ORIGINAL Afr J Psychiatry 2010;13:99-108
A situation analysis of mental
health services and legislation in
Ghana: challenges for
transformation 
A Ofori-Atta1, UM Read2, C Lund3, MHaPP Research Programme Consortium4
1University of Ghana Medical School, Korle-Bu, Ghana. 
2Department of Anthropology, University College London, UK
3Department of Psychiatry and Mental Health, University of Cape Town, South Africa
4The Mental Health and Poverty Project (MHaPP) is a Research Programme Consortium (RPC) funded by the UK Department for
International Development (DfID)(RPC HD6 2005-2010) for the benefit of developing countries. The views expressed are not necessarily
those of DfID. RPC members include Alan J. Flisher (Director) and Crick Lund (Co-ordinator) (University of Cape Town, Republic of
South Africa (RSA)); Therese Agossou, Natalie Drew, Edwige Faydi and Michelle Funk (World Health Organization); Arvin Bhana (Human
Sciences Research Council, RSA); Victor Doku (Kintampo Health Research Centre, Ghana); Andrew Green and Mayeh Omar (University
of Leeds, UK); Fred Kigozi (Butabika Hospital, Uganda); Martin Knapp (University of London, UK); John Mayeya (Ministry of Health,
Zambia); Eva N Mulutsi (Department of Health, RSA); Sheila Zaramba Ndyanabangi (Ministry of Health, Uganda); Angela Ofori-Atta
(University of Ghana); Akwasi Osei (Ghana Health Service); and Inge Petersen (University of KwaZulu-Natal, RSA).
Abstract
Objective: To conduct a situation analysis of the status of mental health care in Ghana and to propose options for scaling up the
provision of mental health care. Method: A survey of the existing mental health system in Ghana was conducted using the WHO
Assessment Instrument for Mental Health Systems. Documentary analysis was undertaken of mental health legislation, utilizing the
WHO Legislation checklists. Semi-structured interviews and focus group discussions were conducted with a broad range of mental
health stakeholders (n=122) at the national, regional and district levels. Results: There are shortfalls in the provision of mental
health care including insufficient numbers of mental health professionals, aging infrastructure, widespread stigma, inadequate
funding and an inequitable geographical distribution of services. Conclusion: Community-based services need to be delivered
in the primary care setting to provide accessible and humane mental health care. There is an urgent need for legislation reform,
to improve mental health care delivery and protect human rights. 
Key words: Mental health; Legislation; Ghana
Received: 07-11-2008
Accepted: 02-03-2009
Introduction growth in the numbers of people suffering from mental
Mental health care is often one of the lowest health priorities disorders. Recent research has revealed the extent to which
for low-income countries1 and Ghana is no exception. In mental health care in many low and middle-income countries
common with many low-income post-colonial countries in is consistently under-resourced.3-5 In the relative absence of
Africa, Ghana has not developed the infrastructure and public community care, institutionalised care remains the norm for
services, including mental health care, to keep pace with many of those with mental health problems in low-income
population expansion. The population of Ghana has more than countries.5 Indeed, in countries such as Ghana, many of those
doubled since independence in 19572 with a consequent in need of treatment do not reach psychiatric services at all,
but seek the care of informal community mental health
services6 such as traditional and faith healers and family
Correspondence: members who offer a varying quality of service and level of
Angela Ofori-Atta
University of Ghana Medical School, Korle-Bu, efficacy. 
c/o P.O. Box 3859, Accra, Ghana In addition, there is increasing evidence from developing
email: angielam@4u.com.gh countries that mental illness is strongly associated with
African Journal of Psychiatry • May 2010 99
ORIGINAL Afr J Psychiatry 2010;13:99-108
poverty.7-9 Despite some significant economic growth in Methods
recent years, Ghana is classified as a low-income country with The WHO Assessment Instrument for Mental Health Systems
28.5% of the population living in poverty, and 18.2% living in Version 2.2 (WHO AIMS)25 was completed by the researchers
extreme poverty, especially in rural areas.10 Yet there is a with the aid of 48 key stakeholders in health and mental health
growing body of research demonstrating innovative, cost- care to provide an overview of mental health policy and
effective interventions for mental disorders such as services. Data for the WHO-AIMS was collected for the index
schizophrenia and depression in low-income African year of 2005. 
