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Munakampe Int J Ment Health Syst (2020) 14:28
https://doi.org/10.1186/s13033-020-00360-z
RESEARCH
Strengthening mental health systems
inZambia
Margarate Nzala Munakampe1,2*
Abstract
Background: Studies in mental health care for low resource settings indicate that providing services at primary care
level would significantly improve provision and utilisation of mental health services. Challenges related to inadequate
funding were noted as significant barriers to service provision, with the contribution of low knowledge of mental
health conditions and stigma in the community. This study aimed to explore the barriers to the use of mental health
services in Zambia, suggesting health systems thinking approaches to solving these challenges.
Methods: Primary data were collected through individual interviews from 12 participants; primary caregivers, health
workers from public health institutions that treat mental health conditions and policymakers and implementers. The
digitally recorded responses were transcribed and analysed using thematic analysis.
Results: Key barriers to care included inadequate funding, few human resources, poor infrastructure and stigma.
Barriers to care at policy, facility and individual or community level could be alleviated by strengthening the mental
health system. Engagement of community health workers and increasing efforts to sensitise the community about
mental health would prove beneficial.
Conclusions: Strengthening the community health systems for mental health could improve access and increase
utilisation of services.
Keywords: Mental health, Mental health systems, Mental health services, Barriers to service use
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Background
Studies have suggested that providing services at primary
care level would significantly improve the provision of
community mental health services [1]. However, chal-
lenges related to inadequate funding are noted as signifi-
cant barriers to service provision at that level, with the
contribution of insufficient knowledge of mental health
and mental health conditions in the community, stigma
and the lack of prioritisation of cost-effective options
from the policy level [2, 3]. Despite a global prevalence
of 13%, inclusive of neurological and substance use dis-
orders, mental disorders do not attract much attention
[4]. e magnitude of mental disorders is amplified when
comorbid with other disorders such as HIV/AIDS and
coronary heart disease [5, 6]. Projections for this disease
burden wereset to increase to about 15 per cent by 2020
and depression producing the second most significant
disease burden across all age groups.
In Zambia, the prevalence of mental disorders is
approximately 20 per cent.Common mental disorders
include acute psychotic episodes, schizophrenia, affec-
tive disorders, alcohol-related problems and organic
brain syndromes [7]. The potential causes of mental
health conditions include stressful family relation-
ships, infections such as malaria, meningitis, syphilis
and HIV, use, and the use and dependence on alcohol
and other psychotropic substances [8–12]. Poverty
increases susceptibility to mental health conditions [1].
About 60 per cent of Zambiansare classified as poor
Open Access
International Journal of
Mental Health Systems
*Correspondence: margaratemuna@yahoo.com
1 Department of Health Policy and Management, School of Public Health,
University of Zambia, Lusaka, Zambia
Full list of author information is available at the end of the article
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Page 2 of 9
Munakampe Int J Ment Health Syst (2020) 14:28
[13]—poverty defined as thelack of access to employ-
ment, income, freedom on which goods and services to
consume, and a lack of other basic needs [14]. A signif-
icant portion of individuals with severe and persistent
mental health conditions live in rural areas [15].
Historically, mental health care has been a neglected
part of the health system in Zambia, with services con-
centrated at provincial government hospitals and not
at the primary care level [1]. There islow funding for
activities at less than 1% of the national health budget
[2]. A profile of mental health in Zambia [7], high-
lighting the arrangement of mental health care in the
country, is described as ‘critical’. Key factors such as
few trained human resources and the reliance on tra-
ditional medicine at the community level contribute to
challenges of inadequate care. Services were also gov-
erned by the 1951 Mental Disorders Act, which was
repealed. The Mental Health Act of 2018 isin place,
but has not been operationalized yet.
Within the community, the stigma surrounding men-
tal disorders is a significant barrier to mental health
service utilisation [16]. In Zambia, students, detainees,
prisoners, unemployed and others are described as ‘at
risk of developing mental disorders’. However, only 15
per cent of them can use mental health services, and
these are mostly students and prisoners, as they have
targeted interventions and services [17]. Even among
the covered, a majority of them face significant chal-
lenges as revealed in a study at an urban health centre
in Lusaka, which showed that over 80 per cent of people
face problems of poor accessibility and underutilisation
[16].
