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Moroetal. BMC Public Health (2022) 22:639
https://doi.org/10.1186/s12889-022-13102-2
RESEARCH
A nationwide evaluation study ofthequality
ofcare andrespect ofhuman rights inmental
health facilities inGhana: results fromtheWorld
Health Organization QualityRights initiative
Maria Francesca Moro1*, Mauro Giovanni Carta2, Leveana Gyimah3, Martin Orrell4, Caroline Amissah5,
Florence Baingana6, Humphrey Kofie7, Dan Taylor8, Nurokinan Chimbar9, Martha Coffie7, Celline Cole10,
Joana Ansong3, Sally‑ann Ohene3, Priscilla Elikplim Tawiah5, Michela Atzeni2, Silvia D’Oca2, Oye Gureje11,
Michelle Funk12, Nathalie Drew12 and Akwasi Osei5
Abstract
Background: In 2012, Ghana ratified the United Nations Convention on the Rights of Persons with Disabilities and
enacted a Mental Health Act to improve the quality of mental health care and stop human rights violations against
people with mental health conditions. In line with these objectives, Ghanaian stakeholders collected data on the
quality of mental health services and respect for human rights in psychiatric facilities to identify challenges and gather
useful information for the development of plans aimed to improve the quality of the services offered. This study
aimed to assess psychiatric facilities from different Ghanaian regions and provide evidence on the quality of care and
respect of human rights in mental health services.
Methods: Assessments were conducted by independent visiting committees that collected data through observa‑
tion, review of documentation, and interviews with service users, staff, and carers, and provided scores using the
World Health Organization QualityRights Toolkit methodology.
Results: This study revealed significant key challenges in the implementation of the United Nations Convention on
the Rights of Persons with Disabilities principles in Ghanaian psychiatric services. The rights to an adequate standard
of living and enjoyment of the highest attainable standard of health were not fully promoted. Only initial steps had
been taken to guarantee the right to exercise legal capacity and the right to personal liberty and security. Significant
gaps in the promotion of the right to live independently and be included in the community were identified.
Conclusions: This study identifies shortcomings and critical areas that the Ghanaian government and facilities need
to target for implementing a human rights‑based approach in mental health and improve the quality of mental
health care throughout the country.
Keywords: WHO QualityRights, Human Rights, Psychiatric services, Ghana, UN CRPD, Mental healthcare, Quality of
care
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Background
e World Health Organization (WHO) estimates that,
out of 28 million Ghanaians, around 2.3 million peo-
ple live with a mental health condition and are in need
Open Access
*Correspondence: mfmoro@gmail.com
1 Columbia University Irving Medical Center, New York, US, USA
Full list of author information is available at the end of the article
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Page 2 of 14
Moroetal. BMC Public Health (2022) 22:639
of mental health care. However, only 2% of them receive
treatment and support in psychiatric services [1, 2]. One
of the reasons why this happens is that mental health ser-
vices in Ghana are significantly underfunded. Ghana’s
health expenditure is roughly 4.5% of the gross national
product [3], with only 1.3% of the health expenditure
allocated to mental health [4]. Most of the mental health
budget (80%) goes to the maintenance of the three gov-
ernment psychiatric hospitals, Accra, Pantang, and
Ankaful, although psychiatric in-patient units are pre-
sent also in 5 of the 10 regional general hospitals in the
country [5]. e ratio of psychiatric beds in mental health
facilities in or around the capital, Accra, to the total num-
ber of beds in the rest of the country is around 6.28 to
1 [5]. In addition, most mental health professionals (psy-
chiatrists, psychiatric nurses, medical doctors, psycholo-
gists, social workers, and occupational therapists) work
in mental health facilities located in the main cities of
the country, indicating that the allocation of resources
for mental health is very much skewed towards urban
areas [5, 6]. Community mental health care exists in
Ghana, but it is not well developed and does not cover
the whole country [3]. Due to the difficulty in accessing
mental health services and the widespread beliefs about
the supernatural causation of mental ill health, most
Ghanaians with a mental health condition, especially in
rural areas, receive needed care from faith-based and tra-
ditional healers [7, 8].
In addition to facing challenges in providing access to
mental health services, Ghana has recently come under
scrutiny for human rights violations against people with
mental health conditions, as reflected in several reports
by local and international organizations [9–11]. Accord-
ing to these reports, Ghanaians with mental health
conditions in psychiatric facilities are exposed to poor
conditions in regard to physical infrastructure, food inad-
equacy, and overcrowding. Many residents are forced to
live in these institutions against their will and without
any possibility to challenge their situation. Incidents of
verbal and physical abuses have been reported against
service users who try to escape and fail to take medica-
tion or follow hospital rules. ere are also reports sug-
gesting that unmodified electroconvulsive therapy (i.e.,
without anesthesia) is used and people are sometimes
isolated in seclusion rooms for up to three days, although
such practices constitute ill-treatment according to the
United Nations Special Rapporteur on Torture.
