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The Mauritanian Model: An Effective Way to Improve Access to Mental Healthcare in Developing Countries

Author(s): Ahmed Ould Hamady1, Daniel A Gérard2, Osman Sall, Youssouf Ould Limame1
Affiliation(s): 1Ministry of Health, Mauritania, 2Chronic Diseases, Sanofi, France
1st country of focus: Mauritania
Relevant to the conference theme: Non-communicable chronic diseases
Summary (max 100 words): Mauritania is a wide country of 1 million square kilometers mainly covered by desert, with 3 million inhabitants and only 3 psychiatrists. A pilot project designed to improve access to mental healthcare in the country was implemented in Nouadhibou city at the North West country border. In May 2009, 7 mental health clinics were opened in the city and surrounding areas. Thanks to the commitment of the medical staff and local NGOs, the treatment gap in schizophrenia was reduced by 38% in 2.5 years (from 93% to 58%) by running a strong awareness program and providing adapted, available, affordable medicines.
Background (max 200 words): Four mental disorders are in the top ten leading causes of disability (depression, bipolar disorders, schizophrenia, alcohol abuse) and the prevalence of main mental disorders is similar in developed and developing countries. Mental disorders are one of the leading contributors to the Global Burden of Diseases in Low- and Lower-Middle-Income countries yet only scarce resources are devoted to them.

A survey conducted in the general population of Nouakchott in 2003 indicated that 35% of the sample population had at least one mental disorder: anxiety: 20%, mood disorders: 19% and psychotic disorders: 2.4%.  Available mental health care systems are not aligned with needs in Mauritania.
Resources are mainly concentrated in the capital, Nouakchott: 3 outpatient psychiatric clinics, 1 Neuropsychiatric center and 1 psychiatric department in the Military Hospital and very few resources are accessible in the rest of the country.
In addition the survey highlighted the overlap between madness and mental disorders in the perception of the population who mainly believes that psychiatric symptoms are from magic or religious origin.
These data underline that improving mental health care in Mauritania requires a comprehensive process that combines: conducting awareness campaign; setting up services; getting funding; training healthcare professionals and making medicines accessible.
Objectives (max 100 words): The aim of this pilot project was :

(1) to test the feasibility of implementing one mental health clinic in each of the 13 Mauritanian provinces, working in a close network with the specialists from the Nouakchott neuropsychiatric center;
(2) to assess the impact of the project on the access to mental health care
(3) to learn from this experience for preparing an extension of the project to the rest of the country.
Methodology (max 400 words): This project is an action research project focused on access to healthcare for psychotic patients.

Intervention: inclusive approach bringing together:
  1. Advocacy towards decision makers (national, regional and local) so as to get their support for the implementation of the project;
  2. Training of health care professionals selected by the Head of the Regional Health Services;
  3. Regular supervision from specialists from the Nouakchott Neuropsychiatric center;
  4. Sustainable supply of quality affordable antipsychotics;
  5. Patients and families psycho-education sessions;
  6. Communities awareness initiatives on mental health issues;
Collected data: Number of patients included in the program, sex, age and diagnosis according to CIM 10. In addition, specifically for psychotic patients: estimation of the number of people with schizophrenia in the area; number of patients treated at baseline; conformity of the diagnosis made by the “investigator” and the diagnosis made by the specialist; Clinical Global Improvement, number of hospitalizations, questionnaire of integration in family and community; Drug Attitude Inventory-10 questionnaire; Involvement Evaluation Questionnaire
Results (max 400 words): An agreement was concluded between the Mauritania Ministry of Health represented by the Nouakchott Neuropsychiatric Center and Sanofi Access to Medicines in July 2008.

Nouadhibou (100,000 population), at the north border of the country, in front of the Canary islands, was selected as pilot site because of its population exposure to many risk factors for mental disorders: life style changes (from nomad life to settlement), transit place for illegal migration and drug trafficking…
The pilot program commenced in October 2008 with a meeting in the National Assembly and the endorsement of the national and local political and administrative decision makers. Between October 2008 and December 2010:
  • 37 health professionals from both public and private sectors were trained;
  • Outpatient mental health clinics were opened (since May 2009) in seven centers in the city (regional hospital, city hall dispensary, mine polyclinic, military infirmary, Moughataa dispensary) and in the surrounding areas (Boulenouar dispensary, Nouamghar dispensary).
  • Information tools were specifically designed for awareness campaigns and are used by several NGOs: posters, flipcharts and booklets.
  • More than 1000 people (patients, patient families, teachers, woman associations…) attended the different information meetings.
  • About 1200 patients are followed up in the mental health clinics (mainly for psychosis, depressive disorders, anxiety disorders and epilepsy)
  • In schizophrenia, with 342 new patients in 30 months, the treatment gap has decreased by 38% from 93% (May 2009) to 58.8% (December 2010).
The detailed results of the impact assessment will be presented.
Conclusion (max 400 words): This pilot program has a positive impact on the Nouadhibou population mental health. It indicates that access to care for patients with mental disorders can greatly be improved by a simple, assessable, replicable and scalable program. An agreement for the program extension to the whole country over 5 years through a partnership between the Mauritania Ministry of Health, the World Association for Social Psychiatry and Sanofi Access to Medicines was signed in June 2011. In addition to psychosis, the expanded program will also include other major mental disorders and epilepsy

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