countries.11-13 Among these are agricultural rehabilitation Documentary analysis of mental health legislation was
villages in Tanzania14, family involvement in hospital care in conducted utilising the WHO Checklist for Mental Health
Senegal15,16, group therapy for the treatment of depression in Legislation26, which is designed to assess the content and
Uganda17, and collaborations with traditional healers in development of mental health legislation, according to a
northern Ghana.18 In Africa therefore, as in other regions of number of criteria. The checklist was completed by a team
the world, the deficit is not in the evidence for interventions to consisting of a clinical psychologist, a psychiatrist, a research
address mental health problems, but in the resources and officer, the national coordinator of community psychiatric
political will that can make these interventions available to nurses (CPNs), and the deputy director of nursing services at
those who need them. the Accra Psychiatric Hospital. Documents evaluated included:
Ghana currently stands in a relatively unique position the 1972 Mental Health Decree27, and the 2006 draft Mental
within the African continent to respond to this challenge. In Health Bill.28
spite of its low-income status, the country has one of the Eighty-one interviews and 7 focus group discussions were
highest literacy rates within West Africa (57.9%)19, is held with policy makers, health professionals, healers, users of
considered a relatively stable and peaceful democracy with psychiatric services, teachers, police officers, academics, and
good standards of governance, and has a strong and diverse religious and traditional leaders drawn from five of the ten
civil society. As one of the first countries to gain independence regions in Ghana. The interviews and focus group discussions
in 1957, it was also one of the pioneers of primary health care were conducted with 122 respondents, who were purposively
in the region20 and initiated early attempts to develop mental sampled from among the major stakeholders in mental health
health care in the first years of independence with the at the national, regional and district levels. 
establishment of new psychiatric hospitals and later the Semi-structured interview guides were tailored according
introduction of psychology, occupational therapy and to the specific individual being interviewed. Topics covered
community psychiatric nursing. Today, despite the shortage of included general policy making process in Ghana, the process
specialist psychiatric personnel, Ghana remains relatively of mental health policy and legislation development, the role of
well-resourced for mental health care in comparison to other stakeholders in mental health policy and legislation
countries in the region.3 development, the content of the current mental health policy
There have also been several attempts to respond to the and legislation, and the implementation of mental health policy
call to develop mental health provision in primary care and to and legislation at the national and regional levels. Thirty-five
provide community-based mental health services. The interviews were held at the national level, and 23 at the
training of community psychiatric nurses was instituted in regional level. One focus group discussion was held at the
1976 when these nurses were posted to approximately half national level.
the districts in the country. Between 1994 and 1998 primary Interviews were digitally recorded with participants’
health care and development workers in the Upper West consent and transcribed verbatim. Interviews in the local
Region of Ghana were trained in mental health care, Ghanaian language (Twi) were first transcribed and then
integrating mental health into primary care.21 Similarly, in translated into English by staff of the Bureau of Ghana
1998 the WHO Nations for Mental Health Project trained Languages. All transcripts were entered into Nvivo 7 which
health volunteers to provide community support to patients was used for coding and analysis. A framework analysis
with mental disorders.22,23 approach was adopted29 in which certain themes were agreed
Despite these innovations, a comprehensive situation upon by investigators from all four study countries based on
analysis of the mental health system in Ghana has not yet been the objectives of the study. From these objectives, sub-themes
undertaken. This paper presents the results of a situation were suggested by country partners, and reviewed by all
analysis of the current status of mental health policy and partners through a process of iteration, until a single
services in Ghana which was conducted as part of the first framework was agreed upon that could be used by all four
phase of the Mental Health and Poverty Project (MHaPP). The study countries. Where specific themes emerged from the
MHaPP, which is being conducted in four African countries: interviews that were not included in the generic cross-country
Ghana, South Africa, Uganda and Zambia, aims to investigate framework, these were added to the coding frame, to adapt the
the policy level interventions that are required to break the analysis to issues specific to Ghana. Transcripts were coded
vicious cycle of poverty and mental ill-health, in order to on the basis of these themes, with additional themes added to
generate lessons for a range of low- and middle-income the coding framework as determined by the data. Interviews
countries.24 Based on the findings of the situation analysis, the were coded independently for 10% of randomly sampled
paper presents proposals for transforming mental health care interviews to ensure inter-rater reliability. Inter-rater reliability
in Ghana to provide for the majority of those in need and to was always above 90%. 