In 2012, the government of Ghana ratified the United
Nations Convention on the Rights of Persons with Dis-
abilities (UN CRPD) and enacted a Mental Health Act
to improve the quality of mental health care (including
the provision of better access to services) and eliminate
the human rights violations against people with mental
health conditions in psychiatric facilities and the com-
munity [12]. e Act created a Mental Health Authority
within the Ministry of Health, for which the initial pri-
orities were the improvement of the quality of mental
health care and the promotion of the rights of Ghana-
ians with mental health conditions. In February 2019, the
Mental Health Authority and non-governmental organi-
zations including organizations of people with mental
health conditions launched the “QualityRights in Mental
Health, Ghana” initiative. is project aims to transform
mental health services and promote the rights of persons
with mental health conditions in Ghana [13]. As part of
this project, Ghanaian stakeholders collected data on
the quality of mental health care and respect of human
rights in psychiatric facilities in their country, to identify
the key challenges and gather useful information for the
development of plans aimed to improve the quality of the
services offered. ese stakeholders chose to collect data
using the WHO QualityRights Assessment Toolkit [14],
an instrument developed to evaluate the quality of care
and respect of human rights in mental health facilities
and designed for global applicability. e WHO Quali-
tyRights Assessment Toolkit follows the recent human
rights framework of the United Nations Convention on
the Rights of Persons with Disabilities (UN CRPD) [15]
and has been previously used in other countries, such as
India [16], Chile [17], Czech Republic [18], and Tunisia
[19]. In 2018, this instrument was also used for evaluat-
ing four mental health facilities in West Africa, including
Pantang Psychiatric Hospital in Ghana [20].
e present study builds on this previous work and, in
line with the efforts of the Ghana government to tackle
human rights violations in mental health, aims to evalu-
ate psychiatric facilities from different Ghanaian regions
and provide evidence on the quality of care and respect
of human rights in mental health services throughout the
country.
Methods
Aim anddesign ofthestudy
is is a mixed-methods convergent design study aimed
to assess psychiatric facilities from different Ghanaian
regions and provide evidence on the quality of care and
respect of human rights in mental health services.
Setting ofthestudy
We conducted the study in seven different mental
health facilities: Accra Psychiatric Hospital, Ankaful
Psychiatric Hospital, Eastern Regional Hospital, Ho
Teaching Hospital, Komfo Anokye Hospital, Sunyani
Regional Hospital, and Korle Bu Teaching Hospital
(psychiatric facility). ese mental health facilities are
located in different Ghanaian regions and were selected
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Moroetal. BMC Public Health (2022) 22:639
to provide a representative picture of the quality of care
and respect of human rights in psychiatric services
throughout the country.
Evaluation visits
In each facility, the assessment was conducted by
independent visiting committees. Members of the
visiting committees were selected from multidiscipli-
nary backgrounds and also included 1 Human rights
advocate from NGO, 2 service users, 5 Mental health
advocates from NGO, 1 Psychiatrist, 2 Intellectual
Disability Organization advocates, 1 Psychosocial
Disability Organization advocate and 1 Researcher. A
three-day training was organised in Accra for 34 par-
ticipants (10 women, 24 men) to build their capacity
on the evaluation of the quality of care and human
rights respect in mental health facilities (using the
WHO Quality Rights Toolkit). Thirteen visiting com-
mittees’ members were selected from the pool of
participants based on their availability and personal
background (to guarantee a broad range of expertise
and skills). At least one service user was present in
all the visits to the facilities. To ensure the committee
was well-trained on the methodology for the assess-
ment, there was a simulation exercise at the Pantang
Psychiatric Hospital in Accra. The evaluation visits
were planned in collaboration with the management
staff in each facility. During the evaluation visits, the
visiting committees carried out an observation of the
facilities, the review of the documentation, and inter-
views with service users, their carers, and staff mem-
bers. Visiting committee members collected both
quantitative (e.g., data on length of stay at the hos-
pital, number of users per ward, quantity of essential
psychotropic medications) and qualitative data (e.g.,
photographs of the facilities’ physical environment,
notes regarding the presence of policies and guide-
lines, notes regarding the information in medical
files and nurses’ charts, notes based on the interviews
including verbatim quotes by respondents). All the
visiting committees’ members collected data through
observation. The retired psychiatrist was assigned to
carry out the documentation review because of his
wealth of experience in direct mental health practice.
The researcher was designated as rapporteur to col-
late notes and compile results while the rest of the
trained visiting committee members collected data
through interviews. In between the assessments, the
coordinating team continued to organise virtual meet-
ings through zoom to discuss challenges and feed-
back from the field for redress. Assessment reports
were written for each of the facilities evaluated, with
recommendations for improving the quality of care
and respect of human rights.
