I. Mental Disability in Ghana

Overview

The World Health Organization (WHO) has estimated that there are 2.8 million persons with mental disabilities in Ghana, 650,000 of whom have severe mental disabilities.[4]

There is no specific international consensus on the definition of disability, but the Convention on the Rights of Persons with Disabilities (CRPD), the newest international human rights treaty, describes persons with disabilities as including “those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others.”[5] Ghana signed the CRPD in March 2007 and ratified it on July 31, 2012. The 1992 Constitution of Ghana in article 75 stipulates that parliament must pass an act or a resolution with the votes of more than one-half of all members for the CRPD to enter into force, and parliament passed such a resolution in March 2012, which confirmed the entry into force of the CRPD before it was officially ratified in July 2012.

In this report, mental disability refers to mental health problems such as depression, bipolar disorder, and schizophrenia. Persons with mental health problems also refer to themselves as having psychosocial disabilities, a term that reflects the interaction between psychological differences and social or cultural limits for behavior, as well as the stigma that the society attaches to persons with mental impairments.[6]

The vast majority of patients in Ghana’s psychiatric hospitals are treated for mental health problems. According to Dr. Akwasi Osei, director of Accra Psychiatric Hospital, 20-30 percent of patients are diagnosed with schizophrenia, 20 percent with bipolar disorder, and 15-20 percent with major depression. Drug-related psychosis affects 8-10 percent of patients and epilepsy was found in 5 percent of patients.[7]

According to a senior health official, mental disability in Ghana is widely considered as having a spiritual origin, caused by evil spirits or demons.[8] This view on the causes of disability was held by all camp leaders that Human Rights Watch interviewed, as well as some persons with mental disabilities (mainly in the community and camps) who believed evil spirits caused their mental conditions.

Although Ghana is a middle-income country with per capita gross domestic product (GDP) of around US$1,300,[9] 40 percent of adults live on less than $2 a day.[10] The quality of, and access to, health care are concerns for most Ghanaians, but poor Ghanaians with mental disabilities confront particular challenges, such as high transport fares from their homes to psychiatric hospitals, which are often several kilometers away, and the high cost of health care. While there are no conclusive statistics about the prevalence of poverty among persons with disabilities in Ghana, some studies found that poor households with persons who have disabilities face significant barriers in realizing their right to adequate health care.[11]

Although there is no clear data about Ghana’s mental health care budget, interviews conducted with officials from Ghana Health Service indicate that it is as low as 0.5-6 percent of the total health care budget allocation.[12] Expenditure of the mental health budget is also disputed, with varying figures showing that between 72 percent[13] and 94 percent of the health budget is spent on remunerations of medical professionals.[14] In 2011 less than one percent of the national budget was dedicated to mental health care.[15]

Treatment and Care Options

Individuals with mental disabilities in Ghana who receive treatment generally have three main care options: public mental health services, prayer camps, and traditional healers—people who use ritual and herbal methods of treatment. [16] Community care providers are another, albeit limited, option. Most people utilize more than one option and sometimes more than one at a time.

Public Mental Health Services

Like many developing countries, Ghana faces staff shortages within the public health system. The problem is particularly acute when it comes to mental health: there are only 12 practicing psychiatrists and 600 psychiatric nurses nationwide, serving over 2 million persons with mental disabilities.[17]

Ghana has three public psychiatric hospitals: Accra Psychiatric Hospital, Pantang Psychiatric Hospital, and Ankaful Psychiatric hospital. [18] The capacity of each is 200, 500, and 250 individuals respectively. Accra Psychiatric Hospital is considerably overcrowded, with numbers ranging from 900 to 1200 at any given period between 2010 and 2012. [19]

Staff shortage was identified as a major challenge by all the hospital staff that Human Rights Watch interviewed in the three hospitals. In Accra Psychiatric Hospital’s Special Ward, formerly called the Criminal Ward because patients arrived under police arrest or court order, three nurses were on duty caring for 205 patients at the time Human Rights Watch visited.[20] One ward at Pantang Psychiatric Hospital had four nurses on duty to care for forty patients with visibly critical needs.[21] According to the director of Accra Psychiatric Hospital, to achieve proper care, Ghana needs to increase the number of nurses in the three psychiatric hospitals almost seven-fold, from the current 600 to about 4,000.[22]

Currently, Ghana has 15 psychiatric social workers serving the whole country, which is especially low given that the 2000 Mental Health Training Policy requires the government to train at least 15 psychiatric social workers every 5 years.[23] Ebu Blankson, head of the Social Welfare Department at Ankaful Psychiatric Hospital, told Human Rights Watch, “We have three social welfare staff… taking care of… 500 patients.”[24]

