Sustainable Communities Review

ARTICLE
Sustainable Mental Health Provision Options in
Zimbabwe: Insights from Non-Pharmacological
Practitioners
Herbert Zirima
Behavioural Sciences Department, School of Medical & Health Sciences
Great Zimbabwe University

Abstract
Mental health service provision in Zimbabwe is currently under strain as it is not
only largely unavailable but heavily relies on an unsustainable pharmacological
approach which is understaffed and under-resourced. This study sought to
gather insights from practitioners in the field of mental health on sustainable
mental health options. The ultimate aim of this study was to come up with a
sustainable model for mental health provision in the country. The researcher
employed an explorative case study design in which 11 practitioners were
purposively selected to take part in the study. The participants represented
psychologists, clinical social workers and counsellors. This study revealed that
there is no equilibrium between the demand for mental health services and the
available services as very few mental health specialists and very few mental
health centres are available in Zimbabwe. The study exposed the need for policy
reformulation such that there is a focus and investment in non-pharmacological
interventions which can be used alongside current pharmacological approaches.
Non-pharmacological approaches are more sustainable as they are less expensive
and largely available. There is a need for a multi-disciplinary approach to the
provision of mental health as a team of professionals is more likely to offer
effective treatment than just one specialist. The study proffered a model of mental
health provision which is based on the integration of non-pharmacological
interventions in primary health care facilities, schools and all public institutions.

Keywords: Non-pharmacological, sustainable mental health, integration,

pharmacological.

Introduction and substance misuse. There is therefore a

There is a surge in the need for mental greater need to explore viable and
health services globally and locally. This sustainable options for providing mental
surge is partly due to the COVID-19 health care to all groups of people. The
disturbances and also due to a rise in drug World Health Organisation (WHO, 2009)
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defines mental health as "a state of well- disorders are managed, away from long-
being in which every individual realizes his term institutionalization and towards
or her potential, can cope with the normal community-based mental health care
stresses of life, can work productively and (WHO, 2013). It is the emphasis on
fruitfully, and can make a contribution to community health services that gives
her or his community”. Modern mental relevance to non-pharmacological
health provision was initiated at the interventions as they present a more
beginning of the 20th century in the United sustainable option for the provision of
States of America when Clifford Beers mental health. The other focus of the de-
founded the first outpatient mental health institutionalisation campaign was on
clinic in 1908 (Peck, 2013). Traditionally, reforming psychiatric care to reduce (or
mentally ill persons were treated under avoid encouraging) feelings of dependency,
strict institutionalisation in what were hopelessness and other behaviours that
regarded as asylums. In those asylums, make it hard for patients to adjust to a life
traditional treatments were well outside of care (Wright, 1997). What is clear
implemented: drugs were not used as a therefore is that psychiatric drugs although
cure for a disease, but as a way to reset very useful, are not sustainable in the long
equilibrium in a person's body, along with term as they encourage dependency and
other essential elements such as healthy sometimes feelings of hopelessness.
diets, fresh air, middle-class culture, and Moreover, for low-resourced countries such
the visits by their neighbouring residents as Zimbabwe, reliance on psychiatric drugs
(Novella, 2010). There was a transition from is an economic strain. It is against this
institutionalisation to trans- background that it becomes critical for
institutionalisation where patients were governments to invest in non-
moved from one therapeutic centre to pharmacological interventions as they can
another either due to planned moves or be provided within community settings
unforeseen consequences. which makes them much more sustainable.
The mid-20th century witnessed Non-pharmacological interventions include
advocacy in favour of de- formal psychological therapies such as
institutionalisation. De-institutionalisation cognitive behaviour therapy (CBT) and
is the process of replacing long-stay in interpersonal psychotherapy (IPT), as well
psychiatric hospitals with less isolated as less formal supportive therapies such as
community health services for those counselling within primary care,
diagnosed with a mental disorder or mindfulness-based therapy, behavioural
developmental disability (Fakhourya & activation and self-help strategies. Lifestyle
Priebe, 2007). Despite decades of changes to improve diet, exercise,
promoting deinstitutionalization, mental relaxation and sleeping habits should also
health service delivery is still largely be part of a broader management plan
dominated by hospital care, which absorbs (Sarris, O’Neil, Coulson, Scweitzer & Berk,
the largest proportion of the mental health 2014). When properly implemented non-
budget, particularly in low and medium- pharmacological interventions can
income countries. There is an urgent need effectively complement pharmacological
for a radical shift in the way mental interventions and as such provide a more
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sustainable mental health system. trained in the pharmacological treatment of

