Health Policy

Mental health in Zimbabwe: a health systems analysis

Khameer Kidia, Debra Machando, Walter Mangezi, Reuben Hendler, Megan Crooks, Melanie Abas, Dixon Chibanda, Graham Thornicroft,
Maya Semrau, Helen Jack

There has been little external analysis of Zimbabwes mental health system. We did a systems analysis to identify Lancet Psychiatry 2017
bottlenecks and opportunities for mental health service improvement in Zimbabwe and to generate cost-effective, Published Online
policy-relevant solutions. We combined in-depth interviews with a range of key stakeholders in health and mental June 15, 2017
http://dx.doi.org/10.1016/
health, analysis of mental health laws and policies, and publicly available data about mental health. Five themes are key
S2215-0366(17)30128-1
to mental health service delivery in Zimbabwe: policy and law; financing and resources; criminal justice; workforce,
Kushinga, Harare, Zimbabwe
training, and research; and beliefs about mental illness. We identified human resources, rehabilitation facilities, (K Kidia MPhil, D Machando MA,
psychotropic medication, and community mental health as funding priorities. Moreover, we found that researchers R Hendler BA, H Jack BA);
should prioritise measuring the economic impact of mental health and exploring substance use, forensic care, and Arnhold Institute for Global
Health, Icahn School of
mental health integration. Our study highlights forensic services as a central component of the mental health system,
Medicine, New York, NY, USA
which has been a neglected concept. We also describe a tailored process for mental health systems that is transferable (K Kidia, R Hendler);
to other low-income settings and that garners political will, builds capacity, and raises the profile of mental health. Department of Psychiatry,
University of Zimbabwe
Introduction WHO has proposed several frameworks for assessing College of Health Sciences,
Harare, Zimbabwe
Mental, neurological, and substance use disorders account health systems, such as Building Blocks13,17 and the (W Mangezi MBChB,
for between 74% and 13% of disability-adjusted life-years Innovative Care for Chronic Conditions Framework.18 D Chibanda PhD); Institute of
and are the leading global cause of years lived with Additionally, several large research and capacity building Psychiatry, Psychology and
Neuroscience, Kings College
disability.1,2 However, mental health receives less than 1% consortia, in collabor ation with WHO, have used a
London, London, UK (M Crooks,
of health-care funding in many low-income and middle- health systems approach to analyse and strengthen M Abas MD,
income countries (LMICs),3 in which up to 98% of patients mental health services in LMICs.1922 Broadly, all these Prof G Thornicroft PhD,
with mental illness can go untreated.4 Challenges to frameworks examined common health system building M Semrau PhD, H Jack); and
Harvard Medical School,
main taining mental health services in LMICs include blocks, including services, workforce, information Boston, MA, USA (H Jack)
funding and workforce shortages,5,6 supply chain issues systems, resources, financing, and governance.13 These
Correspondence to:
with psycho tropic medications,7 stigma,8 outdated or groups concluded that the most robust mental health Mr Khameer Kidia, Arnhold
inadequate mental health policies,9 and controversy over systems were those that were effectively integrated into Institute for Global Health, Icahn
culturally appropriate diagnosis and treatment.10 primary care and other services and used broad, system- School of Medicine, New York,
NY 10029, USA
Strong health systems are needed to tackle the burden level analyses to structure transitions to a more integrated
kkidia@alumni.princeton.edu
of mental illness.11 A health system is the sum total of all model of service provision.19
the organizations, institutions, and resources whose Zimbabwe is a country with a historically vibrant
primary purpose is to improve health.12 According to community of mental health researchers who helped
WHO, health systems strengthening is a priority for kindle the broader global mental health movement.23,24 On
global health, and systems analysis is a key first step.13 this basis, with increased mental health funding
Health systems analysis identifies bottlenecks and weak opportunities in recent times, Zimbabwean researchers
nesses in health-care delivery to generate cost-effective, have been able to make substantial progress. Their studies
policy-relevant solutions that build on existing structures.14 have explored interventions for de pression in people
There are countless examples in global health where living with HIV/AIDS,25,26 task shifting (ie, delegating
health systems research has fundamentally changed health-care duties usually done by specialised staff to less
the delivery of health care. Researchers in Zimbabwe, specialised or non-specialised staff) for common mental
for instance, identified suboptimal uptake of provider- disorders,27,28 traditional healing,29 and training and
initiated testing and counselling for HIV in children.15 capacity building.30 However, there has been no system-
By use of mixed methods, they identified several wide research on mental health services in Zimbabwe
system-level barriers to uptake: children were often since the 1980s.31 During the past decade, the strain of a
brought to the hospital without an appropriate care hyperinflationary economy has had negative consequences
giver; health-care workers were uncertain about consent on health services in the form of decimation of infra
requirements for testing; and long waiting times and structure, supply chain challenges, worsening access to
lack of stock of testing kits created logistical barriers. In services, and the so-called brain drain of health-care
response to these findings, the team worked with the professionals (ie, skilled health workers seeking
government to implement programmatic changes, opportunities outside the country, in other fields, or in the
including switching to a strategy of routine opt-out private sector).30,32,33 Furthermore, major economic turmoil
testing, training health workers about who can consent and the resulting social stress might increase the burden
for children to be tested, and updating guidelines on of mental illness.34,35 In a recent subanalysis, we found that
consent. With these changes, uptake improved from mental health advocacy was a crucial and desired
71% to 95%.16 component for Zimbabwean stakeholders.36 Despite this

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 Health Policy
finding, the broader evidence base for advocacy has
been inadequate. This study aimed to address this gap
by providing an overview of public mental health in
Zimbabwe, with emphasis on understanding what
structures and services exist, how they are interrelated,
key challenges, and opportunities and priorities for future
action. These system-level findings could inform the work
of researchers, policy makers, and advocates in Zimbabwe
and other low-income settings where similar challenges
and opportunities exist.