Instrument
e quality of care and respect of human rights in men-
tal health facilities were assessed using the WHO Quali-
tyRights Toolkit [14]. is instrument is based on the
modern human rights framework of the United Nations
Convention on the Rights of Persons with Disabilities
and includes five themes. Each theme focuses on a spe-
cific UN CRPD right: 1) e right to an adequate stand-
ard of living (Article 28); 2) e right to enjoyment of the
highest attainable standard of physical and mental health
(Article 25), 3) e right to exercise legal capacity and the
right to personal liberty and security of person (Articles
12 and 14); 4) Freedom from torture or cruel, inhuman or
degrading treatment or punishment and from exploita-
tion, violence and abuse (Articles 15 and 16); and 5) e
right to live independently and be included in the com-
munity (Article 19). e themes are organized into stand-
ards, which consist of different criteria (see the example
in Fig. 1). e WHO QualityRights Toolkit has been
previously used in several countries [16–19], including
Ghana [20]. Although the Toolkit has not been formally
validated for use in Ghana, the members of the visiting
committees checked its contents and adapted them to
the local context (e.g., adding prompts relevant to Ghana
in the interview instrument). e adapted WHO Quali-
tyRights Toolkit was pilot tested before the evaluations
started, during a training simulation exercise at the Pan-
tang Psychiatric Hospital in Accra.
Analyses
e visiting committee members integrated qualitative
and quantitative data using a mixed methods convergent
design [21, 22]. First, in all the facilities assessed, they
assigned a score to each theme, standard, and criterion
using a mixed-method approach, based on 1) the data
collected with the observation of the facility, the review of
the documentation, and the interviews with service users,
their carers, and staff and 2) extensive discussions among
visiting committee members. During the discussions, the
rapporteur presented the notes and photographs from
the visits and the visiting committee members integrated
with their own notes when needed. Each theme, standard
and criterion was scored as follows: “Not initiated—N/I,”
“Achievement initiated—A/I,” “Achieved partially—A/P”
“Achieved in full—A/F”, or “Not applicable – N/A.” First,
the visiting committee members evaluated criteria. en,
based on the scores at the criteria, a score was assigned to
the corresponding standard. Finally, scores at the stand-
ards were used to assign a score at each theme. Using the
ratings, provided by the visiting committees, for each
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Moroetal. BMC Public Health (2022) 22:639
standard, we calculated the total number of criteria (with
corresponding percentages) that received the different
scores (i.e., N/I, A/I, A/P, A/F, N/A) in all the facilities
evaluated. ese percentages were then presented in the
form of bar charts reflecting the adherence to the rights
represented by each theme. Finally, we analyzed the
qualitative descriptions and justifications provided by the
visiting committees in the reports to identify areas for
improvement surrounding each of the five themes and
provide recommendations. e same analytical method
has been used for analyzing the data from evaluations
carried out in other countries.
Results
Details ontheassessment team’s visits
During each visit, the assessment team conducted an
observation of the facility, a review of the documentation,
and interviews with service users, their family members,
friends, or caregivers, and staff members. Table1 pro-
vides information on the number of staff members and
service users in each facility, the number of interviews
completed, and the length of the visits.
Theme 1: The right toanadequate standard ofliving
In regard to adherence to theme 1 (see Fig.2), three of
the mental health facilities evaluated had actively initi-
ated changes to guarantee an adequate standard of living
for service users, while the other four had partially met
the standards of this theme.
Overall, most of the buildings were found suitable for
use, but some of the wards were old and required struc-
tural renovations (e.g., for leaking roofs, cracks in the
walls, electric wires exposed, broken windows, insuffi-
cient lighting, and absence of mosquitos’ nets). None of
Fig. 1 Example of the WHO QualityRights Toolkit’s organization, with the division of themes into standards and criteria
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Moroetal. BMC Public Health (2022) 22:639
the mental health facilities was barrier-free for people
with disabilities. In most hospitals, fire extinguishers
were only available at a few vantage points, and, with
some exceptions, both staff and service users were not
well informed on fire safety protocols and other safety
measures.
ere were separate sleeping quarters for males and
females in all psychiatric facilities, and the sleeping
conditions of service users were generally comfort-
able. However, in some facilities, service users were
not provided with clean mattresses and bedsheets. Fur-
thermore, most of the sleeping wards did not have a
Table 1 Profile of the mental health facilities evaluated, and details of the assessment team’s visits
a Data on in-patient and out-patient services provided by the Mental Health Authority (Ministry of Health of Ghana)
b Data on in-patient units’ daily service users, provided by the Mental Health Authority (Ministry of Health of Ghana)
Mental health
facility N. of
Sta membersaNo. of Service
usersbSta
members
Interviewed
Service Users
Interviewed Carers (family member/
friend) Interviewed Length
of the
visit
Accra Psychiatric Hospital 782 319 57 68 34 2 days
Ankaful Psychiatric Hospital 462 236 34 53 26 2 days
Eastern Regional Hospital 15 20 12 19 9 2 days
Ho Teaching Hospital 37 10 7 19 9 3 days
Komfo Anokye Hospital 73 80 7 17 8 2 days
Sunyani Regional Hospital 19 22 7 14 7 2 days
Korle Bu Teaching Hospital 74 32 7 15 6 2 days
Fig. 2 Adherence to the WHO QualityRights Toolkit’s Theme 1 in the seven mental health facilities
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Moroetal. BMC Public Health (2022) 22:639
designated place for changing clothes, and no provision
was made for partitions or lockers to provide privacy
to service users. Overall, washrooms and toilet facili-
ties were found to be clean and functioning during the
visits. However, bathrooms and toilets were in poor
hygienic conditions in some wards and needed mainte-
nance work (e.g., they were not cleaned regularly, toi-
lets seats were spoilt, flushing handles were broken).