protect the human rights of patients and their families in a way Ethical approval was granted by the Ghana Health Service
which is culturally responsive and cost-effective within the Ethics Committee and the Institutional Ethics Board at
budget of a low-income country. Kintampo Health Research Centre. Information sheets
African Journal of Psychiatry • May 2010 100
ORIGINAL Afr J Psychiatry 2010;13:99-108
containing essential information about the study and the The majority of the budget for mental health (nearly
implications of participation were given to all participants. 80%) is allocated for the maintenance of the three
Participants who were unable to read had a witness read psychiatric hospitals. Despite this, funding for the
the information sheet and consent form to them in Twi. psychiatric hospitals was described by one psychiatric
Participants were requested to sign a consent form to nurse as “woefully inadequate”. Participants reported that
indicate their willingness to participate in the study. Those funds are quickly absorbed in meeting the basic needs of
participants who were unable to write were requested to patients, and the psychiatric hospitals often run out of
provide a thumb print in lieu of a signature in the presence sufficient funds to feed patients. Therefore little of the
of a witness. The names and other identifying features of budget is available for psychosocial and rehabilitative
the respondents were removed from the transcripts in interventions.
order to ensure confidentiality. The National Health Insurance Scheme (NHIS) does not
cover psychiatric services because by policy treatment for
Results mental disorders is provided free of charge at the
Policy, governance and organisational structure government psychiatric hospitals and through community
Policy is formulated at the ministerial level, and psychiatric nurses. However if these are not accessible, or
implemented through the Ghana Health Service (GHS). medication runs out as can occur, then patients have to
The Mental Health Unit which oversees mental health purchase these privately without recourse to a refund. Many
services, is placed under GHS’s Institutional Care Division psychiatric patients who do not have health insurance are
(see Figure 1). The Mental Health Unit acts as the national not covered for treatment of co-morbid physical conditions. 
mental health authority, advising the government on mental
health policies and legislation, and providing monitoring Mental health services
and quality assessment of mental health services. The Unit Inpatient care
oversees the three government psychiatric hospitals, the There are three government psychiatric hospitals in Ghana
psychiatric wings of the 5 regional hospitals, community providing 7.04 beds per 100,000 population. Accra and
mental health services, and private psychiatric facilities. Pantang Psychiatric Hospitals are located in Accra, and
Traditional and faith healers are also supposed to be under Ankaful Psychiatric Hospital is in the Central region. There
the supervision of the unit, however in practice there is are 4 private psychiatric institutions which provide
little oversight. outpatient clinics and inpatient care. Two are located close
to Accra and two near the second largest city of Kumasi.
Financing of Mental Health Services There are psychiatric in-patient units in 5 of the 10 regional
It was reported that approximately 6.2 % of the health care general hospitals in the country providing a total of 77 beds
budget of the Ministry of Health was dedicated to mental (0.33 beds per 100,000 population), with the number of
health in 2005. In addition to this, results of interviews with beds per unit ranging from 10 to 22. The ratio of psychiatric
mental health professionals and Ministry of Finance beds in the mental hospitals in or around Accra, the capital,
officials indicated that due to the policy of de- to the total number of beds in the rest of the country is 6.28
centralisation, funding is disbursed to Budget Management to 1, indicating a concentration of inpatient resources in
Centres at the regional and district levels some of which urban areas. 
may be allocated to mental health. However there were no There were 6,605 admissions to the three state
figures available on mental health expenditure at the psychiatric hospitals in 2005. Approximately 50% of these
district level. were female. It is likely that this number may include repeat
Figure 1: Organisation of mental health services in Ghana. 
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admissions due to the failure to capture unique patient
Table III: Outpatient attendance by gender at psychiatric
identifiers in the health information system. The state hospitals in Ghana, 2005.
psychiatric hospitals are chronically overcrowded by as much
as a third more patients than beds. Hospital Male Female Total
Inpatient stays are frequently lengthy which exacerbates
the pressure on hospital beds (Table I). One of the reasons for Accra 20,462 23,682 44,211
such long admissions is the stigma attached to mental Pantang 6,922 5,963 12,885
disorders, which can result in relatives or caregivers Ankaful N/A N/A 28,907
abandoning the person at the psychiatric hospitals. Secondly,
while the individual is in the care of the hospital they receive Total N/A N/A 86,003
free board and lodging, as well as treatment. This can prove an
(N/A = not available)
attractive benefit for both the patient and the family,
particularly those with limited financial means. In addition, due
to the absence of secure hospitals and the inefficiency of the
legal system, some offenders who have been ordered by the Sub-Specialist services 
courts to be admitted for a psychiatric assessment can remain There are no dedicated outpatient facilities for child and
in the psychiatric hospitals for many months. adolescent mental health in Ghana. A total of 2,578 patients
under the age of 19 years were seen at all three hospitals.