Methods
Setting
Zimbabwe is a landlocked country in sub-Saharan Africa
with a population of 15 million.37 The broader health
system has been decimated by economic and political
turmoil38,39 and the major focus is on HIV treatment and
prevention. No comprehensive studies have examined
the burden of mental illness; however, small studies on
depression estimate a prevalence of 1530%, with a
particularly high burden in women.24,40 Although these
estimates are high, similarly high rates (eg, 21% in
Uganda41) have been reported in other LMICs. WHO
reports an alcohol consumption rate of 57 litres per
person per year42 (similar to the average in the WHO
African region of 60 litres per person per year) and a
suicide rate of 166 per 100000 people compared with
30 per 100000 people in neighbouring South Africa.3
Study design
For more on Emerald see Emerald is a mental health system strengthening
https://www.emerald-project. consortium working in six LMICs. We chose to adapt
eu/the-group/consortium
their national-level needs assessment methods for our
study because these tools, created by experts from
leading institutions including WHO, generate in-depth
system-level data about mental health services. Our
teams contextual understanding and experience in
iterative qualitative methods allowed us to adapt these
instruments to the Zimbabwean setting and make
them amenable to generating open-ended, novel data.
We collected data between Jan 5, 2013, and Nov 30, 2015,
and analysed only data that were available during this
period.
Contextual information about mental health services
Through meetings with officials, practitioners, and
other key stakeholders, we collected publicly available
background information about public mental health
care in Zimbabwe. We documented the numbers and
types of health-care workers in the mental health
workforce, cross-checked these lists with other local
sources, and compiled a list of currently operating
See Online for appendix mental health facilities (appendix pp 67).
Policy analysis
Although several policy analysis tools exist,43 we used the
Emerald policy checklists because they had been used in
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other sub-Saharan African countries;21 were tailored for
mental health; and were designed to be used in concert
with other Emerald tools, allowing us to maintain
uniformity and completeness across our data. One
member of the research team (KK or HJ) read each
document and completed the checklists. Other members
of the team reviewed the checklists to ensure that they
were completed correctly. The wider policy environment
was examined via qualitative interviews.
Qualitative interviews
We adapted an interview guide for national-level policy
makers and planners from the Emerald Consortium.21
The interview guide included open-ended questions
about the following areas of the mental health system:
law and policy, coordination and consultation, financing,
integration, human resources, monitoring and evalu
ation, and quality assurance and ethics. These methods
have been described elsewhere36 and are further detailed
in the appendix (pp 14).
Before the study, we obtained ethical approval from
the Medical Research Council of Zimbabwe, the Joint
Research Ethics Committee, and the Icahn School of
Medicine Institutional Review Board. Before each
interview, the interviewer described the study to the
participant in plain English or Shona and obtained
written consent.
Results
Study sample
We interviewed a range of leaders and national-level
stakeholders in mental health, including policy makers,
administrators, providers, and researchers (30 participants;
appendix p 5), between Jan 5, 2013, and Nov 30, 2015. The
interviews revealed five themes that are key to mental
health service delivery in Zimbabwe: policy and law;
financing and resources; criminal justice and forensic
services; workforce, training, and research; and beliefs
about mental illness. Illustrative quotations are provided
in panel 1. The following sections are structured on the
basis of information from the qualitative interviews and
enriched with publicly available data and policy analysis if
available.