e food was generally prepared under hygienic condi-
tions, adequate, and in a sufficient quantity for the die-
tary needs of service users, although in some hospitals,
service users had to buy their drinking water. All the
facilities respected service users’ right to use clothes of
their choice.
Service users were allowed to receive visitors dur-
ing scheduled visiting times. Generally, service users
were permitted to use their own electronic gadgets (e.g.,
phones and laptops), although sometimes this right was
restricted “depending on the service users’ condition”
and “for fear such gadgets could be used to order illegal
drugs into the hospital.” As a result, some service users
were only allowed to use the ward phone, and their con-
versations were monitored by staff, so privacy was not
fully respected.
e visiting committees found that the facilities’ build-
ing environment was, in general, not stimulating and
conducive to interaction. Only in certain facilities, the
layout of the wards promoted interaction among service
users and staff, and service users could watch television
or play ludo and other local board games such as oware
for leisure activities.
Service users also had difficulties in remaining engaged
in their communities’ life and activities. In some hospi-
tals, they were allowed to participate in activities outside
the facility (but only if requested by their families).
Theme 2: The right toenjoyment ofthehighest attainable
standard ofphysical andmental health
Adherence to theme 2 (see Fig.3) was partially achieved
in two of the psychiatric facilities evaluated and initiated
in the other five.
Overall, mental health services were available, publicly
funded, and accessible to the general public. e admis-
sion protocols did not discriminate based on gender,
race, religion, and ethnicity. However, some of the hospi-
tals did not admit service users with physical disabilities
and children or adolescents, and no referral policy was
in place. In some facilities, users or their families were
Fig. 3 Adherence to the WHO QualityRights Toolkit’s Theme 2 in the seven mental health facilities
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Moroetal. BMC Public Health (2022) 22:639
asked to make a financial commitment before treatment
was provided. Furthermore, service users with higher
economic resources had access to special wards and
could pay for a better quality of care. In all facilities, ser-
vice users were found to stay sometimes longer than their
planned discharge because their families were not willing
to welcome them back home, and they had no economic
resources for living on their own.
All the facilities had a reasonable number of psychiat-
ric nurses, but they lacked adequate numbers of psychia-
trists, psychologists, occupational therapists, and social
workers. e prevalent treatment approach was medical
or pharmacological, while psychosocial support, occu-
pational therapy or rehabilitation were often unavailable
due to the scarcity of professionals trained to provide
them. Furthermore, staff and service users reported that
the facilities sometimes experienced shortages of medi-
cations due to a lack of funding. When psychotropic
medications were not available, relatives were required
to procure them from pharmacies operating outside the
facilities.
ere was an individual treatment plan for each service
user in all the facilities, although this plan was generally
not comprehensive and mainly based on mental health
professionals’ or family members’ inputs. e visit-
ing committees found that, although service users were
sometimes informed about these plans, they were seldom
asked to provide their input and express their preferences
on treatment and recovery.
Overall, with some exceptions, staff had limited knowl-
edge of international and national human rights stand-
ards, such as those included in the UN CRPD and the
Mental Health Act. e visiting committees also found
significant gaps in staff knowledge about community ser-
vices and resources to promote independent living of ser-
vice users and facilitate inclusion in the community. Staff
facilitated linkages mostly between service users and
other community psychiatric services or the Social Wel-
fare Department. However, the Social Welfare Depart-
ment was often unable to address service users’ needs
due to a lack of funding.
In some of the facilities assessed, service users undergo
physical health examinations and screening for physical
ailments upon entry. Some hospitals also provided basic
general health services, although, for specialized general
health care (e.g., surgery), service users were referred to
other facilities.
In most of the facilities evaluated, health education
and promotion were conducted to educate service users
and, in some cases, visitors. For instance, following the
outbreak of the COVID-19 pandemic, the hospitals
embarked on constant education on the symptoms of
the infection, the mode of transmission, how it can be
acquired, safety protocols, and where to receive treat-
ment. However, there was no evidence of service users
being educated on any reproductive and family planning
matters.
Theme 3: The right toexercise legal capacity andtheright
topersonal liberty andsecurity ofperson
Six of the seven mental health facilities evaluated had
taken at least initial steps toward fulfilling service users’
right to legal capacity and personal liberty and security
(see Fig.4). Only one facility had not initiated changes
toward fulfilling this theme.