There are 45 dedicated inpatient beds for children and
Table I: Number of beds and length of inpatient admission to adolescents in the psychiatric hospitals, representing 4% of
psychiatric hospitals. the total. There are 10 residential facilities for children under
17 with intellectual disabilities, one in each of the regions. In
Hospital Bed capacity Average length of Number of long stay addition, a non-governmental organisation (NGO) provides
hospital admission patients* residential care and rehabilitation in the Brong Ahafo region
for children with intellectual disabilities. There is also a private
Ankaful 250 82.2 days Not available
Pantang 500 285 days 205 school for children with intellectual disabilities in Accra. There
Accra 800 Not available 520 are dedicated beds for older people at the Accra Psychiatric
Hospital. However there are no specialised mental health
*patients who have recovered but remain in hospital services for older people, or people with dementia.
In Accra psychiatric hospital there is a dedicated forensic
ward with 15 beds and more than 300 patients. However this is
Psychotic disorders are the most frequent in-patient diagnosis not used solely by forensic patients. In Pantang hospital in
in the psychiatric hospitals, followed by substance use 2005, there were 88 forensic patients. There are 2 private
disorders and mood and affective disorders (Table II). Neurotic residential facilities for people with substance abuse and one
disorders are rarely diagnosed and recorded. There are also private hospital in Accra has a detoxification unit. 
many cases with unspecified diagnoses. There are difficulties
interpreting the data as diagnosis is frequently not Rehabilitation, residential and day services
standardised, according to several stakeholders who were There are very few rehabilitation and day services for people
interviewed. with mental disorders. Those which exist are largely run by
NGOs and faith-based organisations. There are 15 beds in an
Outpatient care inpatient rehabilitation facility which forms part of Ankaful
A total of 86,003 service attended the outpatient departments psychiatric hospital and 6 community residential facilities run
at the three psychiatric hospitals in 2005 (Table III). There is by voluntary and church organisations which provide drug
some overlap in these statistics since some patients attend rehabilitation. Cheshire Home in Kumasi provides residential
more than one psychiatric hospital. rehabilitation and vocational training for up to 55 adults with
Table II: Inpatient diagnoses at psychiatric hospitals in Ghana, 2005.
Diagnosis Accra Pantang Ankaful Total %
Mental and behavioural disorders due to psychoactive substance use  (F10-F19) 808 338 362 1508 22.8%
Schizophrenia, schizotypal, and delusional disorders (F20-F29) 1442 516 511 2469 37.4%
Mood, affective disorders (F30-39) 605 138 510 1253 19.0%
Neurotic, stress-related and somatoform disorders (F40-F48) 0 0 0 None recorded
Disorders of adult personality and behaviour (F60-F69) 0 0 0 None recorded
Others* 1232 86 57 1375 20.8%
Total 6605 100%
*includes epilepsy, dementia, other organic disorders, and unspecified
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mental disorders. More recently the NGOs Basic Needs services is poor and the physical health needs of the mentally
and Christian Blind Mission have established three ill are often neglected. Between 1-20% of workers in the
community-based rehabilitation projects for people with district hospitals and primary health care clinics are estimated
mental disorders in the north of Ghana. to have had contact with a traditional or faith healer. However,
There are three known day treatment facilities in Ghana no records of such contacts are maintained. Collaboration with
run by NGOs or church organisations. The Damien Centre traditional or faith healers tends to be informal and is largely
at Takoradi in the southwest of the country is run by the undocumented.
Catholic Church. Two drop-in facilities for vagrants are
provided in Tamale in the Northern region based on the Training in mental health care for primary care staff
club house model: Tsi-sampa run by Basic Needs, and Seven percent of the training for medical doctors is devoted to
Shekina, run by a private practitioner. There are no day mental health. General nurses undertake six weeks affiliation
treatment facilities run by GHS. at the psychiatric hospitals as part of their training. Post-basic
medical assistants receive only one week’s training in mental
Mental health in primary health care health. Some training of primary health care workers in mental
Doctors provide primary mental health care through the health has been facilitated by Basic Needs and an outreach
outpatient departments of the hospitals. Most government team from Ankaful Psychiatric Hospital.