Policy and law
We have summarised documents governing mental
health care by use of criteria adapted from checklists used
by Emerald for assessing mental health policies in other
LMICs (table). Most interviewees were aware of the
existing policies and laws. Three ideas emerged in their
discussions: lack of implementation, a need to update the
older policies, and minimal consultation of stakeholders
in policy formation. The overwhelming concern of all
participants was that policies were never fully
implemented, generally because of human and material
resource constraints. Participants also highlighted that
policy creation and revision was not a resource-neutral

process. They explained that the government did not have
adequate funding and technical resources to complete
policy revisions, which requires funding for meetings,
public consultation, and printing.
Communication was poor in the policy-making process
and some stakeholders, especially patients and providers,
were not adequately consulted. For example, psychiatrists
said that a set of treatment protocols created by the
Panel 1: Illustrative quotations for the five key themes in mental health service delivery
Policy and law
I think it was in the Mental Health Policy. I last saw it I think 2 years
ago, I tell you if you go through it, its a brilliant piece of paper with
brilliant ideas and brilliant things Policy is very good but it all
comes back to the implementation of what is on the paper
[The authorities say:] We are not allocated enough budget from
the treasury. We do not have enough money Thats the same
excuse every time: budget. (Participant 10, psychologist)
The current Mental Health Act is actually outdated because
according to WHO any policy or legislation should be reviewed
every 10 years and this Mental Health Act was launched in
1996. So obviously it expired in 2006 and we are almost going
to 2016, which will be 10 yearsso its outdated. We have been
advocating to review it but finances are not coming.
(Participant 14, policy maker)
Financing and resources
So thats the challenge of medication: one, short supply;
two, old generation [drugs], which have a lot of side-effects
and can lead to medication default... Most [patients] relapse
because there are no drugs. (Participant 4, psychiatrist)
You can have huge sums of money going into HIV and huge
sums of money for cancer because these are killing diseases. But
for mental health because maybe its presumed it doesnt kill so
maybe people [dont] give [mental health] enough attention.
(Participant 10, psychologist)
Criminal justice and forensic services
Here the police come direct and say, Sister, inject that person
its none of our businesshe is mad. We will leave him here. will come to me as well Some just come and dump their
(Participant 16, mental health nurse)
I mean its an embarrassing backlog: you would find somebody
sitting in prison for 10 years and they are still waiting for that
mental health assessment. (Participant 18, policy maker)
That relationship [between the Ministry of Health and Ministry
of Justice] is not good because there is this misunderstanding
about who is responsible for the mental health division in the
prisons. (Participant 2, psychiatrist)
Workforce, training, and research
the strength is knowledge and skills of existing professionals.
I tell you, we have experienced and skilled people who have got
a lot of knowledge, brilliant ideas, but the implementation of
those ideas can be limited because of funds. (Participant 10,
psychologist)
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Health Policy
Ministry of Health and Child Care in collaboration with
WHO were written without adequately consulting
psychiatrists. This oversight led to delays in the
dissemination and implementation of the protocols
because psychiatrists felt that the protocols were
inaccurate and needed several corrections, which were
submitted and ultimately reflected in the final document.
Regarding the involvement of patients, the Zimbabwe
The biggest challenge really is the manpower services because
we are saying the structures are laid but there are no personnel
to actually occupy those. (Participant 11, administrator)
Most of all I think what is needed is, first the baseline research.
A very carefully thought-out strategy that builds on what
existing resources there are. (Participant 15,
non-governmental organisation worker)
A lot of work also needs to be done in terms of research and
establishing the facts As an advocate you really need to be
very much well based in the issues that you will be advocating
for. (Participant 6, non-governmental organisation worker)
The traditional healer...is alreadyworking with the people at
community care level with mental illness...so...the
western-trained person [should] train the traditional healer to
identify people who are at risk at [the] community care level.
(Participant 1, physician)
Beliefs about mental illness across the sectors
Instead of leaving mental health to stand on its own, it should
be integrated just like we are talking [for] HIV. We should also
say HIV, TB, add it to mental healtheven reproductive health,
add mental health so that probably it eases the burdens
But today there has been verticalisation of programmes.
(Participant 18, policy maker)
Thats why you find that many of our patients here are
shunned. Once they suffer mental illness no one wants to take
responsibility because they feel like probably the spirits are
there, or something, so if I take responsibility that same thing
relatives and disappear. They give wrong phone numbers and
wrong addresses and they disappear for good because they
dont want to have anything to do with this person anymore.
(Participant 1, physician)
In our setting, you find people think that mental health is due
to spiritual things more than they think its a medical problem.