Strengthening mental health systems in Zambia
responds to the call to advance global mental health
[18] by improving funding and enhancing monitor-
ing of the mental health system in countries, taking
services as close to people as possible. In light of this
background, the main aim of this study was to find
out the barriers to theutilisation of mental health ser-
vices at three levels: policy, facility and individual level.
A ‘systems thinking framework’ [19] is suggested, to
understand these barriers and provide an indication
of how to strengthen the overall mental health system
in Zambia. While studies have looked into barriers
at facility and individual level, such as stigma, seek-
ing traditional healers and inadequate funding of the
mental health activities [20–22], this study aims to add
more information to the policy level dimension, as well
as provide a response to the dearth of context specific
information on mental health in Zambia.
Methods
is paper reports findings from a qualitative case study,
which was part of a mixed-methods study that aimed to
investigate barriers to the utilisation of mental health
services at the policy, facility, and community level.
e case study collected data from the health facilities,
while a cross-sectional survey collected data from the
community.
e case study was conducted in3 provinces; Lusaka,
Ndola, and Kabwe, between August and December 2016.
Five institutions, four public health institutions that treat
mental health conditions and the Ministry of Health,
were purposively selected for this study. Primary data
were collected through individual interviews. An inter-
view guide with open-ended questions was used to steer
the discussions with the participants, administered by
the principal researcher and one research assistant.Both
took field notes throughout data collection. Interviews
were only conducted after the researcher explained the
study aims and procedures involved in the study.
A total of 12 participants were included in the study.
A variety of information sources was introduced when
selecting participants for the study; policymakers, health
workers and the family members of the patients at the
mental health facilities. Table1 describes the study par-
ticipants in some detail.
All interviews were conducted in English, Bemba or
Nyanja, and each interview lasted between 20 minutes
and an hour, depending on the availability of the study
participants. e digitally-recorded responses were tran-
scribed and translated verbatim and read together with
the field notes. Translated data were checked by the
research assistant to ensure meanings were not lost. e
data were managed and analysed using NVivo 10. e-
matic analysis [23] was used as it was appropriate for,
Table 1 Characteristics ofthestudy participant (n = 12)
Participant Location Gender Type
MH001 Kabwe Female Family member (main care-giver)
MH002 Kabwe Female Family member (main care-giver)
MH003 Kabwe Male Nurse
MH004 Lusaka Female Family member (main care-giver)
MH005 Lusaka Male Policymaker
MH006 Ndola Male Clinical Officer
MH007 Ndola Female Nurse
MH008 Ndola Male Family member (main care-giver)
MH009 Lusaka Female Family member (main care-giver)
MH0010 Lusaka Male Doctor
MH0011 Lusaka Male Policy maker
MH0012 Lusaka Female Nurse
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Munakampe Int J Ment Health Syst (2020) 14:28
according to Braun and Clarke, 2006 [24] “analysing and
reporting patterns (themes)” within data collected from
the participants. e key themes were developed from a
predetermined code structure, developed from the litera-
ture reviewed, highlighting barriers at policy, facility, and
individual level in other studies. New themes emerged
from the data at the three different levels, particular to
the Zambian mental health care system. e coded data
were triangulated with the field notes and other less for-
mal discussions and impressions that were noted as the
data were being collected.
Ethical clearance was obtained from the University of
Zambia Biomedical Research Ethics Committee, UNZA-
BREC(REFNo.013-06-15), and permission to carry out
the study in the public health institutions was sought
from the Ministry of Health, and the senior administra-
tors at the health facilities. Individual written informed
consent was obtained from all the participants before the
interviews were conducted in private.
Patient andpublic involvement
No patients who were clinically diagnosed with men-
tal health conditions such as depression and substance
abuse-related disorders at the health facilities were inter-
viewed in this study. is study was conducted in three
provinces in three districts; where the researcher worked
closely with representatives from the district and provin-
cial health offices, as well as the institutional administra-
tive officers. e family caregivers of the patients were
helpful and played an essential role in the study while
caring for their family members.
Results
e findings are presented under three main barrier
domains: policy-level barriers, facility-level barriers, and
individual-level barriers.