clinics in the sub-districts do not employ doctors, but are In terms of refresher training, there were no data available on
staffed by medical assistants or nurses, or by personnel how many primary health care doctors and non-doctor/non-
with lower levels of training such as community health nurse primary health care workers had received refresher
workers or community midwives. Medical assistants training in mental health in the index year of 2005. However,
provide assessment, diagnosis and treatment, including responses from the qualitative data indicated that in-service
prescribing and administering medication, and effectively training in psychiatry is limited. Many of the primary health care
work in a physician role. There are no specialist doctors in workers interviewed stated that they have had no training in
mental health in primary health care clinics in Ghana. In psychiatry since they completed their initial clinical training.
spite of the unavailability of physicians in primary health
care clinics, there are assessment and treatment protocols Psychotropic medication
in most of these clinics which include guidance on the All mental hospitals, psychiatric units in general hospitals, and
treatment of the major psychiatric conditions including outpatient mental health facilities had at least one psychotropic
schizophrenia and depression.30 medicine of each therapeutic class (anti-psychotic,
Data on psychiatric morbidity in outpatient antidepressant, mood stabilizer, anxiolytic, and antiepileptic
consultations at district health facilities is collated at the medicines) available in the facility in 2005. However the range
regional level under four psychiatric categories: epilepsy, of psychotropic medication available within GHS is limited
acute psychosis, neurosis, and substance abuse (Table IV). largely to older generic drugs. The new generation of anti-
However, these data are likely to be a significant psychotics and anti-depressants, as well as mood stabilising
underestimate of the true incidence since many districts drugs such as Lithium and Sodium Valproate, are not widely
lack psychiatric professionals and do not collate data on available, despite the inclusion of Sodium Valproate and
psychiatric disorders. Differences between regions are Risperidone in the Essential Medicines List.31 There is limited
therefore more likely to be due to differences in recording availability of depot anti-psychotic medication within Ghana
of cases, than to true differences in morbidity. Health Service, especially outside the psychiatric hospitals. 
Between 21-50% of primary health care clinics are In the qualitative interviews, several respondents indicated
estimated to refer patients presenting with mental that the supply of psychotropic drugs to inpatient and
disorders to a higher level of care, such as the psychiatric community facilities is often insufficient, leading to shortages
units of the regional hospitals, or the psychiatric hospitals of essential medication. When medication is unavailable at the
in Accra or Cape Coast. Communication and collaboration hospital pharmacies and clinics, patients must purchase the
between primary health care workers and psychiatric necessary medication at their own expense. 
Table IV: Outpatient psychiatric service utilisation per region, 2005.
Disorder WR CR GAR VR ER ASH BAR NR UER UWR Total
Epilepsy 868 200 929 911 581 1,239 737 733 1,005 458 7,661 
Acute Psychosis 194 123 1,607 1,612 755 1,044 1,065 221 645 184 7,450 
Neurosis 288 276 524 304 431 4,101 660 108 332 103 7,127 
Substance Abuse 443 139 739 269 482 1,452 261 84 333 119 4,321 
Total new cases 1,793 738 3,799 3,096 2,249 7,836 2,723 1,146 2,315 864 26,559 
Data collated from returns submitted by district level facilities.
Key to regions: WR= Western, CR= Central, GAR= Greater Accra, VR= Volta, ER= Eastern, ASH=Ashanti, BAR= Brong Ahafo, NR= Northern, 
UER= Upper East, UWR= Upper West
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Human rights protection disorders related to maternity. 
There is no national body to oversee regular inspections in There is some coverage of mental health topics in the
mental health facilities, to review involuntary admission and national newspapers in Ghana. Between 1992 and 2005 the
discharge procedures, to review complaints, investigation most popular national newspaper, the Daily Graphic,
processes and to impose sanctions (e.g. withdraw published 191 articles on mental health. The most
accreditation, impose penalties, or close facilities that commonly reported topics were suicides, drug abuse,
persistently violate human rights). As a result, none of the charitable donations to psychiatric hospitals and
mental hospitals nor the inpatient psychiatric units and overcrowding, understaffing and poor conditions in the
community residential facilities had any review or state psychiatric hospitals. In the last two years there has
inspection of the human rights protection of patients in been more coverage of the human rights of the mentally ill,
2005. However in the following two years of 2006 and 2007, including a review of mental health legislation, and calls for
there were inspections of the psychiatric hospitals by the an improvement in psychiatric services.32 Newspaper
Commission for Human Rights and Administrative Justice, articles are only accessible to those who read English.