None of the facilities prioritised service users’ prefer-
ences regarding where to receive treatment or treatment
options. Most of the time service users did not even
know they had a right to make such decisions. Relatives
usually provided informed consent regarding the type
and place of treatment in consultation with the staff.
Only when service users were deemed to be “stabilized”
or in some instances where service users admitted them-
selves voluntarily into the facilities, was their informed
consent sought.
Although legal avenues to appeal forced admission and
treatment exist in Ghana, service users were not usually
informed of this possibility. In some facilities, service
users could nominate a support person to communicate
their decisions, but this was not allowed in all instances.
In none of the facilities were service users fully able to
exercise their right to legal capacity.
Overall, all service users had personal medical files, and
these were kept confidential from unauthorized access in
all the facilities evaluated. However, service users had no
access to their personal written information, and usually,
they were not informed of their right to require access to
their written records.
Theme 4: Freedom fromtorture orcruel,
inhuman ordegrading treatment orpunishment
andfromexploitation, violence andabuse
Five of the mental health facilities evaluated had taken
initial steps toward fulfilling service users’ rights to free-
dom from torture or cruel, inhuman, or degrading treat-
ment or punishment and from exploitation, violence,
and abuse (see Fig.5). Only one facility had not initiated
changes towards fulfilling this theme, while another facil-
ity had partially achieved this objective.
Service users told the visiting committees that they
were generally treated with dignity and respect within
the facilities. However, there were reports of verbal
abuse by staff (e.g., yelling) and neglect was a common
issue in all the facilities. ere were also some reports
of physical abuse as a form of punishment and control
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Moroetal. BMC Public Health (2022) 22:639
by staff. ese violations were more common when
staff had a heavy workload due to a lack of personnel.
Seclusion and chemical and physical restraints
were found to be used in all the hospitals as a way of
managing crises. e visiting committees found that
sometimes these practices were also used to control
“aggressive behaviors” or as a form of punishment for
service users who tried to escape from the hospital or
refused medication. In addition, alternative practices
to seclusion or restraint (e.g., de-escalation techniques
for potential crises) were rarely in place, and most of
the staff had no training nor knowledge about these
methods.
Not all facilities provided electroconvulsive ther-
apy. e facilities providing electroconvulsive therapy
required for the procedure either the informed consent
of service users or, in line with guidelines contained in
the Mental Health Act but not with the CRPD, approval
of a mental health tribunal where “service users were
unable to give consent”.
Medical and scientific research was conducted in some
of the facilities evaluated, upon approval of the local Ethi-
cal Committee and with the informed consent of service
users.
e visiting committee did not see any formal notice
and information regarding the procedures for filing com-
plaints by service users relating to abuse, violence, and
neglect in the facilities evaluated. In some facilities, ser-
vice users told the visiting committees that they were
regularly asked verbally by nurses if they had any form of
complaints and could express their concerns informally,
but they were not aware of structured avenues to lodge
formal complaints.
ere is an independent body appointed by the gov-
ernment in Ghana, whose mandate is to monitor mental
health facilities. However, the monitoring activities were
found to be inadequate by the visiting committees.
Theme 5: The right tolive independently andbe included
inthecommunity
In regard to theme 5 (see Fig.6), only one out of the seven
mental health facilities evaluated had initiated changes
toward fulfilling service users’ right to live independently
and be included in the community.
In Ghana, opportunities for housing and access to
financial resources for service users in their communi-
ties are limited. is makes it difficult for staff to sup-
port service users in this regard. Even though there is
Fig. 4 Adherence to the WHO QualityRights Toolkit’s Theme 3 in the seven mental health facilities
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Moroetal. BMC Public Health (2022) 22:639
limited funding allocated by the central government for
persons with disabilities at the district level (e.g., the
Livelihood Empowerment Against Poverty program),
these resources are not enough to support persons with
mental health conditions in education, career develop-
ment, and employment opportunities. Furthermore,
the mental health facilities had no resources to link ser-
vice users to the services operating at the community
level.
Most of the facilities evaluated did not actively
support service users to participate in political life,
although staff helped service users register for elections
in some wards. Only in a few wards were service users
provided with information on public activities they
could join outside the facility upon discharge.
Table2 shows representative verbatim quotes from the
interviews.
Discussion
is is the first systematic rights-based assessment of the
quality of care provided to service users receiving mental
healthcare in psychiatric facilities selected across several
parts of Ghana. Our evaluation revealed shortcomings
regarding the rights of persons with mental health condi-
tions in psychiatric facilities in the country. e results
are in consonance with those of evaluations conducted in
other low- and middle-income countries [16–19] and the
findings of a previous assessment carried out in Pantang
Psychiatric Hospital (Ghana) [20] using the WHO Quali-
tyRights Assessment Toolkit [14].
