2. Executive Summary


In 2011, the Lusaka-based NGO Mental Health Users Network of Zambia (MHUNZA) asked the international human rights NGO Mental Disability Advocacy Center (MDAC) to accompany it in monitoring ill-treatment of people with mental health issues in Zambia.1 The two NGOs teamed up and carried out an investigation, looking at the reality of people’s lived experiences through the lens of international human rights law. Three monitoring missions were undertaken: one in 2011, another in 2012 and the final one in early 2014. The team visited five psychiatric hospitals, five traditional healing clinics and a mental health “settlement”. Many people gave testimonies: most importantly people with mental health issues themselves.

This report presents the findings of the first human rights monitoring of Zambia’s mental health services. The two NGOs will convene a process of engaging civil society, governmental representatives and other stakeholders to jointly develop recommendations for action on the basis of international human rights law. Our overarching aim is to secure equality, inclusion and justice for all people with mental health issues in Zambia.

Photo: ShutterstockPhoto: Shutterstock

Mental health services
Mental health care in Zambia is governed by an outdated legal framework. Psychiatric services are chronically under-resourced, overly-centralised and dominated by pharmacology. People with mental health needs are subject to pervasive stigma, often resulting in physical abuse in their homes and communities.

Traditional medicine does play a role in the provision of mental health services. Whilst some traditional healers may offer helpful support, others financially exploit people desperate for help, only offering questionable ‘care’ and frequently without the consent of the individual concerned. Legal orders for detention in psychiatric facilities lack safeguards: there is no assessment by a mental health professional, no legal representation, and no involvement of the person concerned. Many others are detained in psychiatric hospitals without any legal basis at all.

The human rights reality of people with mental health issues in Zambia is far from the human rights standards the Zambian government signed up to under international law. Prompt completion of the planned legislative reform and greater resources to provide for a range of care options accessible at the primary level are essential components in developing more human rights compliant mental health services.

Delivery of mental health services to the 13 million people in Zambia has been thwarted by low levels of funding. Currently, less than one percent of the health budget is spent on mental health service provision. There is also a lack of up-to-date mental health statistics available, limiting understanding of mental health needs and hampering evidence-based development of services.

Human rights
Zambia has ratified United Nations and regional treaties containing obligations relating to the human rights of people with mental health issues, including the Convention on the Rights of Persons with Disabilities. In 2012, the Zambian parliament passed the Persons with Disabilities Act based on human rights principles.2 A mental health bill is reportedly in its final stages of development, to replace a colonial-era law focused on the protection of society and incarceration of people deemed of “unsound mind”.3 Case law relating to people with mental health issues is entirely absent: people’s rights and interests have not been legally defended, upheld or developed.

Family members carry the burden of supporting people with mental health issues. Formal psychiatric services are inaccessible to the vast majority of people. Families have minimal support from their communities, given the intense stigma of people labelled as mad. No services are available to support carers, resulting in families struggling to cope and people with mental health issues being chained and tied up.

Many people with whom monitors spoke testified that they had been chained in their own homes or in their communities. Women told monitors that they were beaten by their husbands and in-laws, and that their relatives and others in their community had physically and sexually abused them. Men reported being bullied, teased, harassed and even stoned by people in their community. A staff member in a hospital told monitors that when someone walks naked in a village, “people might hit him as they think he’s possessed. Most of our patients have physical injuries.” He added, “relatives don’t beat to kill, but others can do.”

Victims of violence who have mental health issues are invisible in the eyes of the criminal law. “If someone comes to the hospital with physical injuries there’s supposed to be a police report,” explained one psychiatric hospital staff member, “but if the person is a psychiatric case, the police aren’t involved. Nothing happens.”

Traditional healing
The head of the Traditional Healers’ Association told monitors that almost half of the association’s members were “cheats masquerading as healers”. This acknowledgment of the scale of quack healers echoed testimonies collected from family members desperate for help. One woman explained that she had taken her relative with mental health issues to 25 traditional healers. She said that she found it, “hard to estimate the financial cost of all this as there were payments and also we had to get and give animals – including two cows.” Monitors asked her what advice she had for the government. Her response: “Arrest these people as it’s a kind of stealing. People are being cheated.”

Monitors spoke to several people who have been “treated” for their mental health issues by traditional healers. One woman said, “[t]he tattoos were all over my body […] it was painful.

The first drugs were very painful, the drugs for the eyes. I would sleep the whole day not feeling well.” Other people agreed that the Zambian government must protect its citizens from those who carry out criminal assault in the guise of “treatment”.