and in 2008 the Parliamentary Sub-Committee on Health
also inspected two of the three state psychiatric hospitals. Inter-sectoral collaboration 
There was no training in the protection of the human rights There are some formal collaborations between the Mental
of patients in the inpatient psychiatric units and community Health Unit and the departments and agencies responsible
residential facilities in 2005. for primary health care/community health, reproductive
health, child and adolescent health, substance abuse,
Human resources in mental health care education, criminal justice and social welfare. However
In 2005 the human resources for mental health care were: there is no collaboration with programmes for HIV/AIDS,
15 psychiatrists, 468 psychiatric nurses, 132 community child protection, employment, housing and the elderly. 
psychiatric nurses (CPNs) based in the ten regions In terms of support for child and adolescent health, no
covering 69 of the 138 districts, 7 psychologists, 10 primary and secondary schools have either a part-time or
medical assistants, 6 social workers, and 1 occupational full-time mental health professional. However, it is
therapist. Nine of the psychiatrists working in GHS are estimated that between 1-20% of primary and secondary
officially retired. The distribution of psychiatric nurses per schools have school-based activities to promote mental
100,000 of the population is 6.29 times greater in Accra health and prevent mental disorders in the form of talks
than in the entire country. The low numbers of and lay counselling. 
psychologists and occupational therapists is largely
attributable to the fact that GHS does not hire Mental Health and Poverty
psychologists and has no training for occupational There is an absence of mental health in the development
therapists. discourse on poverty in Ghana. For instance, several
initiatives for the alleviation of poverty do not expressly
Training professionals in mental health target people living with mental illness even though they
The number of health professionals who graduated from may be classified as among the most vulnerable and
health training institutions in 2005 is as follows: excluded in the society. A National Social Protection
approximately 190 medical doctors (not specialized in Strategy was introduced in 2008 to provide social
psychiatry), no psychiatrists, 150 nurses with at least 1 year assistance to the ‘poor, vulnerable and excluded’. Although
training in mental health care, approximately 7 it aims to assist the ‘extremely poor’ and ‘severely
psychologists with at least 1 year training in mental health disabled’ it has not yet specifically targeted the mentally ill
care, and 35 medical assistants (not specialised in as needing assistance.33 This is partly because the mentally
psychiatry). ill fall under the Ministry of Health while the policy is
implemented by the Ministry of Manpower, Youth and
Public education and awareness campaigns on mental Employment which has oversight over the Department of
health Social Welfare. 
Mental health professionals and NGOs have conducted a There are very limited social welfare benefits available
few public education and awareness campaigns in mental in Ghana, two of which have been introduced in the last 2
health in the last five years, such as World Mental Health years. The District Poverty Alleviation fund is available for
Day and the 100th anniversary of the Accra Psychiatric those facing severe economic hardship. Social welfare
Hospital in 2006. The NGO Mindfreedom has held two departments can also make discretionary payments to the
‘Mad Pride’ marches in Accra in 2006 and 2007 to raise destitute, for example meeting their emergency medical
awareness of mental health and promote the rights of costs. Since the passage of the Disability Act in 200634,the
mental health service users. Several respondents reported District Assemblies are supposed to dedicate up to 2% of
conducting occasional educational talks on mental health their Common Fund (funds dispersed to local government
in schools and churches, as well as local radio broadcasts. for development projects) to those with disabilities. In 2008
Others reported providing training in mental health for the government introduced the Livelihood Empowerment
traditional healers and pastors. Participants reported that Against Poverty (LEAP) programme alongside the Social
campaigns often target adolescents who are at risk of drug Protection Strategy to provide direct cash transfers to the
abuse. In addition campaigns are targeted at women of extremely poor, with additional amounts for households
maternal age who are at risk of depression and other with a ‘severely disabled person’.33 However whilst people
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with mental illness are included within the definition of those resources which are expended largely on institutional care.3,36
living with a disability under the Disability Act, mental illness is The research reveals the continued reliance on the inpatient
not readily recognised by many policy makers and and outpatient services of the national psychiatric hospitals,
implementers as a cause of disability and in the criteria for despite a policy of de-centralisation and a commitment in
inclusion into the LEAP programme the emphasis is on principle to community mental health care. 
