Decentralizing Mental Healthcare in Rural Rwanda: A Conversation with Hildegarde Mukasakindi

Hildegarde Mukasakindi at the Partners in Health/Inshuti Mu Buzima Kigali Office. Photo taken by author

As a development practitioner and anthropologist, I am deeply interested in the diverse cultural understandings and social implications of mental illnesses and psychosocial interventions. October 10th is Global Mental Health Day, and this year I am celebrating it in Rwanda.

On this day and every day, it is important to uplift the visionary leaders and passionate advocates who are working to strengthen primary health care systems to include quality mental health care in their communities. As a Global Health Corps Fellow at Partners In Health’s sister organization Inshuti Mu Buzima (IMB), I have the opportunity to work with a leader who is constantly raising the standards of excellence in mental healthcare for herself and her team.

Hildegarde Mukasakindi is the Assistant Director for Mental Health at IMB, where she has spent over two years advancing the Ministry of Health’s vision for decentralized mental healthcare services in Burera, an IMB-supported district in Northern Rwanda. Hildegarde graciously agreed to talk with me about her vision for the future, what challenges she’s faced in making quality mental healthcare accessible and affordable in rural communities, and her advice for young professionals interested in global mental health.

What is your vision for mental health in Rwanda and what would you like to see happen in the next five years?

We would like to see quality mental health services fully integrated into primary health care in the three IMB-supported districts and then throughout the country. We would like to have enough fully trained workers to be able to deliver mental health care in decentralized settings. At the community level, we want the community to fight against stigma towards mentally ill patients, to improve their understanding of mental health, and to be able to access mental healthcare close to where they live.

In five years, we would also like to have a psychotherapy intervention integrated in the mental healthcare package in IMB-supported districts and later on, throughout Rwanda. There are some mental illnesses that require a combination of medication and psychotherapy. There are others, according to the level of the illness, that don’t require medication for patients to recover from crisis. For example, for minor depression or PTSD, sometimes psychotherapy can be enough.

When you say fighting against stigma at the community level, what does that look like for you?

I would like to see families who have people with mental illnesses, local leaders, and neighbors really understanding that mental health is an illness that requires care and support. I want them to understand that mentally ill patients are just like other patients instead of regarding them as dangerous people. I wish for the community to see them as people who need help, people who are approachable, and people who can really contribute to the development of the family, community and country as long as they are well-treated.

When I talk about stigma, I’m talking about the perception the community has towards mentally ill patients — essentially how they lose trust in them as fellow human beings. When a mental health patient is treated and has recovered, it is still difficult for them to be well-integrated and accepted by their family and their community. This is not true for someone who has recovered from malaria or another other physical illness. In five years, I wish to see our community welcoming people who have recovered from mental illness.

What does improved access to mental healthcare look like for you?

When patients suffer from mental illnesses, they go first to traditional healers and church leaders to receive advice and prayer. We must improve the community’s understanding of the medical component of mental illnesses so they move away from interpretations that the ill are possessed by ghosts, evil spirits, or ancestors as punishment. We must ensure that they understand the medical component first.

Of course, we also need to make sure that the appropriate health services are available to the community. To do this the primary healthcare system must be strengthened so it can deliver quality mental healthcare alongside other medical interventions. The more the family and community believes the patient will receive proper care, the more they will come back to the health facilities for support and treatment.

What do you envision when you think about a trained workforce for mental health?

Rwanda and other developing countries are facing a shortage of mental healthcare providers. One of the Rwandan government’s major priorities is to train people at the community level to deliver quality mental healthcare through primary healthcare centers at district hospitals. So when we think about a trained workforce, we think about training nurses, general practitioners, and community health workers. We think about having enough of them who are trained, engaged, and committed to serve as mental health service providers.

One of our Mental Health program goals is to promote mental health service decentralization by implementing a sustainable model of care that provides effective, equitable, and high quality mental health services. We take nurses and doctors who receive general training at school and give them in-service training so they can manage mental health cases. We are focusing on Burera, one of the IMB-supported districts in Rwanda, but in five years we hope that the Ministry of Health will take the lessons learnt from Burera district and expand the program to other district hospitals around the country. We are hoping that all general practitioners and nurses in Rwanda will have a chance to gain the knowledge and skills they need to provide quality primary mental healthcare at their facilities.