Ghana started a community psychiatric nursing program in 1975, which evolved into a community mental health system. However in 2003, the latest year for which there are reliable statistics, fewer than half of Ghana’s districts—52 out of 110—had community psychiatric nurses.[25] There are also only three clinical psychologists, out of the eighty who are needed.[26]

In 2003 the government established a National Health Insurance Scheme (NHIS), which aimed to make healthcare readily available and more affordable to Ghanaians and eventually replace the user feesystem throughout the country.[27]

Mental health care is not covered by the NHIS, primarily because of the widespread assumption that mental health care in psychiatric hospitals is cost-free.[28] However, patients are often required to buy their own medicines, which are often very expensive.[29]

Persons with mental disabilities in psychiatric hospitals were therefore responsible for buying their own drugs, especially to treat physical illnesses such as malaria, and yet some of them had no relatives and could not buy these medications.[30] Explaining the effects of the shortage, Dr. Akwasi Osei, chief psychiatrist of the Ghana Health Service and director of Accra Psychiatric Hospital, said that the “lack of resources to buy drugs is state-sponsored human rights abuse.”[31]

The Ghana Federation of the Disabled is working with the Parliamentary Subcommittee on Health to improve coverage for persons with disabilities, especially including those with mental disabilities in the NHIS. The NHIS is currently under review,[32] and an amendment bill which would extend coverage to persons with mental disabilities is before parliament and is expected to be enacted before the end of 2012.[33]

Those treated within the public health care system may be inpatients or outpatients within Ghana’s three psychiatric hospitals or in some regional and district hospitals where there are designated psychiatric wards or staff.

Ghana also has four private psychiatric hospitals: two in Kumasi, one in Accra, and one in Tema. Like the three public psychiatric hospitals, the four private hospitals are located in the south of Ghana. [34] The private facilities have an estimated total inpatient capacity of 100 patients, as per their bed capacity. [35] The high cost of care, estimated at about $150 per month per person[36] in such institutions is beyond the reach of most Ghanaians, 40 percent of whom live on less than $2 a day, [37] and 28.5 percent of whom live below the poverty line. [38]

Prayer Camps

Ghana has several hundred prayer camps, which are believed to have emerged in the 1920s, although little is known about their history, numbers, or operations since they are not state-regulated.[39] There are no clear figures on how many prayer camps actually exist in Ghana, and Human Rights Watch was informed by Rev. Opoku Onyinah, chairperson of the Ghana Pentecostal and Charismatic Council (GPCC), that Ghana Evangelism Committee (GEC) is conducting a survey.[40] Most are located in the south of the country: in Ada district alone, one of the ten districts making up the Greater Accra Region, there are an estimated 70 prayer camps.[41]

The camps offer prayer and healing services for persons with mental disabilities and are private Christian religious institutions that are usually managed by prophets, many of them self-professed religious leaders who claim to be able to cure persons having various conditions, including cancer, infertility ,and physical or mental disability, through prayer and other non-medical techniques. The prayer camps which Human Rights Watch visited were like any other Christian place of worship, conducting normal church activities including prayer and counseling, in addition to supporting charitable activities, such as homes for orphans and the elderly. The main difference between prayer camps and the Catholic or protestant churches, according to a Christian leader, is that “prayer camps are more of charismatic and pentecostal churches, and they specifically believe in the power of miracles, consultation with angels, and spiritual healing.”[42]

All of the prayer camps that Human Rights Watch visited said they were Christian institutions, although some, in addition to prayers, also administer traditional herbs. More established prayer camps such as Mount Horeb and Edumfa had special sections referred to as “sanatoria” where persons with mental disabilities were taken for healing.

The camps are mainly intended as retreats for prayer and spiritual healing, and some of them have units for persons with mental disabilities.[43] However, the primary role of prayer camps, according to those who spoke to Human Rights Watch, is not to treat persons with mental disabilities. While each of the eight camps Human Rights Watch visited has a unit for treating persons with mental disabilities, such treatment was the smallest component of the work being done at such camps. There was considerably greater emphasis on various forms of spiritual and temporal activities like worship and commercial agriculture.

