Burundi is one of the poorest countries in the world, ranking at 185 out 189 per human development index. The history of this eastern and central African country is one of recurrent and widespread violences affecting almost all the categories of the population. Responding to this context and its consequences, SDC initiated several projects in support of the government of Burundi in areas such as health, decentralization, land management, etc. Analyzing deeply the environment, the COOF Bujumbura realized that some incident of violences could be generating from a untreated or ill-treated past, thus perpetrating a vicious cycle of violence as authors are at the same time victims in one way or another, at one point in time in the history of the country. A program aiming at integrating post-traumatic mental health care into primary health services in four out of 18 provinces of Burundi was developed and the first phase will run from January 2020 to December 2023. Apart from the fact that there was in 2018 only one neuropsychiatric center with two branches centers, there were only one psychiatrist and two psychiatric nurses. In the meantime, some psychiatric nurses graduated but are not yet enrolled. Thus, the program focuses on integrating mental health care into primary health system, community sensitization, stigma control, training of human resources (community health workers, nurses, general practitioners, clinical psychologists, psychiatrists, etc.), legal framework revision, research, learning and knowledge management, etc. A baseline conducted in 2019 showed that knowledge of mental health illnesses was still poor. In fact, 7.5% of those surveyed believe it is possible to get a mental illness by greeting, talking to or sharing a meal with a mentally ill person, 20.5% think that prayers could cure such a person, while 7.3% would keep away such person and 4.8% believe they ought to be tied up and locked out. Furthermore, diseases prevalence were found as follows: post-traumatic stress disorder (24%), vitality score (60%), depression (5%), sleep disturbance (13%), mania (12%), acute psychosis (4%), schizophrenia (5%), suicidal thoughts (8.3%), alcohol use problems (30%), etc. For example, the results showed that 8.3% of the population declared that they had seriously considered suicide at least once in their life, including more than three quarters in the past 12 months (6.4% of the population surveyed). As for suicide attempts, 4.3% of the surveyed population attempted suicide at least once in their lifetime and 3.7% attempted suicide in the 12 months preceding the survey. To make these data available for the government of Burundi is per say a great step towards dealing with mental health diseases as until then no serious data of that scale was there. As the magnitude of the problem is now known, there is a basis for the government and other donors to plan their interventions. The effective integration of mental health care into primary health services will be done through a clinical and community approach, taking into account gender aspects and the typology of trauma that particularly affects women. In fact, a gender analysis done as part of the baseline revealed that there was a differentiated access to mental health care services. In general, it appears that women are considered to be more exposed to mental illness than men are. The gender specific factors incriminated during interviews and meetings are linked to socio-cultural constraints. The rank of women in the society is less considered resulting in domestic violence (physical, sexual, psychological and economic). When men get mentally ill, their spouses are caring for them. However, when a woman gets sick, she's chased from home and sent back to her parents. This unequal treatment, coupled with less decision-making power of women in their households, particularly on finances, leads to women with mental illness having difficulties in accessing care. For an overall goal of an improved and functioning health system including mental health at primary health services through enhanced coverage, access, quality of care and safety, the intervention strategy of the project is based on the six WHO health system strengthening pillars. Integration of mental health will bring about service delivery, stimulating indirectly the demand of care. This delivery will pass through building the capacity of both on job and specialized mental health personnel. Supplying subsidized psychotropic medicines, sharing mental health data through the health information system, using the national insurance system and promoting governance and leadership in the health system will strengthen the national health system, putting in place the basis for mental health care system. Nevertheless, we should not lose the reality that for a country like Burundi, the system will not be sustainable in the near future. There will be more shocks pulling back the mental health system. However, more and more patients seeking care for mental health problems will find a place to get help as it is for the organic diseases. At the community level, the approach is to promote and protect the rights of people with mental health problems while fighting stigma and discrimination, facilitate the process of their recovery, participation and inclusion in their families and communities. The project aims at contributing to the prevention and promotion of mental health for all members of the community. Three local organizations will be in charge of community interventions. The community-based psychosocial approach of Switzerland in the fight against gender and sexual violence in the Great Lakes region (Burundi, Rwanda and South Kivu in DRC) will be capitalized and used in the mental health program. The approach will furthermore promote peace at community level through prevention by acting on determinants of mental health and promotion of peaceful cohabitation. With regard to human resources development, already existing national mental health training institutions will be supported, focusing on providing qualified lecturers during the entire phase. Besides, for specialized trainings that are not provided in-country like psychiatrists, general practitioners will be supported to do it in Senegal. It is expected that all trainings will be conducted in Burundi in the second phase of the project. Regional mental health institutions will be used as practicals' fields such as Ndera and Kigali university hospitals in Rwanda and SOSAME Center in South Kivu (DRC). The project will be monitored regularly and evaluated. Applied research, learning and knowledge management will help in tackling the local challenges faced with patients and community members. The set-up of this project will be used to extend it to the entire Great Lakes region as the three countries share a common history of widespread violence, poverty and poor governance. This project is just starting. It will be a learning journey, putting in place all the structures of the project and bringing on board all the partners including the government. But with the support of all stakeholders, bearing in mind the need to alleviate the suffering of mental health patients, families and communities, a responsive mental health care system will be put in place in Burundi.
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