Policy level barriers
Absence ofanupdated legal framework
Information collected from respondents at the policy
level revealed barriers to effective implementation of the
mental health policy. It was mentioned that reference
the old Mental Disorders Act and implementation of the
mental health policy was problematic because the two
were not aligned on how to manage the patients. While
the policy stipulated mental health management and
care, the law reinforced the use of violence to manage
the patients, usually with the help of the police. e bill
had been under revision for over 10 years and was only
passed in 2019. At the time of data collection, there was
hope that the new law would allow for the management
of patients to be responsive to current mental health pol-
icy rather than based on 1949 experiences and thinking.
“e reading of the bill in parliament to enact the
new laws that is the will of the government. So we
expect that before, by the coming quarter next year
[2016], we might have a new law in mental health
that will bring in better innovation in mental
health.” MH0011, Policymaker (Lusaka).
Budget constraints andinadequate allocations
Financial constraints also emerged as a barrier to ade-
quate mental health services provision and the over-
allimplementation of the mental health policy in Zambia.
Budget limitations affected the provision of services in
the community. One nurse from Kabwe had this to say:
“We have in the past trained some Mental Health
Assistants, but these have been based here at the
facility. However, if the same people in the com-
munity were able to be trained and then share the
knowledge with the rest of the community, I think
that would be very useful. If there were an increase
in the budget for mental health, then there would be
an improvement”. MH0001.
Also, the insufficient budget affected the training of
mental health service providers. It was noted that the
mental health sector attracts very little funding on its
own, however linking mental health to other more priori-
tised diseases and conditions; and that attract more fund-
ing would be beneficial to mental health care.
“(…) definitely the funding isn’t sufficient. It goes
with what the WHO says, that it’s below 1%, like
many other African countries. e budgetary alloca-
tion is not enough, and it usually has a ceiling. Last
year it was about K300, 000. What can you do with
that for national mental health service? We have a
program to do with mental health and HIV. We are
now trying to convince people in child health, mater-
nal health to see if we can do a program on child
and maternal mental health, it would help improve
the health status of maternal mental health. e
solution is riding on other services”. MH0005, Policy
Maker (Lusaka).
Drugs
At the primary care level, primary care kits with essen-
tial medicines needed to provide services were regularly
provided to the health facilities. However, these kits did
not contain drugs specific tomental health care. e lack
of drugs was seen as a contributing factor to the many
referralsat the provincial facilities from lower-level insti-
tutions. e Mental Health Policy stressed ‘bringing the
services as close to the people as possible’, but this was
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Munakampe Int J Ment Health Syst (2020) 14:28
not possible because it had not yet been effected at the
lower levels of service provision. e health system did
not provide services at the primary level, and the drugs
were not provided. Besides, it was also noted that these
drugs were very costly, and this affected access to drugs
when the patients needed them, sometimes even at the
higher-level institutions.
“(…) some of the drugs are not available, and so
we have to tell the relatives to go and buy for them.
ere are about five types of Antipsychotics, but
‘anti-side-effect’ drugs are not available. Even though
we give the patients the prescriptions, the medicines
are quite expensive”. MH0007, Nurse (Ndola).
Management
e management of mental health services was noted
as a barrier to the provision of mental health services
in Zambia. Despite feeling that the mental health sec-
tor was neglected and not prioritised in terms of over-
all funding and the provision of medicines among other
issues, health care providers felt that airing their views
would not lead to any significant changes in their work.
us, they continued working despite the challenging
conditions.
“I can blame this on management because to do
these; we need money and transport (…) I feel there
are no key people who can make decisions and
implement them. If you have no voice, being heard
is difficult, you continue working the way you work.
Your voice has no impact, so you do things within
your circles of influence” MH0003, Nurse (Kabwe).
In terms of managing patients, the existing legal
framework was seen as demeaning and discriminatory
towards the patients, with terms such as ‘imbecile’ refer-
ring to the patients. It was also common practice for the
members of the community to report any mental health-
related case to the police first, usually because of the vio-
lence associated with some conditions. As a result, the
lack of legal protection or support allowed many patients
of mental conditions to be dragged to the mental health
institutions against their will with the help of police
officers, through the use of court orders. Some patients
were antagonistic towards receiving any medication
attached to such treatment. Hospitalisation in the old
and dilapidated facilitiesalso affected the re-socialisation
of individuals after treatment as the community contin-
ued to remember them in that way even when they had
received treatment and were better. A caregiver had this
to say;
“It is government policy for the police to come in
because of the way he was he was scaring people so
they cannot lock him up (…) until he stabilises and
until the doctor says now he is okay. However, even
with a court order, the police should treat him well,
because he isn’t a criminal, it is an illness. You just
talk to the person nicely” MH000 4, Family Member
(Lusaka).
