Current efforts to close the mental health treatment gap have focused on task-shifting and integration of services within primary care settings. In low- and middle-income income countries (LMIC), inequalities in access to health services, difficulties in integrating mental health services into primary health care, inefficiencies in the use of services and scarce resources are barriers to access to mental health care (1). To properly target minimal resources in LMIC, it is critical to understand the demographic profile and mental health needs of patients served in different types of clinics within the health care system.
Mozambique is one of the poorest countries in the world, with a human development index in the “low development” category that ranks it in the 180th position of 189 countries (2). It has a population of over 29 million, with an annual growth rate of 2.46% and a life expectancy at birth of 54.4 years. The literacy rate is 58.0% for the total population; 73.3% for men and 45.4% for women (3). The country is mostly rural, with 70% of the population living and working in rural areas. The annual per capita income is US $460 but approximately 70% of the population lives below the poverty line with an income below US $0.40 per day (< US $146 per year) (2).
The Mozambican National Health System (Serviço Nacional de Saúde) has approximately 5.07 physicians and 84 beds per 100,000 inhabitants, compared to an average of 30 physicians per 100,000 for low income countries. There are 1,249 primary health care units, which are not sufficient to cover the health care needs of the country’s population (4). Like other LMIC (5), resources dedicated to mental health services are even more limited, with just 0.06 psychiatrists and 0.78 psychiatric beds per 100,000 inhabitants (6). For context, the Organization for Economic Cooperation and Development recommends 15 psychiatrists per 100,000 inhabitants (7).
Faced with this gap in mental health treatment capacity, in 1993, the Mozambican Ministry of Health (MISAU), Department of Mental Health, created a national strategy and a sustainable action plan with guidelines for implementation and transfer of competencies (task-shifting) for provision of neuropsychiatric services to a new type of mental health specialist, Psychiatric Technicians. These technicians are mid-level professionals, trained in a 30-month program to conduct community-based mental health and epilepsy prevention and promotion activities; recognize, diagnose and treat neuropsychiatric disorders; provide counselling, psychosocial support and brief psychotherapy; design and implement community-based follow-up programs; and prescribe psychotropic and antiepileptic drugs according to the prescription level of the National Drug Formulary under the supervision of psychiatrists. Of note, this program was developed and implemented before the terms task shifting and task sharing were coined. (6, 8)
The Mozambican national mental health system aims to offer the majority of its mental health services in primary care units (6, 9). In the majority of provinces, when mental health services are not available at a primary care unit, which is the rule, patients are referred to the next levels of care—secondary (district level), tertiary (province level) or quaternary (in one of the four central hospitals or in one of the two psychiatric hospitals in the country) — depending on the severity of patients’ conditions and need for inpatient treatment. At the secondary, tertiary, and quaternary levels of care, mental health services may include inpatient and outpatient services. The difference between the levels of care is the availability of resources, with more multidisciplinary mental health teams and more beds occupied by patients with psychiatric conditions as the level of care increases. At the primary care level, there are no beds and, in some cases, mental health services are provided by psychiatric technicians and, in other cases, there are no specialized mental health services and psychiatric patients are referred to the next levels of care. At the secondary/district level, there are four beds for psychiatric patients in each facility and psychiatry technicians most often provide mental health services, though in a few sites, a psychologist may provide care at the secondary level as well. At the tertiary/provincial level, there are eight beds for psychiatric patients in each facility and mental health services are provided by a multidisciplinary team, including a psychiatry technician, a psychologist, and, in some cases, an occupational therapist and a psychiatrist. At the quaternary level, in each of the five facilities nationwide, there are specialized mental health units with 30 or more beds and mental health services are provided by a team including a psychiatric technician, psychologist, occupational therapist, and psychiatrist.
With the development of the Psychiatric Technician program, Mozambique has designed and implemented a feasible and sustainable way to provide public mental health services despite scarce human resources and negligible budgets through task shifting. Yet, as mental health human resources are still insufficient, knowing how different types of mental health problems may vary across different types of primary care settings remains crucial to proper allocation of limited resources. Most prior studies quantifying the burden of mental disorders in LMIC (10, 11) were population-based and utilized screening tools. Rarely have studies focused on the primary care setting, where interventions are likely to occur. Particularly, studies that performed a more in-depth characterization of mental disorders, by relying on a diagnostic structured interview, rather than on screening tools are needed. Although there are prevalence estimates for mental disorders for Mozambique based on global studies (5), large-scale population-based studies of a wide range of mental disorders have not been conducted in Mozambique.
This study examines how the frequencies of mental disorders vary along a spectrum of types of health care facilities where patients with mental disorders could be identified and receive care in Mozambique: five primary care units (some including mental health specialists and some not) and a tertiary care unit (where more specialized psychiatric care is available). We hypothesized that more severe psychiatric disorders would be found in tertiary care followed by primary care with and then without specialists, reflecting the level of specialty mental health care available and existing referral pathways in these settings, regardless of differences in socioeconomic conditions across the different settings studied.
The data for this report originates from a study that had as its primary goal to develop a low-burden, effective screening tool for the practical identification of common and severe mental disorders in low-resource settings (12). The data generated as part of this study is, to date, the most comprehensive source of information about mental disorders in the public health system of care in Mozambique.