Mental health services in the community
Mental health services are nearly non-existent at the primary healthcare level. Instead, mental health services are highly centralised, available only in eight hospitals across Zambia, a country with a landmass larger than France. Costs and journey times mean that mental health services are completely inaccessible to the vast majority of the population. Outpatient psychiatry amounts to symptom management with cheap drugs. No other forms of support are offered. Clinical staff are so few in number that they often do not have time (and in some cases willingness) to inform patients of the potential benefits and risks of different treatments, nor to discuss patient views on medication options. There is little opportunity for early identification and intervention. This seriously undermines the ability of people with mental health issues to get the support they may need to fully participate in their communities.

Psychiatric wards
The country-wide practice of arbitrary detention and forced sedation falls short of Zambia’s commitments under international human rights law.4 According to a 2005 Mental Health Policy, there were 560 psychiatric beds in the country which has a population of 13 million. Working in the country’s mental health system are a total of five psychiatrists, two psychiatric social workers, two psychologists and no trained occupational therapist. All are based in the Lusaka, the capital city, which has a population of over 3 million. Despite the high levels of dedication of the meagre staff, mental health care is inevitably limited: on any mental health ward there are one or two trained nurses on duty at any time. Many of the wards are overcrowded, in particular the acute wards at Chainama Hills Hospital and the male wards at the Ndola psychiatric unit. In-patient psychiatry can be characterised as achieving two things: containing people in decrepit dormitory wards, and sedating people with high doses of psychiatric drugs.

Overcrowding is prevalent, resulting in patients having to share mattresses on the male wards at Ndola psychiatric unit and at Chainama Hills Hospital acute wards. There are insufficient washing facilities and toilets. Some patients have no access to outdoor space. Some are allowed out of the ward only once a week. The wards generally have nothing for people to do. There are no newspapers, books, pens, paper or telephones. There is no information about health, mental illness or rights.

Seclusion rooms are squalid and do not even contain a bucket. In these rooms, detainees are required to defecate and urinate on the floor. People in seclusion are often dependent on other patients to bring food. Chemical restraints are widespread: sedatives are either injected or people are forced to swallow tablets. Psychiatric hospitals use handcuffs. Seclusion and restraints are subject to no review or appeal process, and there is no legal framework regulating these practices. None of the hospitals visited had any policy or operational guidance for staff, nor any note-taking when restraints or seclusion were used. There is no scrutiny by any independent body. Abuses take place behind closed doors and with impunity.

The physical health of patients is compromised by poor hygiene facilities, an inadequate diet and violence by other patients. Many people reported feeling unsafe. Healthcare is routinely denied to psychiatric patients, and clinical negligence has reportedly resulted in deaths. No independent investigations take place after a death in a mental health facility unless the relatives request this.

None of the facilities has a complaints system. Patients are unaware of how they can complain, so abuses are hushed up and no-one is ever held to account. Zambia’s psychiatric hospitals are breeding grounds for abuse. This report seeks to initiate a discussion on how the situation could change. The 1951 Mental Health Act is in urgent need of repeal. It empowers magistrates to sign 14-day detention orders without obtaining the views of the person concerned. Deprivation of liberty and placement of people with mental health issues in psychiatric wards also happens outside of the law. Relatives frequently give proxy consent: an act which has no legal authority.

Mental health care in prisons appears to be minimal. Prisoners and people assessed as being “of unsound mind” during court procedures may be detained in forensic psychiatric facilities. Discharge is possible only when clinicians and a prison officer make a recommendation to the country’s President. Under international law, these people are arbitrarily and unlawfully detained.

Photo: Mattresses are given newly-admitted patients rather than being left on beds at Chipata Hospital. Nurses  complained that people steal the mattresses so they are kept in a locked room. 26 October 2012 © MDAC.Photo: Mattresses are given newly-admitted patients rather than being left on beds at Chipata Hospital. Nurses complained that people steal the mattresses so they are kept in a locked room. 26 October 2012 © MDAC.

1 In this report we refer to ‘people with mental health issues’ throughout to mean people with psycho-social (mental health) disabilities. People with psycho-social disabilities include those who experience mental health issues or mental illness, and/or who identify as mental health consumers, users of mental health services, survivors of psychiatry, or mad.

2 The principles, outlined in section 4 of the Act, include: respect for dignity and autonomy, non-discrimination, recognition before the law, respect for physical and mental integrity, independent living, social inclusion, respect for difference and diversity, equality of opportunity, accessibility, gender equality, respect for the evolving capacities of children with disabilities and the preservation of their identities.

3 Mental Disorders Act 1951.

4 Zambia has ratified the International Covenant on Civil and Political Rights (ICCPR) and its First Optional Protocol, the International Covenant on Economic, Social and Cultural Rights (ICESCR), the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment (CAT), the Convention on the Rights of the Child (CRC), and the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW).

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