Sustainability in mental health is the ability mental illness.
to provide high-value care now and in the It is also important to note that the four
future in the face of environmental, psychiatric centres available in the country
economic and social constraints are usually affected by the shortage of
(Community Research Connections, 2021). drugs, not to mention the unavailability of
Strong links exist between mental specialists (WHO, 2020). This unavailability
disorders and other chronic diseases such of psychiatric drugs then pushes patients to
as heart disease, diabetes and HIV/AIDS, purchase the drugs from private
not just in terms of their common co- pharmaceuticals, which of course is
occurrence but also in terms of their expensive. This presents a very
underlying determinants and their public unsustainable mental health provision
health consequences (WHO, 2014). The system. Zimbabwe does not have much in
prevention and management of these its system to support mental health besides
chronic conditions can be enhanced by the four major referral centres and a few
taking a more holistic, integrated and school psychologists based at Provincial
person-centred approach. Integrating offices. The country also currently relies
mental health services into general, non- heavily on a pharmacological approach to
specialized health care is not only a mental health as there are no non-
sustainable option but a key strategy to pharmacological specialists at primary
expand coverage, and for the overall health care facilities and very few to none
integration of services at the level of the at secondary and tertiary health care
healthcare system. centres (WHO, 2020). Non-pharmacological
Zimbabwe has Four Public psychiatric specialists include psychologists,
referral centres: Ingutsheni Central counsellors and clinical social workers. It is
Hospital, Harare Psychiatric Unit, against this background that this study
Parirenyatwa Hospital Annexe and seeks to explore sustainable mental health
Ngomahuru Hospital. Two of these are in provision options for a low income country
Harare. Bulawayo and Masvingo have one such as Zimbabwe.
each. These do represent only three The specific objectives of this study
provinces in a country with ten provinces. were to:
The Medical and Dental Practitioners 1) Identify challenges in the current
Council of Zimbabwe register (2021) has 19 mental health system in Zimbabwe,
registered psychiatrists in a country of 15 2) Explore non-pharmacological
million people (according to the mental health options available in
Worldometer) representing that there is Zimbabwe,
one psychiatrist for about every 790 000 3) Proffer a sustainable mental health
people. The few psychiatrists highlighted provision model for Zimbabwe.
above are only available in Harare and
Bulawayo meaning that the other eight
provinces do not have psychiatrists.
Psychiatrists are mental health specialists

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Methodology online communication platform, Google-