According to leaders of camps who administer treatment and are referred to as prophets, persons with mental disabilities are often brought by their families, [44] and may reside in the camps for several days to several years. [45]

Some prayer camps that Human Rights Watch visited were located in open fields or forests; some operated out of structures that were half-built and offered only a rooftop for shelter. Others still were more established and better funded by church networks and looked like small villages. The more established camps included Mount Horeb and Edumfa Prayer camps, both of which occupied large areas of land and had large church halls and retreat facilities for anyone who wanted spiritual services, including prayers, counseling, and consultation on various issues. These camps had several pastors assigned to different ministerial responsibilities, including counseling. Edumfa Prayer Camp management engaged in activities like commercial agriculture and baking, the proceeds of which, according to Prophetess Rebekah Bedford, help fund the day-to-day running of the prayer camp.[46]

In the camps Human Rights Watch visited, we observed that most people brought for healing for mental disabilities, drug use, or epilepsy—unlike those who had come for healing related to illnesses such as cancer—were chained to logs, trees, or other fixed spots and underwent a regime of daily prayer and fasting. Most individuals treated in the prayer camps for mental disability stayed from a few days to more than a year.[47]

In one camp residents were formally registered and received a spiritual healing plan, a form describing an internal code of conduct for prayer camp visitors, responsibilities of visitors, prayer schedules, procedures for discharge from the camp, and regular administrative tasks.[48]

Some prayer camps, like Edumfa, are affiliated with Faith Complementary Health Care Association of Ghana, an association of camps that use natural elements and the bible in healing.[49] The association issued members a booklet with instructions on how to record information of those admitted to the camps, including name, age, occupation, marital status, religion, and nearest relative, as well as individual medical histories, including examination, diagnosis, and treatment.[50] Edumfa Prayer Camp also gave Human Rights Watch a copy of an Indemnity Form, to be signed by the person with mental disability, with entries like “derangement of mind proposed treatment.” Modes of treatment listed on the form include “prayers, fasting, confinement, and such appropriate restraints as circumstances demand.”

Inside a Typical Prayer Camp There are wide variations in the way prayer camps in Ghana operate. Some, like Mount Horeb and Edumfa, are well organized with predictable daily schedules for patients, while most do not follow particular schedules. The prayer camps vary widely in size, some are as big as a small village and include a church building, a special section for persons with mental disabilities, residences for the prophets, and rooms rented to guests and other visitors. Some of these visitors stay within the camp premises for days or weeks. Some camps have big church buildings, while in others, church buildings were under construction. A day at a prayer camp, according to Mount Horeb’s Pastor Christian Hukipoti (the pastor overseeing the section housing persons with mental disabilities) starts with morning devotion (5:00 to 6:00 a.m.) after which patients take their baths. Breakfast, for those who are not fasting, is between 8:00 and 9:00 a.m. This is followed by bible study, which takes place in the church building “for those who are calm,” while those who are not considered calm are kept back in their rooms. Bible study continues until 3:00 p.m., when those who are not fasting take lunch, which lasts until 4:00 p.m. Between 4:00 and 8:00 p.m. is free time, after which those who are calm and are not in chains go for evening prayers, which end at 10:00 p.m. Pastor Hukipoti told Human Rights Watch, Between 11 p.m. and 1 a.m. we do intercession for those who are in chains and can’t go to church, and during this time, the prophet visits the respective rooms, prays for them, and casts demons out of some of them. We also have a nurse who visits our patients from Tetteh Quashi hospital; she comes twice a week (Tuesday and Friday), and we call her during emergencies, for example, when someone reacts [adversely] to medication. At Edumfa and Mount Horeb the prophets would counsel people at different hours of the day, some of whom Human Rights Watch found waiting in tents for a chance to have a one-on-one session with the prophet or prophetess. In addition, the prophets manage and oversee the administration of the camps. The m ajority of people with mental disabilities admitted to prayer camps are often chained around the clock, for several weeks until discharged. Those in chains are unable to join prayers or other activities in the camp. A few of those that Human Rights Watch interviewed who at some point were chained, especially at Mount Horeb and Edumfa prayer camps, were relocated to special wards called the “calm rooms.” Compared to other rooms, “calm rooms” were less crowded and housed the fewest number of people. Such rooms had a few makeshift beds, but some occupants slept on small mattresses, and others slept on the bare floor. A few had been declared by the prophets as healed, but stayed at the camp to provide support to those who were still undergoing treatment. They helped with the cleaning and preparing food, and some were paid a token by the camp. At Mount Horeb Human Rights Watch was told by Pastor Christian Hukipoti that the prophet would go around all the wards at night praying for the people. On Sundays, those deemed healed by the prophet would be unchained, transferred to the calm room, and allowed to attend Sunday service. Family members of camp patients told Human Rights Watch that they made the decision to take their family members to prayer camps usually on the recommendation of people who had been to such camps and had been healed. Some took their relatives to the camps after they could not be cured at psychiatric hospitals and traditional shrines. For others, prayer camps were closer to their communities, which made it easier to bring a family member for admission. While Human Rights Watch could not ascertain whether people actually got healed at the camps, prophets strongly reported that it happened. Our endeavors to ask them for addresses of those who were healed and returned to communities were futile because they said they did not keep records of the people they treated. While some prophets claimed that those healed never came back to the camp after relapses, some people with mental disabilities that Human Rights Watch interviewed said they had been to such camps more than twice. At Mount Horeb, however, two officials working in the “sanatorium,” the section set aside for people with mental disabilities, said they came in as patients, and when they got healed, they chose to serve those who came in for treatment. However, a nurse who visits Mount Horeb Prayer Camp, said she has not seen someone completely healed in the two years she has been visiting the camps, but she said some get better for some time.