Thats why even in private practice, when you see a patient
coming, he is actually afraid to see a psychiatrist. Because they
would rather go to a prophet or other people. (Participant 20,
psychiatrist)
 Health Policy

Mental Health Act Mental Health Policy Mental Health Strategy

Author Ministry of Health and Child Care Ministry of Health and Child Care Ministry of Health and Child Care and WHO
Date enacted 1996 2004 201418
Description Outlines the legal rights of patients Governments guiding principles Specifies, with targets and objectives,
with mental illnesses, their for provision of mental health a plan for implementing the countrys
caregivers, and their providers services policy
Standalone
Based on data
Appropriate consultation with other
health departments in Ministry
Appropriate consultation with service
users and caregivers
Promotes cultural approach
Human rights
Community care
Integration
Evidence-based practice
Intersectoral collaboration
Equity with physical health
Deinstitutionalisation
Financing and funding
Preventive mental health
Chronic care and rehabilitation
Advocacy
Information systems
Human resources and training
Ability for service users, caregivers,
and health-care workers to voice
grievances
Severe mental disorders
Children and adolescents
Elderly people
Intellectual disabilities
Substance use
People affected by trauma
Underserved populations
Notes Lacks costing of specific targets and plans
for how activities will be funded

A tick indicates that the item describes or is present in the document. Other relevant documents: Mental Health Regulation Statutory Instrument 62 (1999); Guidelines and
Treatment Protocols for the Management of Common Mental Health Disorders in Primary Care (2011); National Alcohol Policy (currently in draft). There are policies and legal
frameworks outside of mental health that have implications for mental health service users, especially in the forensic system (eg, Police Act and Prison Act), but these are not
widely known or understood.

Table: Mental health documents

National Association for Mental Health, a leading local
non-governmental organisation that has been advocating
for the inclusion of service users in policy formation, was
not consulted in the writing of the Mental Health
Strategy in 2013.
Financing and resources
Although efforts were made to deinstitutionalise mental
health in the 1980s, no facilities or community services
were created for care of patients with chronic mental
disorders. Only two non-governmental organisations
are dedicated to mental health in vulnerable populations,
one that provides mental health care for victims of torture
and another focused on advocacy and rehabilitation
services. These organisations rely on funding from
international organisations such as USAID and provide
services primarily in several small facilities outside Harare
in northern Zimbabwe.
Most government funding is allocated to public mental
health facilities (figure and appendix p 6), which submit
annual budgets to the Department of Mental Health
Services at the Ministry of Health and Child Care via the
provincial medical director for their respective districts.
The Ministry of Health and Child Care submits a final

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budget to the Ministry of Finance, which is ultimately
responsible for allocating funds for health.
Participants overwhelmingly believed that funding
allocation for mental health care was insufficient and
inequitable and had worsened because of Zimbabwes
economic downturn. Administrators struggled to
communicate their mental health budget justifications to
national-level decision makers, who viewed other areas of
health care (such as HIV, tuberculosis, or malaria) as more
important. Additional funding in areas such as HIV and
tuberculosis allowed government-health-worker salaries to
be augmented, aiding recruitment and retention. Funding
priorities suggested by participants included increased
salaries for mental health workers, expansion of
rehabilitation and chronic care facilities, and improving
the supply of psychotropic medications (panel 2).
Some psychiatric units had been closed down or were
non-functional because of inadequate resources. For
example, Sakubva Hospital in Mutare was closed
because the building was condemned and there was
insufficient funding to repair it. Although psychotropic
medications are technically available for free in the
public sector, many facilities do not have a steady
supply chain for the three main drug classes
(antipsychotics, antidepressants, and mood stabilisers),
even though these drugs are available in Zimbabwe to
paying users in the private sector. Health-care workers
often used one or two medications to treat a wide range
of psychiatric disorders, because these were the only
medications available.
Criminal justice and forensic services
Many participants explained that if a law enforcement
official determines that a person who has committed a
crime is mentally ill, that individual will be tried before
a judge who will decide whether or not to sentence him
or her to Mlondolozi or Chikurubi: facilities termed in
policy as special psychiatric institutions for the care
and custody of offenders with mental illnesses. The
Zimbabwe Correctional and Prison Services, a branch
of the Ministry of Justice, governs these facilities.
Participants were uncertain whether forensic patients
should be managed by the Ministry of Justice or the
Ministry of Health and Child Care and believed that
coordination between these two ministries was limited.
There are three forensic psychiatrists in Zimbabwe,
two of whom only work part-time in the prison system.
Two bodies are responsible for upholding the rights of
these patients: the Special Board and the Mental
Health Review Tribunal. The Special Board reviews
patients who the mental health-care team at the facility
deem fit for reintegration into society and then refers
them to the Mental Health Review Tribunal. The
Tribunal, which regulates the legal welfare of forensic
patients, is supposed to review every case within
30 days of detainment, and ultimately determines a
patients release date.