While the facility and community level actors saw a
failure in managing mental health services, on the poli-
cymaker’s side, however, it was reported that much had
been done for mental health services; considering the
changes that had happened over time, even though they
also felt that there was more work to be done.
Facility level barriers
Few experts orhuman resources
Generally, a shortage of human resources to meet the
burden of mental health conditions in the country was
reported by almost all the participants interviewed. e
shortage was attributed to several reasons. Most of the
health workers who decided to take the mental health
career path ended up disinterested because they did not
have many opportunities to develop their careers. When
compared to HIV/AIDS management or maternal and
child health, mental health providers did not have as
many training opportunities as part of their continuous
professional development. Some health workers were
deployed at these facilities with basicmental health man-
agement knowledge but lacked opportunities to practice
or see patients. ey eventually diverting into other areas
instead, and this was typical of many nurses and clinical
officers. One nurse had this to say;
“ere is no motivation to work despite having
knowledge and skill. ere are no drugs, so we can-
not treat the patient. ere are no support staff like
psychologists or social workers to come in using the
multi-disciplinary approach. ere should be all
these people so that a patient is treated holistically.
Demotivation is too much, despite having the knowl-
edge (…) within PHC there is also the secondary
level where someone is already sick, there should be
a lot of manpower, social worker, psychiatrist a psy-
chologist so that a patient can be treated holistically
instead of just providing medication and allowing
then to go”. MH0003, (Kabwe).
Poor referral system
Ideally, the structure was that the clinics or health centres
were supported by the zonal health centres (community
health centres),and bothwere supported by the district
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Munakampe Int J Ment Health Syst (2020) 14:28
hospitals which were in turn also supported by the pro-
vincial hospitals. Where the cases are complicated, the
patients were referred to the district or provincial hos-
pitals or the nationalspecialist hospitals. However, this
was not the case with the mental health referral system,
as clients went directly to the provincial hospitals; at the
mental health annexes or to Chainama Hills Hospital
(thenational mental health hospital) when the cases were
more complicated or alarming for the caregivers. is
was a severe breach of the system and thus led to over-
crowding in the provincial hospitals and at the national
specialist hospital. A nurse from Ndola (MH0007) said
“We receive very few referrals. People come straight to the
hospital. Once they get detention orders, they come here
and “dump” their patients here”.
Despite the weak or “different” referral system, the fam-
ily caregivers acknowledged that the health care provid-
ers were well trained as they were able to attend to them
when they sought assistance. However, they were not
sufficient to handle all their demands due to staff short-
ages. Training of Mental Health Assistants (Community
Health Workers) helped alleviate the problem of insuf-
ficient human resources at Lusaka and Ndola hospitals.
Conversely, the continuity was problematic due to insuf-
ficient budgetary allocation to mental health. A need
for more personnel to be trained at the different levels
of health care to support mental health programs was
reported as a way to reach the community as these activi-
ties were already specified in the mental health policy.
Individual‑level barriers
Stigma
Stigma was one of the most significant barriers to the uti-
lisation of mental health services notedat the individual
or community level. Stigma was captured at three levels:
self-stigma, stigma from family members and the com-
munity in which the patient lived, and stigma from the
health care providers. Self-stigma came about when the
patient was aware that they were sick, and they began to
lose hope in medication and are from the family. A nurse
from Ndola (MH0006) said “(…) also self-stigma from the
clients themselves it becomes very difficult for someone to
recover because of certain beliefs they come with from the
community”.
e community was also reported to stigmatise
patients with mental health conditions and this caused
challenges related to adherence to medication and the
general well-being of the patient. Even when the fam-
ily took care of the patient, they could not protect them
from the ridicule and judgment from their neighbours
and friends. Finding out and being aware of the commu-
nity’s stigma was reported to contribute to self-stigma as
the patient was made aware of their condition.
“ere is a stigma in the community. Because they
see you here at ward 12 [mental health ward] and
they even know that my husband is mad. Even when
we are discharged when we reach the community,
they are very mean; they call him “lishilu” [a mad/
foolish person] “her husband is a mad man”. We may
also try to hide from him, to hide the fact that he was
here like when he asks me what brought him here I
say its high blood pressure because of fear that the
truth could cause a relapse. So people in the com-
munity are the ones that tell him what was wrong,
that he had a mental health condition. So he some-
times feels too embarrassed to even come back here
for medication” MH0002, Family Member (Kabwe).