meet as it was difficult to meet the
Design participants physically due to the COVID-
This study took a qualitative approach 19 restrictions as well as the long physical
and employed the exploratory case study distances involved in contacting the
design. The explorative case study seeks to practitioners physically.
describe what exists and to observe and
document aspects of a situation. It is used Data Analysis
when there is no single set of outcomes, Thematic analysis was used to analyse
(Yin, 2014). This design was selected as data. Thematic analysis is a qualitative
there was no anticipated single set of analysis method for identifying, analysing
outcomes when the research began. The and reporting patterns within data (Braun
design also enabled the researcher to & Clarke, 2006). It minimally organizes and
appropriately capture in adequate detail describes data in rich detail. Some of the
the insights from practitioners regarding themes that emerged include the need for a
mental health provision in Zimbabwe. multi-disciplinary approach, the absence of
an efficient mental health system and non-
Population and Sampling pharmacological treatment options.
The population for this study was all Pseudonyms were used to protect the
non-pharmacological mental health identity of the participants.
practitioners registered by the regulatory
board in Zimbabwe which is the Allied Results and Discussion
Health Practitioners Council of Zimbabwe The results are presented under themes
(AHPCZ). Practitioners targeted for this which emerged from the study. Findings
study were psychologists, clinical social were categorised under four themes which
workers and counsellors. According to the were (i) Challenges with the Zimbabwean
AHPCZ register (2021), there are 243 intern mental health system, (ii) Non-
and fully registered psychologists, 273 pharmacological mental health options in
counsellors and 29 clinical social workers. Zimbabwe, (iii) Toward a multi-
This makes a population total of 545. The disciplinary approach to mental health and
researcher then used a purposive sampling (iv) Sustainable mental health provision
technique to select practitioners from the model. Direct quotations are used to
three professions who gave their insights. accurately capture the insights of the
The final sample included 11 practitioners, respondents.
five were psychologists, four were
counsellors and two were clinical social Challenges with the Zimbabwean Mental
workers. Health System
There is a rising demand for mental
Data collection instrument health services which is however not
The researcher utilized in-depth tallying with the available services.
interviews to collect rich and meaningful Zimbabwean public health facilities and
data from the practitioners. In-depth generally most public facilities do not have
interviews were conducted through an non-pharmacological mental health
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specialists such as psychologists and medical doctors and nurses in the provision
counsellors. A critical challenge that exists of mental health services.”
is therefore the scarcity of mental health Participant 10 explained the sidelining
specialists, both pharmacological and non- of non-pharmacological practitioners;
pharmacological. Participant 7 aptly put “Tertiary and provincial hospitals have
this as intern psychologists who are currently
“It would be difficult to even say we have a offering mental health services under
mental health system in this country, we supervision as they are still in training. It
have these things on paper but nothing is however unfortunate that despite the
much practical”. critical role played by the interns, they have
Participant 2 said, not been receiving any monetary
“The mental health system is strained, look remuneration. This is despite the fact that
at the number of substance abuse cases that their counterparts in other health fields
we have versus practitioners who can such as nurses and radiographers get
assist…” remunerated.”
These findings are in line with the Participant 9 revealed the lack of
WHO special initiative for mental health trained mental health practitioners at
situational assessment report, (2020) which health institutions;
revealed that ‘there is a lack of funding for “There are only three fully trained
medication, human resources, and mental psychologists in Zimbabwean tertiary
health promotion in both psychiatric hospitals and none at all at provincial and
hospitals and community-based care.’ district hospitals. In the education system,
These findings also confirm Kohn’s, psychologists are only found at provincial
(2004) findings that despite the ubiquity offices and none at the district level and
and prevalence of mental disorders, many public schools.”
countries have inadequate mental health These challenges are also highlighted
systems and services. In most countries, in the WHO special initiative for mental
especially those with low- and middle- health Zimbabwe situational assessment of
income economies, there is an enormous 2020 which reported that Zimbabwe has a
gap between those who need mental health severe shortage of human resources for
care, on one hand and those who receive mental health, with an estimated 18
care, on the other hand. Sexana, (2007) psychiatrists (17 of them in Harare) or
asserted that “fewer than 28% of countries approximately 0.1 per 100,000 population.
have a specific budget for mental health There are 917 psychiatric nurses (6.5 per
care, and many countries face acute 100,000) and 6 psychologists (0.04 per
shortages of mental health workers”. This 100,000). However, it is important to note
goes on to show that the problem is not that Zimbabwe has about 243 psychologists
only local but global. however almost all of them are not in the
The lack of a multi-disciplinary public mental health space due to
approach was highlighted by participant 1, unavailability of the posts in the Ministry
“Currently, there is no multidisciplinary of Health and Child Care structures.
approach to mental health service provision Participant 8 commented on the lack of
with the government only supporting psychiatric drugs in hospitals,
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“Locally psychotropic drugs are not being difficult cases to psychologists, Community
manufactured especially the newer drugs education by community Psychologists,