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Health Policy
Mashonaland central
Mashonaland west
Harare
Mashonaland
Matabeleland north east
Midlands
Manicaland
Bulawayo
Masvingo
Matabeleland south
Teaching hospital
Chronic facility
Provincial hospital
Forensic facility
Halfway homes,
rehabilitation, or day care facilities
Figure: Public mental health facilities in Zimbabwe
Nearly every respondent voiced concerns about
human rights in the forensic system and spoke about
the centrality of forensic care within mental health
services since this system houses a large proportion of
patients requiring chronic care. Participants working in
the forensic system noted that police officials often did
not correctly complete the appropriate paperwork to
commit an offender who is mentally ill. Consequently,
missing or inaccurate documents could prolong the
pre-trial holding period. Participants were also
concerned about the low frequency of meetings and
inaccessibility of the Mental Health Review Tribunal,
which reviews patients for release. Without frequent
meetings, patients in the prison system often stay far
longer (sometimes several years) than the official review
period of 30 days.
Some participants felt that the paucity of chronic care
facilities might have contributed to the additional burden
on the forensic system because patients with chronic
disorders who have no community-based care might be
charged with minor crimes, such as petty theft, and then
be arrested and admitted to Chikurubi or Mlondolozi.
According to respondents, forensic facilities were sub
stantially under-resourced. Patients lived in very over
crowded holding cells with unhygienic living conditions,
a high prevalence of sexual assault and HIV transmission,
minimal access to psychotropic medications and
psychiatric care, and little food. The Ministry of Justice,
together with Mdecins Sans Frontires (MSF), began a
project at Chikurubi Prison in 2013 to provide mental
 Health Policy
Panel 2: Areas for action in Zimbabwe and similar settings
Funding priorities
Workforce
Increase remuneration for mental health workers and
expand the capacity of non-specialist providers
Medications
Improve supply of psychotropic medications and work to
remove barriers to access and adherence to psychiatric
medications
Forensic care
Enhance service provision, living conditions, and human
rights for prisoners with mental illnesses
Rehabilitation
Expand chronic care and rehabilitation facilities for people
with chronic, severe mental illness
Community mental health
Improve education, outreach, and awareness and engage
communities
Policy
Provide funding for the policy-making process including
building diverse steering committees and basic costs such
as printing and dissemination
Research priorities
Forensic care
What does forensic care look like in Zimbabwe and other
African countries?
How do we best support forensic systems?
Economic impact of mental health
What is the economic burden of not acting on mental
health?
What is the comparative cost-effectiveness of different
interventions?
Substance use
What is the burden of substance use in Zimbabwe and
similar countries in the region?
Which interventions work well in low-income settings?
What are the system-based drivers for substance use in
low-income and middle-income countries and where can
we intervene?
Integration of mental health
How do we best integrate mental health into other
health-care services?
health care and material resources, such as food and
blankets.
Workforce, training, and research
Since the mental health workforce was primarily trained
at local academic institutions that performed research,
many participants working in this part of the system
had substantial overlap between education and research.
On the basis of data from national registries in 2016,
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there were 17 psychiatrists, 25 clinical psychologists,
463 psychiatric nurses, and 150 occupational therapists
registered in Zimbabwe. The actual number of providers
in the Zimbabwean workforce is generally lower. For
example, of the 17 registered psychiatrists, only 14 work
in mental health care in Zimbabwe. 12 of the
14 psychiatrists are based in Harare, leaving most of the
country without access to specialist care. The countrys
2014 dir ectory of private mental health practitioners
lists 26 private clinicians (unpublished). However, only
one psychiatrist and two clinical psychologists work in
full-time private practice. Prices in the private sector are
typically high (for instance, one psychiatrist charges
US$150 per hour) and unaffordable for most of the
countrys population.
Because of cultural beliefs surrounding the causes of
mental illness and the paucity of public mental health
care, traditional and faith healers are often the first pro
viders that individuals or families with a mental health
concern consult for help. Zimbabwe African National
Traditional Healers Association and Traditional Medical
Practitioners Council govern traditional healing services.
Some patients also consult faith healers, who, unlike
traditional healers, are associated with specific churches.
Although participants noted that there were not
enough mental health workers, they praised the current
mental health workforce for being skilled and motivated
and for working well in care teams. Respondents raised
three concerns about the workforce: communication,
retention of trained providers, and a health worker hiring
freeze.
Although members of the mental health workforce
work well together, they do not communicate well with
other health-care workers, such as primary care doctors
or traditional and faith healers. This shortcoming creates
duplication of services and incompatible treatment plans
from different providers. Siloing (when stakeholders in
one part of a system isolate their activities from
stakeholders in another part of the system) also occurred
between researchers and practitioners.
The brain drain of health-care professionals has been a
persistent problem in Zimbabwe and many LMICs;
however, within the past decade, this trend has increased
in Zimbabwe because of the economic instability.