Sometimes clients or families were stigmatised because
mental health conditions were seen as a sign of some
involvement in the “supernatural” that had backfired.
is form of judgment was founded in myths and mis-
conceptions about the causes and implications of mental
health conditions. Some misconceptions noted were that
mental health conditions could be spread to other people
through bites from patients and that mental health con-
ditions were sexually transmitted. Community members
were seen to propagate relapse as they remind the patient
that they had a mental health condition.
While the health workers mentioned that most of the
male patients were hospitalised due to substance abuse-
related conditions, most female patients in the hospitals
suffered from depression.
Education orawareness (Knowledge aboutmental health
conditions)
Knowledge about mental health conditions was reported
as vital in mental health care. All the family members
acknowledged that before caring for a patient within their
household, they had very little or no knowledge at all
about mental health conditions. Having to face the condi-
tion through their family members made them more aware
and knowledgeable. ey also mentioned that knowing
more about the conditions before their family members
were afflicted would have improved their experience of
caring for their family members. When a family caregiver
was asked if she knew about the mental health condition
before dealing it in her family, she had this to say;
“No. I only knew after she [her daughter] was sick.
I just used to look at people who are sick. I did not
have any thoughts regarding mental health prob-
lems. I just worried about feeding my family and
seeing to it that their needs were met. Because I am
single. I did not know anything about these diseases”.
MH0001, Family Member (Kabwe).
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Munakampe Int J Ment Health Syst (2020) 14:28
Discussion
e barriers to mental health service utilisation were
investigated at the three levels; policy, facility and
individual level. While inadequate financing for men-
tal health affected most of the other health system
domains, a ‘systems thinking’ approach [19], empha-
sises examining the different parts of the health sys-
tem and how they all need to be prioritised to improve
mental health in Zambia. e barriers are therefore dis-
cussed in terms of; leadership and governance of men-
tal health and mental health services, mental health
financing, human resources for mental health, mental
health service provision, mental health commodities
and information systems.
Leadership andgovernance ofmental health services
At the policy level, management was noted as one of the
critical factors affecting the provision and utilisation
of mental health services. ough management alone
could not be blamed, it was cited as a key contributing
factor, especially at policy and facility levels. Poor man-
agement was a barrier with regards to the prioritising
of funds and actual budgetary allocation to the mental
health sector. Due to theold and outdated Mental Dis-
orders Act, which was still being reinforced [25] at the
time of the study, thetreatment that patients faced was
that of criminals because that was stated inthe law and
the justice system enforced the law. It is hoped that the
Mental Health Act of 2019 law will change the face of
mental health in the country [26].
Mental health nancing
Regarding financing for mental health, the study found
that the monetary allocation to the sector was too lit-
tle to do much meaningful work. Priority was given to
other diseases and disorders, and less than 1% of the
health budget was allocated to mental health. ese
findings were consistent with studies in Ghana, Uganda
and Sudan [20, 27]. Budgetary allocation directly
affected the provision of drugs as shortages were
reported in some instances, though some drugs were
available. It also affected the management of services,
as they could not be provided at the primary care level,
particularly in the community. e plans (policies) were
in place, but the finances were inadequate to imple-
ment them. e lack of sufficient funding also affected
the physicalstate of the facilities. Most of the buildings
were old or dilapidated and patients were stigmatized
also based on the state these facilities. Similar findings
were reported in other countries [18].
Human resources formental health
Inadequate funding, lack of prioritisation at the policy
level, few human resources (specialists) led to a shortage
of mental health services at primary care level. Because
many health care providers opted to refer cases to the
secondary or even tertiary facility, regardless of the sever-
ity of the case [28], this was noted as a form of stigma.
Some of the cases seen at the secondary institutions
could have been handled at the clinics and health posts,
but because of lack of interest or experience in provid-
ing such services, the referrals took place. e inadequate
funding also led to fewer opportunities for most of the
health care providers to further their careers in mental
health. e sector is not as well funded as other sectors
such as HIV and adolescent health. As such, the health
care providers did not choose mental health in their
career progression. ese findings were consistent with
the studies done in Malawi related to mental health [28].
e lack of human resources [25] for mental health
prevented the continued provision of Community Men-
tal Health. Without such an intervention, many people
are not aware of the importance of mental health, mental
health conditions, and how to manage them.