Fig. 5 Adherence to the WHO QualityRights Toolkit’s Theme 4 in the seven mental health facilities
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Moroetal. BMC Public Health (2022) 22:639
e right to an adequate standard of living (UN CRPD,
Article 28) was not fully achieved in the mental health
facilities evaluated. Most of the buildings, which were all
old structures, had not been renovated for a long time.
Many wards needed repairs and maintenance works, but
the hospitals had no financial resources to pay for them.
To create an environment suitable for UN CRPD adher-
ence, more funding should be allocated by the Ghanaian
government to make the facilities disability-friendly and
pay for necessary renovations. Furthermore, financial
resources should be provided for installing safety equip-
ment and the provision of training on safety measures for
staff and service users.
While none of the psychiatric facilities fully achieved
the right to the enjoyment of the highest attainable stand-
ard of physical and mental health (UN CRPD, Article
25), most of them had at least initiated changes toward
its fulfillment. A major problem was the inconsistency
of government support for medical supplies, includ-
ing psychotropic medications, that, sometimes, forced
hospital authorities to rely on private arrangements to
obtain them. Also, family members often had to purchase
medications for service users in pharmacies outside the
facilities. e document review and the interviews also
revealed that the hospitals did not have sufficient men-
tal health professionals to meet the needs of service users
seeking care. Although psychiatric nurses were present
in adequate numbers, there was a lack of psychiatrists,
psychologists, occupational therapists, and social work-
ers, amongst the others. As a result, service users had
little or no access to non-pharmacological interventions.
Further efforts to train and hire mental health provid-
ers with different skills, able to provide a diverse range
of interventions, should be made by the government and
hospital authorities. In line with numerous studies in dif-
ferent countries [23–25], mental health workers in Ghana
were found to have limited knowledge of international
human rights standards. To address this problem, the
Mental Health Authority is currently providing face-to-
face and online QualityRights training on human rights
in mental health in some of the facilities assessed [26].
e visiting committees found serious shortcomings in
the adherence to the CRPD requirement for service users
to have a right to exercise legal capacity (UN CRPD, Arti-
cle 12) and to personal liberty and security (UN CRPD,
Article 14). Service users were usually unaware they
had a right to make decisions about their lives, includ-
ing decisions about their treatment and place of care.
Family members generally provided informed consent
in consultation with staff, and the input of service users
was rarely sought. ese findings align with data from
previous studies carried out in Ghana that show a strong
endorsement of paternalistic and socially restrictive atti-
tudes towards people with mental health conditions [27].
For instance, a recent study conducted in Ghana found
that more than 40% of the respondents saw no problem
Fig. 6 Adherence to the WHO QualityRights Toolkit’s Theme 5 in the seven mental health facilities
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 11 of 14
Moroetal. BMC Public Health (2022) 22:639
Table 2 Verbatim quotes from the interviews, organized by theme
Representative verbatim quotes
Theme 1: The right to an adequate standard of living “Facility is always dark when there is power outage because the generator is
unable to supply power to the entire facility.” Service user
“We are not crowded because we used to be eight in a room. Also, our beds have
been spread out to accommodate three beds due to the COVID-19.” Service
user
“The building is not accessible to wheelchair users. The staircase is narrow and
there are no lifts too. The staff or relatives or carers usually carry the physically
disabled service users to the first floor of the building for treatment or admis-
sion.” Sta member
“Individual phones are prohibited for fear they could be used negatively such as
arranging for weed to be brought into the facility.” Sta member
Theme 2: The right to enjoyment of the highest attainable standard
of physical and mental health “They make sure to look out for other underlying health conditions as well.
I remember very well there was a time that they allowed for our liver to be
checked. That is hepatitis B screening.” Service user
“There is no constant supply, sometimes we experience shortage of medica-
tions.” Sta member
“Yes, he did not get treatment because he could not afford.” Family member
“We are not sufficiently knowledgeable of the rights of persons with mental
disabilities.” Sta member
“No staff has ever helped to come up with such comprehensive plan… we don’t
have such recovery plans.” Service user
“I am only given the medicine to take, I am not told about any other thing.”
Service user
“I don’t know about recovery plan.” Sta member
“Service users have no recovery plan.” Service user
Theme 3: The right to exercise legal capacity and the right to per-
sonal liberty and security of person “It is not you who decides this. If you need to be admitted, you will be admitted.