Although many nurses have been trained in mental
health, a large proportion have not stayed in this field or
have taken jobs at non-governmental organisations for
higher salaries. Stigma and poor compensation make
psychiatry the least popular specialty among Zimbabwean
medical school graduates; however, an initiative funded
by the National Institutes of Health has improved in
centives for trainee psychiatrists, such as research
funding, external mentorship, and opportunities to travel
to further training.
According to participants, the government instituted a
hiring freeze for health-care workers in 2012. Since that
time, many psychiatric nurses have been diverted to

other areas of care such as HIV and their roles in
positions in mental health have been left empty. Several
job positions in psychiatric wards at regional hospitals
have been assigned for hiring in accordance with the
countrys mental health strategy, but no funding is
available for their salaries.
Several research programmes and training opportunities
exist (appendix p 7). Most notably, the Friendship Bench,
a task-shifting intervention for common mental disorders,
has been scaled to more than 70 primary health-care sites
nationwide in a cluster-randomised controlled trial funded
by Grand Challenges Canada.28
Researchers, clinicians, and non-governmental organ
isation workers noted that mental health research was a
strength for Zimbabwe; however, several practitioners
called for better dissemination of findings and more
data and evidence about mental health care in the
country. Participants were able to identify several key
priorities for future research (panel 2).
Beliefs about mental disorders
Many interview responses focused on the impact of
politics and the economy on the prevalence of mental
illness, cultural interpretations of mental disorders, and
the pervasiveness of stigma surrounding mental illness.
Some researchers and non-governmental-organisation
workers believed that the burden of mental illness was
unusually high in Zimbabwe because trauma and
political violence, together with financial stress from the
economic climate, have fuelled the prevalence of
depression, anxiety disorders, post-traumatic stress dis
order, and suicide. Clinicians also felt that, in recent
times, the burden of substance use disorders (especially
alcohol and several illegal energy drinks with unknown,
unregulated ingredients imported from neighbouring
countries) was rising in both urban and rural settings
and that they were not well prepared for clinical work in
this area because of a paucity of training and available
treatments. However, there was great interest in research
about substance use disorders from ministry officials,
researchers, psychiatry trainees, and practising
clinicians. Many respondents called for additional
inquiry into prevalence and management of substance
use disorders in the country.
When discussing the causes of mental disorders,
respondents noted that many people in the community,
although not the respondents themselves, thought
mental illness had a spiritual cause. Some participants
believed mental health was highly dependent on cultural
context and that mental illness should be viewed
contextually by obtaining collateral information from
family members during treatment. Local idioms for
mental distress, such as kufungisisa (thinking too
much) and moyo unorwadza (burdened heart) were
regarded by participants as far more prevalent than
classic symptoms seen in high-income countries, such
as depression, anxiety, or sadness.
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All participants noted that stigma surrounding mental
illness continues to be a major challenge. In addition to
affecting help seeking, it prevents individuals with
mental illness from integrating into the community,
particularly after an inpatient hospital stay. To help tackle
stigma, participants, particularly practitioners, explained
the importance of advocacy, clear communication with
family members about a patients care, and promoting For more on the Friendship
community-based mental health services. For example, Bench see http://www.
friendshipbenchzimbabwe.org
as part of the Mental Health Strategy, many mental
health facilities were allocated a post for a public relations
officer, whose job description includes community
outreach and contacting willing family members of
patients. However, these posts, deemed non-essential,
have not been filled because of insufficient funding.
Discussion
To our knowledge, this is the first in-depth study of
the Zimbabwean mental health system in nearly
three decades.31 Since then, some strengths have anchored
the system. We identified several facilities dedicated to
mental health and a motivated, skilled workforce.
Substantial progress has been made in terms of mental
health laws and policies, which were standalone (rather
than part of broader documents) and fairly up-to-date
relative to those seen in the 1980s and those currently seen
in many other LMICs.3,11,20,4446 Despite these successes,
resource constraints and communication and coordination
challenges emerged as cross-cutting themes and were
barriers for policy implementation and service provision.
These challenges were most pronounced in the forensic
system: another central issue across our data. We discuss
lessons learned from and limitations of our work and
explain how we have used our research for advocacy.
