남아공 - 정신건강 이슈 (2013.9.2)

thinking mental health in Africa

정신 건강에 대한 아프리카의 재고

                                        2013년 9월 2일자

 정신 질환과 빈곤에는 연관성이 있다. 아프리카 국가들은 유엔(UN)의 새천년개발목표(Millennium Development Goals :MDGs)를 2015년까지 달성하기 위해 고군분투하며 그에 맞는 새로운 안건을 계획한다. 하지만 건강분야 전문가들은 대륙에 퍼져있는 수백만의 정신적 환자들에 더욱 주목해야 한다는 증거를 얻고 있다.

전세계 전문가들은 5월 세계 정신건강이 날에 세계보건기구(World Health Assembly: WHO)의 실행계획이 통과된 것을 축하했다. 국제적 불균형을 해결할 수 있는 획기적인 방안이라는 것이다. 세계보건기구의 추측에 따르면, 저, 중소득 국가에서 심각한 정신질환자의 75-85퍼센트가 치료를 받지 못하는데 이는 고소득 국가의 35-50퍼센트와 대비된다.

정신건강 문제에 정부와 기부자들의 관심은 더 늘어날 필요가 있다. 전문가들은 새로운 발전 시대에 통합적 접근이 없다면 세계의 취약한 사람들은 똑같은 반복 속에 갇히기만 할 것이라 말한다. 연구 지도자 음풍구(Ethel Mpungu)는 “가난에서 벗어나기 위해서는 정신적으로 건강해야 할 필요가 있다”고 말했다.

대부분의 아프리카 국가에서 정신건강 관련 법률 제정은 통과하기 힘들지만, 우간다는 정신, 신경학 그리고 물질사용 서비스에 관해 2010년에 입안된 포괄적인 국가 법률로 앞서있다. 또한 개발도상국의 정신건강 문제를 주도하는 연구 기관과 건강 부서의 컨소시움에 속해있다. 정신건강 개선 프로그램(the programme for improving mental health care: PRIME)은 2011년에 개발도상국에서 정신건강 서비스의 확장을 지원하기 위해 만들어졌다.

 아직 수십억의 자선 달러가 에이즈(human immunodeficiency virus: AIDS)나 물, 말라리아 같은 데에 쓰이고 있다. 하지만 사람들이 사느냐 죽느냐를 신경쓰지 않으면, 그렇게 제공된 것의 이점을 얻지 못하게 될 것이다.

 

 

원문

KAMPALA, 2 September 2013 (IRIN) - As African countries strive to meet the UN Millennium Development Goals (MDGs) by 2015 and plot a new development agenda thereafter, health experts are gathering evidence across the continent to make a case for a greater focus on its millions of mentally ill. 

 Experts say investing in mental health treatment for African countries would bolster development across the continent, but national health priorities have been overtaken by the existing MDG structure, which has specific targets for diseases like malaria and HIV, placing them higher on countries' agendas than other health issues. 

 "Everyone is putting their money in HIV, reproductive health, malaria," says Sheila Ndyanabangi, director of mental health at Uganda's Ministry of Health. "They need also to remember these unfunded priorities like mental health are cross-cutting, and are also affecting the performance of those other programmes like HIV and the rest." 

 Global experts celebrated the passing of a World Health Assembly action plan on World Mental Health Day in May, calling it a landmark step in addressing a staggering global disparity: The World Health Organization (WHO) estimates 75-85 percent of people with severe mental disorders receive no treatment in low- and middle-income countries, compared to 35-50 percent in high-income countries. The action plan outlines four broad targets, for member states to: update their policies and laws on mental health; integrate mental health care into community-based settings; integrate awareness and prevention of mental health disorders; and strengthen evidence-based research. 

 In order for the plan to be implemented, both governments and donors will need to increase their focus on mental health issues. As it stands, the US Agency for International Development (USAID), the world's biggest bilateral donor, will only support mental health if it is under another MDG health priority such as HIV/AIDS. Meanwhile, mental health receives on average 1 percent of health budgets in sub-Saharan Africa despite the WHO estimate that it carries 13 percent of the global burden of disease. 