physical disability. Mental health care in Ghana falls far short of WHO’s
suggested principles for the organization of services, namely
Mental health legislation accessibility, comprehensiveness, coordination and continuity
The existing legislation for mental health in Ghana is the of care, effectiveness, equity, and respect for human rights.6
Mental Health Decree of 1972.27 The 1972 decree has WHO suggests that the optimal mix of mental health services
provisions for procedures for involuntary admission, including may be conceptualized as a pyramid with most, at the base of
rights to appeal, accreditation of professionals and facilities, the pyramid, able to give self care, while a small minority at
enforcement of judicial issues for people with mental illness, the top of the pyramid need to use specialised psychiatric
and mechanisms to implement the provisions of mental health services6 (see figure 2). 
legislation. 
The review of the 1972 legislation utilising the WHO
Checklist on Mental Health Legislation identified several areas Figure 2: Optimal mix of mental health services (WHO, 2003)
which were not adequately addressed in the Mental Health
Decree. These included inadequate attention to human rights
provisions for service users, including the right to humane
treatment; confidentiality and privacy; informed consent; the
rights of carers and families of users; competency, capacity,
and guardianship issues; involuntary admission; and issues of
seclusion and restraint. There is little protection in the
legislation of vulnerable groups, including minors and women.
There is no provision for financing of mental health care and
inadequate promotion of mental health within primary or
community-based care. There is also insufficient promotion of
access to psychotropic drugs, and no provision for educational
activities, vocational training, leisure activities, and the
religious and cultural needs of people with mental disorders.
There is no provision made for the involvement of users of
mental health services, families and carers in mental health
policy and legislation development and planning. This model argues that greater numbers of people with mental
The new Mental Health Bill was drafted in 2006 with illness should be treated through informal community care and
support from WHO.28 It is currently in the office of the Minister primary health care, than within specialised community mental
of Health, pending submission to parliament to be enacted into health and psychiatric services. Such a model aims to ensure
law. The 2006 Mental Health Bill adopts a human rights that specialised resources are targeted to those most in need,
approach to mental health, in accordance with the UN Charter and that everyone who needs treatment for mental disorders
on Human Rights and international consensus on the health has access to the appropriate level of care. Given the limited
care needs of a person with mental disorder. The Bill aims to resources for mental health in Ghana, and the inequitable
prevent discrimination and provide equal opportunities for spread of services, we consider how the different levels of this
people with mental disorder. It addresses many of the pyramid could be enacted in Ghana, maximising the
weaknesses of the current Decree, providing for a mental resources available at each level.
health authority, a mental health review tribunal, and the
protection of the rights of people with mental disorder, Self Care
including the principle of the least restrictive environment and The situation analysis showed that there is a lack of awareness
the right to information and participation. The Bill is endorsed of mental health and illness among many in Ghana and few
by WHO as reflecting best practice in mental health public education programmes for mental health. There is
legislation.35 It promotes de-centralisation and community therefore a need to empower people to give self care through
mental health care and regulates traditional and faith-based an active public mental health education programme. Topics
healing practices. A missing element of the law, identified by need to include causes, symptoms, and prevention of mental
the WHO checklist is that although there is mention of the illness, access to treatment and government programmes on
sources of funding for the mental health authority, there is no disability and poverty alleviation, and safeguarding patient
stipulation on minimum funding requirements for mental health rights. 
care. Support for families through education and carers’ groups
would assist families in caring for family members with mental
Discussion illness. Such programmes have proved successful in India and
The results of the situation analysis reveal that mental health China37,38 and carers’ groups have been initiated by Basic
care in Ghana is comparable to many other low income Needs in Ghana, but there is a need to scale up such
countries in Africa, which show similar patterns of inadequate interventions nationally. 
African Journal of Psychiatry • May 2010 105
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Informal Community Care efficient planning and resource allocation for mental health.