hence old type drugs with more side effects who should work to prevent mental illness
are used which increases poor adherence by and educate communities on the need to
clients.” seek the services of mental health
Therefore reliance on a professionals.”
pharmacological approach becomes This was complemented by participant
unsustainable since the drugs will not 2 who said;
always be available. “There is need for referral of patients with
Participant 10 commented on the lack mental health problems, by medical
of professionalism among some non- practitioners, to mental health care
pharmacological practitioners; professionals, for psychotherapy and
“….I have sadly noted that the provision of counselling services”
mental health is not always professional Participant 7 highlighted the need for
and is mostly done by unqualified the establishment of special psychological
individuals who may cause harm to rehabilitation institutions, such as
clients… some students are doing Substance Use Rehabilitation Centres and
undergraduate degrees who are Depression Treatment Centres for the
experimenting on people.” management of mental illness. Participant 3
Such comments are indicative of a also explained the need for peer-to-peer
weak regulatory system in mental health support in communities where there are
practice. It appears the shortage of properly people who previously suffered from
qualified specialists has created a vacuum mental health conditions. Such people can
for unqualified people to claim to offer offer knowledge on coping strategies to
mental health services. patients and caregivers alike.
These findings are in line with existing
Non-pharmacological mental health literature on what is currently happening in
options in Zimbabwe Zimbabwe regards psychotherapeutic
Non-pharmacological treatment plans services. The Friendship Bench for instance
can be used to complement currently offers non-pharmacological
pharmacological interventions. Such an mental health interventions at the
approach presents a sustainable option for community level in low-income areas of
mental health provision in Zimbabwe as Zimbabwe. Their programme is lay
there are more non-pharmacological counsellor-delivered problem-solving
practitioners in the country and also therapy for patients in primary care with
because it is cost-effective in the long term. depressive symptoms, (Community Mental
Participant 11 outlined the possible non- Health, 2019). Their programme has
pharmacological treatments for mental demonstrated effectiveness and is currently
illness which can be offered at low cost; being scaled up across primary health care
“Psycho-diagnosis and psychotherapy by facilities in Harare and other urban and
psychologists; Occupational Therapy by rural areas in Zimbabwe. The WHO Special
occupational therapists, Counselling Initiative assessment report, (2020) revealed
services by counsellors, who should refer that some evidence-based psychosocial
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interventions are offered at the few public teams is that the combined expertise of a
specialist mental health facilities in range of mental health professionals is used
Zimbabwe, though shortages in trained to deliver seamless, comprehensive care to
human resources and appropriate the individual. The research evidence
supervision structures limit service supports a multidisciplinary team working
availability. The little work done in as the most effective means of delivering
Zimbabwe with non-pharmacological comprehensive mental health services to
options has shown that they present a people with mental health problems,
sustainable alternative or option for especially those with long-term mental
prevention, treatment and management of health problems. According to Jefferies and
mental health conditions. Chan, (2004) multidisciplinary team
working is described as the main
Towards a multi-disciplinary approach to mechanism to ensure truly holistic care for
mental health patients and seamless service for patients
Findings from this study have revealed throughout their disease trajectory and
that there is a need to institute a multi- across the boundaries of primary,
disciplinary approach to mental health if secondary and tertiary care.
there is going to be the realisation of a
sustainable mental health system in Sustainable mental health provisions
Zimbabwe. The multi-disciplinary team model
refers to members of different professions A sustainable mental health provision
working together. There is a need to ensure model submitted here was informed by
that teams of mental health experts work insights proffered by the practitioners.
together as colleagues to ensure the There is an urgent need for policy
prevention and treatment of mental health reformulation such that mental health
conditions. Participant 5 commented on the services are fully integrated within the
need for a multi-disciplinary approach; primary health care system and public
“A multidisciplinary approach is a very institutions. Primary health care is the
excellent way of dealing with mental foundation for high-quality and sustainable
health. There is a need to establish and mental health care. According to WHO,
strengthen a referral pathway so that (2009), mental health services integrated
patients may enjoy a comprehensive/ into primary care include the identification
holistic package of care. Psychiatrists, and treatment of mental disorders, referral
Psychologists, Social workers, and to other levels where required, attention to
Occupational therapists only to mention a the mental health needs of people with
few should be offering mental health. In physical health problems, and mental
schools, colleges, and universities there is a health promotion and prevention. Where
need to upscale mental health as there are a mental health is integrated into primary
lot of suicide cases being reported. Every care, access is improved, mental disorders
sector should have mental health services.” are more likely to be identified and treated,
These sentiments are supported by and comorbid physical and mental health
research, particularly Tyrer, (1998) who problems are managed seamlessly.
posits that the strength of multidisciplinary
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Figure 1: Chart showing the sustainable mental health provision model