 "Mental health hasn't found its way into the core programmes [in developing countries], so the NGOs continue to rely on scraping together funds to be able to respond," Harry Minas, a psychiatrist on the WHO International Expert Panel on Mental Health and Substance Abuse and director of the expert coalition Movement for Global Mental Health, told IRIN. "Unless we collectively do something much more effective about NCDs [non-communicable diseases], national economies are going to be bankrupted by the health budgets." 

The post-MDG era 

 According to a May report from the UN Secretary-General's High-Level Panel of Eminent Persons on the Post-2015 Development Agenda, the MDGs have overseen the fastest reduction of poverty in human history. 

"Mental health hasn't found its way into the core programmes [in developing countries], so the NGOs continue to rely on scraping together funds to be able to respond"

 Yet it also acknowledges that they have done little to reach the world's most vulnerable. The report says the MDGs were "silent on the devastating effects of conflict and violence on development" and focused too heavily on individual programmes instead of collaborating between sectors, resulting in a largely disjointed approach to health. Experts say without a more holistic approach to global health in the new development era, the world's most vulnerable will only be trapped in that cycle. 

 "The MDGs were essentially a set of vertical programmes which were essentially in competition with each other for resources and for attention," said Minas. "We've gone beyond that, and now understand we're dealing with complex systems, where all of the important issues are very closely interrelated." 

Poverty and mental illness 

 In Africa, where many countries are dealing with current or recent emergencies, WHO sees opportunities to build better mental health care. 

 "The surge of aid [that usually follows an emergency]combined with sudden, focused attention on the mental health of the population, creates unparalleled opportunities to transform mental health care for the long term," say the authors of the report Building Back Better: Sustainable Mental Health Care after Emergencies, released earlier this month. 

 In a study published in the Journal of Affective Disorders in July, researchers in northern Uganda - which, starting in the late 1980s suffered a two-decade long war between the government and the rebel Lords' Resistance Army - monitored the impact of group counselling on vulnerable groups such as victims of sexual and domestic violence, HIV-infected populations, and former abductees of the civil war. It found that those groups who engaged in group counselling were able to return and function markedly faster than those who did not receive counselling, while reducing their risks of developing long-term psychiatric conditions. 

 "We need to be mentally healthy to get out of poverty," Ethel Mpungu, the study's lead researcher, told IRIN. 

 The link between mental illness and persisting poverty is being made the world over. According to a 2011 World Economic Forum report, NCDs will cost the global economy more than US$30 trillion by 2030, with mental health conditions alone costing an additional $16 trillion over the same time span. 

Access to mental health services remains a key challenge in Africa

 "It really is around issues of development and economics - those things can no longer be ignored," says Minas. "They are now so clear that ministries of health all around the place are starting to think about how they are going to develop their mental health programmes." 

Putting mental health on the agenda 

 As mental health legislation is hard to come by in most African countries, Uganda is ahead of most on the continent with its comprehensive National Policy on Mental, Neurological and Substance Use Services, drafted in 2010. The bill would update its colonial era Mental Treatment Act, which has not been revised since 1964, and bring the country in line with international standards, but is still waiting to be reviewed by cabinet and be voted into law. 

 Uganda is also part of a consortium of research institutions and health ministries (alongside Ethiopia, India, Nepal and South Africa) leading the developing world on mental health care. PRIME - the programme for improving mental health care - was formed in 2011 to support the scale-up of mental health services in developing countries, and is currently running a series of pilot projects to measure their impact on primary healthcare systems in low-income settings. 

Research shows that low- and middle-income countries can successfully provide mental health services at a lower cost through, among other strategies, easing detection and diagnosis procedures, the use of non-specialist health workers and the integration of mental healthcare into primary healthcare systems. 

 Although a number of projects have shown success in working with existing government structures to ultimately integrate mental health into primary health care, the scaling up of such initiatives is being hindered by a lack of investment, as the funding of African health systems is still largely seen through donor priorities, which have been focused elsewhere. 

 "Billions of philanthropic dollars are being spent on things like HIV/AIDS or water or malaria," said Liz Alderman, co-founder of the Peter C. Alderman Foundation (PCAF), which works with survivors of terrorism and mass violence. "But if people don't care whether they live or die, they're not going to be able to take advantage of these things that are offered."