Service provision andcommodities formental health
A pattern of utilisation where services began at the sec-
ondary level, instead of primary care level emerged in
the Zambian mental health system. Clients avoided the
clinics as their first point of contact with the health sys-
tem and went directly to the provincialhospitals when
they sought care for the mental health conditions. Even
when a health care provider was willing to provide ser-
vices, the primary health care package had no medication
to respond to the need for these services. ese findings
were not in line with those found in South Africa [29],
as efforts were made to decentralise services and include
them in the primary health care package.
The impact ofstigma
A health system cannot function without people. ere-
fore, the people who utilise these services must also be
aware of and be able to access these services. However,
individual-level barriers continued to affect access and
utilisation. e main barrier at the individuals and com-
munity level was the stigma attached to mental disorders.
Stigma was reported to be fueled by lack of knowledge
or awareness about mental disorders as well as the state
of facilities where these disorders were treated. Most
studies also allude to this [30, 31]. is study highlighted
stigma at three levels. e first was at the facilities where
they accessed services, the second in the community and
the third was ‘self-stigma’. Self-stigma was reported to
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Munakampe Int J Ment Health Syst (2020) 14:28
be stigma the patient has towards himself and also due
toadverse treatment from the people around.
Within the community, stigma towards the patients
affected the pathway of treatment and in some cases
may have contributed to relapse, as the patients found
comfort in their old behaviour (particularly for sub-
stance-induced disorders). Other studies indicate that
post-hospitalisation stigma is related to negative health
outcomes for patients, including relapse [32] but can be
combated by anti-stigma initiatives in the community
[33]. e lack of provision of community mental health
services from the health sector left little room for aware-
ness and knowledge of mental health and mental health
conditions in the community.
e study revealed that people who utilised services
were more likely to be knowledgeable about mental
health conditions are and that this was because most of
the family members and patients only knew of these con-
ditions after they encountered mental health conditions
in the family. However, stigma still affected the man-
agement of these conditions in the community, as well
as through the health system. Ultimately, financing of
mental health care was seen as the solution to reducing
stigma and increasing awareness of mental health condi-
tions in the communities.
Strengths andlimitations
is study did not capture data on the functioning of
health information systems as they relate to mental
health. However, factors relating to how data is captured
and used are crucial and could provide more information
on the magnitude and burden of mental health condi-
tions, the barriers related to specific mental disorders and
impact overall management of the entire health system.
is study was carried out in selected locations;
hence, transferability may be limited as these locations
may have been representative of specific social contexts
in the country. Since this information was acquired in
government institutions, the private institutions may
have had some insights that may not have been cap-
tured. Besides, the study excluded perspectives from
patients themselves, but from their family caregivers
as institutional permission to do so was not granted in
time. e institutions included in the study required
mental health practitioners from their institutions to
interview the patients, instead of the research team.
is was a requirement for conducting the research
with patients, but could not be done within the study
timeline. Nevertheless, the primary caregivers were
capable of providing information on barriers to the uti-
lization of mental health services in Zambia. is study
focused on barriers at the policy, facility and individual
level, but mostly on the supply side. Hence barriers in
the community were not adequately captured.
Despite these challenges and limitations, the study
collected data from 5 institutions in three provinces
and these were different enough to transfer [34] infor-
mation to most parts of the country with the same
socio-economic and cultural landscape and created
proxies for the situation in the other provinces, provid-
ing variation [34, 35] in study location needed to trian-
gulate the findings. While theoretical saturation was
not achieved in the study due to sample size limitations,
variation and triangulation of data sources; the addition
of the health workers, policy makers and implementers’
perspectives provided credible information that adds to
the dearth of knowledge on mental health care in Zam-
bia and the data generated is relevant for policy consid-
erations. e findings are also a basis for more research
on mental health in Zambia.
Also, the study adopted ‘well established and clearly
exposed’ qualitative research methods and these added
to the dependability or consistency of the methods [34–
36]. While the sample was small and theoretical satura-
tion was not achieved, the data was ‘relevant to society’
[35] as highlighted by Mays and Pope, providing cred-
ible information on barriers to utilisation of mental
health services in Zambia. Overall, additional rigorous
and scientifically valid studies on mental health care in
Zambia are needed to fill-up the immense information
gap in this sector.