system and should get paid during
To be fully effective and efficient, training. Fully trained psychologists should
primary mental health care must be be engaged in all health care facilities and
complemented by additional levels of care, public institutions to offer training and
(WHO, 2009). These include secondary care mental health services. Besides health care
components to which primary health facilities, psychologists, clinical social
workers can turn for referrals, support, and workers and counsellors should be
supervision. Linkages to informal and engaged in public schools, district
community-based services also are education offices, prisons, colleges and
necessary. This integration will entail that other public institutions.
the training of counsellors and The government should invest in non-
psychologists is embedded in the health pharmacological mental health service
system. The students should be part of the provision. This will be done partly by

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employing psychologists and counsellors There is a need to raise awareness of

within the primary health care system and the causes and treatment of mental illnesses
public institutions. There should also be to deal with the stigma currently associated
serious investment in tools of the trade with mental illnesses in our communities.
such as psychometric instruments which This will need the full engagement of
are necessary for screening and diagnosis psychologists, counsellors and social
of mental disorders. workers.
This model also posits that the The integration of non-pharmacological
government should absorb clinical and mental health options in primary health
counselling psychology interns into the care facilities in a sustainable approach to
health sector as a matter of urgency. The the prevention, treatment and management
proposal is that every Psychiatric Hospital of mental illness as these primary health
should have at least ten (10) interns, every care facilities are within reach of most
Provincial Hospital to have at least five (5) people. Moreover, currently, there is a
interns and at least one intern psychologist relatively high number of non-
for every District Hospital. This pharmacological practitioners who are fully
arrangement will entail the engagement of trained and some still under training who
fully registered psychologists at all the can provide the services. The availability of
stated hospitals to ensure proper these practitioners entails that the approach
supervision of the interns. will be sustainable.
The school system represents a greater
chunk of the population of Zimbabwe. In Conclusion
that regard, it is necessary to ensure that This study revealed that there are
educational psychologists are engaged at many challenges with the Zimbabwean
every public school. Currently, only private mental health system. Participants revealed
schools are engaging psychologists in their many non-pharmacological options that
schools and public schools access can be pursued in the Zimbabwean context.
psychologists at the provincial level. The options provided pointed towards a
Registration and compliance of mental multi-disciplinary approach to mental
health practitioners are critical as it ensures health and a sustainable mental health
that only properly qualified people are provision model.
engaged to offer mental health services. The Zimbabwean mental health system
This arrangement ensures that the mental is currently unsustainable as it is relying on
health of members of the public is a poorly resourced pharmacological
protected from charlatans and persons of approach hinged on only four psychiatric
dubious qualifications who may end up centres and very few psychiatrists and
hurting instead of healing clients. The psychiatric nurses. The system currently
emphasis on professionalism is a key issue does not seem to give any serious
that arose from the findings of this study recognition to non-pharmacological
and as such, it is necessary that regulatory practitioners who include psychologists,
bodies should monitor those who offer counsellors and clinical social workers.
mental services. A sustainable approach to the
provision of mental health entails the
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engagement of treatment plans that are Community Research Connections.

affordable to the government. Currently, (2021). Statement on Sustainability in
there is an over-reliance on Mental Health. Royal Roads
pharmacological treatment plans which are University.
not only largely unavailable to the majority Fakhourya, W. & Priebe, S. (2007).
of citizens but also too expensive to both Deinstitutionalisation and
the government and individuals. There is reinstitutionalisation: major changes
therefore a need for policy reformulation so in the provision of mental
that there can be a focus and an investment healthcare. Psychiatry. 6(8): 313–316
in non-pharmacological treatment options. Jefferies, H. & Chan, K.K. (2004).
These non-pharmacological interventions Multidisciplinary team working: is it
would need to be integrated within the both holistic and effective?
primary health care system which is International Journal of Gynecological
available to the majority of the people. To Cancer, 14 (2).
enhance the sustainability of this approach, Kohn, R. (2004). The treatment gap in
there will be a need to adopt a multi- mental health care. Bulletin of the
disciplinary approach to the treatment of World Health Organization. 82:858-
mental illness. 866.
There is a need to ensure that Medical and Dental Practitioners
counsellors and psychologists are available Council of Zimbabwe, (2021).
at the school level. That will guarantee the Doctors Retention Register.
sustainability of mental health services in https://www.mdpcz.co.zw/registrati
the school system to which almost all on-2/registered-doctors/
children belong. Overall there is a need to Novella, E. J. (2010). Mental health care
ensure that mental health provision is and the politics of inclusion: A social
pervasive in all public institutions. There systems account of psychiatric
should be clear screening and treatment deinstitutionalization. Theoretical
platforms at all primary health care centres. Medicine and Bioethics, 31(6), 411-427.
Sarris, O’Neil, Coulson, Scweitzer &
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