Resource shortages
In view of the countrys recent economic instability,
resource constraints have been particularly detrimental
for the Zimbabwean mental health system, even relative
to other LMICs.11,47,48 These constraints affected med
ication supply chains and policy implementation, and
created workforce challenges. Access to psychotropic
medication is a core component of strong mental health
systems; however, supply and demand side issues are
prevalent in low-income settings.49,50 Aspirational policies
(eg, provision of free psychotropic medication in the
public sector) were difficult to implement in Zimbabwe
because of few resources. Policy makers had little
funding for creating diverse steering committees,
technical assistance, and associated expenses needed to
draft and disseminate new policies. Similar findings
have been described in South Africa,51 underscoring that
policy formation and implementation are not resource-
neutral interventions in low-income settings. Finally, low
salaries, minimal incentives, and adverse working
conditions have made it difficult to recruit and retain
health-care workers and to maintain an equitable
 Health Policy
distribution across the country. The Global Health
Observatory shows 008 psychiatrists per 100000 people
in Zimbabwe, which is consistent with our findings and
is typical for most countries in the region.3,52 Similar
workforce challenges were identified in Ghana53 and
other sub-Saharan African countries,6,54 but these
challenges have been intensified in Zimbabwe by the
adverse economic and political climate.30 Human and
material resource constraints increase the urgency for
development of community-based interventions that
build capacity among non-specialist providers, an area
where Zimbabwean researchers have quickly reached
substantial scale.27,28 Concurrent work establishing the
effectiveness of lay health workers for delivering inter
ventions for depression and anxiety has been successful
in Pakistan,55 India,56 and several other LMICs.6,54,57,58 In
Uganda, group interpersonal therapy has been another
successful approach for overcoming workforce gaps.59
These interventions are transforming mental health
services in low-resource settings and should continue to
be prioritised by researchers and funders.
Communication and coordination
An issue that cut across themes was poor communication
and coordination between stakeholders and institutions
and with the community. Our findings parallel those
from South Africa where collaboration was poor at the
district level and with the justice sector,60 making it
difficult to intervene on forensic services.
Panel 3: Lessons learned from our work that are transferable to other low-income
settings
Mental health systems data collection and analysis is not a one-size-fits-all process.
Tailored methods, based on existing frameworks but iteratively adapted by experts
with deep contextual understanding, can elicit novel findings that can help pave the
way for future change. Triangulating publicly available quantitative and contextual
data with policy analysis and rigorous qualitative methods increases the utility of any
of these components alone.
Performing health systems research can help build networks and capacity. By
approaching and involving stakeholders at every corner of the system, it is possible to
develop key partnerships for advocacy and system change. Health systems research
also strengthens communication throughout the system and builds capacity among
local researchers.
Diverse research teams are best equipped to study mental health systems. Team
diversity builds capacity in conducting health systems research and increases the
validity of findings. We believe that ideal teams should include:
Members from multiple disciplines and areas of practice, including research and
policy experts and practitioners.
Local researchers familiar with the culture and context, and international members
able to provide comparative input.
Early-career and experienced researchers.
Broad, ethical, and iterative dissemination of health systems data is essential. Health
systems data should be shared widely, as soon as it is available. This strategy allows for
cross-checking of facts, gives stakeholders evidence of where to make change in their
practice, and increases the profile of mental health by highlighting areas for discussion.
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General medical providers rarely communicated with
mental health workers, and received only minimal
training in mental health. Thus, poor communication
and coordination have made it difficult to integrate
mental health care into other health-care settings.
Findings from other sub-Saharan African countries have
shown that integration can be challenging,61 and that
education and strong communication channels with
district-level coordinators are crucial for achieving well
integrated and decentralised mental health-care
systems.62
Poor communication and collaboration also hinder
community engagement because providers and planners
tend not to involve service users or their family members
in policy making or advocacy.36 These obstacles are
pervasive and require future work in LMICs, where
strong community mental health services are key for
closing the mental health treatment gap.63
Forensic services
Across our data, forensic care was a primary means for
service delivery for those requiring chronic care and an
area with concern for human rights abuses. Conditions
for patients with mental illnesses in prisons, although
improved after the joint efforts of the government and
MSF, remain unacceptable. Since multiple stakeholders
and government departments are responsible for
offenders with mental illnesses, policy making and
implementation for these patients has been fragmented.
This issue possibly only came to the fore in our study
because Zimbabwe has a relatively developed referral
pathway for criminals with mental illnesses compared
with other African countries.6467 In LMICs where forensic
pathways are less clearly defined, patients with mental
illnesses who commit crimes are likely to be equally as
neglected. This situation combined with political
barriers, probably explains the dearth of literature on the
topic.6870 In view of the bureaucratic and legal challenges
to understanding this important component of mental
health systems, researchers and policy makers in the
region must prioritise future inquiry into prison mental
health.
Applications for practice
In Zimbabwe, our study created dialogue about mental
health. We found that the data collection and dis
semination process, including the stakeholders meeting
and subsequent policy meetings, gave rare opportunities
for people who were interested in mental health to voice
their opinions. Our findings will provide current
information for practitioners and policy makers and
identify priority funding areas and key gaps for future
research. Many of the gaps exist in other LMICs, which
have similar barriers to the implementation of policy and
provision of equitable mental health care (panel 2).