Conclusion
e study aimed to explore the barriers to the utilisa-
tion of mental health services in Zambia, and the mental
health system is deeply affected by these barriers. A need
to integrate mental health services into primary health
care is one way to increase the accessibility and utilisa-
tion of mental health services. Some cases that were
transferred to the provincial centres could have han-
dled at the primary care level. Hence, integration at this
level would improve the efficiency of the mental health
system. Sensitising of health care providers about the
need for mental health professionals, particularly at the
community level was seen as a solution to increasing the
human resourcebase for mental health, as well as provid-
ing incentives for career progression in the field. For the
community members, awareness and community educa-
tion efforts are needed to tackle the myths and miscon-
ceptions and stigma that perpetuates poor mental health
management at the community level. Overall, strength-
ening the community health systems would improve
access and increase utilisation of mental health services.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 8 of 9
Munakampe Int J Ment Health Syst (2020) 14:28
Supplementary information
Supplementary information accompanies this paper at https ://doi.
org/10.1186/s1303 3-020-00360 -z.
Additional le1. Data collection tools: interview guides for the health
workers, family care givers and policymakers.
Acknowledgements
Special gratitude to the Publication Mentorship for Women in Health Policy
and Systems Research by the Alliance for Health Policy and Systems Research
and Dr. Aditi Iyer for her invaluable support and mentorship. The participants,
the provincial and district health officers and hospital administrators are also
acknowledged.
Authors’ contributions
MM contributed towards the study design, carried out the data collection,
analysed the data, drafted and revised the manuscript. The author read and
approved the final manuscript.
Funding
Not applicable.
Availability of data and materials
The data used or analysed during the current study are available from the cor-
responding author on reasonable request. The articles reviewed are available
online.
Ethics approval and consent to participate
Ethical clearance was obtained from the University of Zambia Biomedi-
cal Research Ethics Committee, UNZABREC at the School of Medicine (REF
No. 013-06-15) and permission to carry out the study in the public institutions
was sought from the Ministry of Health, and the senior administrators at the
health facilities. Informed consent was administered before each participant
took part in the study.
Consent for publication
Not Applicable.
Competing interests
The author declares no competing interests.
Author details
1 Department of Health Policy and Management, School of Public Health,
University of Zambia, Lusaka, Zambia. 2 Strategic Centre for Health Systems
Metrics & Evaluations (SCHEME), Department of Epidemiology & Biostatistics,
School of Public Health, University of Zambia, Lusaka, Zambia.
Received: 17 September 2019 Accepted: 4 April 2020
References
1. Mwape L, Mweemba P, Kasonde JM. Strengthening the health system
for mental health in Zambia. Lusaka: Zambia Forum for Health Research;
2010.
2. Mwape L, Mweemba P, Kasonde J. Strengthening the health system to
enhance mental health in Zambia: a policy brief. Int J Technol Assess
Health Care. 2012;28(3):294–300.
3. Sikwese A, et al. Human resource challenges facing Zambia’s mental
health care system and possible solutions: results from a combined quan-
titative and qualitative study. Int Rev Psychiatry. 2010;22(6):550–7.
4. WHO, Comprehensive mental health action plan 2013–2020. 2013, World
Health Organization: Geneva.
5. Chipimo PJ, Tuba M, Fylkesnes K. Conceptual models for mental distress
among HIV-infected and uninfected individuals: a contribution to clinical
practice and research in primary-health-care centers in Zambia. BMC
Health Serv Res. 2011;11(1):7.
6. NCCMH, Common Mental Health Disorders: Identification And Pathways
To Care. National Collaborating Centre for Mental Health, in The British
Psychological Society and The Royal College of Psychiatrist. 2011, The
British Psychological Society: London, Leister.
7. Mayeya J, et al. Zambia mental health country profile. Int Rev Psychiatry.
2004;16(1–2):63–72.
8. Kapata J, et al. Report of the Committee on Health Community Develop-
ment and Social Welfare for the Fifth Session of the National Assembly. N.
Assembly Editor. 2010: Lusaka. p. 28.
9. Anakwenze U, Zuberi D. Mental health and poverty in the inner city.
Health Social Work. 2013;38(3):147–57.