So I’m hearing you say that there is a clear commitment from both government leaders and health providers to addressing mental health. Who else is connected and responsible for improving mental healthcare in Rwanda?

Mental health requires collaboration between sectors at every level, and our development and health systems must complement each other. If we consider a development goal for our country like universal education, we can’t achieve this without adequate mental healthcare services. If a parent is mentally ill, they will not be able to take a child to school. If a child is a mentally ill, they will not be able to follow lessons well in school. With proper mental healthcare, we can help each of them recover from their illnesses so that the child can follow lessons in school and the parent can take care of their family and support their child’s studies.

Mental health also connects to other indicators and goals for our health system. If a mother has depression, she may not take care of herself during her pregnancy. Zero maternal deaths cannot be achieved without mental health services. Mental healthcare is a key component for achieving our health and development goals as a country.

What are some of the main challenges that you’ve faced in decentralizing mental healthcare services in Rwanda?

The strategic plan to integrate mental health into primary care by decentralizing mental health at the community level is well-defined by the Government of Rwanda. IMB’s role is to support the Ministry of Health in implementing this plan.

Of course, the beginning is always challenging. We are struggling to find qualified personnel to implement the strategic plan at the primary healthcare level. Stigma related to mental illness has been a challenge. Stigma is not only an issue in the community; even some professionals who are not trained in mental health perpetuate stigma. Poverty and lack of family support also hinder adherence to medical care.

Step-by-step, we’ve been working to support the government and prove that change is feasible. We do outreach to improve the knowledge of healthcare providers and help families to change their behaviors and attitudes towards mental health patients. We provide financial and medical support to patients. We help create rehabilitation activities to make mental health patients productive so that the family and community can see that they are people who have value. We also provide psycho-education to the entire community and engage with local leaders to get buy-in.

Currently Inshuti Mu Buzima’s mental health program is in 19 health centers in Rwanda. When you think back on your past two years at IMB, can you think of one example of a challenge that you faced and how you overcame it?

In the beginning, it wasn’t easy. At the health center level there was a need to review policy to allow mental health medication to be available and covered by public health insurance. This was our main challenge. We worked with the government health care providers, the Ministry of Health and government officials in charge of public health insurance and the essential medications. We worked with them to make amendments to ensure that patients receiving mental healthcare at facilities were included and could have their medication costs covered by public health insurance.

What is your advice for young professionals who are interested in global mental health?

We really need the younger generation’s commitment and sacrifice to make change in this field. I know some people consider mental health a difficult field, but in my seven years of experience, I have found that when you are committed and engaged, it is a very interesting field to work in. You can have tangible wins. In most developing countries, mental health is a new domain so it’s an area ripe with opportunities for growth. It’s an opportunity for young people to show they’re capable of bringing change and continuing the work of others before them.

I encourage young people to fall in love with this field and continue working in it despite the challenges. The strength of a person is shown in overcoming challenges, not being afraid of challenges. The government and global health community are committed to develop mental health services. If we consider the Sustainable Development Goals, for example, we know that we cannot have sustainable development without mental health. As we are moving globally to develop our countries, I invite young people to contribute, starting with mental health.

It is really the root of development. I remember I had a discussion with colleagues who shared that they were struggling with persistent cases of malnutrition. They told me that despite their efforts to fight malnutrition, they were still seeing children suffering from acute cases. I told them that I would start with the mind of the mothers. It is difficult for a mother who has untreated depression to take care of her child. You can give me healthy food, but if my mind is not ready to prepare this balanced diet and give it to my children, you will not end my child’s malnutrition.

…you cannot care about your heart (or anything else) when you are not mentally well. You cannot adhere to your medications or a certain diet when you are not mentally well. We care about ourselves because our mental health is good.

One day I was conducting a training. First, a cardiologist came and trained the participants on heart health. He said that the heart is the motor of life. After he finished, it was my turn. I came and trained the participants and I said the mind is the motor of life. The participants laughed, and I explained that you cannot care about your heart (or anything else) when you are not mentally well. You cannot adhere to your medications or a certain diet when you are not mentally well. We care about ourselves because our mental health is good. For younger generations, I ask them to look beyond physical health status. We want more people to join us in improving the mental health of our community. This is the basis of everything we achieve in the health care system.

*This interview was edited for clarity and brevity.