Despite serving as an alternative residential facility for those with mental disabilities, prayer camps operate with little or no state regulation. Many nominally fall under the authority of the Ghana Pentecostal and Charismatic Council (GPCC), an umbrella body for 122 churches and evangelical associations in the country, having been either registered directly as council members or founded by individual members of churches affiliated with the council.[51] The council has an ad hoc committee of elders, which monitors compliance of member churches with the guidelines regulating prayer camps.[52] However, the council’s oversight of the camps is limited, and the camps’ operations are often inconsistent with council guidelines. Prayer camps whose affiliation with the Pentecostal Council has been terminated, or which operate outside its purview, are not subject to any regulation.

The Pentecostal Council has set up structures to govern prayer camps registered with it. These structures include ad hoc committees to monitor their operations and written guidelines for prayer camp operations.[53] According to Rev. Dr. Opoku Onyinah, chairperson of the Ghana Pentecostal and Charismatic Council (GPCC), the guidelines prohibit chaining or fasting of any “sick” person, or restricting which kinds of foods people at the camps could eat. They also require the camps to send persons with mental disabilities to hospitals, and to have vehicles to rush medical cases there if necessary.[54]

The council has sometimes taken disciplinary action based upon these guidelines. For example, in May 2011, the Pentecostal Council disassociated itself and cancelled the membership of Edumfa Prayer Camp—one of the oldest and most prominent prayer camps in Ghana—for failing to meet these standards.[55] Rev. Opoku Onyinah explained that while cancellation of membership does not mean closure of the camp, the public is warned from going to such a camp, until issues that led to cancellation of membership are rectified.[56]

Lack of staff is also a concern in prayer camps. None of the eight camps that Human Rights Watch visited employed a qualified medical or psychiatric practitioner. At Mount Horeb, Edumfa, and Nyakumasi Prayer Camps, where researchers found the largest numbers of persons with mental disabilities, the staff consisted mainly of pastors, prophets, and former patients whose conditions had improved.[57] At Edumfa Prayer Camp, it was largely family members, well-wishers, and a few pastors.

Table 1. Number of Persons with Mental Disabilities Housed at Prayer Camps Visited by Human Rights Watch, November 2011-January 2012

Name of Prayer Camp	Number of people with Mental Disabilities at Time of Visit
Mountains Jesus Divine Temple Mission (Nyakumasi Prayer Camp)	30
Mount Horeb International Prayer Ministries (Mount Horeb Prayer Camp)	135
Heavenly Ministries Spiritual Revival and Healing Center – Church of Pentecost, (Edumfa Prayer Camp)	25
United Bethel Pentecostal Ministry International- Kordiabe	3
Charity Prayer Ministry, Kwadoegye	2

Traditional Healers

According to a report by the Commonwealth Human Rights Initiative Africa, an estimated 70-80 percent of Ghanaians utilize traditional medicine.[58] Many seek treatment from the estimated 45,000 traditional healers (people who practice based on theories, beliefs, and experiences indigenous to different cultures including ritual and herbal methods of treatment).[59]

The Community

According to responses from persons with mental disabilities living in the community and their family members who Human Rights Watch interviewed, there were no medical or physical support systems after patients were discharged from psychiatric institutions. [60]

The community support available to persons with mental disabilities was mainly rendered by civil society organizations, including BasicNeeds Ghana (currently working in five out of Ghana’s ten regions), Mindfreedom Ghana, and Mental Health Society of Ghana (primarily working in the southern parts of Ghana). These organizations help community members with mental disabilities, as well as epilepsy and drug-related psychosis, to access services, especially medication. These organizations mainly work with government-trained community psychiatric nurses or volunteers. [61]