10. Wolff G, et al. Community knowledge of mental illness and reaction to
mentally ill people. Br J Psychiatry. 1996;168(2):191–8.
11. Lam DCK, Salkovskis PM, Warwick HMC. An experimental investigation of
the impact of biological versus psychological explanations of the cause
of “mental illness”. J Mental Health. 2005;14(5):453–64.
12. Marrone JG. If work makes people with mental illness sick, what do
unemployment, poverty, and social isolation cause? Psychiatric Rehab J.
1999;23(2):187.
13. Chigunta F, V. Mwanza, 4 Measuring and promoting youth entrepreneur-
ship in Zambia. Young Entrepreneurs in Sub-Saharan Africa, 2016. p. 48.
14. CSO, Living Conditions Monitoring Survey Report 2006 and 2010,
C.S.O.a.t.M.o. Health/Zambia, Editor. 2011, Central Statistical Office Lusaka,
Zambia.
15. Bjorklund RW, Pippard JL. The mental health consumer movement: Impli-
cations for rural practice. Commun Mental Health J. 1999;35(4):347–59.
16. Lungu M. Factors contributing to underutilization of mental health ser-
vices in health centres within Lusaka urban. Lusaka: University of Zambia;
2015.
17. Banda WW, Constraints affecting the administration of mental health
services in Zambia With special reference to manpower training and
utilization. 2012.
18. Jacob K, et al. Mental health systems in countries: where are we now?
Lancet. 2007;370(9592):1061–77.
19. Mutale W, et al. Application of system thinking concepts in health system
strengthening in low-income settings: a proposed conceptual framework
for the evaluation of a complex health system intervention: the case of
the BHOMA intervention in Zambia. J Eval Clin Pract. 2016;22(1):112–21.
20. Abdelgadir E. Exploring Barriers to the Utilization of Mental Health Ser-
vices at the Policy and Facility Levels in Khartoum State, Sudan, in Global
Health. 2012, University of Washington: Washington. p. 38.
21. Kakuma R, et al. Mental health stigma: what is being done to raise
awareness and reduce stigma in South Africa? Afr J Psychiatry.
2010;13(2):116–24.
22. Omar MA, et al. Mental health policy process: a comparative study of
Ghana, South Africa, Uganda and Zambia. Int Journal Mental Health Syst.
2010;4(1):24.
23. Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analy-
sis: implications for conducting a qualitative descriptive study. Nursing
Health Sci. 2013;15(3):398–405.
24. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol.
2006;3(2):77–101.
25. Ngungu J, Beezhold J. Mental health in Zambia-challenges and way
forward. Int Psychiatry. 2009;6(2):39–40.
26. Zambia G. The Mental Health Act. 2019, Government Printers: Lusaka.
27. Bird P, et al. Increasing the priority of mental health in Africa: findings
from qualitative research in Ghana, South Africa, Uganda and Zambia, in
Health Policy and Planning. The London School of Hygiene and Tropical
Medicine, 2010: p. 1-9.
28. Kauye F. Management of mental health services in Malawi. Int Psychiatry.
2008;5:29–31.
29. Mkhize N, Komesta MJ. Community access to mental health services: les-
sons and recommendation: primary health care: programme areas. South
Afr Health Rev. 2008;2008:103–13.
30. Corrigan P. How stigma interferes with mental health care. Am Psychol.
2004;59:614–25.
31. Shim R, Rust G. Primary care, behavioral health, and public health:
Partners in reducing mental health stigma. Am J Public Health.
2013;103(5):5–7.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 9 of 9
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32. Loch AA. Discharged from a mental health admission ward: is it safe to go
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Psychol Res Behav Manag. 2014;7:137–45.
33. Rüsch N, Angermeyer MC, Corrigan PW. Mental illness stigma: con-
cepts, consequences, and initiatives to reduce stigma. Eur Psychiatry.
2005;20(8):529–39.
34. Guba EG. Criteria for assessing the trustworthiness of naturalistic inquir-
ies. ECTJ. 1981;29(2):75.
35. Mays N, Pope C. Assessing quality in qualitative research. BMJ.
2000;320(7226):50–2.
36. Shenton AK. Strategies for ensuring trustworthiness in qualitative
research projects. Education Inform. 2004;22(2):63–75.
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