In this hospital, you are not the one to decide when it comes to treatment and
care services.” Service user
“Consent is done on behalf of service users by their relatives often.” Sta mem-
ber
“My consent was verbally sought by the staff.” Family member
“If they refuse treatment, they are forced.” Carer
“No, we don’t agree with them not to take their medication because the person
may be a danger to himself and others.” Sta member
“On most occasions we don’t allow service users to refuse treatment…yes,
service users have the right to refuse treatment but sometimes we force them to
take the medications.” Sta member
“There are times you meet with a health official who will listen to you; at other
times they don’t.” Service user
“Yes, a folder is created for each service user and information is very confiden-
tial.” Sta member
Theme 4: Freedom from torture or cruel, inhuman or degrading
treatment or punishment and from exploitation, violence and abuse “I was once pecked by a male staff unaware.” Service user
“Yes, a nurse held a user by the shirt and kicked him down.” Service user
“Staff members do respect us.” Service user
“Staff in this facility treat us with human rights and respect us.” Service user
“Not yet seen abuse, but I see the nurses do grumble.” Family member
“Sometime back, a service user who is a friend was physically abused as a form
of punishment and control.” Sta member
“Yes, sometimes the service user may be doing something wrong, and the staff
will shout at him.” Sta member
“Staff who are found abusing service users are reprimanded and service users
involved are rendered an apology and counselled. Also, such incidents are
recorded.” Sta member
“No standard procedure is in place, but staff are made to render an apology to
the service user and queried not to behave negatively towards service users.”
Sta member
“There is no avenue for complaint lodging.” Ser vice user
Theme 5: The right to live independently and be included in the
community “No, we have no knowledge about the role and availability of community
services or resources”. Family member
“No, we don’t have the knowledge about community ser vices.” Sta member
“Yes, I know of department of social welfare and currently a service user is work-
ing at the laundry.” Service user
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Moroetal. BMC Public Health (2022) 22:639
in denying persons with mental health conditions their
rights, while 68.3% believed that they required “the same
kind of control as children” [27]. To promote service
users’ rights to legal capacity and personal liberty and
security, it would be fundamental to educate staff, service
users, and carers to ensure that informed consent of ser-
vice users is sought before admission, treatment, and in
all decisions regarding service users’ lives. Service users
should also be provided with information, in accessible
formats, about their rights and the legal opportunities
and appeal procedures available to redress potential vio-
lations. Staff, service users, and carers could benefit from
training on working together to develop recovery plans
and advance directives.
ere were reports of violations of the rights to free-
dom from torture or cruel, inhuman, or degrading treat-
ment or punishment and from exploitation, violence, and
abuse (UN CRPD, Articles 15 and 16) in all the facilities
evaluated. e visiting committees observed instances of
verbal and physical abuse against service users. Neglect
was also a significant issue in all the facilities. Seclu-
sion and restraints were often used as a way of manag-
ing crises. However, the visiting committees found that
sometimes seclusion and restraint were also used to con-
trol “aggressive behaviors” or as a form of punishment,
although the Mental Health Act forbids this. In addition,
alternative practices to the use of coercion were seldom
in place, and most of the staff had no training nor knowl-
edge about these methods. e UN CRPD demand States
to end the use of seclusion and restraint and replace
these with practices that align with people’s will and pref-
erences. Although this objective will require time to be
achieved, it is essential that facilities and staff in Ghana
make more efforts to implement alternatives and put in
place measures to avoid the use of involuntary practices
in the future. Training for staff and service users on de-
escalation techniques for potential crises, advance direc-
tives, and supported-decision making could help achieve
this objective. It could also be useful to develop action
plans setting out goals and deadlines for implementing
alternatives to the use of seclusion and restraint in each
facility.
Our assessment also revealed that most mental health
facilities evaluated had not initiated changes toward ful-
filling service users’ right to live independently and be
included in the community. is was mainly due to a
general lack of formal opportunities in Ghana for hous-
ing, education, or employment for people with men-
tal health conditions. However, Ghana has numerous
civil society organizations and organizations of peo-
ple with disabilities working in the mental health field
(e.g., Mental Health Society of Ghana, MindFreedom
Ghana, BasicNeeds Ghana, Special Olympics Ghana) and
advocating for service users’ rights. ese organizations
partner with the Mental Health Authority to create more
opportunities at the community level for people with
mental health conditions and promote their right to liv-
ing independently.
Based on the results of our evaluation, some critical
steps to improve the quality of care and respect of human
rights in mental health facilities are underway in Ghana.
In collaboration with WHO, the Mental Health Author-
ity and local organizations of persons with mental health
conditions are working together with hospital authori-
ties, staff, and service users to develop improvement
plans in the facilities assessed.
Our study presents several strengths: e high number
of interviews conducted in each facility; the rigorously
trained visiting committees; the use of a structured and
comprehensive evaluation instrument, the WHO Quali-
tyRights Assessment Toolkit; the inclusion of people
with mental health conditions and their organizations
in all phases of the project; and the inclusion of mental
health facilities located in different Ghanaian regions
that allowed us to obtain a representative picture of the
quality of care and respect of human rights in the men-
tal health system in Ghana. However, the study also pre-
sents some limitations that are worth highlighting. For
instance, different visiting committee members were
employed in the visits to the different facilities. However,
a core group of four visiting committee members was
present during all the visits and participated in all discus-
sions on the scoring and reporting to reduce subjectiv-
ity and increase reliability of the findings. Furthermore,
all the visits were scheduled, so we cannot exclude that
the hospital authorities prepared for the visit by “clean-
ing up” the facility so that committee members will see a
“sanitized” version of it rather than the actual conditions,
a situation that might indicate that some of our findings
represent conservative evaluations of the true situation.
