten country is needed, but gets no attention and even WHO has no recent details about it on the websites (although WHO was involved in policy making activities) while in the past decade a lot of work was done. Another reason was that for the sake of all Burundians public mental health should be further developed and this needs funds. But the most important reason was that Burundians need attention to survive. Sustainable foreign financial and material help is much needed to build an economy and machines are needed to develop the country. Foreign countries can fight a cold battle on resilience policies in Burundi, NGOs can write about social policies and we can continue to share knowledge on mental help, but without money we will all win the battle and loose the war.
VIII.
Conclusions
This story ends with some conclusions about organizing public mental health in Burundi in 2019 and in following years. Although there are small groups of educated and employed Burundians, we all know that Burundi is still in crisis because of poverty. The average age is 17 years. Even in a developed country as The Netherlands, one out of ten young people under 18 years are in need of child protective services (Radio News NPO 1 on 30 april 2019), so we guess that in Burundi much help is needed. Two out of three people living below the poverty line, being the third poorest country in the world, lack of food and more than 50% of people not having access to health care at all, a crisis cannot be denied. Compared to 2011 devaluation in Burundi in 2019 was 50% so nowadays socio-economic situation is worsening like predicted. But in the beginning of 2019 we cannot speak about a country being in conflict, notwithstanding the fact that violation of human rights could occur (and in that case have to be conquered) of which lack of freedom of speech is most evident, and poverty can be a source of corruption, criminality and death. Most Burundians nowadays deny ethnic conflicts and they live peacefully together, but the world still witnesses every day that in poverty major ethnic problems, corruption and criminality easily can be provoked wherever on our planet. It is not rocket science.
The development of higher standards of public MHPSS will bring more quality of life and next to an improvement of economy in Burundi this might assist in maintaining sustainable peace. An important way to reach better public MHPSS is bringing budget, being in itself the most important way now (not always) to stop inflation and to develop economy by empowering livelihood and education and raised quality of life. Rural population needs economically viable and steady means of earning an income. The vicious circle of poverty must be broken. No health without mental health, but also no health without budget. International press should pay attention to this very poor country.
The discussion about resilience in Burundi even appeared in NGO publications on mental health, while unfortunately publications about other Burundian chapters are scarce. Burundians are proud people, as proud as their governmental leaders are, and they in general prefer to restore people-to-people contacts on their own, avoiding negative words and building on former traditions. They don’t critisize the president, but they critisize the fact that one has to vote to stay registrered in ones community. They live in a superficial democracy. In 2020 a new president will be elected and population is looking forward to this because it might lead to a restart of EU budget. We hope funds will come sooner. Burundi needs education, materials, infrastructure and other facilities for many other sectors including public mental health.
Acknowledgements
The author would like to thank Herménégilde Nduwimana, Genereal Director of the CNPK, Franck Ninos Sokoroza, physician, medical manager in the CNPK and mhGAP-HIG trainer, and Salvator Bihirabake, psychologist in the CNPK and mhGAP-HIG trainer, for their valuable contributions to this report.
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