Informal community care in Ghana is offered through faith In addition, multi-sectoral district mental health advisory
and traditional healers. Human rights abuses by these committees should be established to advocate for mental
healers have been reported, however they remain very health within relevant sectors such as education, the police
popular. Many Ghanaians approach faith and traditional and judiciary, social services, and faith and traditional
healers for common mental disorders such as anxiety and healers.
mood disorders.39 This is reflected in the low numbers of
people with common mental disorders who utilise mental Community Mental Health and Psychiatric Services in
health services. General Hospitals 
There have been few attempts to develop and As the results show, only 69 of the 138 districts have
supervise the services of traditional and faith healers in community psychiatric nurses Even where a CPN service
Ghana.18,40 In order to reduce the abuse of people with is provided, there are often only one or two nurses for the
mental illness within informal treatment facilities, it is district, and they have no access to transport. Therefore the
recommended that a mental health authority and tribunal service is severely limited in its ability to reach those in
is established as stipulated in the new Mental Health Bill need. The number of CPNs is diminishing as many are
to regulate the practices of traditional and faith healers. nearing retirement and there is no programme for their
Closer collaboration between faith and traditional healers replacement. In addition to training and posting more
and orthodox psychiatric care could help to protect the CPNs, the proposed training of new cadres of community
human rights of those with mental illness and ensure that mental health workers (see
those who would benefit from psychiatric treatment are http://thekintampoproject.squarespace.com) would enable
referred to appropriate services. Initiatives by Basic the expansion of community mental health care.
Needs to work with traditional healers in Northern Ghana Strengthening the provision of community mental health
have suggested the potential for successful services, ensuring an adequate and reliable supply of
collaboration.18 There is a need to provide training for psychotropic drugs, as well as the provision of transport for
traditional and faith healers on mental health, psychiatric community health workers, would improve access to
treatment, ethics and human rights. Local government at treatment within the community and help prevent the need
the district level (District Assemblies) could help by for hospital admission for many. The Ministry of Health
providing some funding to upgrade the facilities at faith should also consider the hiring of allied mental health
and traditional healers to further improve care given to professionals such as psychologists, for districts to provide
patients.41 psychosocial interventions. 
In addition there is a large number of Community Access to treatment at the community level is
Based Surveillance Volunteers (CBSVs) and Traditional particularly important in Ghana since many communities
Birth Attendants (TBAs) who are posted to mainly rural are far from inpatient psychiatric services which are
communities. WHO calls them ‘local experts’6, who as located in only half of the regional capitals. Many patients
frontline workers can direct community members to bypass these and are admitted to the large psychiatric
appropriate healthcare. The training of such volunteers in hospitals in the south, meaning treatment is even further
mental health could enable them to extend their support from the person’s home. This has implications for the re-
services and make appropriate referrals of people with integration of the person into his or her community
mental illness. There is however a need to consider issues following discharge, particularly given the frequently
of remuneration for such volunteers in order to ensure they lengthy admissions and the stigma associated with the
are motivated and committed to complete their work psychiatric hospitals. 
effectively. Psychiatric units should be opened in general hospitals
in the remaining regions, and systems of referral and back-
Mental Health Services through Primary Health Care referral with primary care strengthened so that use of the
The integration of mental health into primary health care regional units is maximised. More beds should be
services would ensure that those with mild and moderate provided at the regional psychiatric units in order to aid
mental disorders are able to access care through primary the process of de-institutionalisation and provision of care
health care facilities, with referral to specialist services nearer home.
only for those with severe symptoms. This would require
training primary health care workers in the detection and Specialist Services 
treatment of mental disorders and providing regular De-institutionalisation is required to reduce the numbers of
supervision by mental health professionals. There should long-stay patients in the psychiatric hospitals so as to offer
be reliable access to psychotropic medication at the humane, high quality care for those most in need. There is
district and sub-district level and effective systems of also a need for more diversity within specialised services.
referral and back-referral between primary care and At present inpatient care is largely medicinal with little
specialised mental health services. Mental health should attention to psychosocial interventions. Half-way houses
also be included within the wider public health care and vocational rehabilitation could help with the process of
initiatives of district health services such as maternal, child, de-institutionalisation, particularly for those long-stay
and adolescent health. patients who are estranged from their families, and are in
There is also a need to strengthen the mental health need of a graded reintroduction to life within the
information system in primary care to enable more community.
African Journal of Psychiatry • May 2010 106
ORIGINAL Afr J Psychiatry 2010;13:99-108
Information systems are not necessarily those of DfID. We thank the Hon. Frema
The completion of the WHO-AIMS, which relies on data Opare, former Deputy Minister of Manpower Youth and
collection by government, private and voluntary services, Employment for her helpful comments on disability and the
revealed some of the weaknesses of the health information LEAP, and Dr. Ahmed, retired Director of Medical Services,
system in Ghana, particularly in respect of mental health, in for his comments on funding and the Mental Health Bill. 
which much data is not gathered at all, or is inconsistent or
unreliable. This highlights the need for the introduction of a References
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