However, this limitation was addressed by asking our
interviewees (service users and staff) to provide informa-
tion using a typical day as their reference.
Conclusions
e data from our study and the recommendations pro-
vided may be a valuable resource for Ghanaian stake-
holders to develop improvement plans and implement a
human rights-based approach in mental health facilities
throughout the country. Furthermore, the strong com-
mitment of the Mental Health Authority to mental health
service reform as well as the collaboration of the Ghana-
ian organizations working on the ground, and of hospital
management in the facilities assessed for this study pro-
vides encouraging signs that improvement along the lines
suggested in this paper may be forthcoming.
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Page 13 of 14
Moroetal. BMC Public Health (2022) 22:639
Abbreviations
UN CRPD: United Nations Convention on the Rights of Persons with Disabili‑
ties; WHO: World Health Organization.
Acknowledgements
The authors acknowledge and thank all service users, their carers, and mental
health staff for agreeing to be interviewed for the study. The authors are also
grateful to the members of the visiting committees for their detailed work and
to WHO Ghana and WHO Geneva for the technical support as well as expert
opinion in undertaking these assessments. The authors also acknowledge
the incredible work of the WHO QualityRights in Mental health Ghana Team
(including members of the Christian Health Association of Ghana, Ghana
Health Service, BasicNeeds Ghana, Ta‑Excel Foundation, Inclusion Ghana, Spe‑
cial Olympics Ghana, Passion for Total Care, Mental Health Society of Ghana,
and MindFreedom Ghana) in implementing the WHO QualityRights initiative
in Ghana.
Authors’ contributions
MFM, MGC, HK, DT, and AO designed the study and obtained funding. MFM,
MGC, HK, and CN conducted the analysis with input from LG, MC, JA, SO, MF,
and ND. MFM and HK coordinated the study and conducted the training and,
with CN, MC, and OG contributed to data interpretation; MFM drafted the
paper and, with input from MGC, MO, CA, FB, CC, PET, MA, SDO, OG, MF, ND,
and AO finalized the manuscript. All authors reviewed the manuscript. The
authors alone are responsible for the views expressed in this article and they
do not necessarily represent the views, decisions, or policies of the institu‑
tions with which they are affiliated. The author(s) read and approved the final
manuscript.
Funding
The work presented was supported by the project “Empowering Persons
with Psychosocial Disabilities to Fight for their Rights: An implementation
of the CRPD and QualityRights principles in Ghana, Lebanon, and Arme‑
nia” (EIDHR/2018/155232–4/97), funded by the European Commission (PI:
University of Cagliari, Italy). Additional funding in support of this work was
provided by the Foreign, Commonwealth & Development Office (FCDO), and
the Fondation d’Harcourt. These funding bodies had no role in the design of
the study and collection, analysis, and interpretation of data and in writing the
manuscript.
Availability of data and materials
The datasets used and analysed during the current study are available from
the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The study was approved by the Ghana Health Services Ethics Review Commit‑
tee (study protocol approval: GSH‑ERC 001/09/19) and conducted according
to the Declaration of Helsinki and its revisions. All data were made confidential
according to the provisions that protect privacy in Ghana (Data Protection Act,
2012) and Europe (Article 5 and 9 of EU Regulation No. 679). All participants
interviewed provided written informed consent to participate in the study. In
line with the principles of the UN CRPD (15), which require the full inclusion of
persons with disabilities in all the processes that may affect them, people with
mental health conditions and their organizations were active contributors
in all phases of the present project: Design of the study, training, visits to the
facilities, analysis of the data. and drafting of the paper.
Consent for publication
Not applicable.
Competing interests
MFM, MGC, LG, MO, CA, FB, HK, DT, CN, MC, CC, JA, SO, PET, MA, SDO, OG, MF,
ND, and AO have nothing to disclose.
Author details
1 Columbia University Irving Medical Center, New York, US, USA. 2 University
of Cagliari, Cagliari, IT, Italy. 3 WHO Country Office for Ghana, Accra, GH, Ghana.
4 Institute of Mental Health, University of Nottingham, Nottingham, UK. 5 Ghana
Ministry of Health ‑ Mental Health Authority, Accra, GH, Ghana. 6 WHO Regional
Office for Africa, Brazzaville, CG, Congo. 7 Mental Health Society of Ghana,
Accra, GH, Ghana. 8 MindFreedom Ghana, Accra, GH, Ghana. 9 Methods
Consult, Accra, GH, Ghana. 10 Charité University Medicine Berlin, Berlin, DE,
Germany. 11 Department of Psychiatry, WHO Collaborating Centre for Research
and Training in Mental Health, Neurosciences and Substance Abuse, University
of Ibadan, Ibadan, NG, Nigeria. 12 Policy, Law and Human Rights, Department
of Mental Health & Substance Use, World Health Organization, Geneva, CH,
Switzerland.
Received: 29 October 2021 Accepted: 28 March 2022
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