There are several lessons from our research process and
findings that are generalisable to other settings (panel 3).

We believe that diverse research teams, capacity building,
and broad dissemination are key ingredients for high-
quality systems research.43 Additionally, our tailored
research processwhich triangulated quanti tative data
from stakeholders, stakeholder meetings, worker registries,
and official documents; systematic analysis of policy
documents; and rigorous qualitative methodsadds to
existing frameworks for collecting and presenting data on
mental health systems in LMICs.21,22
Limitations
Our research had several limitations. First, it was often
difficult to discern the accuracy of information provided
by participants. Some participants were guarded in
interviews because of concerns about retaliation or the
confidentiality of their work. We worked to resolve this
by cross-checking opinions with written reports and the
views of other respondents and by holding a stakeholders
meeting. Second, our study did not include service users,
a group that is too often marginalised from discussions
about challenges and priorities within mental health. In
view of the ethical challenges posed by conducting
qualitative research with vulnerable populations (such as
some people with mental illness), we believed that a
preliminary study to understand the mental health
system was essential before designing a tailored,
sensitive interview guide for completing thorough
interviews with a range of patients. Because service users
might have a range of perspectives, we do not believe
that including one or two service user voices (as would
have been appropriate in the context of a broad study
such as this one) would have adequately conveyed the
depth and diversity of experiences. Finally, this study was
limited by how quickly the Zimbabwean mental health
system was changing. Some of the data we obtained
became outdated during the 3-year data collection period
(eg, the number of mental health workers); however, we
have striven to provide information that is correct at the
time of publication.
Progress since this study and research as advocacy
There has been some progress since our data collection.
For example, the government, in collaboration with
MSF, has worked in Harare to reopen a large acute
psychiatric ward and provide forensic psychiatric services
at Chikurubi. Despite the challenging political and
economic climate, these recent successes are testament
to the resilience of the Zimbabwean health system.
Since the study closed, our team has disseminated our
findings broadly. We wrote a summary report of our
findings and a series of targeted policy briefs. On the
basis of a stakeholder analysis, we contacted and met
with many of the participants and other key personnel
in health services in Zimbabwe to present these
documents, describe our findings, make recom
mendations, and obtain further feedback on the study.
We realise that there are still many gaps leaving patients
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Health Policy
Search strategy and selection criteria
For academic literature on mental health systems in
Zimbabwe, we searched PubMed and Google Scholar from
inception to Nov 30, 2016, with key terms including mental
health, Zimbabwe, Africa, health system*, depression,
schizophrenia, and health policy. We obtained survey data
from WHOs Mental Health Atlas and Global Health
Observatory. Key informants in Zimbabwe provided policy
and legal documents. We consulted with experts in the field
to ensure that we had not missed any important sources on
mental health in Zimbabwe.
with mental illness underserved. By building trusting
relationships and engaging the very people who can
take action on the basis of our findings, we hope this
dissemination strategy will help to raise awareness
about mental health, combat stigma, and provide ideas
and contextual information that facilitates action to
strategically close existing gaps in service provision.
Contributors
KK, HJ, GT, MS, WM, and DC conceptualised the study. RH was
responsible for data curation. KK, HJ, RH, MC, and DM contributed
to formal analysis. KK acquired funding. KK, HJ, and DM conducted
investigations. KK, HJ, and MS designed the methods. GT, MA, DC,
and WM supervised the study. KK and DM wrote the first draft and
HJ, RH, WM, MA, GT, MS, DC reviewed and edited subsequent
versions of the manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
This project was supported in part by an Alpha Omega Alpha
Carolyn L Kuckein Student Research Fellowship to KK. GT and
MS are supported by the European Union Seventh Framework
Programme (FP7/2007-2013) Emerald project. The development of the
tools used to collect the data for this publication was funded in part by
the European Unions Seventh Framework Programme
(FP7/2007-2013) under grant agreement number 305968. GT is
supported by the National Institute for Health Research (NIHR)
Collaboration for Leadership in Applied Health Research and Care
South London at Kings College London Foundation Trust. The views
expressed are those of the authors and not necessarily those of the
NHS, the NIHR, or the Department of Health. GT acknowledges
financial support from the Department of Health via the NIHR
Biomedical Research Centre and Dementia Unit awarded to South
London and Maudsley NHS Foundation Trust in partnership with
Kings College London and Kings College Hospital NHS Foundation
Trust. The funders had no role in study design, data collection, data
analysis, the decision to submit for publication, or preparation of the
report. We would like to thank Alex B Hill for preparing the
illustration of mental health facilities in Zimbabwe.
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